Abstract:
An installation for image-assisted shockwave therapy has a C-arm x-ray unit that is orbitally movable around an isocenter, and that carries an x-ray imaging system thereon. The installation also has a shockwave head and a carrier device for the shockwave head that is disposed stationarily relative to the x-ray C-arm. A boom that extends toward the x-ray C-arm is carried by the carrier device, the boom having a free end at which the shockwave head is mounted. The boom is movably guided by the carrier device so that the shockwave head is arbitrarily movable to any position and can be arbitrarily aligned to the isocenter within a minimum range of 180° delimited by the top table position and the bottom table position of a patient table.

Description:
BACKGROUND OF THE INVENTION 
   1. Field of the Invention 
   The invention concerns a system for image-supported shockwave treatment 
   2. Description of the Prior Art 
   The main components of a system of the above type are a therapy system and an x-ray system. The therapy system includes a shockwave head that generates ultrasonic waves directed towards a focus point. The primary purpose of such a treatment is the disintegration of kidney and ureter stones. Other applications for treatment of Peyronie&#39;s disease or in the field of pain therapy and gastroenterology are also conceivable. The x-ray system serves for location of the stone in the treatment area of a patient and for observation of the treatment success accompanying therapy. It has an x-ray source and an x-ray receiver or image intensifier. Both devices are fixed on the ends of a c-shaped arc (called an x-ray C-arm in the following) that can move orbitally around its isocenter. In the application case the x-ray C-arm partially encompasses a patient table or is partially crossed by this in the direction of an axis running at a right angle to the orbital plane of said x-ray C-arm. 
   In the treatment of a patient with a system of the type illustrated above, the focus point of the shockwave head must be aligned on the isocenter of the x-ray C-arm or coincide therewith so that, given orbital or angular movement of the x-ray system required for 3D positioning, the beam axis of the x-ray system always proceeds through the focus point or through a volume region surrounding this focus point. In the application case, the therapy subject to be treated must correspondingly likewise be arranged in the aforementioned region, meaning that the patient must be suitably positioned on the patient table. In systems with stationary shockwave head, this requirement can only be satisfied by a position that is uncomfortable for the patient, for example by a prone position, which is particularly uncomfortable for adipose patients. 
   In a system known from DE 298 24 080 U1, a carrier device (fashioned as a C-arm) for a shockwave head is arranged in the orbital plane of an x-ray C-arm that can be only angularly moved. The C-arm has a first arc segment fixed on the x-ray C-arm and a second arc segment supported on the first fixed arc segment such that it can shift along this segment. The second arc segment carries the shockwave head on its free end. The first arc segment and the x-ray C-arm itself can be rotated around a common horizontal axis angularly running in the orbital plane and through the isocenter of the x-ray C-arm. Due to this embodiment, a shockwave head can be positioned both above and below a patient table. A disadvantage of this arrangement is that the space circumscribed by the x-ray C-arm is crowded by the carrier device such that a displacement of the patient table running horizontal and parallel to the orbital plane operating system is barely possible. Given a change from a left-side treatment position to a right-side treatment position, with an unchanged patient position, the patient volume therefore cannot be brought into the focus point or the isocenter via a table displacement. Rather, a head-to-foot rearrangement of the patient is necessary. The result is that the previous spatial orientation must be adapted to the new patient position; for example, a time-consuming reconstruction of auxiliary devices (such as anesthesia devices) must be effected. 
   SUMMARY OF THE INVENTION 
   An object of the invention to provide a system for shockwave treatment that is improved in this regard. 
