UNIVERSITY OF CALIFORNIA AT LOS ANGELES OS M LETTER OF TRANSMITTAL. U. S. Akmy General Hospital, Washington Barracks, Washinf/ton, I). C, December f), 1899. Brigadier General George M. Sternberg, Siirqeon-Gmeral, Umted States Army. o Sir- I have the honor to transmit herewith a report prepared by your ,^ direction on the use of the Rontgen ray by the Medical Department of the ^ United States Army in the war with Spain. "^ In submitting this report, I desire to express my great appreciation ot the earnest support you have given its preparation, both personall)' and X by attording me every possible facility for the work. '^ Very respectfully, your obedient servant, ji . W. C. Borden, x^ Captain and Assistant Surgeon, United States Anm/. 352528 TABLE OF CONTENTS. Page. Introduction Section I: Eontgen ray apparatus _ . _ - - - Static apparatus Coil apparatus Storage batteries -*■* Primary batteries ^^ Where Rontgen ray apparatus should ])e placed for military surgical use- . 18 Eontgen ray apparatus compared - - 26 Section II: Lodged missiles — ''" Lodged, Mauser bullets deformed by ricochet . _ _ 33 Lodged, undef ormed, Mauser bullets - 35 Lodged, shrapnel bullets - . 37 Lodged, brass-jacketed bullets 39 Injuries to the central nervous system l)y lodg°d, Mauser bullets 40 General conclu.sions relative to lodged missiles 44 Section III: The localization of lodged missiles - - '^^ The Eontgen ray and wound (exploration compared 45 Necessity for the localization and removal of lodged missiles. - 46 Localization methods "*"' By direct observation ■*•' By multiple observation - 51 Photo;;-raphic apparatus for localization - 52 Apparatus for visual localization - - - - ^** Section IV: Gunshot fractures of the diaphyses of long bones _ _ - 63 Fractures by perforating bullets *''^ Fractures by perforating bullets at short range 64 Fractures by perforating bullets striking the bone in the median line - ^'>^ Fractures by liullets striking the bone tangentially 6it Fractures by penetrating, undefoinied bullets , 71 Fractures l)y penetrating, deformed bullets 7^ Clinical conclusions . _ - - ' "^ 5 6 CONTENTS. Section V: Papc. Giinsliot fractures of tbo oxtroniities of lony hones and of tlic cancellous hones urns .__ 93 Development . 97 Printing '... 98 LIST OF ILLUSTRATIONS. I. II. III. IV. V. VI. VII. VIII. IX. X. XI. XII. XIII. XIV. XV. XVI. XVII. XVIII. XIX. XX. XXI. XXII. XXIII. XXIV. XXV. XXVI. XXVII. XXVIIL XXIX. XXX XXXI, PLATES. To face page The Edison battery apparatus and the .static apparatus 14 Lodficd. Mauser bullets 30 Radiooraph of deformed, Mauser bullet lodged in the leg 3^ Radiograph of deformed, Mauser bullet lodged superficially in knee U Radiooraph of undeformed, Mauser bullet lodged in the thigh 3(5 Lodged, shrapnel bullets, ^o Radiograph of shrapnel bullet, lodged in the back 38 Radiograph of shrapnel l)ullet, lodged in thigh 38 Lodged, bra.ss-jacketed bullets ^^ Radiograph of Mau.ser l)ullet, lodged in the back -i^* Radiograph of Mauser bullet, lodged in the brain 4^ Radiograph of fragment of missile, lodged in the fibula 48 Radiograph of Mauser bullet, lodged in the foot 52 Radiograph of Mauser bullet fracture of metacarpal bones 66 Radiogi'aph of Mauser bullet fracture of radius by •■contact" --. 66 Radiograph of Mau.ser bullet fracture of femur 68 Radiograph of Mauser bullet fracture of femur after union 68 Radiograph of Mauser bullet fracture of phalan.x QS Radiograph of Mauser bullet fracture of metatarsal bones 68 Radiograph of Mauser bullet fracture of humerus 7(i Radiograph of Mauser bullet fracture of radius - 7(i Radiograph of Mauser bullet fracture of humerus 7(> Radiograph of Mauser bullet fracture of femur 7(» Radiograph of Mauser bullet fracture of humerus 72 Radiograph of Mauser bullet fracture of ulna 72 Radiograph of Mauser bullet fracture of femur by "nmshroomed" bullet - - - ■^^ Photograph of bone fragments from a ca.se of fracture of the thigh by a '' mushroomed" Mauser bullet 72 Radiograph of gunshot fracture of the fenmr 74 Radiograph of fracture of tibia by brass-jacketed bullet 74 Radiograph of Mauser bullet, embedded butt-end foremost in the tibia 'i'" Radiograph of shrapnel bullet in the thigh, the bullet having per- forated the fenuir . - ■ '6 7 8 ILLUSTRATIONS. To face page XXXII. Hadiofrrupli of Mauser bullet fraeture of neck of femur 78 XXXIII. Hadiojrraph of Keniinullet - -- - - 80 XXX\'I1. Radiograph of Remington bullet perforation of o.s calcis 82 XXXVIII. Ridiograph of Remington bullet. lodged in the face .. - 82 FIGURES. 1. Edison-Lalande cell 16 2. Edison. l)reak-wheel apparatus 28 8. Diagram of location of ball in case of Private Keene, First United States Volunteer Cavalry 35 4. Diagram of location of bullet in case of Private Cooper, Tenth Cavalry .- 3lj 5. Diagram explanatory of Plate ^^I 38 6. Diagram explanatory of Plate VIII _ 38 7. Diagram sht>\ving location of bullet in ca.se of Edward Marshall - . 41 8. Photograph of Private Gretzer. First Nebraska Volunteers - 43 9. Diagram showing location of bullet in case of Major Eskridge 47 10. Diagram showing relative size of umbi'a and penumbra in foreign todies lodged in the tissues 50 1 1. Mackcnzie-David.son exposer _ 53 12. Mackcuzic-Dayidson localizer 54 13. Diagram showing method of using localizer 68 14. Diagram showing method of localization 58 15. Harri.son portable localizing apparatus 60 16. Dennis fluorometer 60 17. Diagram illustrating lateral transmission of energy by osseous tissue 65 18. Diagram explanatory of Plato XIV 66 19. Diagram explanatory of Plate XVI 67 20. Diagram explanatory of Plate XX 69 21. Diagram explanatory of Plate XXVI 73 22. Diagram explanatory of Plate XXIX 74 23. Diagram explanatory of Plate XXXII 78 24. Diagram explanatory of Plate XXXVI 81 25. ROntgen ray burn, case of Private ^IcKenna 94 26. Rontgen ray burn, case of Private Booth 95 THE USE III' THK RONTGEN RAY BY THE MEDICAL DEPARTMENT OF THE UNITED STATES ARMY IN THE WAR WITH SPAIN. ( 1S9S. ) THE USE OF THE RiiNTGEN RAY BY THE MEDICAL DEPARTMENT OF THE UNITED STATES ARMY IN THE WAR WITH SPAIN. INTRODUCTION. Soon after the discovery by Professor Rontgen of the new form of radiation and the placing on the market of apparatus for its production, the Surgeon-General of the Army supplied Rontgen-ray apparatus to several of the larger post hospitals. On the outbreak of the war with Spain and the establishment of general hospitals the most prominent and important of these hospitals and the three hospital ships Reliefs Missouri, and Bay State were su[)plied with similar appliances. In all, seventeen apparatus were available during the war, of which five were static and twelve were coil machines. These apparatus proved to be not only invaluable aids hi military surgery, but the use of the two types, coil and static, gave an opportunity for comparison of these two methods for producing the Rontgen ray as adapted t(^ the needs and environments of military ho.spitals. The use of the Rontgen ray has marked a distinct advance in military surgery. It has favored conservatism and promoted the aseptic healing of bullet wounds made by lodged missiles, in that it has done away with the neces- sity for the exploration of wovmds by probes or other means, and by this has obviated the dangers of infection and additional traumatism in. this class of injuries. In gunshot fractures it has been of great scientific value by showing the character of the bone lesions, the form of fracture, and the amount of bone comminution produced by the small-caliber and other bullets — condi- tions which could not have been otherwise determined in the living body. In the treatment of these traumatisms it has been of great value in determining the course of treatment to be pursued, as its use, together with the course of the cases under treatment, has shown that aseptic or 11 12 k(")nt(;en ray in spanish-american war. septic roudition of tlu- wouuil is of far gTeater importance than the amount (if V)one coinininutiou. Tliis is ilhistrated by those cases of extensive bone connninntion which, when connected with aseptic wounds, progress to favorable termination with a miuinunn of immediate and remote ill effects; while those cases in which the bone traumatism is slight, if complicated by infection of the wound, are much more difficult to ti-eat and serious in their result. In the sections of this report which are devoted to a consideration of the effects produced by missiles, care has been taken to select the cases and radiogi-aphs which are, as far as possible, typical of the conditions treated of. In making these selections, many case reports and radiographs, which have been submitted to the Surgeon-General, and which are similar to those introduced in the text, have been omitted, as the reproduction of radiographs which onlv show that which is illustrated by those introduced would add to the bulk of the report without increasing its value. As the scientific value of tlie ])lates depends upon their being true representations of the objects as shown by the Riintgen ray, the radiographs and the nega- tives, from which they were printed, have not in any case been retouched other than to remove some slight defects which may have appeared in the prints or negatives during their prepai'ation. In this connection the writer wishes to express his appreciation of the work done bv Dr. W. 31. Grav, of the Amiy Medical Museum, in preparing many of the negatives, and of the preparation of many of the prints by Private Hany Utter, Hospital Corjjs, United States Army. In the sections devoted to teclmic, the theory and physics of Rontgen radiation have been omitted as ha^^ng no practical bearing upon the use of the Rontgen ray in militaiy surgery, and these sections have been devoted to questions of practical teclmic, knowledge of w liicli has proved of value in manipulating the apparatus used to produce the new kind of radiation. I. RONTGEN RAY APPARATUS. Two types of a])paratus — coil and static — were in use in the Medical Department of the United States Army during the Spanish-American war. In both apparatus, Rontgen rays are produced by passing a rapidly inter- rupted electrical current of high potential tlu-ough a specially constructed glass Ijullj (Crookes tube) of liigh vacuum. In the static machine, the electrical current is produced directly by the machine and can-ied direc^t from it to the tube. The electrical enei'gy given out by the static machine is derived from the motor energy used in di-iving the machine. In the coil machine, the electrical current is produced in the secondary portions or coils of a special appai-atus — Ruhmkorif coil— by induction through the passage of a primary current of low potential through the primary portions or coils of the apparatus. The primary current is obtained from many forms of elecjtrical sources; either from primary batteries, accumulators, dynamo machines, or from local electrical installations, and is led to the Ruhmkorff coil by means of insulated wires. In the Ruhmkorff coil, the primary current traverses the primary coil, which is placed within the secondary coil, and in so doing induces a second- ary current of high potential in the outer or secondary coil. This secondary cun-ent, after being interrupted with high frequency by mechanical means, is. carried to the tube and there gives rise to the peculiar form of energy known as Rontgen radiation. When working properly, both the static and the coil apparatus produce Rontgen rays <»f practically equal power ;ind working efficiency. The ai)paratus are, however, so utterl}' unlike in construction and require such different means for their manipulation that they are not, under all condi- tions, equally adapted to the requirements of military surgery. 13 14 U()NT(iK.\ KAY IN SPANISH- AMEKK A \ WAR. THE STATIC APPARATUS. Tlic Static niacliiues iu»w used for the production of Kiintgeii radiation areof theWiiushurst-Holtz type, which iiichides a charger and an inthiction apparatus, the latter consisting of eight or ten circular glass plates su])- ported on an axle, with intervening oblong plates of glass, combs, connections, etc., all inclosed in a case of glass and wood. The circular plates are revolved ])y hand or by motor power. With the latter, a motor of one-sixth to one-fourth horsepower is required. The static machines used by the Medical Depai-tmeut were made by Otis Clapp & Son, of Pro^^dence, R. I. Their apjiaratus weighs about 500 pounds, is well constructed and reliable, and, with proper manipulation, gives Rontgen rays of high power. COIL APPARATUS. The coil machines used by the Medical Department were of several different patterns. They comprised those made l)y the Kdison Manufactur- ing Company, the Fessenden Company, and the General Electric Company. In these apparatus, the primary current is supplied from primary bat- teries, st( the Royal I'niteil Service Institntion, Vol. XLII, page 1152. London, 1898. B648 2 16 R()NTUEN HAY IN SPANISH-AMERICAN WAR. iu tilt.' i-t'Us is su.s|icii(le(l a nillcd zinc plate. These zinc- ])lat('s are fastened by a bolt to a knob on the cover. This prevents any movement in the relative position of the elements, and does away with tlie necessity of using vulcanite se])arators to jtrevent anv .short circuits occurring in the solution. The zincs are amalgamated and, as in most l)atteries, the zinc is attacked more vigorously near the top than at the lower part of the \)h\ie, the zincs for this cell are made slightlv tapering, the thick part being uppermost. The exciting liquid employed in the battery consists of a 25 per cent .solution of caustic potash in water, or in other words, of a solution of 1 pound of caustic potash in o ])ounds of water. AVhen the circuit is closed and the cell is put iu action, tlu' wati-r is decomposed, the oxygen forming, Fhi. 1.— Edisoii-U-laudu i-i-ll. ly|.c \V. with the zinc, oxide of zinc, which, in turn, condtines with the potash to form an exceedingly .soluble double salt of zinc and jyotash, which di.s.solves as rapidly as it is formed; the hydrogen, liberated by tlie decomposition ot the water, reduces the copper oxide to metallic coi)i)er. A layer of heavy paraffin oil three-eighths of an inch deep is added to keep out the air and prevent creeping. The Edis(m-Lalande battery has an initial electromotor force of 0.95 volt, which drojjs to 0.7 volt on closed circuit. At first sight it appears that the electro-motive force is low. The internal resistance is, however, corresjiondiugly lower (in the ty[)e \V cell being only 0.02 ohm), and PRIMARY BATTP:RIES. 17 c-diisequently it follows that the available electrf)-niotive force (potential diliereiice) is very high. The efficiency of the Edison-Lalande cell as compared with other primary batteries is shown in Table I. Table I. Dr. A. E. Kenndlya tahL- shaaung comparative efficiency tenU het-wwn the Edison-Lalande cell, type W, and other t.ype^s of hatteiy mi the marhet, fo7' purposes of driving small electric i/iotors, or for moderate general delivery of power. Type of eell. 1. Mean working, E. M. F. volts. Edison-Lalande, type W . Fuller bichromate Western Union carbon, bichromate type Partz motor eel 1 Hussey Eclipse Leclanohe Gravity Daniell, Western Union type, local 0.67 1.8 1.8 1.83 1.4 1.6 toO. .5 1.0 2. Aver- age inter- nal resist- ance. 3. Maxi- mum de- livery current. 4. Capac- ity in am pere hours. 5. Power valuation. 6. Eco- nomic power valuation. Ohms. A tnperes. 0.028 33.35 300 22. 22 4.58 0.40 4.50 68 8.1 8.1 0.40 4.50 5 8.1 6.48 0.51 3.58 65 6.57 1.458 0.8 1.75 45 2. 45 0,98 0.5 0.5 3.0 2.0 1.0 2.0 1.0 2.22 The third column gives the current that the cells will deliver when placed on short circuit, and the fourth and fifth columns show the great capacity in ampere hours and the high-power valuation of the type W cell compared with other similar sources of electrical energy. The Edison-Lalande battery has the following advantages for Rontgen ray work : 1. High and constant available electromotive force. 2. Little loss of energy while the cell is idle, the chemical action in the cell being only about 1 per cent a month. 3. Constant and heavy current delivery. 4. No attention or inspection required until the elements are exhausted. 5. Freedom from noxious fumes or chemical deposits. No freezing or influence by temperature changes or differences. 6. Comparatively cheap materials, easily obtained. 18 KONTGEN KAY IN SPAM81J-AMER1CAN WAR. The Routgen rav battery of ten cells, type W, luis a life of GOO ampere limu-s, or about "200 wi^rking liours. The cost of renewal of the elements is about S22, making- the hourly running cost only about 11 cents per hour. The Edison battery apparatus complete, as furnished the ^ledical Dejjartment, is as follows: 1 Edisoii-Kuhiiikorif coil. 6-inch .spark, with adjustable condenser and vibrator. 1 P^dison tluoroscope, 6 inches by S inches. 1 Edison X-ray focus tube, medium size. 1 Edison X-ray focus tube, large size. 1 adjustable stand for tube. 10 Edison -Lalande cells, type W, in metal-lined polished oak box. 1 combination rheostat, for using battery for X-ray. cautery, motor, diagnostic, and centrifugal work. 1 battery cord, connecting combination rheostat to coil. 1 battery cord, connecting battery to combination rheostat. •2 insulated wires for connecting tube to coil. For a battery apjjaratus, this outfit is quite compact and can be trans- ported without danger of breakage. WHERE RONTGEN RAY APPARATUS SHOULD BE PLACED FOR MILITARY SURGICAL USE. Before comparing the different tvpes of apparatus it should be deter- mined where the apparatus is to be placed for use. In the Spanish-American war, apparatus were supplied to general hospitals and hospital shij)s only. Xoiie were used in movable hospitals or in the field. Some advocates of the Rontgen ray in military surgery have advised the use of apparatus in the field hospitals. In the Tei'ah expedi- tion an api)aratus was used at the extreme front — so far to the front that the operate u's were, at one time, under fire when engaged in removing a bullet with its aid. Experience with its use in the late war and the conditions of military surgery lead to the conclusion, that the use of the apparatus in niovaljle hospitals is not advisable, and that its use should be restricted to perma- nent l)ase and general ho.spitals and to ho.spital ships. This conclusion is reached through a combhiation of reasons: First. Tliat lodged bullets only in exti-emel)' rare cases require imme- iiate removal. Rr)NT(iJEN RAY APPARATUS. 