occur later. Many expenses have to be met that will not happen
again. The society has met all these unusual expenses and finds
itself upon a firm financial basis.
Dr. Thomas Reilly : Dr. Joseph H. Byrne and I have audited
the report and find it correct.
Dr. R. W. Wilcox: And you have certified to that effect?
Dr. Reilly : Yes.
16 THE AMERICAN CONGRESS ON INTERNAL MEDICINE
Dr. R. W. Wilcox : In every society death must come, and dur-
ing the past year some of our members have left us. Dr. Edward E.
Cornwall will present this subject more fully to you.
Dr. Cornwall : The members who have died are : Dr. Claude L.
Wheeler, editor of the New York Medical Journal, for many years,
a man of delightful personality and very well known in the pro-
fession. Dr. Henry L. Coit, of Newark, whose name is intimately
connected with movements toward the furtherance of infant wel-
fare, and who was one of the first to advocate and insist upon cer-
tified milk. Dr. LeRoy Satterlee, who was widely known and
much esteemed. He was in practice as an internist for many years
and was connected with the teaching staff of the New York Dental
The president announced that the next order of business was the
election of officers, and that the council of the congress, acting ac-
cording to the by-laws, and as a nominating committee, presented
the following nominees for office, and they were unanimously elected
for the year 1918-1919.
President, Dr. Glentworth R. Butler.
Vice-President, Dr. Elias H. Bartley.
Treasurer, Dr. Augustus Caille.
Assistant Secretary, Dr. Joseph H. Byrne.
Council : Drs. Reynold Webb Wilcox, H. Enos Tuley, Charles
E. deM. Sajous, Wm. H. Mercur and Thomas E. Satterthwaite in
the Class of 1922, and Dr. Frederick Tice in the Class of 1918.
Notice of an amendment to the constitution was presented to
the society, to be acted upon at the next annual meeting. This
amendment, offered by Dr. Bartley, was in effect that a second vice-
president should be elected as one of the officers of the congress.
Dr. Caille then moved that a vote of thanks be tendered to Dr.
Wilcox for the efficient and dignified services he had rendered to
members of the association, as their president. He felt personally
that he would very much miss Dr. Wilcox in this capacity. Dr.
Satterthwaite seconded this motion and a rising vote of thanks was
Dr. R. W. Wilcox: Gentlemen, I wish to thank you for your ex-
pression of appreciation. I came into this organization at the in-
stigation of the secretary-general and I esteem it a great honor to
have been your president for two terms. Whatever energy I have
THE AMERICAN CONGRESS ON INTERNAL MEDICINE 17
put into my task I have regarded as only what the organization well
deserved; whatever talents I have shown in the execution of my
duties I have been glad to devote toward making a success of the
society. I feel that in this way I may have been of service to my
profession and to my country.
ROENTGENOLOGY AND THE INTERNIST
By CHARLES D. AARON
The days of experimentation with the roentgen ray are far from
past. No sooner has a new technic been devised for certain manipu-
lations, or an instrument perfected, than fresh ideas and discoveries
demand recognition, and what is considered a great success to-day
may be superseded to-morrow. Roentgenology is still in an active
stage of evolution and bids fair to remain so for a considerable
time to come, until, perhaps, some genius shall discover the very
nature of the rays and solve on a scientific basis what must now be
empirically gathered from laborious experimentation and observa-
However, it is gratifying to record the fact that the rapid advances
which have been accomplished in the evolution of this new science,
from its crude inception to the comparative perfection of the pres-
ent day, have given it a quality of positiveness which renders it a
valuable aid in both diagnosis and treatment.