   This object is achieved by a system according to the invention having an x-ray C-arm that can move orbitally around an isocenter and a carrier device for the shockwave head that is arranged stationary and axially offset relative to the x-ray C-arm. A boom extending up to the x-ray C-arm is connected with the carrier device with its fixed end and supports the shockwave head with its free end. With the carrier device, the boom is movably directed such that the shockwave head can be arbitrarily positioned in the orbital plane within an angle range of at least 180° above and below a patient table and can be aligned on the isocenter. Due to the axially-offset arrangement of the carrier device, the entire space enclosed by the x-ray C-arm is freely accessible. This allows a patient table to be horizontally displaced so that a treatment change from the right patient side to the left patient side (thus a positioning of the left-side or right-side treatment area of the patient in the isocenter) can ensue without having to effect a head-to-foot rearrangement. The original setup of the system can be retained, which is particularly advantageous when, for instance, a patient with kidney stones on both sides is treated. Due to the movement capability of the boom (and with it of the shockwave head) in an angle range of at least 180°, the latter can be arranged, for example, in an under-table position with vertical alignment of its shockwave axis (0° position) and in an over-table position with the same shockwave axes alignment (180° position). Given a movement range of 230°, a movement from the vertical over-table position (180°) up to a −50° position under the table can ensue. Nearly all treatment situations on a patient can be implemented with the patient in the same position. In the extreme case, the carrier device can be designed such that an angle range of 360° can be covered with the shockwave head. A large variability is thus available with regard to the selection of the treatment position of the shockwave head; for example, a ureter stone treatment can be effected from an over-table position or an under-table position given a dorsal position of the patient. 
   If the carrier device for the shockwave head is arranged in the head direction of the patient with regard to the x-ray C-arm, the doctor has free access to the patient up to the height of the point of the patient to be treated and from the foot region of the patient on the side facing towards the machine such that, for instance, a trans-urethral procedure is possible without hindrance. The inventive arrangement also provides sufficient freedom of movement for an anesthesiologist operating in the head region of the patient. 
   Due to the orbital movement capability of the x-ray C-arm, both the locating and the observation during the treatment (perhaps the progress of a stone disintegration) can ensue from the direction of the shockwave axis, which offers a higher targeted precision (inline positioning). Shadowing of the x-rays by a carrier structure for the shockwave head that is arranged within the x-ray C-arm thus is not a concern. Only the shockwave head itself is arranged within the volume range swept by the x-ray of the x-ray system. The boom that supports the shockwave head does not interfere, particularly when it holds the shockwave head from the side with its free end. In summary, according to the invention a system is provides that allows a shockwave treatment in arbitrary angle positions as well as from different intromission angles with an always-constant alignment and dorsal position of the patient, as well as the precisely-targeted x-ray inline positioning and a nearly hindrance-free observation with the x-ray system during the treatment. The system is therefore likewise suitable for a number of applications, for example IPP, kidney, ureter and bladder stones, trans-urethral procedures. 
   Because both sub-systems (namely the x-ray system and the therapy system) are stationary relative to one another, for example accommodated on a common base, their position relative to one another is mechanically fixed. For instance, given the mounting of the system an adjustment can ensue to cause the focus point of the shockwave head to be directed on the isocenter or to coincide therewith in every treatment position. For instance, the usage of an electronic positioning system for position establishment or calculation of the position of focus and isocenter is not necessary. 
   In a preferred embodiment the boom is forced to stay in a plane parallel to the orbital plane of the x-ray C-arm. A lateral existing of the focus point of the shockwave head from the orbital plane of the x-ray C-arm is thereby prevented. 
   Preferably, the carrier device is a C-arm (designated in the following as a therapy arc) arranged axially offset and coaxial relative to the x-ray C-arm, on which therapy arc C-arm the boom is supported with its fixed end such that the boom can move orbitally. This embodiment allows a complete guided movement of the shockwave head in the orbital plane of the x-ray C-arm. An adjustment of the focus point of the shockwave head to the isocenter of the x-ray C-arm, which adjustment is effected given the new installation of a system, is retained. 