19 Second. That the environments of, and conditions incident to moval)le tield hospitals, render asepsis in operating' practicably impossible; and, in consequence, in field hospitals noninterference with wounds should be practiced to the utmost extent possible. Third. That surgical interference with lodged bullets, except where adequate asepsis is available or the necessity urgent, is to be condemned, as the suppuration which follows is much more detrimental to the patient than the presence of the lodged missile. Foui'th. That a Rontgen ray apparatus in the field is an additional incentive to surgeons to operate under conditions not adequately aseptic. The percentage of the recoveries of the wounded in the war with Spain was high compared with preceding wars, as will be seen by reference to Table II, which shows the comparative mortality of the wounded in recent wars. In the American civil war, where the larger caliber rifle was used and asepsis and antisepsis were unknown, the mortality was nearly double that of the Spanish-American war (12.96 to 6.64 per cent). The question naturally arises, how much of the reduction in mortality is due to the use of a smaller caliber rifle firing a small bullet with high velocity and how much is due to modern surgical methods. In an attempt to determine this question, attention is called to Table III, which shows the mortality of regional wounds in the two wars. From this table, it will be seen that the mortality from wounds of the head, face, neck, spine, and abdomen did not materially diff"er in the two wars. There was, however, a marked difi'erence in the chest wounds (27.8 to 11.4), and a very great dif- ference in wounds of the extremities and flesh wounds of the back. The great difi'erence in mortality from injuries of the pelvis and genital organs is mainly to be ascribed to the fact that these injuries recorded in the Spanish-American war were mostly flesh wounds, while in the civil war many penetrating wounds of the pelvis and severe fractures of the pelvic bones were tabulated. 20 liUNTCiEN KAY IN SPANISH-AMERICAN WAR. Taiu.k ll.—]Vumher of womided in recent wars who mnw under treatment and per- centage of mortality. Wounded. Died. Mortality. Per cent. 12,094 1,840 15.21 39, 868 4, 359 10.90 17.0.54 2,962 17.36 l'4ii. 712 31,978 12.96 2,021 316 15.63 13, 731 1,455 10.59 99, 566 11,023 11.07 56, 652 6,824 12.04 1,105 108 9.77 948 99 10.44 1,594 106 6. 64 ( 'riinoaii. lS54-;i6— English (Matthew ') Krench (Uhenu *) In Italy, IS5i)-iiM— Krem-h (Chenu ') .\nn'rUan livil, 1861-<>.^— Federals (Otis ') I'riissia-Denmark, 1864— Prussians ( Loeffler ^) .Viistria-Prus..03 [ht cent. Pirogow's figures are entirely erronedus, being ba.sed on estimates only and not on utticial records. ' Haga. Kriegschirurgische Erfanrungen aus deni .lapanisch-Chinesischen Krieg, 1894-95. Archiv fiir klinische Chirurgie, vol. .55, pp. 256-2.57. Berlin, 1897. '"Gore. Army Medical Department (British) Report, 1897. Appendix Xo. VI, "p. 4.51. I>le. '->'> KOMXiEN HAY IN bl'ANlSH-AMlilUCAN \VAH. The o-reat reduftion in inortaHt\- in wounds of the extremities is especially noticeable (Table IV). Table IV. — A^umber of cases and mortal it 1/ from gunshot of the extremities in t/ie civil war and United States JRignhirs in Spanish-Amet^ican tear. Cases. Died. Mortality. Pivil wiir in>npr extrpmiti^s . . 87, 793 429 86, 413 562 5,608 1 11, 813 9 6.5 0.2 13.6 1.6 Spanish-American war, upper extremities Civil war lower t^\ti"6UiitiL'S - .. ............ Snanish-American war. lower extremities .... Tliusin the civil war, while the mortality of all wounds of the extremi- ties, upper and lower, was 6.5 and 13.6 per cent, similar wounds, in the Spanish-American war, had a total mortality of but 1.0 per cent. The number of deaths in the latter war from wounds of these regions were surprisingly small, being but 10 in 991 cases, and of these 10 cases, 3 died very shortly after the receipt of their injunes, probably from hemorrhage.' The differ- ence in treatment adopted in these wars is not less great than the mortalitv (Table V). Table V. — ^Vounds of the extremities treated hi/ excision and amprdation, and hy conservatism, aiid the relative mortality of each treatment for two wars {in Spanish-American war. United States Beg%dars). War. Wounds of extrem- ities. Amputations and excisions. Percentage of opera- tions to wounds. Operative mortality. Conserva- tive mor- tality. Total. Deaths. Total. Deaths. Civil Spanish-American 174,206 991 17,421 12,193 10 32 2,636 6 6.99 3.20 21.6 18.7 9.1 0.4 This table shows at once (a) the small number of operations done or required to be done in wounds of the extremities since the adoption of the new rifle and modern surgical methods, the proportion having been reduced over one-half (6.99 to 3.20); (li) the great decrease in mortality in these cases, the morality being reduced over twenty-two times in cases treated conservatively (9.1 to 0.4) and somewhat decreased in those treated by amputation or excision. ' Report of the Surgeon-General of the Army, 1899, p. 314. Wa-shington, 1899. rOntgen ray apparatus. 23 The hio'h mortality in operation cases in the Spanish-American war arose from the fact that only the extremely serious cases were operated on. In the cases reported among the Regulars, the deaths that occurred were all from high amputations (Table VI). Table VI. — Rexn'tiom, amputat-i/m,r moving- field hospitals their apjjlication is very limited. Abbott,' in an article in the London Lancet of Jannary 14, 1899, on Surgery in the Gra-co-Turkish war, states that a coil, battery apparatus was used in the base hospital at Phalerum. As a result of his experience in this war, he says : The use of the Rontgen ray becomes an iinpossibility at the actual front. For- tunately it is not necessary there, and could very possibly do harm by stinnilating the young surgeon to premature operations under l)ad surroundings. We believe that the X-ray in future wars will be of the greatest use. hut not at the actual front. In closing his article Abbott formulates the following: The apparatus is of no use on the field where the detection of bullets ean only be an incentives to premature exploration. The less wounds are tampered with before satisfactory suri'oundings are reached the l)etter. The modern bullet * * * is practieally useptie. and there is no urgency for its removal. Surgeon Major-General Jameson, of the medical department of the British arm}-, in discussing the use of the Rontgen ray in warfare and as used by the British medical department, says: Reference has l)een made to the necessity of supplying these various apparatuses to the hospitals at the front, but the difficulty of transport nuist really be considered. It seems to me that from our present knowledge the advantages are not so very great after all in that part. The place, I think, for them is in the line of communication or at the base hospital, l)ecause after all nothing except very urgent operations are advised to be performed in advanced places. What the photography really deter- mines is more the position of the l)ullet or the kind of fracture, but the urgency of operation is determined by other conditions. ' Our experience in the war with Spain was full}- in accord with the above opinions, as the use of the Rontgen-ray apparatus at general hospitals and on board hospital ships met all practical requirements. As to the use of the Rontgen ray in gunshot fractures, the same rules hold as for lodged missiles; i. e., occlusive dressings and noninterference at the field hosiiitals except where operation is imperatively demanded, and in this connection it may be stated that cases of gunshot fractures are extremely 1 Abbott, (F. C). Surgery in the Graeco-Turkish War. Lancet, Vol. I, pp. :W and 152. London, 1899. ■'Journal of the Royal United Service In.stitution, Vol. XLII. London, 18HS. Janie.siin i\\t^- cussing Beevor'H paper "The woikiiij; of the Riintjien ray in warfare." 26 RONTGEN KAY IN SPANISH-AMERICAN WAR. infnniiK'iu which can be benefited in any way by tlie use of Rontgen apparatus at the trout. Also, in considering where Rontgen apparatus are to be placed for use iu military surgery in time of war, the fact must be taken into account that these apparatus are all more or less bulky, heavy, somewhat difficult to transport, and that their use requires crdinarily be as easily or safely DIFFERENT APPARATUS COMPARED. 27 transported to, or set up at hospitals established tor military purposes as can the coil apparatus. It is subject to a certain extent to atmosplieric influences, and while these can be laro-ely overcome bv pi'ojter ])recautious, they add to the difficulty ot obtaining g-ood work. The apjjaratus can l)e run by hand power; but, when so run, its output is not eqi;al to that of the same machine when run by motor power at an even rate dged missile is undeformed, it may or may not have struck some object before producing the penetrathig wound If the wound was received at extremely long range, the evidence is presumptive that the lowered velocity of the ball was due to the length of its flight, ^yhen, how- ever, the range is short or indcnown, it is impossible to say whether lodge- ment was caused by decreased velocity from unknown long range, t>r from the bullet at short range having passed through some obstacle whit-h lowered its velocity witliout altering its shape. For, while the jacketed bullet is frequently deformed by ricochet, its resistance to deformation is so gi'eat that in many cases where it produces penetrating wounds, it is C[uite reasonable to suppose that it may have impinged against objects not sufficiently dense to deform it, or even may have passed through trees or wooden obstacles, for it is known that the jacketed bullet will pass through many inches of hnrd wood without becoming deformed. In cases of penetrating wounds, where the lodged bullets are undeformed, it is fair to suppose that quite a percentage of these wounds are due to lowered velocity from causes, such as those given above. In the Santiago campaign, the large number of lodged missiles was commented on by the surgeons. In 198 Mauser bullet wounds, seen by the writer, there were "21 lodged bullets. This number is unusually high, but serves to show that, imder certain conditions, quite a number of lodged missiles maj^ be expected. At Santiago, many wounds were received at long range and in a wooded terraine. It is quite })ossible that, in some cases, the velocity of the bullets was reduced by passage through the brandies of trees, in which event, from the resistance of the 1)ullet to deforming violence, its velocity might be lowered and the bullet not be deformed. Where the bullet is lodged butt end foremost in the tissues, it is to be concluded that the ball has ricocheted and turned end for end before strik- ing the part. The fact that quite a number of bullets were found lodged butt end foremost, and that so many lodged missiles showed deformation PLATE III. PLATE III. Case 1, Section II. — Ralph Barkman, j)nvate, Company K, Second Massachusetts Vokmteer Infantry. Kadiograjili of left leg, viewed from the inner side, showing- deformed, Mauser bullet lodged behind the tibia. PLATE III. L0DGP:D. MAUSER BULLETS. 33 produced b^^ ricochet, demonstrates the property this biilU^t lias of retainino- sufficient momentum to produce penetrating wounds after ricochet impact. Wliile, tlierefore, under conthtions of direct impact, tlie small size and great s(H'tional density of tlie small-caliber jacketed bullet cause it to produce perforating wounds, except at extremely long range, so raising the percent- age of perforating to jjenetrating wounds which it is liable to inflict, relative to these percentages compared with similar wounds made by the older lead bullet of lai-g(^ caliber; the ricocheting property of the modern j)rojectile, which is greatly in excess of that of the old bullet, increases the j)ropor- tionate number of penetrating wounds which it is liable to inflict in actual warfare. This ricocheting property of the compound bullet and its ability to produce penetrating wounds after ricochet, as well as after having its velocity re(Uiced in other ways, accounts for the fact that the numl)er of cases of lodged bullets was greater in the late war than was anticipated from experimental trials of the bullet made ])revious to its use under actual conditions of warfare. DEFORMED, LODGED, MAUSER BULLETS. In the two following cases, the first illustrates the direct course of a bullet wliicli has been blunted at tiie point by impact with some object before entering the body, but without materially lessening its sectional densit\', and both cases illustrate the noninfection of wounds b}' deformed bullets. Cnac 1. — Deformed^ Mmmcr hiiUct Iixh/cd in. leg; aseptic wound; localizatiouhy Rdntgtm ray; removal. Riilph l)iirkniiin, private, Company K, Second Massachusetts Vohuiteer Infantry, wounded July 1. 1.S98, l)y two bullets, one of which passed through the loft arm, shat- tering the liunierus; the other entered the left leg, at the outer surface, upper third, and lodged. The patient was transferred from the field hospital to the Relief., whei'e Rontgen examination located the bullet behind the tibia, 8 inches above the ankle joint (Plate III). The bullet was removed and it (No. 4, Phite II) and the radiograph show that the missile had been blunted at the point, from impact with some other object, before entering the leg. The wound of entrance was small and not infected. There was marked discoloration of the skin from the entrance wound downward, by which the course of the bullet could easily be traced. — ('(Lfe report compiled from reeordu In Hu:r(jeon- OeneraV H Office. Caxe2. — Defcmned., MaM.^er hidlet lodged in thigh; (inepfic n'oimd; local ization hy Rwitgex ray; removal. Augustus Snoten, private, Company C, Twenty-fourth United States Infantry, wounded July 1, 1898, by a Mauser Itullet, whicli enter(Ml at the anterior and outer 34 KONTGEN ray in SPANISH-AMERICAN AVAR. surface, uiiddlo third, right thigh. The patient was transferred to the Relief, where a nmch-defornied bullet was located by Rontgen ray, partially behind the femur, some distani'C lower down the limb. It was removed, when it was found to 1)(> greatly deformed from lateral impact, the casing being split and the body of tlie bullet concaved and flattened (Plate II, No. 5.). The wound of entrance was small and uninfected and, despite the deformed mi.ssileby which it had been made, presented nothing in appearance ditierent from an entrance wound made by an undeformed liullet. — Cme report compiled from reeonls in 6' urgeo7i,- Genera fx Office. It would be supposed that bullets which had struck other objects and had been det'oriued before euterino- the body, would, from their jag-g-ed and irregular form and lowered velocity, be more likely to carry infection into a wound than undeformed bullets which struck the body without ha\'ino- ricocheted. There are, however, but two cases reported of infection by deformed Mauser bullets, though probably many others occurred. The fact that so few cases of infection were reported, as arising in this way, tends to show that infection so caused, is not as common as would be supposed. In one of the infected cases reported, the large size of the wound and its location in the sole of the foot would make it ])articularly liable to infection. In tlie other case, the bullet was greatly deformed and had lodged very superticially. Case 3. — Deformed, Mamer hnilet lodged superficially in hnce; woviid slightly infected; Realisation iy Rontgen ray; removal. Samuel Davis, private. Company L, First ITnited States Volunteer Infantry, wounded July 1 by a ricochet ball, which entered and lodg(;d superticially. behind the internal condyle of the left femur. The patient was transferred to the Rdief and the bullet (No. 7. Plate II), the whole point of which had been carried away by ricochet, was located (IMate IV) by the Rontgen ray and removed. The wound of entrance was infected, but healed readily under antiseptic dressings. — Case rejaort compiled from records in Surgeon- OeneraVs Office. Case If.. — Deformed, Maimer hvUet lodged in foot; septic wound; localisation hy Rontgen ray; remmnil. John N. Taylor, private, Company B, Twelfth Ignited States Infantry, was wounded July 1 by a Mauser bullet, which passed through the sole of his shoe and entered the bottom of the left foot, directly below the arch. The wound was (juite large and irregular in shape and, on that account, was thought to have been made by a fragment of shell, until the ROntgen ray disclosed a Mauser bullet, with an indentation near the point, lying directly beneath the cuboid bone, in a line with the .second metatarsal bone (Plate XIII). The wound was infected and suppuration set in. The patient was transferred to the Rdief and then to Washington Barracks, D. C, where the bullet was removed December 26, 1898, and the patient returned to dutv shortlv afterward. PLATE IV. PLATE IV. Case 3, Section II. — Samuel Davis, private. Company L, First U. S. Volunteer Cavalry. Radiograph of left knee,^^e■wed from the inner .side, showing a Mauser biiUet, deformed by ricochet, lodged behind tlie internal condyle. As the radiograph was taken through the dressings, a pin and the mottling due to the iodoform gauze are also showu. PLATE IV. • J)i'tbrf//t'd Matisii'r huilet -lodolovjii tji/iau THE HELIOTVPE PRINTING CO.. BOSTON. L0DGP:D, MArSEK BULLETS. 35 LODGED, UNDEFORMED. MAUSER BULLETS. From its ivsistauce to extcnuil violence, the compound bullet is probably frequently ricocheted without Ijecomuif;' deformed. In mauj^ cases, the bullet, from its irregularity of flight, may produce extremely jaggeil wounds, as in the case next given, or may enter the l)ody butt end first, and the radiograph or extraction, alone, show that ricochet had occurred. Cased. — Maimer hullvt lodged in chest; fractun' ■'"V Fig. 3. — Course and location of bullet in case of Private John R. Keen, Troop L, First United States Volunteer Cavalry. PLATE V. Case 6, Section II. — Willimu A. Cooper, private, Company A, Tenth United States Ca\alry. Radiograph sliowing imdet'ornied Mauser bullet lodged in right thigh. The vii'w is from the posterior surface mid the bullet lies at nearly a right aua'le to its line of entrance. PLATE V. TltC MEL:0TVPE PftlNDNG CO.. BOSTON PLATE VT. Lodged slirapnel bullets (natural size), located by the Rontgen ray and removed by operation. These bullets show slight deformation, probably produced at the time of explosion of the case in which thev were contained, and not due to ricochet. From the low velocity of the shrapnel ball, it probably seldom ricochets with sufficient force to jjroduce jienetrating wounds. PLATE VI. • THt MCtlOTVPf PRINTING CO. BOSTON LODGED, SHRAPNEL BULLETS. 