In the early period of the roentgen era, some claims were made
for the ray which could not be substantiated and which were
promptly discarded, surviving only in the minds of pseudo-scientists
who have no standing in the profession. Having successfully
passed through the storm and stress of its early history, the science
has acquired a definite significance which commands universal pro-
fessional respect. Colleges have introduced the study of the sub-
ject, and the laboratory of Roentgen diagnosis and treatment has
become one of the essentials, not only of every well-equipped hos-
pital and kindred institution, but even of methodic modern office
practice. The academic standing of roentgenology is assured, and
no less its practical value. Still, its service to the medical profes-
sion is not what it might be with more perfect technic and a better
correlation between the science of roentgenology and the science of
18 THE AMERICAN CONGRESS ON INTERNAL MEDICINE
One of the stumbling blocks that hinder the progress of roentgen-
ology is the lack of uniformity in technical details. For example,
there is as yet no generally accepted standard test meal preceding
the roentgenologic observation of the gastrointestinal tract. Not
only do the American, English, French, German and other test meals
differ for apparently no other reason than that they have been de-
vised or promulgated by a leader to whom allegiance is naturally
rendered for racial or national reasons, but various authorities in
the same country have been unable to agree upon a standard. The
matter of expense and also the idiosyncrasy of the patient are
factors in the case, but not to such an extent as to render an agree-
ment on a desirable standard impossible. The value of roentgeno-
graphic examination consists not only in the information it furnishes
to the examiner in an individual case, but also, and even to a greater
extent, in the possibility of comparing results in a large number of
cases which have been examined by different men in different offices,
institutions and countries. Such a comparison is impossible unless
a standardized test meal is used, together with a standardized
technic of administration. Want of standardization is one of the
greatest drawbacks in the evolution of a new science, and although
the roentgenologic fraternity admits the fact, the conditions are not
likely to be changed as long as the leaders, who have set up what
they consider standards for themselves, expect others to adopt them
and are unwilling to compromise.
This may be and probably is due to their meager experience with
test meals other than their own, inasmuch, as each roentgenologist
will, unless actuated by broader motives, adhere to his own method
and refuse to experiment with others. But is it too much to hope
that recognized authorities will ultimately allow themselves to be
convinced by demonstrable facts, to sink their personal proclivities
and to settle upon a standard which a competent majority proclaims
to be acceptable? The advantage in obtaining comparable results
for the furtherance of the practical usefulness of the art ought to
carry sufficient weight with it to lead them to agree upon uniform
procedures in this respect.
Another reason why internists have looked askance at the intru-
sion of roentgenology upon the domain of diagnosis is that they
rightly objected to the idea of roentgenologic examinations displac-
ing the ordinary routine diagnostic methods. There may have been
a trend in that direction on the part of early roentgenologists who
allowed themselves to be swayed by youthful enthusiasm, but such
THE AMERICAN CONGRESS ON INTERNAL MEDICINE 19
is fortunately no longer the ease, and the specialists of the new
science do not claim to render any but supplementary service in
diagnosis. At the same time, it should be admitted that in some
conditions the roentgen ray reveals more pathology than the clinical
diagnosis, provided the interpretation of the shadow pictures is
correct. In incipient tuberculosis, for instance, the early signs may
be roentgenologically detected while clinical symptoms are as yet
absent. Cases of osteitis fibrosa cystica have been reported in
winch the roentgenograms were so characteristic that it would have
been difficult to mistake them, and yet the diagnosis could not have
been made from the clinical pathologic picture. All roentgenologic
findings are, however, only placed in the hands of the clinician for
what they may be worth. They will serve to direct his attention
to the probable presence of conditions which have not yet advanced
far enough to produce clinical symptoms. But in view of the fact
that the roentgen ray furnishes only shadows which have to be in-
terpreted, and not complete reproductions of actual pathologic facts,
no roentgenologist worthy of the name would think of suggesting
that his findings should take the place of a regular clinical examina-
Another point I would emphasize as a truth beyond all possible
cavil is that a knowledge of pathology is an absolute necessity for
making a roentgenologic examination and interpreting the shadows
correctly ; and that accuracy in diagnosis by this means requires an
equally thorough clinical knowledge, because the roentgenographic
findings must be correlated with the clinical history and the present
condition of the patient. The right interpretation of the fluoroscope
or plate is dependent upon this knowledge. How is the roentgenolo-
gist to have a clear mental perception of the changes consequent
upon disease, unless pathology is an open book to him? It is with
roentgen ray as with the microscope ; both reveal the condition
of tissues in health and disease, but the revelation cannot be inter-
preted with any pretence to usefulness, except in the light of accurate
knowledge of larger subjects — anatomy, physiology, histology, and
Similarly, it is not too much to ask that the skilful roentgenolo-
gist should also be a good clinician. Indeed, all these demands have
now been recognized for some time by leading specialists in the art.