   In the normal case, movement of the shockwave head around a specific angle range requires a therapy arc with an at least correspondingly-dimensioned arc length. Given a movement capability of the shockwave head, for example by 250°, a correspondingly-dimensioned therapy arm would significantly overlap a treatment table on the top and bottom and thereby limit the movement freedom of a treating doctor on the treatment side of the patient table. In order to prevent this, in an embodiment the therapy arc is supported such that it can be orbitally displaced. The therapy arc can then be significantly shortened since the maximum travel path of the shockwave head results from the travel length of the therapy arc and the travel length of the shockwave head on the therapy arc. To shorten the therapy arc length it is also conceivable to form this from two arc segments that can be orbitally displaced against one another. Another possibility for arc truncation is to affix the boom on the therapy arc such that the boom can rotate, such that its free end can be pivoted into a position protruding over a free end of the therapy arc. 
   In a second embodiment of the system, the carrier device is an articulated arm formed by a number of arm segments connected by joints, with fixed end of the boom connected to the free end of the articulated arm. While establishment of the movement of the boom or of the shockwave head in an orbit is determined by the therapy arc, the desired treatment positions of the shockwave head can be achieved with the use of an articulated arm as a carrier device with arbitrary movement paths, in which case a control device for isocentric alignment of the shockwave head is then required. In an embodiment the degree of freedom of the articulated arm is limited such that it can move only within a plane parallel to the orbital plane of the x-ray C-arm. This is achieved in an appropriate manner by the joints of the articulated arm connecting the arm segments exhibiting rotation axes proceeding parallel to one another and at right angles to the orbital plane of the x-ray C-arm, thus are all fashioned as hinge joints. In order to be able to isocentrically align the shockwave head in each angle position, the boom is rotatably connected with the free end of the articulated arm. 
   In both embodiments, the shockwave head is traversed (penetrated) by a central region that is permeable to x-rays and extends along the shockwave axis of the shockwave head. This embodiment allows a precisely targeted “inline positioning” with the x-ray system without position change of the shockwave head, thus also during a lithotripsy treatment. In a design that is likewise advantageous for both embodiments, the carrier device (together with the shockwave head) can be moved from a treatment position into a park position removed from a patient table or, a patient borne thereupon. The freedom of movement in the space located between x-ray C-arm and head end of the patient table or, respectively, generally in the abdominal region of the patient thus can be increased. 
   In order to not hinder orbital movement of the x-ray C-arm and of the therapy arc, or a movement of the articulated arm on the underside of the patient table, the arm is supported at one end, for example at the head end, thus outside of the movement range of the aforementioned devices. 

   
     DESCRIPTION OF THE DRAWINGS 
       FIG. 1  shows a shockwave lithotripsy system in a first embodiment with shockwave head in the over-table treatment position and the x-ray C-arm in a base position (inline with the shockwave head). 
       FIG. 2  shows the system from  FIG. 1  with shockwave head in an under-table treatment position for the left (machine-remote) patient side, with the x-ray system orbitally panned into inline position. 
       FIG. 3  shows the system from  FIG. 1  with the therapy C-arm and the shockwave head in a park position. 
       FIG. 4  shows the shockwave lithotripsy (SWL) system in a second embodiment with an articulated arm and the shockwave head in a park position and the x-ray C-arm in a base position. 
       FIG. 5  shows the SWL system of  FIG. 4  with a parked (thus swiveled-out) x-ray C-arm and the shockwave head in a treatment position (under-table—right). 
       FIG. 6  shows the system of  FIG. 4  with the shockwave head in a treatment position (under-table—left) and a tilted x-ray C-arm in the inline position. 
   

   DESCRIPTION OF THE PREFERRED EMBODIMENTS 
     FIG. 1  shows an SWL system  2  in a first embodiment that has the following sub-components: an x-ray C-arm  4 , a therapy C-arm  8  (bearing a shockwave head  6  and characterizing the first embodiment) as a carrier device, a patient table  10  and a display module  12 . The x-ray C-arm  4  has a two-part base body  14  on which a C-arm segment  16  is movably supported. A segment-shaped support  18  (not visible) is present in the base body  14  for this purpose, in which support  18  the C-arm segment  16  is forcibly guided, optimally without play. The C-arm segment  16  can therefore be moved one-dimensionally in the orbital direction indicated by the double arrow  20 . 