37 LODGED, -SHRAPNEL HULLETS. The shrapnel l)u]let, used 1a' the Spaniards, was a round, soft lead bullet, nieasurinji' 1.25 centimeters in diameter, and weighing- a little over 1 1 .ii-rains. (Plate VI.) As the velocit)' of these bullets is <>uly that of the bursting' charge of the shrapnel, plus some of the initial velocity of the shell, their velocity is comparatively low, and these missiles belong to the large caliber, low velocity type. Theoretically, wounds i)roduced by these missiles should differ materialh' from those produced ]}x the small-caliber bullet. Practi- cally, there was not so marked a dift'erence as would have been expected, for, in the reported cases, the woinids which had been given a primarv dress- ing with the tirst-aid packet generally healed as readih' as thos(i made by the Mauser bullet. Also, i'e[)orted cases show that in many instances, neither by the appearance of the entrance wound or the sensation of the wounded man, could the nature of the missile be determined. In consequence, many cases of penetrating wounds by shrapnel bullets were thought to have been made by Mauser bullets, until the Rontgen ray or removal of the missiles showed them to be shrapnel. These cases ai"e of s])ecial clinical value, as they show that wounds made by the larger lead bullets, when luiiuterfered with and treated by occlusive dressings, are usually asejttic and I'un favorable courses. 7. — Shrapiwl haU lodged in m'fh; nxcptic iroii))d ; Uic(d>zati.(>n hy Riintgen ray; removal. George A. Harper, private. Conipaii}' E, Thirteenth United States hifantry, was woiuided July 1, by a shrapnel ))all which entered the back of the nei'k, half an inch to the left of the second cervical spine. The wound was dre.ssed with the tirst- aid packet and the patient was transferred by the steamer Troqw/is to the general hospital. Key West, Fla. When admitted to the hospital, the wound of entrance was aseptic and so .small that there was nothing to indicate that it had been made by other than a Mauser bullet, and the patient himself believed that he hud been wounded by that missile. The fluoroscope, however, showed that it was a shrapnel l)idl, and it was removed July It), from beneath the anterior edge of the sterno-mastoid muscle, 2 inches below the lower end of the mastoid process. Though made by a shrapnel, the wound track was not infected, the wound of operation healed by first intention, and the patient was well when furloughed August (>. (JaseS. — Shrapnel hall lodijed in liach : aseptic ino'wn. — Diagram explana- tory of I'latc VII, showing lixmtioii of shraptu'l Imllet, 'I, in the case of Private Henry E. Conover, Com- jiany E, Nintli Tuited States Infantry. the juiictioii of the outer and middle thirds of the hone. The wound was dros.sed with the tirst-aid dressing- and the jKitient was transferred to the g-eneral hospital. Key West. Fia.. where tiuoroseopie examination was made, but the liuUet eoidd not he located. A statie machine was used at Key West, and, owing to the great humidity of the air at that place, the apparatus failed to produce sufficient light to penetrate the thicker parts of the hotly. For that rea- son, lodged bull(>ts t'ould not be located in some cases while at that hospital. On admission to the hospititl, tht' wound was small and aseptic, healed (]iiickly, and from its appearance it was thought to have been made by a small-caliber bullet. The patient complained of pain in the region of the shoulder blade, but had no other symptoms. He was furloughed August t). but on rejoining his regiment at the expira- tion of his furlough he found it difficult to handle a gun, and was sent to the general hospital at Washington Bar- racks, D. C. The bitllet was located just beneath the pos- scapula. The radiograph showed it to be a shrapnel (Plate terior border of the left VII and tig. 5). The bullet was removed D(>cemt)er 8. llSiiS. the wound healed by rii-st intention, and the patient returned to duty six days later. In this case the woiuid, though made by a shrapnel, was entirely aseptic and remained so luitil the bullet was removed, tixc months after receipt of the injury. .Vt the operation, the tissue about the bullet wound showed no evidence of inflammation, and the bullet was producing trouble only through friction in movements of the shoulder. Oaiy the sln-apnel, like tliose by other missiles, generally become infected. Case 10. — Shrapnel, ball Uxk/ed In axilla; h^diukI i.vplorciL at jiiUl lidxpiial : si/j>- jmratimi; localization hy Rontgen ray; removal. Patrick McDonnell, private. Company F, Sixteenth United States Infantry, was wounded July 1, by a shrapnel l)ullet which enteied 2 inches below the right acromion process. No wound (jf exit. An unsuccessful attempt was made in the field hospital to remove the bullet. Suppuration occurred, and an incision for drain- age was made. The patient was transferred to Fort McPherson, thence to the general hospital, Washington Barracks, D. C. Suppuration ceased and the wound healed. Radiograph di.sclosed bullet Ij'ing in the axilla beneath the nei'k of the scapula. Operation, under ether, December 7, the bulk^t removed. Wound healed by first intention and patient returned to duty January ^6, 1891>. Cane 11. — Sltra^inel hall Imlgi-d i^aperlicially ; xeptlc wound; localization hy Rontgen ray; rein, hemorrhage or fracture. Reflex functions, .so far as it is po.ssible to ascertain, were entirely absent below that portion of the spine where thl^ injury was suppt)sed to be. Thei'e was rect^d and vesicle paralysis. After an interval of three weeks, during which time there was no improvement, he began to regain conti'ol of his arms. A progressive change for the better was inaugu- rated, followed by partial restoration of power oi movement. Complete sensibility, both as to pain and temperature, returned to the right half of the body. He was transferred to the division hospital, Presidio, San Frant'isco, t"al., October 22, 1898. At that time he was able to walk, but with great dithculty. On his arrival at Presidio there was a loss of electro-contractility as to setisil)ility in the left arm. fore- arm and hand, left half of the thorax, left half of the abdt)nieii and left leg and foot. There was loss of sense of temperature over this area. Tactile sense, however, was generally present. A paitial paralysis of the sphincter ani and vesicse pei'sisted. Knee jerk increased on right side, feebly present on left side. Motion of the PLATE IX. PLATE IX. Lodged, brass-jacketed bullets, uattiral size. The bullets liave been defcn-ined 1)\' ricochet, one having the jacket entirely stripped oii". PLATE IX. ^ 1 # THt HELIOTVPE PRINTING CO.. BOSTON. PLATE X. PLATE X. Case 12, Section II. — C James Edwards, private. Hospital Corps. Radi()<)Taph of chest, viewed from the back, showing lodged Mauser IniUet, which has passed through the sjiine, lyiug 2 inches to the right of the spine over tlic tliii'd intercostal space. PLATE X. GUNSHOT OF CENTRAL NERVOUS SYSTEM. 41 extremities was almost completely restoivrl. Symptom.s in reference to the brain, negative. Sexiuii povviM- iind desire almost nil. No ankle clonus. No irreo-iilaritv in any of the internal organs, but a languid and sluggish condition, lacking the power of vigorous action. January 2, 18!)!t, motion now only slightly iiuijuired in left upper and h'ft lower extremity. Coordination of muscles virtually normal. Power of nuisi-Ies is inhibited in right leg. Electro-contractility absent in the left lower exti-emity. extending from the crest of the ilium to the planter surface of the foot. There is also loss of the .sensation of temperature over this area. Sensibility completely alisent in the left leo- and foot. Mobility ab.sent in the left foot. Micturation and defecation disturbances are still present. Sexual power is diminished, but desire is normal. As far as he can remember there has been a constant dull pain iri the back, in the reo-ion of the third intercostal .space, an inch and one half to tiie right of the spinous process of the third dorsal Aertebra. Radiograph (Plate X) shows a lodg(>d Mausei' bidlet at the point where the pain at)ove mentioned exists. Bul- let was extract(^d March 7. 1899, and as the patient remained disqualified for military service, he was finally discharged on account of impairment of mobility of right leg and thigh, and loss of .sense and contraction of the left leg. — Case reported hy Maj. W. A'. H. MatthmcK, Svrgmn, TJ. S. Vols. In the followiiio' case, spinal injur>' was caused by depressed fragments of bone. Localization of the bullet showed that the inissile was producing no ill ef- fect in the tissue. T.,aminectomy was done and recovery followed. The posi- tion of the bullet, butt end foremost in the tissues, makes it ])rol)able that the missile had ricocheted before entering the body. / •a Fid. 7. — DiajJiram sliouiiific wouml nl entrance, Ju'<4ti\ and entered the Roosevelt Hospital, New York City, where he came under the care of Dr. Robert Abbe. Dr. At>be took a radiograph of the case, which located the missile lying butt end foremost. 1 inch to the right of tlie first lumbar vertebra and deeply placed in the neighborhot)d of the renal vessels (Fig. 7). ' The position of the bullet precluded the possibility that the .symptoms were due to the pressure from the missile. Dr. Abbe did a laniinectom}- and removed al! 42 HONTCIKN KAY IN SPANISH-AMERICAN WAR. depressed frajJiiU'iits of hone whioh wtnv pl■es!^ill^■ on the spinul cord. The bullet was not i-eiiioved. The next case i.s of interest, in that it sIkpws the result of a gainshot wouikI of the brain, the bullet being' unrenioved, and what slight disability and how few inipoi'tant or disturbing symptoms ma\' persist as a result of lodgement of a small-caliber liuUet in the bi-ain. Canellf.. — Peni'traimij. MaitxirhulUt u^oioid ofhmln ; irimnil as, jitic; liullrt imf n uini-rd. .John (iretzer. jr.. private. Company D. First Ncl)rask;i \'oJunteer Infantry, wounded at lono- ranye. March 27. 18!Mt. at ^larihoa. Pliiiii)j)iiie Islands, hy a Mau.ser bullet eiUerini;- ca\ity of iTaniuni. three-fourths of an incii abo\e the supraorl)ital ridge and one-fourth of an inch to the left of the median line. There was total k)ss of eon.sciousness during first few hours following receipt of the traumatism, with the exception of a few short intervals of .semiconsciousness, at which time, excruciating pain in the head was experienced. The patient was taken to the First Reserve Hos- pital at Manila, where he laid in bed for about four weeks. While in bed, he sutlered extremely from pain in the head, most severe the first three days, moderat- ing slightly at the end of the iifth week, becoming intermittent, greatly exaggerated on exertion, by heat, and i^sjxH'ially direct rays of the sun, exposure to which caused him to reel, stagger, and almost lose consciousness. At the present time (August, 1899), is still ijuite su,sceptible to direct rays of the sun. First few days of illne.ss were marked l)y extreme naus(>a and persistent vomitiny; the slightest thiny- taken in the stomach would be rejected. The pain in the head increased the severity of these attacks. During early, weeks of ilhiess any exertion of the brain, as reading, caused ])ain in l)ack of eyes and vertex of the head. Returned to San Francisco with his regiment in August. V6W. Radiogi-aph taken August 20, showed Mauser bullet eml)edded in left oct-ipital lobe (Plate XI). General condition good, as shown by photograi)h (Fig;. S). Condition. Octol)er 1. ItS'.tH, six months aftei' receipt of the injury: Occasionally has pain in the lumbar region, and describes it as being a "catch," lastmg about five minutes at a time. Pain in the head, when pivsent, is located a little anterit)r to p:iiietal eminence on left side. There is no history- of loss of power on either side, but a weakness is appreciated in the right arm and leg, and a slowness in response to miMital impidse. This last is demon.strated in the act of writing: though the thought is perfectly clear, there is a slowness in the forming of the words. Voice : Patient did not. to his knowledge, exercise this function for first two days of illness, but on beginning to do so. notic(?d a slight confusion of ideas, it being necessary to Hrst clearly tix a thought before giving expression. There was also temporary loss of power to recall past events and names of companions. I'his returned with full clearness at other times. A slight confusion still remains. Eye : Pain back of left eye more or less .severe, and increased by use, and relieved by closing the lid. During continement to lied following injury, patient tested vision of left eye by closing right. The vision was clear, but slight weakness and jjhotophobia was noticed. Ptosis of left eye was marked during early weeks of PLATE XI. PLATE XI. Case 14, Section II. — Jolm Gretzer, jr., ))rivate, Company D, First Nebraska Volunteers. RadiogTaj)!! of head viewed from the left side, sliowiug Mauser bullet lodged in the braiu. PLATE XI. Jl^ s- % .i«i** i*i| ■'S*^#«*^' THE HELIOTVPE PRINTrNO CO., BOSTON. GUNSHOT OF CENTRAL NERVOUS SYSTEM. 43 illness. Aperture is now sinaller thiin that of right eye. A slight diplopia was also present, a line of printing- appearing double. Pupils are regular, l)ut left slightly larger. Reaction to light and power of aceonimodation is noticeably decreased, especially in left eye. Visual field normal. No nystagmus. Hearing is normal. Sense of smell more acute on right side. Sense of taste more acute on right side, the anterior two-thirds of left showing marked didlness. Fi(i. 8.— Photograph of Private John Gretzer, jr., Company D, First Nebraska Volunteer Infantry, taljen live months after receipt of injury. Scar of wound of entrance aliove left eye. Tactile sense seemingly slightly dull on right side. General sensation of right side not as acute as on opposite side. Reflexes: Knee reflex very marked on right side, n'sponding to touch above, as well as below tiie joint; the contact, from finger causing a disagreeable tingling throughout the thigh. On left side, reflex is exaggerated, but not to such a marked 6648—5 44 RONTGEN RAY IN SPANISH-AMERICAN WAR. extent. Wrist reflex marked on i-ight .side, ca 's ng a chronic .spasmodic contraction of the fingers, and the hands tingling. Reflex absent on left side. Ankle clonus and patellar reflex ab.sent. Chreniaster'/J marked on both sides. Sphincters uninvolved at any period of illness ; coordmauon good, though a slight uncertainty is felt on attempting to walk with the eyes closed. No epileptiform seizures. No disturbance of nutrition or ))odily functions. The patient afterwards entered the mail service and returned to Manila on duty. — Reported hy Major A. C. Girard, Surgeon, United States Army. GENERAL CONCLUSIONS RELATIVE TO PENETRATING MISSILES. From the foregoing, it seems reasonable to conclude that the compound bullet of small caliber is not apt to lodge in the tissues unless its velocity has been greatly reduced by long range, by ricochet, or by having passed through some obstacle before entering the body. Relative to infection of the wound, it would seem probable that missiles which had struck some other object before entering the body would be more liable to be infected and to produce infected wounds than those which had passed tlu'ough the air only; and that the small caliber bullet, toward the end of its flight, when traveling with low velocity, would be extremely liable to can-y foreign matter, shreds of clothing, etc., into the wound and so infect it. In fact, that all bullets which lodge, would be more likely to produce infection of the wound than bullets which have sufficient velocity to pass through the part. It appears, however, that neither ricochet, jjassage through other objects, or lowered velocity nmrkedly increases the proneness of the jacketed missile to produce infection. This is of clinical importance in that the lodgment of a bullet does not necessitate the treatment of the wound which it has made as though it were an infected one. It appears that such wounds are best treated by occlusive dressings and non- interference, unless manifestly infected or some special condition calls for ojjeration. It further appears that large lead bullets of low velocity are not as aj)t to make infected wounds as was supposed, and that the same conclusions as to treatment hold witli them as with the modern, jacketed projectile. III. THE LOCALIZATION OF LODGED MISSILES. THE RONTGEN RAY AND WOUND EXPLORATION. The superiority of the Rontg-en ray over other methods of locating k)clged missiles is so great that, wlien available, it should be used to the exclusion of all others. It is a most distinct aid to conservative surgery, in that, with it obtainable, disturbance of the wound through immediate attemjjts to locate missiles is usually unnecessary. Before its introduction, it was frequently thought recjuisite to follow, or attempt to follow, the track of the bullet before the track was healed, as the only way of locating a missile which might produce subsequent trouble. When tlie probe, or one of its substitutes, is used, one of the tenets of modern military surgery, namely, noninterference, can not be followed, and septic infection is made possible or probable. With the Rontgeu ray at hand, the surgeon can locate a lodged missile at any time when necessity demands, and its track can safely be left undisturbed. The unreliability of the probe for locating lodged missiles is well known. With the probe it is p(»ssible to follow only a small minority of bullet tracks. The contractility of the tissues may interpose obstacles to its passage and a change of position on the part of the patient may cause such a shifting of muscular and fascial structure as to completetely obstruct or alter the i)ath made by the projectile. In fact, a great majority of cases, where the bullet has been located by the the Eontgen ray, show clearly how impossible it would have been to determine the position of the missile by means of a probe. Not only is it difficult to follow the path of the bullet with a probe, but, even having done so, assurance that the missile has been touched is often impossible. The nickel-steel jacket of the modern bullet leaves no mark on the porcelain tip of a Nelaton probe, and sensation of cont-^ ^c as differentiated between a missile and fibrous tissue is not sufficiently definite to enable an examiner to determine that the probe is in apposition with the bullet. Nor can the telephonic probe be relied upon; as is shown in Case 5 of the preceding section. 