Norman L. Martin MD
Emeritus Professor of Radiology
University of Kansas School of Medicine

To gain an understanding of the impact on treatment and the limitations of the use of x-rays by Base Hospital # 28 physicians in 1918, a brief review of the infancy of Radiology and the discovery of x-rays, and how it compares with Radiology today, is helpful. Following Wilhelm Roentgen's discovery of x-rays in 1895, it became readily apparent that x-rays could be utilized in the localization of shrapnel, bullets, and broken bones seen in soldiers on the battlefield. In fact the German scientist’s discovery radically changed battlefield surgery in war.

Typical X-Ray Machine with Patient and Technician

The first military use of x-rays was in 1896, in the war between Italy and Abyssinia, just one year after their discovery. Subsequently x-ray technology was used in several British colonial wars, the Greco-Turkish war, and the Spanish-American War in 1898. “Madam Curie” was born in Poland as Marie Sklodowska, and was encouraged by the French physicist Henri Becquerel, who had discovered "rays" given off by certain crystals, notably uranium. Madam Curie continued her mentor’s research and extracted radioactive radium from pitchblende ore in1898. After three German bombs fell on Paris in September 1914, she evacuated her research staff and moved her radiation institutes to Bordeaux for her research and teaching about radiation and x-rays. She was named by the French government as Director of the Red Cross Radiology Service. Begging funds from donors and manufacturers, by October of 1914 she funded the building of 20 vehicles equipped with x-ray equipment to be used in the war; the electricity needed for generating their x-rays was from the trucks’ engines. Previously, x-ray service was not used near front lines because of a lack of a consistent electricity source. In addition Madam Curie helped establish 200 stationary x-ray facilities, with consistent electricity sources, to the rear of the battlefields. Marie's first assistant was her 17 year old daughter, Irene, who would, one day, herself, win a Nobel Prize. In 1916 Madam Curie began training women as x-ray assistants and used her 1903 Nobel Prize money to buy war bonds. By the spring of 1919, she offered courses to groups of American soldiers.

X-Ray Machine Positioned for Skull X-Ray

Edward Holman Skinner, M.D. was born in Milwaukee in 1881. He came to Kansas City in 1906 and then trained in Radiology in Europe in 1909-10. He served as the x-ray specialist at Base Hospital # 28 in 1918, and, as a Lt. Colonel, he also acted as a Radiology consultant for the American Expeditionary Forces in France.

Reviewing photographs of a number of the 3,601 x-rays, taken by Base Hospital # 28 during 1918, was a challenge secondary to the compromised photo-techniques of the x-rays, but also from the primitive x-ray techniques. There was not a consistent energy level of the radiation, no coning or consistent positioning, and fogging of the glass plates occurred from the scatter radiation. No shielding of the patient or the physicians and technologists existed, as shown in the two illustrations. Most of the x-rays taken were of the extremities, totaling 2,012, showing primarily severely comminuted fractures by high velocity bullets and shrapnel impacting bone. Evaluation of soft tissues and vessels was severely limited unlike Radiology in 2013 where computerized tomography and MRI’s give physicians great definition of soft tissue and vessel anatomy. Today's Interventional Radiologist has the ability to demonstrate the anatomy of internal bleeding and many times control it while localizing obstructed vessels, organ injury, and demonstrating and treating embolic phenomena, many times saving the patient surgical intervention.

The photos of the 1918 x-rays showed numerous metallic foreign bodies embedded in patients that the primitive x-rays helped the surgeon localize. Today the use of ultrasound spares the patient radiation by localizing foreign bodies, evaluating vessels, and dealing with trauma in its various forms. Since there was no shielding of patients, physicians and technologists in World War 1, physicians who fluoroscoped patients with their bare hands, ultimately suffered radiation burns, loss of tissue, and cancer as an end result. Today the radiologist must comply with very strict radiation requirements, shielding, and radiation badge monitoring of dosage as well as using the smallest dose possible to the patient in achieving the answer to the medical question. The development of Nuclear Medicine in today's Radiology gives physicians the ability not only to evaluate anatomy, but also the physiology associated with trauma not available to our 1918 colleagues. A few hundred face, skull and dental film x-rays were also taken by Base Hospital # 28. As expected in the chest x-rays there was often evidence of pneumothorax, lung contusion, fractured ribs, metallic foreign bodies, and pneumonia. Comminuted facial fractures with dislodged teeth were evident in skull and dental radiographs.

World War 1 was felt to solidify the importance of the specialty of military and trauma Radiology. Army physicians and surgeons worked together as a team with the Radiologists legitimizing the discipline of military Radiology to the betterment of treatment and survival of the wounded patient. Nowadays, helicopters bring wounded soldiers from the battlefield, within minutes, to a surgical hospital near the front lines with state of the art equipment and Radiology specialists, as popularized by the TV program MASH with Radar and Hawkeye. This same phenomenon happens on a daily basis in medicine today at the civilian level with patients transported within minutes to a hospital specializing in trauma care.

Chest X-ray There are metallic foreign bodies overlying the heart, lower lobe of the left lung, spleen, liver, and left shoulder. The hyperlucent left lung may be a reflection of a pneumothorax.	Extremity X-ray There is a severely comminuted distal humerus fracture with metal foreign bodies around the fracture site. The elbow is not visualized.
Extremity X-ray There is posterior dislocation of the left humerus with comminuted proximal humerus fractures and distal communited scapular fractures. Metal foreign bodies overlie the fracture sites. Additionally there are fractured ribs medial to the scapula also with adjacent metallic foreign bodies.	Chest X-ray Lingular and left lower lobe consolidation may represent lung contusion with metallic foreign bodies overlying the lung and mediastinum. Ovoid densities over the upper mediastinum and lung are probably artifacts caused by blood or water on the patient, the x-ray plate, table top, or dressing over the chest.
Extremity X-ray Marked distraction of mid-shaft humerus fracture with anterior angulation of the distal fragment. There is external bracing at the fracture site.	Skull X-ray Severely distorted anatomy and compromised film technique and positioning. This appears to reveal markedly comminuted mandibular fractures with teeth displaced into the mouth. There is a safety pin, apparently holding dressings and there are other foreign bodies over the anterior mandible.