   The two-part base body  14  has a base  24  that is stationary at rest. A guide  28  that can rotate around a pivot axis  26  proceeding horizontally is attached on this base  24  via a swivel joint  34 . The pivot axis  26  intersects a longitudinal axis  22  at an isocenter  32 . The x-ray C-arm  4  can be moved angularly around the pivot axis  26 . The orbital movement of the C-arm segment  16  ensues around a longitudinal axis  22  proceeding horizontally given the angular base position shown in  FIG. 1 . Given angular movement of the x-ray C-arm  4 , its orbital panning then ensues around a rotation axis (not shown) tilted corresponding to the longitudinal axis  22 . 
   An x-ray source  34  and an image intensifier  36  are mounted on the two ends of the C-arm segment  126 . The x-ray source  34  and the image intensifier  36  together form an imaging system whose center ray  38  likewise runs through the isocenter  32 . It is thus ensured that the center ray  38  pierces the isocenter  32  in every angular and orbital position of the C-arm segment  16 . 
   The C-arm segment  16  is shown in its base position in  FIG. 1 , meaning that the center ray  38  propagates in the perpendicular direction. By orbital movement of the C-arm segment  16  in direction  20  (as, for example, shown in  FIG. 2 ), the center ray  38  moves as well so as to span an orbital plane  40  that contains the center ray  38  and the pivot axis  26 . For clarity, only a small portion of the orbital plane  40  in  FIG. 1  hatched, but it extends beyond the hatched region and the diameter of the x-ray C-arm  4 . 
   On its side  42  situated radially outwards, the therapy C-arm  8  is supported on a guide  44 . A support  46  (not shown) corresponding to the support  18  is present in the guide  44  for this purpose, on which support  46  the therapy C-arm  8  can move orbitally in the direction of the arrow  48 . With its end  50 , the guide is supported on the bearing block  52  of a base body  54 . A non-visible joint  56  is arranged between the bearing block  52  and the guide  44 , which allows a rotation around an axis  58  parallel to the longitudinal axis  22 . 
   As an alternative or in addition to the shown embodiment, guide rails (not shown in Figures) with corresponding sled can also be attached on the base body  54  or bearing block  52  and on the guide  44 , on which guide rails the therapy C-arm  8  can be shifted away from the patient region together with the guide  44 , for example parallel to the axis  26 . Other arrangements of rails are also conceivable, such that the x-ray C-arm  4  together with the shockwave head  6  can move two-dimensionally within certain limits. 
   A sled  62  is supported on the radially-inwards side  60  of the therapy C-arm  8  such that said sled  62  can likewise move orbitally in direction  48 . A boom  64  is attached on the sled  62  with its fixed end  67 , the boom  64  pointing in the direction towards the x-ray C-arm  4  and supporting the shockwave head  6  on its free end  66 . For orbital movement of the shock head  6 , sled  62  on the therapy C-arm  8  and therapy C-arm  8  on the guide  44  are simultaneously moved, for example via a chain drive (not visible in  FIG. 1 ) arranged inside the therapy C-arm  8 . The fact that the two movements just cited are thereby no longer independent of one another is irrelevant for the functionality of the system  2 . The orbital movements of therapy C-arm  8  and sled  62  likewise ensue around the longitudinal axis  22 . 
   The entire therapy C-arm  8  with its base body  54  is displaced at an axial separation from the x-ray C-arm  4  or parallel to the orbital plane  40 , meaning that the plane that the therapy C-arm  8  spans lies parallel to the orbital plane  40  and separated therefrom. The boom  64  extends in the direction towards the x-ray C-arm  5  so far that the shockwave head  6  attached on it in turn lies in the orbital plane  40 . The distance is measured such that a focus point  70  of an ultrasonic shockwave emitted by the shockwave head  6  and represented in  FIG. 1  by the cone  72  lies in the orbital plane  40 . The cone tip forms the focus point  70  and lies in the isocenter  32 . The shockwave head  6  is an ultrasound shockwave head for generation of an ultrasonic pulse focused in the focus point  70 . 