45 4(3 RONTGEN ray in SPANISH-AMERICAN WAR. But iidt (lulv is the probe uureliablL', but it is a source of danger, even wlien used with all possible aseptic and antiseptic precautions. The experi- ments of LaGarde, Delornie, Habart, and P^'aulhaber liave shown that in practical! V all bullet wounds, even tliose made by the modern comjxmnd l)ullet, some foreign matter and bacteria are carried into the wound. The numl)er of bacteria so carried in are usually not sutttcient to j)roduce sm'gical infection and subsequent inflammation and suppuration, jjrovided, the wounds are protected from further infection and are left undisturbed. For, undoulitedly, the factor of noninterfenence with the wound is of great importance. No sooner is a traumatism inflicted than natural processes are brouo'lit into action for protection and repair. There is a local increase in vascular activitv, serum is poured out, leucocytes accumulate, and the defensi\'e factors of })hagocvtosis and serum bactericidal action are brought into plav. That these factors may have best opj)ortunity for action, rest and nondistm-bance of the tissue are necessary. ]\Ieclianical disturbance of the tissues liy probes, by the finger, or by instruments will produce fresh traumatisms and cause disturbance of the defensive action going on, and these trai;matisms and disturbances, however slight, will favor growth of the bacteria and add to the defensive lahoY required of the tissues. So that even aseptic or antiseptic operative or explorative interference may tlu'ow the scale on the side of the invading bacteria and lead to trouble- some or disastrous consequences. For these reasons, and in consideration of tlie unreliability and d;uiger of searching for a bullet through the ^^•ound, it mav be stated that such search is contraindicated, except in cases where the innnediate danger from the presence of the bullet is greater than the possible consequences wdiich mav anse from interference. Fortunately, cases re(iuiring immediate removal of lodged missiles are extremely rare, and for all other cases, the uncertahity and danger of ex])loration through the wound are done awai\' with by the certain and safe action of the Rontgeu ray. NECESSITY FOR THE LOCALIZATION AND REMOVAL OF LODGED MISSILES. It is well known that lodged missiles frecpientlv become encysted in the tissues and cause no further trouble. In other cases, however, they give trouble through causing suppuration, or by pressure upon some neigh- boring nerve or organ, or by l)eing so situated as to interfere ^\•itll, or pro- duce })ain during muscular action. Frecjuenfly, also, knowledge of the i)resence of a foreign l)odv causes mental disquietude, and in other cases it is important to know the exact LOCALIZATION OF LODCiED MISSILES. 47 d-l--- lociition of file missile in order to determine wliether tlie symptoms wliicli sometimes follow its lodgment are due to the lesions incident to the original traumatism or to irritation from the foreign body, or wliether or not the symptoms may not he due to something entirely unconnected either with the original traumatism or the presence of the lodged missile. In such cases, accurate localization of the bullet is of the greatest imj)ortance and value from a standpoint of diagnosis and treatment. The following two cases are illustrative of those cases in which, with- out accurate localization of the bullet, it is impossible to determine whether or not the symptoms are due to the effects of the original traumatism or to irritation set up by the lodged missile. Case 1 is illustrative, also, of the aseptic course of a wound made by a slow-moving lead bullet when left tin- disturbed. Case 1. Shrapnel hall lodged in. hack; traumatic 7ieu,TaKtheiiia; localizatimi hy liiinf- (jcn ray; missile not removed. Richard J. Eskridgo, major, Toiitii United Stiites Infantry, wounded with shrap- nel, July 2, at Santiago and transferred to Massachusetts General Hospital, where fol- lowing historjr was noted: Ball entered back while he was sitting. Inuiiediate shock severe. Intense dyspncea. Complete temporary paralysis of the left side. After being taken to rear was able to move arm and wiggle toes slightlv. I)ysp- noea lasted twenty-four hours. Severe con- stant pain in lower half of left side of trunk and left leg. Wound healed readily. No wound of exit found. Paresis of leg re- mained same for about three weeks, then began to disappear gradually till he was al)le to raise his leg from the bed about three weeks later. Since then, improvement less rapid. Pain has continued with about same severity, requiring one-quarter to one-half grain of morphia at night. More severe at night; more severe in damp weather. August 16. Examination: In left back, 2^ inches from median line, at level of ninth rib, a round scar one-fourth inch in diameter. Marked muscular atrophy of hip, thigh, and leg of left side. 'Phigh and leg (left) very flabby. Extreme sensitive- ness of thigh and leg, most marked just above popliteal space. Knee jeak absent on left side. Able to get around little on crutches and put a little weight on left leg. Fiii. 9. — Diagram showing location of wound of entrance (a) and position of bullet (i) in the case of Maj. Richard Eski-idge, Tenth United States Infantry. 48 RONTGEN KAY IN SPANISH- AMERICAN WAR. November ti. X-ray plates taken; bullet found. Three plates then taken, one dirertly over site of bullet, one on either side at angle of -to-. These located bullet at level of second lumbar intervertebral disk. H inch above level of crests of ilium and about three-fourths inch to 1 inch deep. Removal not advised l)y neurologists, as no source of irritation. From the Massachusetts General Hospital the patient was transferred, with a diagnosis of traumatic neuritis, to the Army and Navy General Hospital. Hot Springs. Ark., and thence to the General Hospital at Washington Barracks. On arrival at the latter hospital the same symptoms of pain and local hyper- asthesia were the same as given above. The motor functions of the left leg had considerably improved. Some doul)t existing as to whether the symptoms were due to the original traimiatism or to pressure from the bullet, a radiograph was taken, from which it was thought that the l)ullet (shrapnel) lay as located in the Massachusetts Hospital. The bullet was cut for. Imt could not be found. The Mackenzie-Davidson localizer was then used aud with it, the bullet was located considerably deeper and in the subperitoneal tissue just below the left kidney. As from its location, it could by no possibility be causing any of the symptoms, the neuritis was undoubtedly traumatic, a result of the original lesion, and no further attempt was made to remove the buUet. The following illiisti'ates those cases iu which it is necessary to locate the lodged missile in order to determine whether symptoms which follow the receipt of a gunshot wound are due to the presence of the bullet or to some entu-ely different condition : Case 2. — Fragment of missile lodged in tin- hack; ncuralffia; loca^'^mtion of fragment hy Rbntgen ray. Alfred W. Bjornstad. captain. Thirteenth ]\Iinne.sota Volunteers, received a slight superficial wound of the left shoulder at Manila. P. I.. August 13. 18t)S. On turning to go to the rear to have the wound dressed, he was struck a second time by what he thought to be a ricochet bullet. The wound of entrance was 3 inches to the left of the spine and midway between the ninth and tenth ribs. The wound was dressed with a first-aid di-essing and healed without trouble. After returning to duty, he was troubled with almost constant pain in his right side, especially when marching. This continued until he was returned to the United States with his reginuMit to be mustered out. After being mustered out, he was appointed captain in the Forty-second United States Volunteer Infantry, and as the pain in the right .side still troubled him somewhat, though much less than formerly, he applied for treatment before being returned to the Philippine Islands, with a view to determine whether or not the pain in his right side was due to the presence of a lodged l)ulli't. He was ordered to the general hospital at Washington Barracks. D. C. where a Rontgen ray examination was made and a small, irregular piece of metal, probably a fragment of a bullet, was located in the left side almost directly beneath the wound of entrance. Careful examination showed no other missile and determined the fact that there was no lodged bullet on the right side producing the pain from which the patient was suflering. As the .small piece of metal on the left side was producing no trouble, it was not removed, and the patient left the hospital shortly afterwards. PLATE XII. PLATE XII. Case 3, Section 3. — Jolui Watson, private, Troop F, Teutli United States Cavalry. Radiooraph of left leg, viewed from the back, showing- fragment of missile embedded in the center of tlie callus formed at the site of a gunshot fi'acture of the fibula. PLATE XII. of metal J LOCALIZATION METHODS. 49 The value of the Roiitgen vny in h)cating' luissilc^s or sum]] fragments of missiles wliich have infected the \Adnnd and cause continued su]i|)ura- tiou is shown b}' the following case: Case 3. — Fragment of mctaJ lodycd in, fibula; supjniratum.; local izuf ion hy Rbntgen ray; removal; recovery. John Watson, private, Troop F, Tenth Cavalry, was wounded July 1, by a missile, supposed to be a Mauser, which entered the anterior surface upper part of middle thii'd right leg, fractured the fibula, and passed out at the internal lateral surface. The patient was transferred north and finally to the general hospital at Washington Barracks. A suppurating sinus persisted at the site of the original woiuid of entrance. A radiograph was taken which showed a small fragment of metal embedded in the callus uniting the fractured fibula, (Plate XII). Operation disclosed a small piece of lead at the point indicated. This was removed, the wound promptly healed, and the patient was returned to duty. LOCALIZATION METHODS. It is to be noted tliat Rontgen rays are projected in right lines from the anode of the Crookes tube. As a consequence of this, the observed shadow of an object, the object itself, and tlie anode are all in line. This direct projection of the observed image is both an advantage and a disad- vantage in locating missiles lodged in the body. It is a disadvantage, in that erroneous conclusions may be formed of the location of a missile, unless the position of the anode and the position of the shadow of the object are accurately observed and noted. For, if the position of the anode is not known, the foreign body may lie in any line projected from the position of the observed shadow. The projection of the shadow of an object in a right line is of advantage in that, knowing the jjosition of the anode and tlie position of tlie sliadow, the object itself must be at some point directly between the two. This fact of the direct projection of the shadow of objects has given rise to two methods of localization of lodged missiles; «, by direct observation; /;, In' multiple observation. LOCALIZATION BY DIRECT OBSERVATION. Direct observation has to be employed in tliose cases in wliich lateral views can not be made through the part in wliich the foreign body is lodged. Thus, in examinations made for foreign bodies in the chest, abdomen, pelvis, shoulder, and ujjper part of the thigh, the observation has to be made from before backward, or vice versa. As no lateral views can be obtained by wliich the depth at which the foreign body lies can be determined, resort 50 KONTdEN RAY IN SPANISH-AMEHR'AN WAR. imist he had to otlier means, of whidi there are two; lirst, the ii^e of some form of localizer, disciissiou of which will be taken up later: and, second, critical ol)servation of the image of the foreign body and its relative posi- tion. Bv carefulh' examining the outline and .size of the image of the lodsred missile and the movement of its iinaae when the tube is shifted from side to side, the depth of tlie foreign body in the part can be approximately ascertained. If a lodged missile is verv near the Huoroscopic screen or the photo- gi-aphic ])late, the outline of its shadow will be quite sharp. If farther away, the outline of its shadow will be blurred and indistinct and its size increased; the blurring, indistinctness and size, increasing with the distance of the lodged missile from the plane u])on which its shadow is cast. If the outline of a lodged missile is sharp and distinct in the radiograph, it indicates that the mi.ssile is near the surface of the body against which the photographic plate was placed. If, on the other hand, the pictiire of the lodged missile appears bluiTed and indistinct in the radiograph or on the screen, it is an evidence that the missile is at a considerable dejjtli in the tissues. The increased size of the image of a deeply placed foreign bod}" is due to the greater dispersion of its shadow the nearer the body lies to the source of light (tig. 10 h). Its blurred outline is due to the fact that the Rilntgen ravs are not projected from a single point on the anode, but from its entire surface. F.G io.-Di^ram showing the reia- ^^ ^^^ ^.^^.^ ^^.^ ^^^^ projected from a single tive aze of umbra, penumbra, ana -^ f j o shadow in foreign iwdie.* located point, they cross each otlicr at the edges of superficially („) and deeply (6) in ^^ object, forming a peuumbra, and, neces- sarily, the penumljra is wider the greater the ilistance between the object and the plane upon which its shadow is cast (fig. 10/>). In making these observations, photography is a much safer guide than visual oliservtious made with a Huoroscope. as the photographic image will show dift'erences of outline more clearly than the eye can determine them. A numljer of examples of the relative dimness of outline and variations in size of the image of lodged missiles, according to the distance of the missiles from the surface of the body, are given in the radiographs accom- panying this report. LOCALIZATION METHODS. 51 III iiilditiou to tlic lucrliDils iilreaiU' g'iveii tor ;i])|)r()xiinatiiiL;' the position of lodg-ed missiles, advantage can be taken of the position of the image of tlie foreign bodies relative to surface markings and points on the bones. Thus in Case 9, Section II, the position of the observed image of the bullet relative to that of tlie lesser trochanter and the fold of the Ijuttock was of the greatest assistance in locating the bullet at the time of operation, while the dinniess of outline and large size of the image of the ball indicated that it was deep in the part. A still further means of approximating the depth at which a lodged missile lies in a part is to note by the Huoroscope, the distance which the image of the object moves when the tube is shifted laterall}-. If \\lien the tube is moved, the image moves but slightly, the missile can not l)e deep in the part; while, If the image movement is considerable, the foreign body is probably quite dee])ly placed. These means of localizing lodged missiles give only inferential results, but by careful observation and by combining all possible factors, foreign bodies can be localized, in a majority of cases, with sufficient exactness for all practical purposes, especially if they are not deeplv placed. On account of its size, a bullet is not likely to be missed by a surgeon when it is situated superficially, provided the operator cuts in direct line from its observed shadow toward the point where the anode of the Crookes tube was located. But in pursuing the inethod of dhect incision, the sur- geon must be quite cei'tain before operating that the body for which he is searching is situated superficially, or he may have to cut too deeply or through important stractures to find it. Wliei-e foreign bodies are deeply placed or in the neighborhood of important structures or organs, it is necessarv that they be accuratelv located before operative interference is adopted, and in such cases one of the methods of localization by multiple observation must be resorted to. LOCALIZATION BY MULTIPLE OBSERVATION. Localization by multiple observation covers all the methods of localiza- tion in which the location of the foreign body is determined b}' observa- tions, so made, that the right lines of light from the anode cross each other. As the anode, the observed body and its shadow nre alwavs in line; when two observations are made with the anode in different positions at each observation, it must follow, that the observed bod^' must lie at a point where tlie lines drawn fi'om the anode to the shadow of tlie bo(U' cross each otlier. 52 H()NTG1-:N ray in SPA^'1SH-AMEKICA^' WAR. As ;i (•(•us('(|ii('iicc' ot" this, it' two obst'vvatious nre nuule with the .mode in (htVcreiit positions, iuid these positions and the i)oints ou the surface of the l)(>(h- whc'iv tlie iinaiivs of the missile are projeeted are recorded, then tlie inissiU^ can be accurately located at the point where lines cross each other which are drawn from the positions occupied by the anode to the points on the surface of the body where the shadows of the missile were cast. A number of means have been de\'ised for determining- the position of tlie anode and the shadow of foreign bodies relative to the surface of that part of the body in which the foreign body is located. The most common method is to make an observation and mark upon the skin the point whei"e tlie shadow of the foreign body is thrown, then to move the anode to a ])osition where it will approximately project the Rontgen rays at right angles to the first observation, and, after marking on the skin the point where the second shadow of the foreign body is cast, the operator can, by angulation, approximately determine the point where the foreign body lies. This method, like the method by single observation, is generally sufficient for cases where the missile lies supei-ficially or in close relation to some bony point. Examples of this method of determining the position of lodged mis.siles by right-angled observation are given in Plate XIII, and in Plate XXXIII. But where the bullet is lodged deeply, this method, like the method by direct observation, while sufficient for some cases, can not be depenrled upon for accuracy, and instruments have been devised for definitely fixing the position of all the jjoints necessary to accurate localization; namely, the positions of the anode, the places on the surface of the body where the projected shadows of the foreign body are thrown, and the position of these points relative to each other. These instruments are divided into two classes; those in which pho- tograph}^ is used, and those in which visual eflFects are relied upon. Instruments of each class have been used and lune l)een found of great value in difficult cases arising from the late war. PHOTOGRAPHIC APPARATUS FOR LOCALIZATION. ]\Iackciizie-Davidsou devised and, in 181)8, descrilx'd a method of localization, since known as the crossed-thread system.' This method, either with Mackenzie-Davidson's original a})j)aratus or one of its modifications, is probal)ly tlic most ace m'ate and reliable means now used for the localization 1 Mafkoiizie Davidson. Rijntgcn ray and localization. British Medical .Journal, January 1. 