But there are still survivals from early times, when roentgenography
was likened to photography and when nothing was supposed to be
required of the "artist" but the ability to "take a picture." These
20 THE AMERICAN CONGRESS ON INTERNAL MEDICINE
times are gone, and the present arraignment is only intended to em-
phasize the fact that the roentgenologist who is insufficiently versed
in the intricacies of the anatomical, medical and surgical require-
ments, or who is inexact in the practical application of his knowl-
edge, must yield the field.
These demands, of course, do not apply to the assistants employed
in a large roentgenologic laboratory whose principal requirements
are a technical knowledge of the instruments and apparatus they
are expected to handle. In other words, there are two phases to be
considered in the problem of turning roentgenology to successful
account : The brain of the physician who directs the proceedings and
interprets the findings, and the technician who carries out the in-
structions. This situation naturally suggests the desirability of
every physician being able to act as his own roentgenologist where,
as a matter of fact, very few clinicians have a sufficient knowledge
of the roentgenologic theory and practice to justify their attempting
an interpretation of a series of plates.
To be sure, there are many instances in which interpretation is
easy. But such instances should not mislead us into indolent cre-
dulity. Gastric pathology is a case in point. It is not difficult to
recognize, in autopsy or at operation, definite lesions or pathologic
alterations, such as an hour-glass stomach, perforating gastric ulcer,
or pyloric obstruction ; but in the clinic identical symptoms may be
due to stomach disease or, for example, to cholecystitis or chronic
appendicitis. Therefore, the primary lesion must be found, if pos-
sible, and it is the business of the roentgenologist to make out cer-
tain identifying marks that will indicate the cause of the patient's
symptoms. Some of his problems may indeed be difficult, for the
pathologic process may be in the gall bladder, in the appendix, or
in the colon. Here he can show his experience as an observer, and
also his technic in application.
All this points to the supreme desideratum — standardization.
Both the methods and the technic need it, the more so since
Roentgen diagnosis has, after all, its limitations as well as its possi-
bilities. It is to be regretted that, as none other, this new specialty
allows such diversities in technic and such variations in the conclu-
sions from the findings.
Many cases have been observed which illustrate the need of a uni-
versal technic, as a diagnosis based on roentgenograms obtained by
one technic is apt to be discredited by a subsequent roentgenogram
of the same case made by a different man and with a different
THE AMERICAN CONGRESS ON INTERNAL MEDICINE 21
technic. This drawback is to a certain extent overcome by ex-
perienced roentgen men stating in their reports the details of the
technic, the position of the patient and of the roentgen tube,
together with all the other incidentals ; but in the first place,
his precaution is in many cases ignored, and in the second place the
necessity for it would largely disappear, at least in routine examina-
tions, if a universal technic were employed. The successful appli-
cation of the roentgen art is largely dependent on the relative posi-
tion of patient and roentgen tube, and the visualization of certain
shadows depends upon this very fact, as for instance in the localiza-
tion of foreign bodies, gallstones, fractures and dislocations ; thus
the individual skill, ingenuity and experience of the roentgenologist
must determine the technic. The personal equation is and will re-
main a deciding factor in the success or failure of a roentgeno-
graphic examination. However, this does not do away with the
further fact that even the work of the expert would be more ex-
pert, and the altruistic value of his work to the community im-
measurably enhanced, were the general trend of his work based on
standardized principles, so that the results could be intelligently
scrutinized, compared and repeated.