   The shock axis  68 , thus the propagation direction of the ultrasonic pulse, passes through the focus point  70 , lies in the orbital plane  40  and coincides with the center ray  38  in  FIG. 1 . For this reason  FIG. 1  represents a type of arrangement known as an inline position of shockwave head  6  and x-ray system  34 ,  36 . Due to an x-ray-transparent zone  96  (visible in  FIG. 2 ) surrounding the shock axis  68  in the shockwave head  6 , during the shockwave treatment of a patient  76  a simultaneous x-ray positioning of the subject to be treated or an exposure of the surroundings of the focus point  70  inside the patient body can in fact occur. The x-rays emitted from the x-ray source  34  can penetrate the x-ray-transparent zone  96  of the shockwave head  6  along the center ray  38 . At the same time the shockwave head  6  is positioned on the stomach-side of the patient in order, for example, to treat a stone in the ureter of the patient. This is known as the over-table treatment position. 
   Due to the coaxial arrangement of x-ray C-arm  4  and therapy arc  8 , the position of the focus point  70  is maintained in the isocenter  32  in every travel position of the shockwave head  6 . The shock axis  68  always lies in the orbital plane  40 . 
   The exact geometric alignment of articulated arm  8  and x-ray C-arm  4  relative to one another ensues in that the base body  14  and the base body  54  are mounted on common foot part  74 . The alignment is effected at the factory in the manufacture of the SWL system  2 . 
   The treatment point of the SWL system  2  represented by the focus point  70  always lies in the isocenter  32 . In an imaging phase of the treatment of the patient  76  he, with his point to be treated, is therefore brought into the isocenter  32  (already occurred in  FIG. 1 ). In order to non-invasively locate the point to be treated inside the patient  76 , the imaging system (x-ray source  34  and image intensifier  36 ) supplies x-ray exposures that are shown on screens  82  of the display module  12 . Due to the flexible, weight-compensating carrier arm  84 , the screen  82  can be moved into an advantageous observation position for the operating personnel of the system  2 . In order to three-dimensionally position the treatment point, at least two x-ray images of the patient  76  are created (possibly given a shockwave head  7  that is initially pivoted away) by moving the x-ray C-arm  4  around the axis  22  (orbital positioning) or  26  (angular positioning), for example between the positions shown in  FIG. 1  and  FIG. 2 . For movement of the patient  76 , a recumbent surface  78  on which the patient  76  rests is one end on a permanently-installed base and can be moved linearly in all spatial directions  90 . 
   The direction of the shockwave head  6  towards the patient  76  can ensue in two manners. One way is for the treatment position of the patient  76  to be sought first and then marked, for example electronically stored given a recumbent surface that can be moved via motors. The recumbent surface  78  together with the patient  76  is subsequently moved a bit so that the shockwave head  6  can be moved into the position shown in  FIG. 1 ; the patient  76  is then moved towards the shockwave head  8  from below until the treatment position stored above is reached again. The position shown in  FIG. 1  is thus reached. 
   Alternatively, due to the entire therapy C-arm  8  that can be moved around the axis  58 , the coupling of the shockwave head  6  can ensue on the patient  76  brought into the treatment position (and henceforth recumbent), with the therapy C-arm  8  that was previously pivoted upwards being lowered together with the shockwave head  6  onto the abdomen (facing upwards) of the patient  76 . This coupling variant applies in particular for the embodiment of the SWL system  2  according to  FIG. 4  through  FIG. 6 . 
   If the shockwave head  6  is coupled on the patient  76 , the treatment can begin by activation of the ultrasonic shockwaves. 