1898. PLATE XIII. PLATE XIII. Case 4, Section II. — John N. Taylor, private, Conipaii}- I>, Twulfth United States Infantry. Radiographs of the left foot, viewed from the inner, and from the plantar surface, showing- a sllti-htlv deformed bullet embedded in the sole of the foot, beneath the cuboid bone and in a line with the second metatarsal bone. The two views accurately locate the missile. PLATE XIII. I MACKENZIE-DAVIDSON LOCALIZER. 53 of foreign bodies with the Routgeu ray. The Mackenzie- Davidson appa- ratus consi.sts of two part.s, tlie exposer (%. II), and tlie h)calizer (%. 12). By means of the exposer, tliat part of the body in wliich the foreign body is lodged is fixed in a definite position relative to a photograpliic plate. Two exposures are then made upon the same plate with the anode Fui. 11. — Mackenzie-Davidson expuser. Tlic phullet to the left was produced by the tube when displaced to the right, and vice versa. 58 rONTGEN ray in SPANISH-AMERICAN WAR. Thus, if we place one of the threads on the point of the bullet in one shadow, it will indicate the path of the ray that produced the shadow of tlie bullet point (P. fig. 13.) Now, if the other thread is placed on the ciiiTespond- ing point, of the other bullet shadow (P\ fig. 13), then it must follow that the position actually occupied by the point of the bullet in question is pre- ciseH' where the two thrends cross at c in fig. 13. If the perpendicular distance of a point can be measured from three planes which are at right angles to each other — in short, if the x, ?/, and z t-an be ascertained — then all will be known about the position of the point in question. This we can do at once with the point c in fig. 13. First, the vertical distance from the negative to where the threads cross each other is measured. This is the distance of the point of the bullet beneath the skin (of the patient), which rested <.n the photo- FiG. 13.— Diagram showing metlioil of using tlif localizer (Mackenzie Davidson). -V 4. int wliere the thi-eads intersect. In this way ./, y/, and .=- of the point of tlie bullet is ascertained and the result noted down, as shown in fig. 14. Tiie arrows in fig. 14 indicate the direction of the disi)lacements of the Crookes tube. We then jjroceed in a similar manner to ascertain the position of tlie butt of the bullet c, in fig. 13. And the distance between .• and r' in fig. 13 gives the direction and actual length of the bullet. From the measurements jotted down, as shown in fig. 14, a line can be marked on the patient's skin in the same plane as the bullet, and the surgeon can be given the exact depth at which each of its extremities can be reached by a vei'tical puncture. Several pairs of threads might be used, and in this way the shape of the fin-eign body might be outlined ; but it is more convenient to use one pair. The point where they intersect can be fixed by the point of a surface gauge; and, when the threads are moved to another position, the diiference between their new point of intersection and their former, where the point of the surface gauge stands, can be measiu-ed at once. In fig. 13, the dark fines indicate the position of the threads, the dotted lines show the position they occupy when they are each directed to the butt of the bullet, and the distance from c to c' is the actual length of the bullet. It also indicates the direction in which the bullet lies. The final result of the process is, that we can draw an outline of the foreign body on the patient's skin and give the depth below the skin of any of its parts, and this enables us to give the direction and depth at which it can be reached from any point the surgeon may select. The original Mackenzie-Davidson localizer has been modified on the lines of portability and simplicity, but the principle remains the same. In the Harrison portable localizing apparatus, the essential features are retained and the apparatus is made very portable and consequently well adapted to military surgical use. This apparatus (fig. 15), consists of a baseboard which supports a slid- ing tube holder. The tube is fixed at a certain height above the surface of the board, and radiographs are taken with the tube at each extremity of the slide. The negative is then developed and placed on the baseboard. Two pillars, which plug into the board, are so arranged that a small notch at the top exactl}' coincides with the two points from which the radiographs were taken without an} measuring or calculations, and silk tlu-eads con- 60 RONTGEN ray in SPANISH-AMERICAN WAR. uecti'd to weighted pointers are taken from these piUars to the image on the negative, as in MacKenzie-Davidson's apparatus. Pig. 15. — llarrisou jjurtuble localiziug api>aratus. The tube holder, piUars, etc., are all removable, and can be packed flat witli the board. APPARATUS FOR LOCALIZATION BY VISUAL OBSERVATION. But one form of a])paratus of this type has been used l)y the Medical Department of the Uniied States Army. It is known as the Dennis fluorometer (fig. 16). This is an instrument bv means of which the position of the anode, Flu. lli. — The Deuuis fluorometer. tlu^ foreign body, and its shadow as projected upon the surface of the body mav l)e noted b\- \isual oljservation tlirougli the tluoroscope. With it. DENNIS FLUOROMETER. 61 lociilization i,s made \>y (leterminiug- the position of tlie foreign body by two observations made at rig-ht aiioles to each other. The instrnment consists, essentially, in a set of carefully designed metallic angle pieces which conform generally to the shape of the body or lind), and which, in their use in connection with the Rontgen ray-s, are susceptible of being squared with a simple and conveniently adjustable table. The patient being laid on the table and a fluorometer appliance adjusted, the Huorometer is brought into the jjarallelism of the rays — that is, when the proper position of the cross section is obtained, the two arms of the fluorometer will present the characteristic single shadow on the field of the fluoroscope. Attachable to the arms of the fluorometer are two pins or sights. By means of these sights, the foreign object having been brought in line with them and the proper adjustment having been made, a correct line is pro- duced, with the sights and foreign t)bject coincident. By means of a metallic grating of inch mesh, which is placed adjacent to one side of the body and consequently one side of the fluorometer, exact measurements can be made with the eye from the base line of the fluoro- meter and from points on the circumference of the body to the foreign object. Then, without moving the body or the fluorometer, the Crookes tube is placed directly over the subject for the purpose of obtaining the vertical line. By means of an adjustable crosspiece, which is placed over the arms of the fluorometer, exactly the same results in a vertical way are obtained by viewing the subject from beneath, the same condition of parallelism having been produced, another set of pins having been placed in position. It will be seen at once that while the first operation locates the foreign object on an exact cross section, the second observation shows the exact position occupied by the foreign object in that cross section. All the elements of distortion having been eliminated, the foreign body will necessarily be at the intersection of the two lines of the right angle. In practice, the surgeon indicates the first cross section obtained by a line of India ink or iodine on the body, and is thus enabled to establish the position of the object by measurements from points on the exterior of the subject, with as much exactness as if the body or limb were actually severed at the first cross section and presented to view. The fluorometer is a useful ai)paratus in many cases. But on account of the difficulty and frequent impossibility of using the fluoroscope where 62 RONTGEN hay in SPANISH-AMERICAN WAR. iniMsik's are lodged in the thicker parts of tlie body, especially in re^'ions where dense shadows are cast by the contained organs of the abdominal cavity, this apparatus has only limited use and can not compare with the Mackenzie-Davidson or cross-thread apparatus, which are applicable to all cases. It is, however, onlv in exceptional cases, and those of considerable rarity, that recourse will have to be made to either form of localization apparatus. In the great majority of cases, visual obsei'vation or radiographs will oive all necessary information to the suro-eon relative to the location of lodged missiles. For this reason, in military surgery, it would not seem necessary to supplement every RiJntgen apparatus with one of these appa- ratus. They should, however, be available for use at a few general hospitals where cases of marked difficulty can be sent for treatment IV. GUNSHOT FRACTURES OF THE DIAPHYSES OF LONG BONES. In gunsliot fractures of the shaft of long- b.^ies, tlie extent of the fracture, its form, and the amount of communition vary considerably according- U\ the cdnditions which obtain at the time of the receipt of the traumatism. The conditions which influence the bone lesion are the part of the bone struck, the structure of the bone at the place of impact, the velocity and form of the missile, and the angle of incidence. As all these factors can hardly be identical in any two cases, bone lesions are bound to vary within certain limits. Of great importance in these factors is the part of the bone struck. The physical qualities of the cancellous tissue of the epiphyses are so different from those of the compact tissue of the shaft of the long bones that, under conditions of gunshot impact, different traumatic results occur according to whether one or the other of these parts is struck. The results of Rontgen-ray examinations made during the late war lead to the conclusion that, minor differences apart, gunshot lesions of the shafts of long bones by small-caliber bullets may be divided into three main classes : Class 1, fractures by bullets having sufficient velocity to produce perforating wounds. Class 2, fractures by uudeformed bullets having sufficient velocity to penetrate only. Class 3, fractures by penetrating, deformed bullets. A possible fourth class, namely, fractures produced by deformed bullets traveling at velocity sufficient to produce perforating wounds, is not recorded and would be extremely difficult to determine. Such bullets pass through the part wounded, and the only evidence that the fracture had been made by a deformed missile would be an atypical appearance of the wounds of entrance and exit, appearances wliicli are not alwajs present, and which if present would lead to inferential conclusions only. CLASS I.— FRACTURES BY PERFORATING BULLETS. Under this class come all fractures produced by bullets traveling with sufficient velocity to pass out of the wounded part after having fractured the bone. So far as observed, fractures by perforating bullets have one 63 (54 k(")NT{jp:n hay in spanisii-amekican wak. comiium charactcristif: tlii-y are all more or less (•(nnininuted. The amount uf comminution apparently depends mainly «>n two factors: First, the velocity of the missile; second, the angle of incidence of impact. Where the velocity of the bullet is extreme, as at sliorl range, the amount of connninution is considerable, and is greater tlian at long- rang-e, whatevei- the angle at which the bullet strikes the bone. With lowered velocity, comminution is great only when the bullet strikes the shaft of the Ixme in the median line. Under the condition of extreme velocity, the so-called "explosive" effects are jn-oduced. Under the condition of median imiiact, connninution of bone is con- siderable, but not so great as where the effect is explosive, mdess the factors of high velocity and perpendicular impact combine. For these reasons, fractures of the hrst class, namely, those made by perforating- bullets, may be divided into three subclasses, in the order of the amount of lione com- minution jjroduced: Subclass 1, fractures by perforating l)ullets at short range. Subclass 2, fractures by |)erforating bullets striking the bone in the median line. Subclass 3, fractures V)y l)ullets striking the b()ne tangentially. SUBCLASS 1.— FRACTURES BY PERFORATIXU BULLETS AT SHORT RANGE. In tills class there is the maximum amount of bone splintering (explo- sive effect), and the lateral destructive action of the bullet is so great in some cases that fractures are produced even when the bullet barely grazes the V)one (Case 2). ^luch has been written of the explosive effect produced by the modern bullet, and man\- theories have been advanced to explain it. In the opinion of the writer, the theorA' which l)esf explains this effect of the bullet is that the destrui'tive effect is the result of the latei'al transmission of energy imparted to the tissues h\ a rapidly moving- missile.^ If energy were ti-ansmittetl only in a line directly in front of a Ijullet, the IniUet would make clean-cut ])erforations in all organs or tissues through which it passed, and inunediately fatal results would arise only from direct womids of blood vessels, perforations of the heart, or impingement of the bullet upon some vital part of the ceuti'al nervous system. 'Stephenson: Wounds in War, p. 7L New York, 1898. FonviKxl: Wiirien A Lioiilil's International Text Book of Siirfjciv, Vol. IL I'liiludiliiliia. liHK). GUNSHOT OF THE DIAPHY8ES. 65 TIk' lateral tniusmis.sioii of tlie energy of the bullet to an extent suffi- cient to cause extensive solutions of continuity occurs in marked degree only'in certain organs and tissues, and in these only when the velocity of the missile is great. As this destructive effect occurs only in certain organs and tissues, it must follow that it is because these organs and tissues best transmit the energy imparted by the Ijullet; and, as the strui-tures which transmit this energy with traumatic-producing violence are either compact bone, or organs containing fluid, or those practically saturated with fluid, it seems most probable that this energy is transmitted in two ways — either through the-transmission of ^'ibration by the closel}' knit compact bone tissue or through the incompressible fluid in fluid-saturated or fluid-containing organs. In compact bone, with the missile at high velocity, In- tlie sudden- ness of the shock, the bone is disrupted, and the osseous pai-ticlcs acting as secondary missiles, are forced outward, increas- ing the disruption and traumatism b}^ lateral transmission of the energy imparted, (Fig. 1 7). With the bullet moving at lower velocity the shock in bone or organ is less, the disrup- tion consequently less, and with still lower velocity, the ball may enter and pass through the same tissue or organ witli practically no lateral destructive eff"ect. In a broad way, the result may be likened to the difterence in effect produced by throwing a bullet into water con- tained in an open leaden vessel or firing the bul- let into it. In the first case, the bullet will enter making slight commotion, and that mainly upon the surface of the water; while, if the bullet is fired into the water, the containing vessel, even though open at the top, will be completely destroyed through the lateral transmission of energy by the iiicompressible fluid. When the shaft of a bone is struck at short range, extensive comminu- tion is ])roduced whatever the angle at which the bullet may impinge against the bone. The bullet in these cases produces an explosive eftect in accoi-dance with the reasons already given, (Fig. 17). This effect is not confined to the bone alone; the bone fragments driven out into the surrounding tissues may produce extensive traiunatisms of the subcutaneous soft parts, and may even be driven out through the Fig. t7. — Lateral traiisinisision of energy in tlie shaft of a long- bone. Diagrammatic; modified from Reger. A similar effect is produced in fiuid-containing and fluid-saturated organs. fifi KOXTdFA HAV IN SPAMSH-AMEKICAN WAH. wound of exit and into a nt'i>ihli(>riu,()ii-\-ii(l- ranye hy a Mau.ser bullet, which passed obliqaely through the hand, fractured the third metai'arpal twne by contact, completely destroyed the distal end of the fourth metacarpal bone, and carried out all the fragments through the exit wound. Though all the fragments of the fourth meta- ;raiu exjilaiiatory of Plati' flexion." XIV. The arrow iuiUciitet' the coiirise front of the right forearm at its lower third, severed the tlexor tendons, grazed the periosteum of the radius, and shattered the bone. The traek of the l)ullet was laid open at the field hospital, the tendons sutured and the wound united by silk sutures. The patient was transferred to the General Hospital, Key West. On his arrival there, pus was escaping from between the sutures and the wound was tense, l)ulging, and nuich inflamed. The sutures were removed under an8esthe.sia and {\\k wound carefully cleansed. Owing to extensive inflammation and suppuration, it was found impossible to unite the tendons. A radiograph (Plate XV). was taken which showed excellently the .shattered condition of the radiu.s and the longitudinally disposed fissures between the lione splintcj-s. The wound was treated with antiseptic applications, but had not entirely healed when the patient was transferred nortli. .Vugust 22, 189^i. In November of the same year, the sol- dier writes that he has no use of the hand, the fingers remaining stiff. The disability is probably permanent. SUBCLASS 2.