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Commentary |
1 1387 Joseph St., North Brunswick, NJ 08902-1509.
Received September 15, 1999; accepted after revision October 14, 1999.
Address correspondence to V. J. Cirillo.
During the Spanish-American War, the United States military used radiographs for the first time as a diagnostic aid in the treatment of the wounded [1]. Radiographs rendered obsolete the time-honored method of probing bullet wounds, with the attendant dangers of infection. Radiographs were essential in determining the extent of bone comminution in gunshot fractures, and aided immeasurably in the diagnosis of joint fractures. The low mortality of American wounded in the war with Spain (95% recovered) was attributed to conservative treatment made possible, in part, by radiography.
At the start of the Spanish-American War, radiographs were still so new that their inherent danger was uncharted territory, although some suspicion existed that X-ray beams might be harmful. The United States Army Medical Department was the first military organization in the world to report that painful burns resulted directly from exposure to X radiation. Guidelines covering exposure time, the distance of the X-ray source from the body, and the spacing of repeated exposures were proposed. There was thus an early recognition that the destructive effect of X radiation was not immediately apparent.
The Early Use of Radiographs in Warfare
On 28 December 1895, German physicist Wilhelm Conrad Roentgen published his epochmaking paper on a new kind of rays emanating from a Crookes tube, which he dubbed "X rays" because of their unknown character and to distinguish them from cathode rays (later identified as electrons) [2]. In discussing the transparency and opacity of various substances to the new rays, Roentgen noted that bones cast a denser shadow on a photographic plate than the soft tissues surrounding them. Here was a novel way to look at inaccessible parts of the human body. This astonishing property of X rays catapulted Roentgen's discovery from the relative oblivion of the physics laboratory to worldwide attention.
Realizing the enormous diagnostic potential of X rays for war injuries, military surgeons of the major world powers quickly put them to practical use [3]. Within 5 months of Roentgen's discovery, Colonel Giuseppe Alvaro used radiographs to pinpoint bullets lodged in the arms of two Italian infantrymen who had been wounded during the ill-fated Abyssinian campaign. Previous attempts to locate these projectiles had proven fruitless. Radiographs were taken at the military hospital in Naples, Italy—thousands of miles from the African battle-fields—more than a month after the wounds were inflicted. The bullets were extracted, and both soldiers recovered [4].
The Greco-Turkish War of 1897 provided the first opportunity to study the usefulness of X-ray apparatus close to the front. The German Red Cross set up their instrument in the Yildiz Hospital at Constantinople to aid the wounded Turks; and the British, who supported the Greeks, had their X-ray machine in a villa on the outskirts of Athens. Despite the short distances of these units from the action, several weeks elapsed between the injury and obtaining the radiograph.
Because of the limitations imposed by the bulky apparatus, the fragility of the Crookes tubes and glass negatives, and the need for a reliable electrical power source, British and German surgeons concluded that radiographs were of great use, but not at the actual front. In addition, they believed that modern high-velocity, metal-jacketed bullets were practically aseptic, obviating any urgency to excise them until the patients could be removed to a hospital behind the lines. Surgeon Francis C. Abbott voiced a theme that was to become familiar in late 19th- and early 20th-century literature on the military use of X rays; namely, if radiographs could be taken on the battlefield, they would give surgeons an incentive to operate under adverse conditions [5].
Radiographs were first taken in proximity to the battlefield by the British Army during the Tirah campaign (1897-1898) in northern India. To accomplish this extraordinary feat, Surgeon-Major Walter C. Beevor had to overcome numerous obstacles in the wild mountainous country in which the military operations were conducted. His success with radiographs led Beevor to declare that "it is now the duty of every civilised nation to supply its wounded in war with an X ray apparatus... not only at base hospitals, but close at hand, wherever they may be fighting and exposing themselves to injury" [6]. Despite Beevor's success, the Director General of Britain's Army Medical Service (equivalent to the United States Surgeon General) declared that the proper place for X-ray apparatus was at the base hospitals, and that only emergency operations should be attempted in the field.
While British forces were fighting in the cold highlands of India, their comrades-in-arms faced other adversaries in the hot deserts of the Sudan. On 2 September 1898, the Nile Expeditionary Force defeated the Sudanese separatists at the Battle of Omdurman. Six score of British casualties were transported down the Nile to the base hospital at Abadieh, hundreds of miles from the battlefield. There Surgeon-Major John Battersby x-rayed 20 patients in whom the bullets could not be found by ordinary methods. Bullets often take an erratic course after entering the body, but the new technology located all of them with "mathematical precision." Radiographs were of the "vastest importance" for an accurate diagnosis, Battersby noted, particularly when the injured parts were too swollen for careful examination, or when manual manipulation was too painful to be borne by the patient. The agelong method of probing for deep-seated bullets, Battersby predicted, would become a thing of the past in military surgery [7].