Standardization is required in many other important points con-
nected with roentgenology in addition to test meals and the position
of the patient under examination, but the object of this paper is
rather to call attention to this requirement on general principles
than to go into technical details. Among the latter may be men-
tioned the deplorable absence of a standard of measuring the dosage,
and the quantity and quality of the rays to be employed in a given
case. The attempts have been many, and the difficulty of the task
is admitted, but its solution is no nearer to-day than it was years
ago, and there is no tangible result in sight. Similarly, attempts
have been made to standardize the application of the rays over
definite areas of the body, especially in deep application for thera-
peutic purposes, to make sure that no one part of the body receives
more or less than its intended share in repeated treatments. While
suggestions have been made along this line from time to time, the
roentgenologic section of the profession is slow in discussing, accept-
ing or rejecting them with a view to arriving at anything like stand-
ardized procedures. The general feeling which prompts them to
adopt an attitude of "masterful inactivity" or "watchful waiting"
is not due to indolence or apathy, but probably to a realization of the
fact that their experience has not yet sufficiently matured to justify
22 THE AMERICAN CONGRESS ON INTERNAL MEDICINE
the adoption of more or less irrevocable plans. But this very con-
sideration should be an incentive to increase and perfect their ex-
perience, and this much-desired result can only be won by a uni-
versal comparison of results and, consequently, by standardization
of the important steps bound up in the practical application of the
ROENTGEN DIAGNOSIS OF DISEASES OF THE CHEST
By GEO. C. JOHNSTON
The subject indicated in the title of this paper is so extensive that
it would be impossible to more than touch lightly on the various
points in the time allotted to this purpose.
In making an examination of the chest, it is always wise to pro-
ceed according to a certain routine, in order that one may not be
misled by the history of the patient or other elements in overlook-
ing some important point upon which the entire diagnosis may rest.
In our clinical work we, therefore, make it a rule in every ex-
amination of the thorax to note the following points:
a. Heart — size, shape, position and action
b. Aorta — size, position, dilatation, aneurysm, calcification
c. Lungs — apices.
1. Illumination of enforced inspiration (light reflex)
2. Relative distensibility
1. Degree of visibility
3. Excursion (equal bilaterally?)
4. Fixation (adhesions)
3. Presence of opaque bodies
7. Persistent thymus
Following this general survey, we now proceed to examine in de-
tail. We. look first for the shadow of the trachea, which upon the
THE AMERICAN CONGRESS ON INTERNAL MEDICINE 23
screen appears as a bright band anterior to the median line and
fading behind the aortic arch. If there be any deviation of the
tracheal shadow, we desire, at once, to know why the displacement
and suspect pressure, which requires explanation.
Further down we notice the hilus shadows on either side, well
marked on the right and hidden on the left behind the heart, cast
by the bronchi and great vessels, and the numerous lymphathics
about the roots of the lungs.
Toward the periphery the lungs become more transparent, but
we are able to trace out the shadows cast by the broncheal tree with
its accompanying lympathics and shadows. If the alveoli are
healthy in all portions of the lungs, lungs will be equally translucent.
Increased radiability showing bright upon the screen and black
upon the plate may indicate a tuberculous cavity or a bronchiectasis,
dilatation, emphysema or pneumothorax, while decreased radiability
might be caused by a pneumonia, lung suppuration, thickened pleura
or pneumonokoniosis, syphilis or malignant disease.
A decreased area of radiability surrounding a more or less circu-
lar area of increased radiability would suggest an abscess cavity.
In an examination of the lungs we study not only lung tissue, but
the pleural cavity and the diaphragm. Thus in the study of an
instance of lobar pneumonia by means of the x-ray (which study is
being made and more in the military hospitals abroad), we might
expect to find the following phenomena present.
Lung. Light shadow over one lobe
Pleura. Increase in pleural shadow
Diaphragm. Visibility lowered and excursion limited
Lung. Dense shadow of one or more lobes
Pleura. Increase in pleural shadow
Diaphragm. Excursion and visibility lost
Lung. Irregular, ill-defined areas of density involving a lobe or
24 THE AMERICAN CONGRESS ON INTERNAL MEDICINE
Diaphragm. Excursion and visibility returning
The above table is taken from Crane's excellent article on the
skiascopy of the chest which appeared more than fifteen years ago.
I mention this point in order that you may see that there is nothing
new in the examination of the chest by means of the x-ray.
Now let us consider for a moment the appearances which we
might expect in a broncho-pneumonia. We will find first that both
lungs are affected, irregular shadows over both lungs, visibility of
diaphragn slightly impaired, excursion of diaphragm unimpaired.