— FRACTURES BY PERFO- RATING BTTLLETS STRIKING THE BONE IN THE MEDIAN LINE. Case J. — Comminuted fracture of femur due to median impact of hall; (ixeptic vxjund; recovei^ without compli- cations. John Robertson, second lieutenant. Sixth United States Infantry, wounded July 1, by a Mauser bullet, which entered the anterior surface of the right thigh ju.st below Scarpa's triangle, passed from l)cfore backward through the femur, and passed out directly posterior. There was profu.se hemorrhage, which was partly controlled by an improvised tourniquet applied by an officer of the line. Lieutenant Robertson was carried to the rear by the men of his conmiand and while thus con- veyed, he was shot in the left sid(\ the bullet entering just below th(» inferior angle of the left scapula, passing beneath the muscles, but not through the thoracic wall, and making exit just below the left nipple. With these wounds of entrance and exit, it was at hrst thought that the bullet had passed through tlu' chest; that il did not do so was due to the extreme outward displacement of the angles of the scapuhe. from his being, at the time, lifted by the armpits. The first dressing was applied at the 6648 7 Fig. 19. — Diagram uxiilauatory of Plate XVI. 68 rOntgen ray in spanish-american war. field hospital. Tin" fnu'tui'o was dressed hy the use of a lono; splint. Tianst'erred July ;>. to Third Division Hospital and two days later to the Relief. At this time, both chest wounds were healed. The thigh wounds remained aseptie. A radiograph showed great comminution and displacement of the fragments by overlapping (Plate XVI). The fracture was then treated by confining the limb upon a double inclined plane, consisting of a hollow posterior splint, made of the sheath of the leaf of the cocoa palm, tt) which was added an anterior thigh splint of wire gauze. After dressing the limb was placed in a sling. Subseiiuently a Buck's extension was applied and finally a plaster splint. The final result was excellent, for, though there was H inches shortening, the callus was firm (Plate XVII), and the position and functional use of the limb were excellent. The above case is very instructive, as it illustrates the possibilities of conservative treatment in marked comminution of the shafts of long bones where the woinid is aseptic. Excellent examples of the effect of the small cahber bullet when it passes directly through the shaft of a small b(ine of the hand or foot are given in the following cases, with their accompanying radiographs : Case Jf.. — Mauser huUet wound of Jingei\ ipith eompound fracture of second phalanx, fourth finger. George H. De Revere, private, Companv L, Second Massachusetts Volunteer Infantry, was wounded July 1, at unknown range. In- a Mauser bullet which passed obliquely through the fourth linger of the left hand, shattered the second phalanx, and then passed across the top of the second metacarpo-phalangeal joint of the middle finger, producing a lacerated wound of the joint. The patient was transferred to the general hospital. Key West, where the radiograph shown in Plate XVIII was taken. The bullet had passed I'entrally through the finger. The wounds of entrance and exit were very small. They had been dressed with a first aid dressing, were aseptic, and healed quickly. A palmar splint was applied and the fracture treated as a simple one. In Novem))er, 1898, the patient wrote that there was complete atikylosis of the second joint of the ring finger. Ca.'se 5. — GunsJuit fracture all noetatartsal h and normal salt solution, and was entirely closed with tirni callus at the seat of the fracture. Auoust U\. when he was transferred to the transport Son Murcm. January 4. his attending sui'geon reports: "The removed hone seems to have lieen largely replaced and the hand and forearm present a good form. The joints are freely movable, passively and actively, hut all motions are feeble. The hand hangs seniitiexcd on the wrist. Adduction, abduction, tlexion. extension, circumduction, i)roiiation and suppination are ))resent on \()luntai'y ettort. but all are feelde. Flexion of the lingers is limited to the second and tiiird joints: the grasp is very feel)le. The thuini) can be apiiroxiinatod to each of the lingers suthciently to pick up a pencil. Init there is little power in it. The hand is relatively of little use, absolutely of considerable." The patient has since been dis- charged for disability and admitted to the Soldiers' Home at Washington. D. C. The above case is of interest from its excellent ])roo;i-ess under antiseptic tveatniiMit. As the wound was infected, this case would formerly have re(|uired imputation, but as it is, the arm, while disabled, is reported to be of considerable use; certainly better than no arm at all. As the bones united firml\-, the resulting disability is probably mainly due to the injury to the soft parts. Cai<:e 7. — Inmmpldf fntvt u reof radUm; meptic lomincl ; ri'nulfhx/ impaired motion due to cicatriiv. Dennis B. Watson, private. Troop C, First United States Cavalry, was wounded July 1, at 80(1 yards, by a Mauser bullet whit'h passed from behind forwai'd through the outer side of the right forearm, fracturing the radius. Th(^ wound was dressed with the tirst-aid dressing. Splints were ajiplied and the patient transferred by the steamer Irt' left forearm, viewed from tlie ])Osteri(>r surface, forearm su|)inated, sliowing- effect of the passage of a Mauser bullet through the side of the shaft of the radius. The comminution is not extensive, one fragment of bone onh- having been separated from the shaft at its outer side. PLATE XX. «l TmE HELIOTVPE PRINTINO CO.. BOSTOh. PLATE XXI. PLATE XXI. Case 7, Seci'idx IV. — Dennis H. Wats()u, private, Trtxtp C, First tlnitud States Cavalry. liadiooTa])]i of riE PHINTING CO.. BOSTON PLATE XXII. 6648- PLATE XXII. Case 8, Section IV. — Albeit B. Swilt, ])nv;ite, Company 11, Tenth United States Cavalry. Radiograph ot" upper part of arm, viewed from the back, showing long, oblique fracture with no comminution, ])roduced by Mauser bullet wliicli struck the shaft of the humerus at its outer side. PLATE XXII. THE, MELIOryPE PRINTING CO., BOSTON. PLATE XXIII. PLATE XXIII. Case 9, Section IV. — Frauk J. Kraus, })rivate, Compauv B, Six- teenth United States Infantry. Radiograph of the lower part of tlie nglit thigh, viewed from the pos- terior surface, showing' an obhque fracture of the femur bv a ])enetrating, Mauser bullet. The bullet is seen behind the inner condyle lying- butt end foremost. PLATE XXIII. Fracture - Mauserbullef- THE MELIOTVPF PRINTING CO.. BOSTON. GUNSHOT {^F THE DIAPHYSES. 71 Offfi,, ^. — Ohliijiir friKiiirr of JniiiimiK from fmirfoifiiil impnctofhill; aKi'pfif ■wound. Albert B. Swift, private, Company H, Tonth Cavalry, was twice wounded July 1. One bullet passed through the ulna at lower third, shattering the l)one, and a resection was made at the tield hospital. The second bullet passed from l)efore backward through the arm at the upper third, striking the humerus at its outer side and producing a long, oblique fracture with no comminution (Plat(> XXH). The arm was inuuobilized and union occurred without trouble. Discharge followed for disability resulting from the injui'v to the ulna. — Ca>«- Jiistonj coiiijiihd from rec(rri Ofjii'e, CLASS 2.— FRACTURES BY UNDEFORMED BULLETS HAVING SUFFICIENT VELOCITY TO PENETRATE ONLY. Fractures bv bullets liaving greatly reduced velocity are usually characterized \>\ small amount of bone splintering. The fractures closely resemble the simpler forms of fracture produced by inchrect violence, and this, apparently, whether the bullet passes through the bone or fractures it b}' impact. Cai^e 9. — Fracture offi'uiur hy ricorlnf holl. iiitcrihg huff tud forciiioKf ; (isej>fw wound. Frank .1. Kraus, private. Company B, Sixteenth United States Infantry, was wounded July l,at a supposed range of 500 yards by a Mauser bullet, which entered the body just to the right of the tip of the coccyx. The wound was dressed and the patient transferred to the Belief, where a radiogi-aph was taken. The radiograph (Plate XXIII), showed an uncommiiuited oblique fracture of the right fenuu- in the lower third, and the bullet lodged. l)utt end foremost just behind the inner condyle. The line of fracture was from above downward and from behind forward, and had apparently been made by the bullet impinging against the bone. Recovery was uneventful, but the limb was shortened 2 inches, and the soldier was finally dis- charo-ed for disability. — Ca.se history v(t]n])iled froiu records in Surgeoii-Geiiendi's Office. Case 10. — Fracture of /nnueriis hy impact (f Mauser hdlet; aseptic wound; resulting disability. Clarence Reed, private, Compyny H, Tenth United States Infantry, July 1, erect position. 500 yards from tiring line, received two gunshot wounds. He was trans- ferred to the Relief where the following wounds were found: One, a flesh wound, per- forating right arm, producing paralysis of the arm; the other, an entrance wound over third rib, anterior part of thorax, was lacerated, triangular in shape, base toward right side, about 1 inch wide at base and 2 inches long. Left arm showed extravasa- tion from clavicle down to wrist. Oblique frat-ture of upper part of humerus. Radiograph (Plate XXIV) shows Mauser bullet close to inner side of humerus at point of fracture, entrance evidently right anterior surface of thorax. July 12, 72 U(")NT(iEN KAY IN SPAMSH-AMEKK'.W WAR. angului- splint of palm hark applied, exteiuliiii;' t'loiii shouhicr to wrist. Kadiograph showed IK) other bullets, and position oi splint very yood. July lio. wounds healed. Considerahlo eallus about fraeture and partial union. November 17. 1899, diseharged on .surgeon's oertitieate of disability for "motoi- and sensory paraly.sis and trophie changes." — C'a«e history compUcd fram li Relief and records of the Surgeon- GenrraT k Ojfir, . In tlie al)ove case, the bullet must have traversed the anterior thoracic wall and entered the arm behind the axillary folds, struck the humerus on its inner side, and fractured it. The utter impossibility of locating- this liullet by means of a i)robe is evident. Case 11. — Fracture of u/na vit/i moderate comminutUm l>y 2)en,et rating Man-ser huUct; aseptic wound/ huJlet located hy Riinfgeu ray and removed. John Casey, private. Company C, Thirteenth Cnited States Infantry, was wounded July 1. at an estimated range of -100 yards, by a penetrating Mauser V>ullet, which entered the posterior and outer aspect of the forearm at the lower third. The wound was dressed with a tirst-aid dressing and the patient transferred to the general hospital at Key West. Examined there July (5; wound small and a.septic. Fracture of ulna at middle third. Examined with the Huoroscope. but the static machine from the excessive dampness of the atmosphere was not working well, and what was thought to be a bullet was dimly seen directly over the fracture. This was cut down upon, July 9. under aseptic precautions, when the supposed bullet was found to be a frag- ment of bone. This was removed and the wound healed by first intention. Subse- quent search. M'ith better light, showed the bullet lodged, butt end foremost, near the internal condyle of the humerus beneath the flexor profundes digitorum. It was removed July 28. The ball had evidently ricochetted. turned end for end. and with reduced velocity entered the arm and pas.sed through the ulna. The ulna was broken transversely and some small fragments of bone separated (Plate XXV). CLASS 3.— FRACTURES BY PENETRATING, DEFORMED BULLETS. Penetrating, deformed bullets appear to produce fractures of \\\v sliaft of the long- bones which are similar in form to those produced h\ unde- formed bullets, unless the deformation of the bullet is excessive. Like the penetrating, undeformed bullets, slightly deformed bullets produce oblique fractures with little sijlintering, while greatl}' deformed and nuishroomed ])idlets produce marked connninution of the bone. Case 12. — Comminuted fracture of femur hy Jlmiscr hulht ^^ niiixliroouicd" ht/ ricocJut ; lone fragments removed; woimd treated atdisepticaUy ; recimry iritlund amputation. Daniel J. (iravos, private. Company M. Eleventh United States Infantry, was wounded at Mayaguez, P. R., August 10, 1898. Wound of entrance, iiuiei- side, lower third, right thigh. Fenuir fractured; no wound of exit. Patient was trans- PLATE XXIV. PLATE XXIV. Case 10, Section IV. — Clarence Reed, private, Company H, Tenth United State.s Infantry. Radinyraph of proximal jjart of the left hnmerns, viewed from the back, showinji' fracture of the humerus produced byim])act of a penetrating Mauser bullet against the inner side of the bone. The bullet, which has been turned by the impact, is seen lying against the inner side of the humerus. PLATE XXIV. fracture — - Mauser\ 6ullet i ■■!-.T-i O'lfice. CLINICAL CONCLUSIONS. Oonsideration of jiunshot trauiiuitisins of tlie .sliaft of long- bones, as shown by the Rontgen ray in connection with tlie ultimate outcome of the cases, points indubitably to the conclu.sion, that infection, or noninfec- tion of the wound .should influence treatment, rather than the amount or extent of bone comminution. In noninfected wounds, extensive comminution is not, as a rule, an indication for operative interference of -.mx kind. ( )cclu.sive dressings and immobilization give assurance of the best possible results. Where there is considerable comminution, shortening of the limb will probably occur as a result of the connninution and the disjilacement of the bone fragments. But excellent functional use of the limb may be I'estored, uidess the lesion of the soft parts is extensive and motion is restricted by the formation of cicatricial connective tissue in the traumatic spaces. Where infection exists, removal of the cause under ase])tic or antisep- tic precautions is indicated. In such cases, complete cleansing of the wound and removal of all loose bone fragments, followe0(l yards from opposite tirin<;- line, reeeived perforating wound riyht ankle, about '.i inches above internal malleolus. Entriuice wound jjunctured. No wound of exit. Considerable o'dema and eccliymo.sis about ankle joint: movement of joint very i)ainful. Kiintgen-ray picture (l'lat(^ XXX) shows the l)ullet embedded in the bony part of the internal malleolus, apex pro- truding, soldier evidently having been exposed to ricochet tirint>-. July J2: Operation. Incision made •> inches lon<;' directly over internal malleolus; skin and subcutaneous tissue divided and bullet felt distinctly by tinii'er. Soft parts separated by blunt dissection and build exposed, hi'iniy embedded in bone. Only with i;reatest difliculty and by usinj;- lion foreejjs could missile be moved. It proved to l)e a .Mauser. The cavity in the l)one was perfectly smooth, 76 PLATE XXX. PLATE XXX. Case I, Section V.— Jolm J. L. Taylor, i)rivate, Company E, Tenth United States Cavalry. RadiogTa|)li sliowing- ]\rauser liullet embedded, Imtt-end foremost, in tlie lower end of the tibia, with no splintering- of the bi>ne. PLATE XXX. jyiauser bii//e/ - # THE MELIOTYPE PRINTIHG CO., BOSTON. PLATE XXXI. platp: XXXI. Case 2, Section V. — Dtiuiel B. Rayinoud, private, Companv D, Six- teeutli United States Infantry. Radiograph showing shrapnel bullet with small fragments of bone about it, lying in the thigh behind the femur, through which it jjassed, making a clean-cut hole. The shadows near the femur are from the iodo- form dressing. A safety pin in the dressings is outlined on the femur. PLATE XXXI. Iodoform yauzr\ an d safdypin J *' /Shrajjttel hullel ■ jafc: TMC MELIOTYPE: printing CO.. BOSTON. GUNSHOT OF THE EWPHYSES. 77 as if drill had been used. No spliiiterino- of l)one. Wound was cleansed with weak solution of l)ichloride of mercury and skin brought together by deep silkworm-gut sutures. July 14, prhnary union; pain and cedenia having disappeared. July 22, a slight discharg(> of jmrulent material. Wound opened at upper part and iodoform gauze introduced. No uedeuia al)out ankle. No pain. Jul}' 2i, wound clear. July 26, transferred. — Vase histonj from hospital ship Relief. That the slow-moving-, lead bullet can at times produce a clean perfora- tion of the extremity of w hone is sliown by the following- case: Vase ^. — Peiforatimi oflmoer end (ffermrr hy a shrapnel haJl; aseptic vynind; missile located, hy Tlimtgeri ray and remolded. Daniel B. Raymond, private. Company D, Sixteenth Infantry, was wounded July 1. Entrance wound small, dressed with first aid dressing. Transferred to Relief, where radiograph was taken which showed that the missile was a shrapnel (Plate XXXI). Transferred to Long Island College Hospital where the following history is given: The l)ullet entered the thigh at the lower third, and by Kontgen ray was shown to be located behind the head of the tibia. An incision was made over the point indicated in the picture and the l)ullet was found with several small fragments of bone it had pushed before it. In the condyle of the femur was a round, clean-cut hole extending completely through the bone. A small amount of turbid fluid was found at the site of the bullet. The wound was closed without drainage. Complete recovery resulted. — Vase history from hosj^ital ship Relief ((ad Long fsland Vollege Hospital. Cases like the above are probably comparatively uncommon, as the lower end of the shaft of the femur is composed of quite compact tissue and is usually completely fractured or splintered. Perforation of the upper end of the feniui', witliout fracture or comminution, is probably much more common. The following case and radiograph sIioav the small amount of connninution produced by a Mauser bullet passing- thi-ough the femur in the region of the great trochanter. From the conflicting- evidence- it is probable that tlie fracture produced by the ball was not complete at lirst, but afterwards became so. Vase 3. — Mamer liallet fractwe of uj>per extrem,ity of feimir; tnnind aseptic; recovery tcifhout anq)idatio)i. Theodore Wint, major Tenth United States Cavalry, July 1, 1898, i)efore Santiago, San Juan Hill, shot in left thigh from before backward, Mau.ser striking cover of small morocco pocket book, which it pierced; ball did not pass out of trousei-s t)ehind after having cut through the thigh. Line of flight was at an angle to surface of thigh, so that entrance was larger than exit wound. Direction of PLATE XXXII. Case 5, Section V. — Theodore J. Wiut, iiuijor, Tenth Cavalry. Radiograph of the upper part of the left thigh, viewed from the back, showing Mauser bullet fracture of the femur in the neighborhood of the iiitcrti-ochanteric line. There appears to l)e considerable loss of bone substance in the neighborhood of the great trochanter, and an oblicpie fracture with no tissuring. It is ])robable that the ball perforated the bone and so weakened it that it afterwards fractured. PLATE XXXII. THE MEt-IOTYPE »R1NTING CO.. BOSTON. PLATE XXXITI. PLATE XXX I II. Plate XXXIII, Section V. — Earnest Knowles. ]n-ivate, C'ompaiu- D. Twenty-first United States Infantry. Radiographs of left knee, viewed from tlie inner side, and from the l)ack, sliowing Reming-toii l)ullet which has passed downward, backward, and inward and lodged in the upper part of the tibia. PLATE XXXIII. THE HELIOTVPE PRINTING CO. , BOSTON. (U'NSHOT OF THE Kl'Il'IlYSES. 