   When it is not directly needed, the entire x-ray C-arm  4  can be pivoted away from the patient region (not shown in Figures) on a further rotation axis  86  that passes perpendicularly through the base body  14  and the foot part  74 , which increases the access for the treatment personnel at the patient  76 . The pivoting ensues from the base position shown in  FIG. 1  in the direction of the arrow  88 . 
   “Wandering” or unwanted movement of the shockwave head  6  (due to its dead weight and the contact pressure on the patient and the deformation of the therapy C-arm  8 ) can be corrected by a slight rotation of the therapy C-arm  8  around the axis  58 . 
   The treatment position shown in  FIG. 2  (known as the under-table left position) treats, for example, the left kidney of the patient  76 . The shockwave head  6  is moved into the under-table position. Relative to  FIG. 1 , the sled  62  (covered in  FIG. 2  by the x-ray source  34 ) is moved to the opposite end of the therapy C-arm  8 . The therapy C-arm  8  itself is additionally moved in its guide  44  to the opposite end relative to  FIG. 1 . The shockwave head  6  protrudes into a recess  92  of the recumbent surface  78  in order to be brought optimally close to direct contact on the patient  76 . The cone  72  of the ultrasonic rays generated by the shockwave head  6  hereby penetrate a water-filled coupling bellows (not shown) which is coupled between shockwave head  6  and patient  76  with an intermediate layer of gel and furthermore with the body tissue of the patient insofar as that the focus point  70  strikes a kidney stone (not shown) in the body of the patient  76 . 
   As in  FIG. 1 , the x-ray C-arm is located in base position with regard to the axis  26 . However, it is pivoted counterclockwise by approximately 40 degrees in direction  20  in order to expose the patient  76  at an angle. The 40 degree position is a typical position for treatment of kidney stones. 
   In  FIG. 2  it can be seen that the shockwave head  6  on the boom  64  is eccentrically mounted, namely on the side of the boom  64  facing away from the system in the under-table position. In the direction of the front side  94  of the recumbent surface, the shockwave head  6  hereby stands further removed from the patient table  10  than the therapy C-arm  8  and the boom  64 . The doctor normally standing next to the patient table  10  on the front side  94  that is limited as little as possible in his legroom or, respectively, freedom of movement. Since, in the upper-table position, the 180 degree position of the shockwave head  6  shown in  FIG. 1  is the most extreme position of the shockwave head  6 , here the projection of therapy C-arm  8  and boom  64  is also bearable for the treating doctor in his head region. A further possibility to make the C-arm smaller is moreover hereby provided. 
   The central x-ray-transparent zone  96  in the shockwave head  6  is visible in  FIG. 2 , which x-ray-transparent zone  96  serves for inline positioning in the shockwave treatment. Due to the stationary resting isocenter  32 , the recumbent surface  78  is somewhat raised relative to  FIG. 1  and displaced towards the right patient side in order to place the patient&#39;s left kidney in the treatment point (thus the isocenter  32 ) instead of the ureter. 
     FIG. 3  shows the therapy C-arm  8  in park position. The entire therapy C-arm  8 , together with the shockwave head  6 , is pivoted upwards by approximately 90 degrees around the axis  58  from the position shown in  FIG. 1 . The entire patient torso region is free, which makes the access to the patient  76  distinctly easier for treatment personnel. This is advantageous in an emergency situation or given the treatment preparation or follow-up. 
     FIG. 4  shows the SWL system  2  in an alternative embodiment, namely with an articulated arm  208  as a carrier device. 
   The articulated arm  208  is borne with its one end  242  on the bearing block  244  of the base body  54 . A joint  248  is arranged between a bearing block  244  and an arm segment  250 , the joint  248  allowing a rotation on an axis parallel to the longitudinal axis  22 . A further joint  256  which can be pivoted on an axis  258  likewise running parallel to the longitudinal axis  22  is attached between the arm segment  250  and a further arm segment  254 . A further joint  262  is attached at the free end  260  of the articulated arm  208 , the joint  262  connecting the arm segment  254  with the boom  64  and allowing rotation (together with the shock head  6 ) on the axis  266  likewise proceeding parallel to the longitudinal axis  22 . 