In pulmonary oedema, on the contrary, the screen appearances of
the thorax is very unusual. If the oedema is extensive we will find
1. Heart and aortic shadow lost
2. Diaphragm shadows lost
3. All chest landmarks lost
Emphysema will show an increased radiability of the lung on one
or both sides confined to the emphysematous areas. Atelectasis,
due to blocking of the bronchus, perhaps from foreign body, will
show a decreased radiability of the portion of the lung extending
to that part of the bronchial tree, the main trunk of which is blocked.
The primary tumors of the lung most often seen are the sarcomata
and the appearances are very striking. In the advanced stages one
or several globular masses of rather uniform density may be seen
to invade the lung tissue. The tumor wall is sharply defined, the
demarcation between tumor and lung being easily observed. This
is in contradistinction to carcinoma of the lung. The remainder of
the lung tissue may be perfectly healthy. These tumors attain con-
siderable size, from one to four inches in diameter, and may give
rise to very few pulmonary symptoms, unless so situated as to make
pressure on some of the great vessels.
Carcinoma of the lungs, usually secondary and quite prone to
produce metastases from the breast or prostate, occur frequently
and give an appearance of very light lung suppuration, but without
the bronchial marking. The lung tissue involved resembles the
body tissue as in periosteal sarcoma. The disease appears at the
hilus and radiates out into the parenchyma of the lung. In early
stages it appears as thoroughly interlobular, but later may involve
the lung very extensively.
THE AMERICAN CONGRESS ON INTERNAL MEDICINE 25
Diseases of the pleura are quite easily diagnosed by means of the
x-ray. This is the first axiom. A visible pleura is always patho-
logical. We may differentiate by means of the x-ray.
1. Acute pleuritis
2. Acute pleuritis with effusion
3. Chronic pleuritis
7. Interlobular pleurisy
PLEURISY WITH EFFUSION
a. Lung retracts.
b. Dark shadows with sharp upper border, which border
changes shape with position of patient.
(Only true with incomplete effusions.)
Pyothorax same as above except darker shadow.
In complete left pleural effusion :
Heart displaced to right.
Diaphragm shadow effected in erect posture, but can be seen
if you can place patient in Trendelenburg position.
Dark shadows rarely extend to apex.
Differential diagnosis between complete pneumonic consolidation
and complete pleural effusion is almost impossible with x-ray.
CHRONIC THICKENING OF PLEURA
Diffuse haziness of a part of one side of chest or lessened radia-
bility. Diaphragmatic excursion normal.
Simply an encysted pleurisy, wedge shape, base outward and the
pleura above and below thickened.
(Pulmonary abscess begins at hilus and extends out and rarely
HYDRO-PNEUMOTHORAX AND PYO-PNEUMOTHORAX
1. Dark shadows in chest, diaphragm lost
2. Changes with position of patient
26 THE AMERICAN CONGRESS ON INTERNAL MEDICINE
3. Upper border very clear
4. Level of fluid seen on shaking patient (waves)
5. Very great increase of radiability above the shadow
Pneumothorax causes a striking appearance on the screen or
plate if the pleural sac has been free from adhesions so that the lung
is free to retract when the negative pressure is relieved. The en-
tire half of the thorax may appear as though the lung had been
removed. Close examination, however, will show a retracted lung
lying against the mediastinal shadow.
Many mistakes are made in the diagnosis of conditions within the
pleural cavity. It is sometimes very difficult or even impossible to
differentiate between an opaque fluid in the pleural cavity and an
unresolved pneumonia involving the entire lung. This condition
is by no means rare and will sometimes require the use of the as-
pirating needle in order to clear up the diagnosis.
Pulmonary abscesses seldom extend to the periphery of the lung
and require very careful localization. It is very unwise to examine
a patient for the determination of the presence of a pulmonary ab-
scess after coughing and expectorating pus. It is much better to
wait and give the abscess cavity a chance to become filled with pus,
at least partially, and then examine in the erect posture or semi-re-
cumbent. Areas of lung suppuration without cavities resemble por-
tions of pus drowned lung, such as are seen after the blocking of a
bronchus by a foreign body has continued for a long period of time.
In all examinations of the chest by means of the x-ray, it is well