Radiology in the Spanish-American War
General Aspects
In the Spanish-American War, X-ray machines were limited to permanent
hospitals in the United States and to the hospital ships Relief,
Missouri, and Bay State (Fig.
1). Their use by field units was deemed inadvisable because the
best medical opinion of the day held that lodged bullets frequently became
encysted in tissues and rarely required immediate removal. Moreover, it was
impossible to achieve asepsis under field conditions, and the availability of
X-ray instruments at the front only tempted surgeons to operate under
unfavorable circumstances.
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In 1900, Captain William C. Borden published his landmark monograph, The Use of the Röntgen Ray by the Medical Department of the United States Army in the War With Spain (1898) [8], which codified the Army Medical Department's wartime X-ray data (Fig. 2). Surgeon General George M. Sternberg selected Borden because of his unique scientific qualifications. Before the war, Borden and Sternberg had conducted an extensive correspondence on microscopy, bacteriology, and photomicrography. More important, Borden had firsthand experience with X rays, which he gained while stationed at Fort Snelling, MN before the war and at the Army General Hospital in Key West, FL during the war [9].
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Borden addressed two technical questions of great practical importance to the Medical Corps: what type of X-ray machine gave the most reliable performance under military conditions, and which localization method most precisely zeroed in on embedded bullets? Comparing results obtained with five static machines (electricity generated by friction between sets of revolving and stationary disks) with those from 12 coil machines (electricity generated by induction coils), he concluded that the latter were better suited to military radiology. Advantages of the coil apparatus included lower weight, less complexity, greater portability, cheaper maintenance, less breakage, and the fact that the instrument was unaffected by climate.
An ordinary radiograph was often not exact enough to guide an operation. The surgeon needed more information, such as the size of the retained object, its position, and its depth in the tissues. In an extensive discussion of various radiographic techniques for localizing foreign bodies in situ, Borden noted the superior accuracy and reliability of Mackenzie Davidson's cross-thread triangulation method [10] in evaluating difficult cases that arose during the war.
The heart of The Use of the Röntgen Ray [8] lay in its clinical histories, most of which were accompanied by magnificent radiographs depicting gunshot fractures and lodged bullets (Figs. 3A and 3B). A total of 44 patients were described: 34 Caucasians and 10 African Americans. Radiographs were taken on board the Relief (n = 17); at military hospitals in Key West, FL (n = 9), Washington Barracks, DC (n = 3), the Presidio, San Francisco, CA (n = 3), and Fort McPherson, Atlanta, GA (n = 1); at civilian hospitals in New York City (Roosevelt, n = 2) and Boston (Massachusetts General, n = 1); and at undisclosed locations (n = 8). At least 41 additional patients were omitted because they were similar to those illustrated. To have included them, Borden explained, would have increased the bulk of the book without adding to its value.
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Borden contended that radiographs made probing for bullets obsolete [11]:
The superiority of the Röntgen ray over other methods of locating lodged missiles is so great that, when available, it should be used to the exclusion of all others....A great majority of cases, where the bullet has been located by the Röntgen ray, show clearly how impossible it would have been to determine the position of the missile by means of a probe.
In addition, the clinical records indicated that the presence or absence of infection, not the presence of lodged bullets or the extent of bone comminution, dictated whether the wound was to be treated conservatively or surgically.
New technology frequently has unintended human consequences. X rays did not yield their benefits without a price. The hazards of X rays were suspected as early as 1896, when the procedure was followed by hair loss and skin irritation. However, the alopecia was attributed to fictitious quasi-electric currents generated by X rays, and the dermatitis to ultraviolet rays, heat rays, or, in the case of operators, to chemicals used in developing the radiographs. Elihu Thomson, a physicist at the General Electric laboratories in Schenectady, NY, was the first to provide experimental evidence that X radiation per se produced adverse biologic effects [12].
The Use of the Röntgen Ray [8] presented the first two cases of X-ray burns reported in military radiography, both of which resulted from long-term exposures that were frequently repeated. The first case was that of a gunshot fracture of the right humerus sustained months earlier in Cuba. Radiographs were taken to determine if proper union of the broken bone had occurred during the healing process. The soldier received three 20-min exposures on successive days, with the X-ray source at a distance of 10 inches (25.4 cm) from his shoulder. The skin on the front of his chest reddened 6 days after the last exposure. Small ulcers formed, spread, and coalesced until the inflammation covered the entire right breast (Fig. 4). The skin necrosed, and the patient experienced marked pain and hyperesthesia. Healing progressed slowly, taking 11 months to resolve. The second patient, suspected of having a kidney stone, was given three 25-min exposures on alternate days. Five days after the last treatment, an erythematous spot appeared on his left abdomen that gradually became pronounced and was accompanied by hyperesthesia. The symptoms disappeared in about 10 days.