7;t ol' oiif-lialf iiK-ii. KiKT s(ill slightly swuilcn. soiiicwhiit slill. I)iii tU-x'um siill g-nidually iiu-rwising-. Crulchcs on Scptciiil.cr fl. ("uii hear some wcio-ht on injured leg. — Cdx,' hiatdni coiiijiilid fruii, m-nrilx 'm Si, rij' ni, -(;,„, niPs Ofice. On accuiiiit of its caiicelloiis structui'i-, tlic upper end of tlie tibia is frequently pierced witlioiit coiniiiinution ur complete fracture. The two foUoAviui)- cases are of inteivsl in that, in eacli case, the missile wounded the kneejoint and passed from above (lowiuvard Into the tibia without producini-- any destruction of Ixme otlier than clean penetration. CoAse J4.. — \\oiiiiil iif l,ii< I jdiiif : jh-rt'(iriifi(iii uf fihia; itsrjiiii- irniiiid; reconeni witJwat ciiliipl iciit miis. Lewis (inuicr. pri\!itc. Coiiipany E, Sixtccntli I'nitcd Slates Infantrv. wounded by a ^hiusei- laillet at San Juan. July M. IS'.IS. distance unknown. I'rojeetile entered outer aspect, rijj-lil kneejoinl. l>et\veen tiie outer condyle and head of tihia. and i'aiu'-in<'- downward and inward lludugli the head of the tibia, it emerged :it tlu' inner side of the leg 2 cm. b(d()w tin' head of the tibia. The limb was placed on a posterior splint. Was sent to the base hospital at Siboney, Jidy 10. Examination February 4. 1900: The wound of entrance is marked by a round scar the size of the jjrojectile; the exit wound by a scar a tritie larger. Flexion of knee somewhat ini])aired. Radiogra))!! shows slight exostosis on iinier surface of tibia at site of exit of bullet. i)robal)ly due to callus formed about small specula of bone displaced outward from exit wound in lione. — Citx,- hinfori/ hi/ _Maj. Lou if A. LaGwrde, Surgeon. United Stairs Acini/. The next case iihistrates how a bnUet of laryc caliber uia\- penetrate the upper em! of the tibia without producing anvfractni'e Ix'vond the direct line of its course. It also shows the good result whicli nia\' be obtained in gunshot wound of the knee, even when made In a large, ricochetted missile, the good result undoubtedly being due to the contiinunl antiseptic treatment employed. Case 5. — tiiiiislint nf km, li,/ rii;,fli,t R,;ini iii/tiiii, ixdiber .Jfii. ■wifhiji'iietrutiini uf til,i,i. Earnest Knowles, privati>, Company I). 'I'wenty-tirst Fnited States Infantr^v, was wounded October 'I'd. 189!t. at San Cristobal, Calaniba. V. I., at about 250 yards range by a Remington bullet. He was kneeling at the time and the bullet struck the ground just in front of his left knee, ricochetted, passed through khaki trousers, apparently without causing loss of sLd)stance of the latter, and struck the knee in front of the external condyle of I he fenuir. grazecl that bone. ))assed through tile joint and downward, inwai'd. and liarkward into the upper end of liie tibia. A tirst-aid dressing was immediately applied and (he patient transported to hospital. The external wound was so large that two lingers could easily lie inserted into it. The wound was cleaned, drained, and iiiigated witJi luitiseptic solution. Healing 6648 10 80 kontgp:n kay in si'amsm-ameiucan a\"ak. was complete in about seven weeks. Soldier Avas discharged for disability on account of impaired motion of the joint, and he entered the Soldiers" Home. Washington, D. C. Radiograph taken May 14. 11*00. shows large l)ullet lodged in upper and back part of tibia (Plate XXXIII). From this localization, the bullet was subsequently removed from the body of the bone by Maj. Ix)uis A. LaGardi'. Surgeon. I'nited States Army. In the uext case, the radiugTaj)!!, thuugli not taken until six nuaitlis after the receipt of the injury, clearly shows the ))erforation made by the bullet (Plate XXXIV). The radiograph indicates that the fracture was not complete, though the j)atient stated that he could feel the bony frag- ments move on each other when pressure was made near the wound at the time of the injury. The short range at wdiicli the wound was inflicted, 10 feet, would give the niaxinutm of destructive effect in osseous tissue, and that the comminution was not greater must be ascribed to the looseness wnth which the bony tissue is knit in the upper part <>f the tibia. Cdxe 6. — Perfiiratioii of tthta In/ KriKj-Jurtiinxrii nt irt ratuji . Private AVesley Kibby, Company H, Twenty-fourth Infantry, while on duty at Presidio, Cal., June 25, 1899. was accidently shot by a comrade. Distance was not over 10 feet. Bullet was a Krag-Jorgensen. Entered left tibia 4 cm. below patella, and emerged from most prominent portion of calf. l)elow bend of knee. Examination February 4. 1900: Wound of entrance, transverse oval. 1 byf cm. Wound of exit, oval, puckered, retracted, '2 by 1 cm. The man says that he could feel the bony fragments move on each other when pressure was made near wound. Treatment: ,Dres.sing and immobilization; wounds healed in three weeks: able to walk in eight weeks with aid of cane; left ankle and foot remained Aveak. and sole of foot felt numb, with occasional needle-like pains shooting through it. He has weakness of all muscles of posterior aspect of leg; also of extensor hallucis, and loss of sensation over anterior two-thirds of plantar surface of foot. Some .stiffness of foot and ankle still present, and he is unable to walk without aid of a cane. — Case history hy Muj. Louis A. LaGardc. surgeon. Zhiited Sfafi-x Army. The small amount of comminution produced bv the Mauser bullet in passing through the extremities of the bones of the arm and forearm is shown in the following cases. Case 7. — Separation of olecranon hy ImUet without comtninution. Theodore H. Lubold. private. Company I. Sixteenth P(>nnsylvaiiia Vohinteei- Infantry, was shot while retreating during the skirmish near Guayamo, Augu.st 9. The l)ullet entered the right arm al)ove the olecranon process and emerged from the extensor side of the forearm between the radius and the ulna. The Kontgen ray I'eveals the presence of a fragment of the t)ullet, or its mantle, lodged in the wound, and that the olecranon was separated from the shaft without comminution (Plate XXXV). — Cane history from records in Sun/ti/n-Oencrars Office. PLATE XXXIV. PLATE XXXIV. Plate XXXIV, Section V. — Wesley Kibby, jirivate, I'onipiui}- H, 'l\venty-toiirtli Tiiited States Intaiitrv. Ka(li()L;i-ai)li of left knee, viewed from the hack, sliowinii- perforaticm ot upper end of til)ia, made Ity Ivrag-Jorg-eusen at short range. PLATE XXXIV. PCRFORdTTOM. 1- THE MELIOTVPE PRINTING CO.. BOSTON. PLATE XXXV. PLATE XXXV. Case 3, Section V. — Theodore H. Liibold, Company I, Sixteenth Pennsylvania Volunteer Int'antry. Radiograph of right elbow, \newed from its inner side, showing separa- tion of the olecranon with no fissuring of the fragments, and a small frag- ment of metal lower down in the forearm. PLATE XXXV. THF HEIJOTVPE PRINTING CO., BOSTON. PLATE XXXVI. PLATE XXXVT. Case 6, Sectiox V. — Horace K. Devereaux. lieutenant. First. United States Cavalry. Radiog-raphs showino- fracture of the lower end of the radius by a lodged Mauser bullet. There is separation of (jnite a large external frag- ment, but the connninution does not extend up the shaft. The hnllet has been displaced hx the flexor tendons and is seen lying ])oint upward in front of the i-adins. From its position, it is probal)lc tliat it entered the ])art butt end foremost. PLATE XXXVI I THE HELiOTYPE PRINTING CO., BOSTON. GUNSHOT OF THE EPU^HYSES. 81 Case 8.—Mavs,'r hxUet fmrf,,,; nf ,nii,r nnidijlr ,,f hiivimis v!fl, no rxfcLsioii offractmri' of ahuft ofhone. Riilph Barkinaii. private, t'oiiipany K, Second Ma.ssaclmsetts Volunteer Infant ly, was twice wounded at Siboney, Cuba, July 1. l.s'.i;). One bullet entered the left leo-; the other passed through the lower third of the left arm. The patient was trans- ferred to the R,-J!,t'. where a radiogi-aph was taken whit'li showed that the outer condyle was separated from the shaft, but that there was no splintering of the bone extending up the shaft. The patient was traii.sferred to St. Peter's Hospital. 15rook- lyn, N. y., and discharged from there July 29, 1899, "cured."— 6W///.>,7'r;/7/ />«//, Tecorclx III Suriii'oii-lreni'i'dVK Ofici'. Ill tlie tollowing- case of fracture of the distal end of tlie radius, tlie bullet was proljahly traveling- at low velooit}-, and entered the ])art, l)utt end foremost. The ainouur of comminution was not great, the fracture being- mainly the separation of a rathei- large external fragment. Case 9. — Fnicture oflmoer md of radvm hy Ma/user hdlet; infection of wound; Jocallzatum of hull rt hy Eontgen ray, and removal; antiseptic treatment; recmv-r-y 'without innpiitatirm. Hoi-aee K. Devereaux, lieutenant. First United States Vol- uuteer (.'a\ali-y. was wounded June 27, at 200 yards, by a Maaser bullet, which entered the dorsal aspect of the left forearm over the ulna. A first-aid dressing was applied twenty minutes after the receipt of the injury. The patient was transferred north on the OJirMe and entered Roose\elt Hospital, where he came under the care of Dr. Robert Abbe, who radiographed the fore- arm (Plate XXXVI). At that time, the forearm was in a condition of ditfuse cellu- lits and suppin-ation, the wound having been infected. Dr. Abbe removed the bidlet July 18, and the case progressed to excellent recovery with wrist motion about one-foui-th and rotation of the forearm about one-half the norniui. Though the bullet lodged, the patient believed that it had not ricochetted. ])ut ascribed its low velocity to defective powder. The position of the bullet, however, indicated that it had i-icochetted and entered butt end foremost, and that its position — oblique to its line of (^ntrance — was due to pressure from the overlying tendons of the forearm. 1m c J Jiagiuiu ex- planatory of Plate XXXVI. o, Flex..r tendon; 6, fractured radius; c, place of entrance iif luillet. GUNSHOT OF THE CANCELLOUS BONES GENERALLY. The effect of the modern bullet upon the hones of the wrist and the cancellous bones of the foot and face, is vevx similnr to its effect upon the epi))liyseal ends of the long bones; i. e., guttering, or perfornfion, with small extent of commiuutiou. 82 liCiKTGEN KAY IN SFANISII-AMEKK'AX WAR. Case 10. — Pi'rfonition of »-s c((/c/!< hi/ JLiks, r luUct. Private John F. Muvphj'^, Company C, Fourth United States Infantry, was wounded at unknown ranoe by a Mauser bullet, whieh passed from behind forward, and from above downward, through the left os cak'is. The wound healed readily, Init pain, located beneath the heel, persisted. A ladiooraph was taken which showed a sharp, bouj' spur projecting downward from the under surface of the os calcis. This exostosis was undoubtedly a caUus, formed about small bone fragments, which had T)een forced outward from the bone at the place of exit of the bullet. The weio-ht of the body being brought upon this spur when walking, caused the disability. The bullet made so clean a perforation of the bone that there was no evidence of fragmentation of the os calcis with the exception of the small fragments forced out at the wound of exit. The exostosis was removed, November 19, 1898; the wound healed by first intention, and the patient returned to duty. The following- case gives the result of a Krag-Jorgensen bullet fracture of one of the metacarpal bones. It is of interest in that the hand was directlv over the muzzle of the gun when it was accidentally discharged, and though the whole charge passed through the hand, the entrance and exit wounds were small and the bone lesion slight. Case 11. — Perfcrration of trapezium, hy Kraq-Jorgenseti hillet. Pri\-ate August Blume. Company C, Twenty -first United States Infantry, acci- dentally discharged his rifle July 2, the bullet and whole discharge passing through the paini of his hand. Radiograph showed that the IjuUet had perforated the tra- peziiua, throwing out only a small fragment. The entrance and exit wounds were small and there was nothing in the appearance of the part different from that seen in wounds received at long range. The wound healed by first intention, but full use of the hand was not restored, as cicitrical tissue in the wound caused some limitation of motion. The following, a case of clean perforation of the os calsis by what was supposed to be a Remington brass-jacketed bullet, like case 5 of this section, shows the clean perforation of cancellous bone by the larger missiles. Case 12. — Perforatum of os calcis hy Remington huUet. Samul S. AYentworth, private. Battery E, First Artillery, wounded June 13, 1899, at Zapote Bridge, near Manila, P. I., presumably by a Remington bullet, as the wounds of entrance and exit were somewhat larger than those made by the Mauser, and the enemy, so far as known, were using Remington rities. The bullet passed from without inward through the heel, perforating the os calcis. The wound did not heal, and three months after the receipt of the injury, an operation was done and a piece of legging, a piece of stocking, and three small pieces of bone, were removed. "Wound has opened twice since and small amount of pus escaped. \Yas discharged for disability December 29, 1899, aud seen by the writer in January, 1900, PLATE XXXVII. PLATK XXXVIT. Case 12, Section \'. — SnnuH'l S. AN'cntworrli, private, lintTciN K, ?''irst United States Artiller} . RadioiiTiiph of left foot, viewed from tlie inner side, showing- Imllet (Remine history hy Maj. A. O. Girard, surgeon, U. A'. ^1. CLINICAL CONCLUSIONS. The same conclusions, relative to treatment, obtain in fractui'es of the extremities of the long bones, as hold in fractures of the shaft. Infection or noninfection of the wound, rather than the amount of comminution, indicates v^^hether, oi- n()t, the wonnd sliould be treated expectantly or otherwise. From a standpoint of the amount of traumatic destruction done by the ball, expectant and conservative treatment is even more indicated in gun.shot injuries of the extremities than in similar injuries of the shaft of tlic Ijones. This is due to the fact that observation shows that the amount of conuui- nution is much less and the size of the fragments nuich smaller, in gunshot fractures of the extremities of the long bones, than in gunshot fractures of the shaft. 84 KONTGEN KAV IX SPANISH-AMERICAN WAR. Nor (li>e>i the fact that joints arc involved necessitate a diverg-auce troMi the rule of expectant treatment. Infection of the wound or extensive destruction of the soft parts may necessitate operative interference. But with ordinary penetrating or perforating wounds, occlusive dressings and immobilization have been followed bv best results. When this treatment is supplemented by rapid transportation to base or general hospitals where operation can, if neces- saiy, be done with adequate aseptic or antiseptic technic, the best possible results may be expected. VI. RADIOGRAPHIC TECHNIC. Proper manipulation of the apparatus is most important in Rr)ntgen- ray work; tor, with imperfect methods, imperfect or negative resuUs are obtained, and serious injury to the [jatient by burns may be intiicted. Maximum radiation in the tube dejjends upon supplying the tube with the current best adapted to its ))articular condition. To obtain a suitable current, proper adjustment nmst be made of the difterent working parts of the a])paratus, and knowledge of technical details by which such adjust- ments are made is essential to success. As the static and the coil machines are entirely different in construction, the means by which radiation is influenced necessarily differs in each, and the metliod of operating each type of ajjpa- ratus has to be separately considered. THE STATIC MACHINE. In operating the static machine, special attention has to Ije given to the condition of the machine relative to atmospheric conditions, to the sjieed of rotation of the plates, and to the adjustment of the spark gaps and the tube. In the static machine, efficient output is deiiendent in large measure upon the absence of all dampness and dust from the interior of the case. To keep the plates clean, they nmst be occasionally carefully wiped. To protect the machine as much as possible from moisture, it should l)e kept in a well lighted and ventilated room, with windows provided with inside wooden shutters, which can be closed when fluorosco})ic examinations are to be made during the daytime. To insure the absence of luuuidity within the case, it is usually necessary to keep dishes of calcium chloride within it. When this is done, fresh chloride shouhl be placed within tlie case whenever any moisture accumulates in the dishes holding the old chloride. In very damp climates, the edges of the frame of the case where the glass is inserted should be thickly and carefully covered with tliick petrolatum, to insure against passage of the damp exterior air into the interior of the case. As a precaution, to prevent loss of current, the front of tlie machine should be carefully wiped dry each time before using i1. 