   The entire articulated arm  208  with its base body  46  is offset by an axial distance from the x-ray C-arm  4  or parallel to the orbital plane  40 , meaning that the longitudinal axes of the arm segments  250  and  254  proceed parallel to the orbital plane  40 . The boom  64  extends in the direction of the x-ray C-arm  4  so far that the shock head  6  attached on it in turn lies in the orbital plane  40 . The separation is measured such that the focus point  70  of the ultrasonic shockwave (represented in  FIG. 4  by the cone  72 ) emitted by shock head  6  lies in the orbital plane  40 . The shock axis  68  again passes through the focus point  70  and lies in the orbital plane  40 . 
   Due to the parallelism of all axes  252 ,  258  and  266  around which the individual parts of the articulated arm  208  can be pivoted, the focus point  70  can only be displaced two-dimensionally and in fact always within a region of the orbital plane  40  demarcated by the dimensions of the articulated arm  208 . The focus point  70  can be directed towards the isocenter  32  by pivoting of the articulated arm  208 . 
   In  FIG. 4  the articulated arm  208  and the shockwave head  6  are moved into what is known as a park (standby) position, i.e. moved as far as possible from the surrounding region of the patient  76  resting on the patient table  10 . The access to the patient  76  from all sides is thus possible without hindrance for treatment personnel or, respectively, doctors (not shown). For example, in the situation shown in  FIG. 4  an imaging phase can ensue before or after the treatment of the patient  76 . The ultrasound cone  72  and the focus point  70  are in fact shown in  FIG. 4 , but the ultrasound source is normally deactivated. 
   If the body region of the patient  76  to be treated lies in the isocenter  32 , the shock head  6  is directed towards the patient by pivoting the articulated arm  208 . The patient does not have to be repositioned for this purpose. The x-ray C-arm  2  is temporarily tilted on the pivot axis  26  out of its angular base position shown in  FIG. 4  in order to avoid a collision. If the focus point  70  is brought into the isocenter  32 , the treatment can be begun via activation of the ultrasonic shockwave. 
   The entire x-ray C-arm  4  can be pivoted out of the patient region on the rotation axis  86  that crosses perpendicular to the base body  14  and the foot part  74 , which enables the unlimited access to the patient  76  for the treatment personnel. This park position of the x-ray C-arm  4  is shown in  FIG. 5 . Instead of this the articulated arm  208  is moved into a treatment position in which the focus point  70  coincides with the isocenter  32 . The right kidney can thus be treated from approximately the 40° position at the back of the patient  76 ; this is what is known as the under-table right position. 
   Angle sensors (not shown) that detect the respective rotation position of the appertaining joint and forward it to a central computer (not shown) are present in the joints  248 ,  256  and  262 . The respective positions of the arm segments  250  and  252  or of the shockwave head  6  and thus of the focus point  70  can be determined in a suitable manner in the central computer from the known dimensions of the entire articulated arm  208  via detection of the rotation angle of the joints  248 ,  256  and  262 . This central computer controls the motors (likewise not shown) in the joints  248 ,  256  and  262  such that the focus point  70  comes to lie exactly in the isocenter  32 . An automated control of the entire articulated arm  208  or, respectively, its movement is thus enabled. 
   Due to the x-ray C-arm  4  being moved away, the longitudinal axis  22 , pivot axis  26  and center ray  38  from  FIG. 4  are again plotted dashed. Due to the space-saving arrangement of the articulated arm  208  on only one side of the patient  76  (namely the right, which is also the treatment side in  FIG. 5 ), the access to the patient is enabled with the largest possible free space. The shock head  6  protrudes into a recess  288  (opposite the recess  92 ) of the recumbent surface  78  in order to be brought optimally close to direct contact on the patient  76 . 