6648 11 85 86 K(')NT(iKX KAY IN SPANlSll-AMKKIC'AN WAR. As surtiririit s|k'C'(1 and steady rotation of tlu' plates is essential to hig-hest eilii-ienc\-, tlic machine is best oi)erated by some kind of motor, the speed of which can l)c re>iulated. Keo-ulation of s])eed is necessary: in that, when a tube is Avorkinj^- iit its highest etheienc}' with the anode glowing l)roperly, diminution of speed will decrease the output of rays; and an increase of speed, while not increasing the efKcieut output, may impair the life of the tube. To operate an eight or ten plate static machine satisfactorily, a motor of one-fourth liorse))ower is rcipiired. An electric motor of some relialjle make is best for use when an elec- trical current is avaihiblc, as such a motor can be easily and quickly adjusted for speed. Unfortunately, electrical currents can not always be oljtained in military hospitals. When electrical current is not available, water motor can be used and will work efficiently, provided the water pressure where the motor is placed is not lower than twenty pounds to the square inch. Such a motor has the advantage of ccMuparatively low original cost and of being free from run- ning expense. Where motor power is not available, manual power may be used, and witli it excellent work can be done; but such labor is extremely tiring, even when relays of men are emjiloyed. Where such jjower lias to be depended u]ion, a tandem bicycle attachment for running the machine would probably be very useful. CROOKES TUBES As the electrical cuiTents supplied ))y the static and the coil machines are quite different; tubes are specially constructed for each type of machine. As a rule, these tubes work best only with the tyjie of machine for which constrttcted, and can not be used with other types without loss of efficiency or danger to the tube. Relative to their excitation and radiation, tubes are divided into two classes — low tubes and high tubes. By a low tube is meant a tube which is readily excited to radiaticm by a comparatively small ciuTent, and which when excited does not proiluce rays of great penetration. Tulles when tirst received from the manufac- turers are generally in tliis conditi(Hi. With such tubes, the bones when viewed by the fluoroscope appear quite dark, anrl metallic objects can not be seen through tliem. Such tubes are unfitted for radiography of tliick parts. They should be eujployedfor i'a-er be illuniinated. For tliis reason, in using a tube, the opei-ator should earetulh- ex^nnine ,ts workiui;' with a fluoroscope to determine its condition and to \vh;it use it is best acUipted. A ready method of determininfj- the condition (if a tube, is to see whether or not a coin or cuff button held against the forearm, can be easih- seen through the radius. If not. the tul)e is a low one and should only be used for work for which such a tube is adapted, or it may be raised to a hig-her vacuum b\ suitable manipulation. A low tube may be raised by continued use or by I'evei'sinu' the current: but in reversing' the current, care should be taken not to continue the reversal too long- a time or the tube may be ruined. This i-eversal of the current is easily managed in the coil machines by reversing the switch le\(!r; but in the static machine, it is necessary to close the current and rever.se the tube. High tubes are distinguished l)y recpuriug a large or maximum cui-reiit to excite them, and by producing rays of great penetration. With such tubes, the bones appear gray, and metallic objects are readily seen through them. A ready test for such a tube is abilit-v^ to see with the fluoroscojx^ the shadow of a watch tlirough a man's skull. A tube which will give this result is fitted for chest and body work and for radiograi)h\- of such dee]) parts as the pelvis or hip joint. Eventually, siu-h ;■. tube will become so high as to resist all attempts to illuminate it, even with powerful current and careful adjustment. When this occurs, the vacuum can be lowered by subjecting tlie tube to heat, by baking it in a hot-air oven, or carefully heating it over a Bunsen burner or alcohol lainp. When the tube no longer responds to these mani]5ulations, it can be returned to the maker for reexhaustion and will then again work satisfactorily for some time. MANIPULATION OF THE TUBE TO SECURE ITS MAXIMUM RADIATION. Maximum radiation of any tul)e is obtained l)y supiihing it with an electrical current of tension, quantity, and rapidit)' of oscillation, best adapted to its vacuum. In the static machine, this is arrived at h\ the use of the spark gaps and the velocity of rotation of the plates. Spark gaps, or current interrupters, are metallic rods attached to, and nio\al>le upon, each sliding pole of the nuu'hine. Wv attaching the wires leading' to tiie tube 88 KONTGEX KAY TX SPANISH- AM ERK'AN WAR. to tlu'se iippliances, the current may l»e carried direct to the tube, or maybe interrupted and caused to pass throug'h any desired distance of air space. The spark gaps and their proper manipuhition are a])sohitely necessary to secure i)roper radiation from most tubes. All tubes, however, do not require their use. Tubes of high vactium and great penetration frequently work best when the wires are coimected direct to the poles of the machine. With low-vacuum tubes, it is necessar}- to pass the cuireut through an air space; the length of air space depending upon the condition of the tube. The h)wer the tube, the farther the spark gaps must be separated; so increasing the air space through which the current has to pass. With the tul)e adjusted and the spark gaps closed, the machine should be started into rapid action and a fluoroscopic examination made. If the bones appear gray and transparent, the tube is probably working at its best and no spark gap is required. Trial, however, sliould be made to ascertain if the fluorescence may not be increased. To do this, separate the positive spark gap and observe the result. Then separate the negative gap and adjust the gaps to the distance which gives the best radiation from the tube. This distance may be a ver>- small fraction of an inch, or it may be an inch or more. This can only be determined by a trial, which takes but a few moments. With the spark gaps properly adjusted, the radiation depends, to a certain extent, upon the rapidity of revolution of the plates. Rathation is at its best when the entire anode glows with a dull red color. When this glow is obtained, the revolution of the plates should not be increased; as over- heating of the anode and destruction of the tube may result, with no ade- quate compensation in the way of increased radiation. THE COIL MACHINE. In the coil machine, radiation in the tube is regulated by the condenser and vi])rator. The condenser is placed in the mahogany base upon which the coil is placed, and it greatly increases the power of the coil. The condenser is made in sections, and is connected to a series of four plugs on the top of base, by which it is possible to use any portion or the whole of the condenser at will. It will be found that some focus tubes will wox-k best when only using a few sheets of the condenser, whereas other focus tubes require considerably more condenser, and in some cases it is necessary to plug it all in. RADIOGRAPHIC TECHNIC. 89 In order to pluy in tliu (■uiuleiiser, the plug sliould l)e inserted l)etween the two parallel Hat brass strips, in the hole provided for that inn-jjose; whereas, if any part of the condenser is not re([uired for use, that particu- lar plug- shoidd be iuserteii ot the lu'intiicii Tins. In this case the vaeuiiiii caii lie lowen-il li\- a|iiil\iiiii- the tianie nt' an aleohol hmip to the siirt'aci- ut the tul)e so as to wanu it, heiiiu' careful to keep the Haine away t'roiu the wire terminals and in continual nuttioii so as to jtrevent lii'eakagc of tile tube 1)\' overheating;- in ut it .shoidd always be remembered that the vacuum decreases, the lono-er the tube is in continuous operation, and consequently, it should be watched so as not to allow the platinum anode to get hotter than a very dull red. At this temperature, the ])est results are obtained with a high vacuum tul)e When the vacuum in a focus tube rises very high, the surface of the tulie shoulil be cleaned carefirlly and frequently, as it has a tendei:c\ to to attract ] (articles of dust from the air, owing to the intense electrification of the g'lass. Gitod alcoiiol should always be used in the lamp when warming focus tubes, as a poor quality will deposit a thin coating of carbon on the outside surface of the glass, \\liich will cause a leakage aronnd the tube. The tube .shoidd always be kept perfectly clean. This is best accom- plished by wi])ing' it with a piece of damp tissue paper. RADIOGRAPHY. Photography is an indispensable adjunct to Kontgen ray work, as it is necessar}- to supplement nearly all fluoroscopic examinations by this agent. This arises from the fact that the visual sense is not sufficiently acute, nor is the outline shown on the fluorescent screen sufficiently distinct, to enable an observer to determine the finer details of most objects through which the Ki'mtgen rays will work. Frequently, in working through the thicker parts of the body, the fluorescence is not sufficient to enable the eye to accitrately determine the outlines of an object or to differentiate it from .surrounding objects. In such cases, accurate images can onl\- lie obtaineuble-coated " ami " nonhalation " plates, all of which are thickly coated. Some ra})id plates wliich are used for ordinary })hot()graphic pur- poses also give excellent results. Notable of tliese plates are those made l)^• tlie Cramer Ihv Plate Comjianv of St. Louis, Mo,, witli which results have lieen ol)tained equal to the l)est obtained with special plates. As ])hotographic plates differ widely in their applicability to Kontg'en- rav work, comparative tests should always be made before adopting a new make. In testing plates, the following method is useful: Place four plates in light-tight envelopes, and put them side by side in the form of a square under the Crookes tube. Place on each plate a circular disk of tin, and in the center of the disk a coin. Fix the anode of the Crookes tube directly above the center of the square formed by the plates, so that all the plates will be equally illuminated. Turn on the current so that the tube will be illuminated and the plates exposed. Expose for about three minutes, and then develop all the plates, together, in the same tray, Avith the same developer. Comparison of the finished negatives will show which plate is the most rapid by the greater density of the shadow where the rays have worked through the tin disk, and the contrast can be judged by the relative density betw^een the shadow and the part of the negative outside of it. Clearness of the negative and absence of chemical fog can be judged from that part of the negati^■e beneath the place where the coin was placed, for as no rays can pass through the coin, this part of the negative should appear perfectly clear. By testing i)lates in this manner, an operator is able to judge the qualit}' and kind of plates w'ith which he is working. The keeping quality of plates is a matter of considerable importance in radiography for military surgical purposes. Plates frequently have to lie bought in large quantities and shipped to distant points, often to tropical climates, where, unless the plates have exceptionally good keeping quali- ties, they are liable to spoil. Under such circumstances, if plates deteriorate, it is difficult to replace them without consideral)le delay. Some kinds of Rontgen-ray plates are put up separately in light-tight envelopes. These jdates do not keep well, as the heat and moisture acts in some way upon the paper and cause deterioration in the sensitized stn-faces of the plate with RONTGEN RAY BURNS. 93 which the paper conies in contact. Plates keep better wlien i)acke(l toj^ether in Hglit-tight pasteboard boxes, as they are ordinaril\- packed foi- cimnuer- cial use. For these reasons, plates packed in snch boxes, with en\elopes separate, should be chosen. Radiographs can be taken ujjon certain kinds of sensitized paper; such as the P^astman permanent bromide. Tliese papers are, however, much slower than plates, and do not give as clear and well- detined pictures. EXPOSURE. The leng-th of exposiire depends upon the amount of radiation from the tul)e, the distance of the tube from tlie plate, tlu- rapiditv of tlic plate, and the density of the part through which the rays have to work. Some ex])erience is required on the part of an operator, in order to estimate the length of time it is necessary to subject the plate to the action of the rays, to obtain a satisfactory image. Relative to this, it may be said; that, in order to take a satisfactorj' radiograph through anv of the thicker parts of the body, such as the knee, thigh, or head, it is essential that the tube should show the shadow of an object on the fluoroscope through the skull of an adult. With a tube having this radiation, placed at 10 inches ti'om the bod)', and using a rapid plate, tlie following lengths of exposure may be considered as the maximum necessary: Forearm ami hand One to two minute.s. Shoulder and i-heft Ten minutes. Knee Nine minutes. Hip joint, head, and pelvis Twenty minutes. Unless radiographs can be taken of the different parts named, in the time given, the tube is not working properly, either from some defei't in the tube or the current by which it is excited, and the attention of the operator should be directed to these defects, and he shonld cori-ect them rather than attempt to obtain a result by prolonging the exposure. RONTGEN-RAY BURNS. Rontgen-ray burns are usually produced by prolonged exposm-e with tubes which are not working properly. There is very little danger if the apparatus is working well; for, with a properly working apparatus, prolonged exjiosures or close approximation of the tube to the body is not necessar}'. But two Rontgen-ray burns have been reported as a result of the use of the Rontgen-ray apparatns during the Spanish-American war. One burn was produced by a coil and one by a static machine. In each case, the i>4 K(')NT(ii:n kav in si'anisii-amkricax war. exposuiv was ]in>lunL;c- the Santiatfo caiiiiiaion. tor which an (nt«rt>n-i;iy Imni "t rifriit lucast dl Tliomas .MiKi-iiiiii, t'onnerly jirivatc Company (', Sixtli riiited States Inlaiitry. The iili(it(>,sri'a|ili was taken when tlie ('(nulitioii was at its wni-st sta^re. usinj)' a Fessendeii coil machine actuated by a dynamo current, with the tube (si low one) 1(» inches from the shoulder. The result was so unsucce.ssful that a second tind tiiird trial on successive days were made, ))ut the tube was working- so poorly that no satisfactory radiooraph wtis obtained. Six days after the la.st exposure, slight redness of the skin iippeared on the front of the chest and shoulder. This erythe- matous condition increased and, two days later, small l)lel)s iippetired. These broke and sniidl idcers formed, whicii yradually spread and cotilesced. The tissue necrosis deepeneil and extended and was ;iccompaiiii'). Treatineiit of \:iriou.skiiid.s wa.s irictl, l)ut tlic greatest hcm'tit \\a> (In-hcd fiinii continuous application of lead and opium lotion. Tlic Imiii showed no sion of heal- iny fof four months. After that time it i\. There was hyperesthesia of the part, but no 96 KONTGEN ray in SPANISH- A.MERICAN WAR. ulfenition occuircd. and llic irTitiition disapppiirt'd in uhmit tt'ii days. IcaviiiL;' no after etferts. It appears that tlu* factors which influence the production of Rontgen ray burns are : («) the length of the exposure ; (h) the nearness of the tube to the surface of the 1 kxIv ; (c) the physical condition of the patient, and (f/) indi- vidual idiosyncras\'. Relative to the length of ex])osure ; it should not exceed thirty minutes, for with this length of exposure any part of the body may be radiographed, 2>i'ovided the apparatus is working properly and good technic is ust'd. If photographic results are not obtained with a thirty- minute exposure, the ojierator should look to improving his apparatus or technic rather than to lengthening the time which he exj)oses the patient to the action of the rays. In regard to the distance of the tube from the bod)' ; ten inches should be taken as the minimum distance. There is no doubt that the nearer the tube is to the surface of the body, the more likelihood there is of producing a burn. A good apparatus, ])roperly adjusted, will work readily through the head, chest, or pelvis with the tube at ten inches; and, in tlie absence of individual idiosyncrasy, witli the tube at that distance, and an exposure not exceeding thirty minutes, there is no danger of a burn. Personal idiosvncras^■ and low \'itality have always to be taken into account. The first, fortunately, is very rare, as it can not be determined beforehand; tlie latter should always be considered. A person in ill health or debilitated in any way is undoubtedly more likely to be burned by the Rontgen rays than one who is strong and vigoroi;s. The well-known fact that weakened tissues easily yield to disturbing forces, holds with the action of the Rontgen rays as with other factors, the action of which, if too long continued, devitalizes the cells. Exposures frequently repeated, with too little interval of time between them, will act in the same way as a single long ex})osure; the tissues disturbed by one exposure not being able to regain their equilibrium before the second exposure is made. It is to be remembered that the pathological efl"ect of a destructive Rontgen ray exposure is not at . once apparent, the first appearance of ;i burn not showing itself for two or three days. It is quite possible, therefore, to seriously increase a trouble already started, if a second exposure is made within tJiat time. For this rea- son, it is a good rule, wliere a thirty-minute exposure has been made, not to repeat the exposure within three days. With exposures of shorter duration, the danger of repetition diimmahea pari passu with the length of the exposure. DEVELOPMENT OF NEGATIVES. 97 DEVELOPMENT OF RONTGEN-RAY NEGATIVES. The development of Rontg:en-ray uegjitive.s doe« not ditFer from tliat of ordmaiy nefj^atives, except that more time i.s usually required to 1)rin B. Boiled water .500 Sodium carbonate 12.5 To develop, take of A, 30 grams; B, 30 grams; water, 200 grams: ])\ro- gallic acid, one-third teaspoonful of dry crystals. By making the developer up as given, and using dry pyrogallic acid, uniform action of the developer is insured, as develo])ers made up with pyrogallic acid in solution are very apt to deteriorate. Metol and hydrochinone, while not having the staining qualities of pyro, do not give negatives with quite as good printing quali- ties. Developers in which they are used are also somewhat more difficidt to make up. But, where thei'e is objection to the use of pyro, the following formula will be found an excellent one: (irams. Boiled water 500 Sodium sulphite 50 Potassium liroraide 1 Metol 2 Hydrochinone 6 Sodium carbonate, crystallized 50 When great contrast is desii-ed, hydrochinone alone, with a caustic alkali as an accelerator, and some potassium bromide as a restrainer, will give best results. Ortol gives good negatives and has the advantage of being ready mixed, only requiring to be dissolved in water. OS RANTGEN ray IX SIWMSII-AMERICAN AVAR. For iixiug tliu neii'ativc, an aciil-iixiiiy bath, with i-liroiiio ahiiii, is better than a plain solution of sodium hyposulphite in water. The acid bath removes stains from the negative and hardens the gelatin ; an important detail in hot weather or warm climates. The following- formula is a good one: Water lul