   The x-ray C-arm  4  can pivot on the rotation axis  86  parallel to the orbital plane  40  and perpendicular to the rotation axes  252 ,  258  and  266 . Since the rotation axes  252 ,  258  and  266  typically proceed horizontally, the orbital plane  40  stands vertically; the rotation axis  86  for the x-ray C-arm  2  likewise stands vertically. The x-ray C-arm  2  can thus be moved away from the treatment area in the manner of the movement of a door when it is not required. In spite of the x-ray C-arm  4  being pivoted away, the treatment of the patient  76  with the shockwave head  6  remains spatially precise since its spatial position relative to the SWL system  2  does not change. 
   In such a position of the SWL system  2  an inline ultrasound positioning is then possible. The access to the patient  76  is then namely also possible from the back side of the patient table  10  facing towards the machine. The back side of the shockwave head  6  is freely accessible via the articulated arm  208  displaced towards the head end of the patient  76 . An ultrasound applicator (not shown) can thus be inserted into a central opening (not shown) in the shockwave head  6  and an ultrasound positioning of the subject to be treated in the patient body can hereby be implemented. The central opening can be arranged in the region of the x-ray-transparent zone  96 . 
     FIG. 6  shows an operating situation of the system  2  in which an x-ray radioscopy with the aid of the x-ray C-arm  4  ensues simultaneously with the shockwave treatment of the patient  76  with the aid of the x-ray C-arm  4 . The shockwave head  6  is located in the inline position. The x-rays emitted from the x-ray source  34  can penetrate through the x-ray-transparent zone  96  along the center ray  38  of the shockwave head  6 . At the same time the shockwave head  6  is positioned on the left patient side corresponding to  FIG. 5  (thus in approximately the −40° position) in order, for example, to treat a kidney stone of the left kidney of the patient (under-table left position as in  FIG. 2 ). Due to the stationary resting isocenter  32 , the recumbent surface  79  is displaced relative to  FIG. 5  by approximately the distance of the kidney of the patient to be treated from the right patient side. The focus point  70  again coincides with the isocenter  32 . The x-ray arrangement  76  is tilted on the longitudinal axis  22  in order to irradiate the patient  76  at an angle. The recess  96  in the recumbent surface  78  in turn offers space for the shockwave head  6 . 
   From  FIG. 6  it is clear that, although the shock head  6  is located on the apparatus-remote side of the patient table  10 , this barely protrudes over the apparatus-remote table edge  294  and thus gives the treating doctor sufficient legroom, and therewith furthermore allows the greatest possible patient access. In contrast to the first embodiment, given an articulated arm  208  as a carrier device no further component (outside of the shockwave head  6 ) is also disruptively present in the head or foot region of the doctor in the over-table position (not shown in Figures). 
   If patient  76  and recumbent surface  78  are located in a lateral middle position between the positions shown in  FIGS. 5 and 6 , the third significant possibility (not shown in Figures) to treat the patient  76  is present. Given a patient position lowered somewhat relative to  FIGS. 5 and 6 , the shock head  6  can be moved into over-table position in order to treat the patient  76  from above; thus to treat the abdomen side of said patient centrally in the ureter region. The shockwave head  76  would then (for example in  FIG. 4 ) be arranged on the top of the abdomen of the patient  76  between this and the image intensifier  36 , such that at the same time an x-ray radioscopy (inline) of the patient  76  can again occur. Here as well no component of the system  2  protrudes beyond the table edge  294  towards the machine-remote side on which the doctor stays. Starting from the position in  FIG. 3 , this can ensue via tilting of the arm segment  254  on the axis  258  and tilting of the shock head  6  on the axis  266 . 
   Although modifications and changes may be suggested by those skilled in the art, it is the invention of the inventors to embody within the patent warranted heron all changes and modifications as reasonably and properly come within the scope of their contribution to the art.