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Borden concluded that the two most important factors for the production of X-ray burns were the time of exposure and the proximity of the cathode tube to the body surface. Guidelines were proposed to protect patients. Exposure should never exceed 30 min; the X-ray tube should never be closer than 10 inches (25.4 cm) from the body; and repeated exposures should never be made within 3 days of the previous exposure, because the destructive effect of X radiation is not apparent for 2-3 days. Borden recommended the following maximum exposure times: forearm or hand (1-2 min); shoulder or chest (10 min); knee (9 min); and head, hip, or pelvis (20 min). Although these exposure times are excessive by today's standards, long exposures were the rule at that time. Hampered by the limitations of fin-de-siècle technology (e.g., scattered radiation and heterogeneity of X rays), radiologists needed protracted exposures to enhance the images of bones while rendering more ghostlike the outlines of the surrounding flesh.
Despite the published results of Borden and Thomson, the medical profession continued to minimize the harmful effects of X rays [13]. On the eve of World War I the debate was still going on, although by that time the tide had changed, and most physicians were convinced that tissue destruction was caused by the actual X rays themselves [14]. The fundamental problem underlying the controversy was the difficulty in quantifying the dose of X radiation administered. Radiologists estimated the intensity of X radiation by a visual assessment of the penetration of X rays through their own hands. This foolhardy method was one of the reasons hand injuries occurred so frequently among the early operators [15].
Surgical Aspects
If, as Hippocrates argued
[16], war is the only proper
school for military surgeons, then war also offers exceptional opportunities
for surgeons to learn the importance of X rays to their craft. The information
revealed by the radiograph is particularly relevant for the types of injuries
incurred in warfare, the greatest proportion of which are bullet wounds and
gunshot fractures. Nearly 93% of all American combat wounds in the
Spanish-American War were inflicted by rifle bullets. The remainder were
caused by shrapnel and shell fragments
[17].
The Spanish-American War gave military surgeons the first opportunity to observe the destructive effects of new reduced-caliber, high-velocity (exceeding 2000 ft/sec [610 m/sec]) bullets on living tissues under actual combat conditions. The Battle of Santiago, Cuba (1 July 1898) was the first engagement of any consequence in military history in which opposing belligerents were armed with small-bore rifles firing metal-jacketed, high-speed bullets.
Though sufficient to disable, the metal-jacketed bullet was heralded as more humane because it was believed to be less likely to deform and more likely to produce cleaner, cauterized wounds. The new bullet was predicted to either kill outright or produce wounds that would heal uneventfully and not result in permanent disability [18]. This humanitarian dream ended abruptly with reports of frightful destruction of tissue, just as though the bullet had exploded. Tissue trauma is related directly to the impact velocity of the bullet: the greater the velocity, the greater the tissue damage. Because the kinetic energy of a missile is proportional to the square of its velocity, doubling the velocity quadruples the amount of energy transferred to the tissue struck [19].
In 1898, Charles Woodruff [20] proposed the hydraulic engineering term "cavitation" to describe the explosive effect of the modern bullet. Although the slow-moving projectile of Civil War weapons cut a cylindric path through tissue with little lateral effect, the new high-velocity bullet produced a large, transient, fusiform cavity around the missile, causing extensive tissue disintegration beyond the permanent wound tract. During the explosive expansion of the cavity, tissues were stretched and torn; when the cavity collapsed, tissues were pushed together so violently that additional injury occurred.
The so-called humane bullet nullified the advantages of aseptic surgery. Mortality rates from wounds of the head, neck, and abdomen in the Spanish-American War were comparable to those observed in the Civil War. Fatal wounds of the chest were halved, because cavitation is minimal when a bullet passes through aerated lung tissue. The greatest reduction in mortality was observed in wounds of the extremities, where conservative treatment ("expectant treatment," in Civil War parlance), made possible, in part, by radiography, superseded operative intervention and was a potent factor in the saving of life and limb (Table 1). Radiographs made conservatism feasible. Borden wrote [21]:
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The use of the Röntgen ray has...favored conservatism and promoted the aseptic healing of bullet wounds made by lodged missiles, in that it has done away with the necessity for the exploration of wounds by probes or other means, and by this has obviated the dangers of infection and additional traumatism in this class of injuries.
The mortality rate of American wounded in the Spanish-American War was the lowest in military history, despite the fact that the war was fought under adverse climatic conditions. Ninety-five percent of the wounded recovered, and conservatism was credited for these "most brilliant" results [22]. A policy of non nocere (do not touch)—especially in abdominal gunshot wounds—made good sense at a time when military surgeons lacked lifesaving resources such as blood transfusions and antibiotics.
Bullets frequently took unpredictable paths after entering the body, and attempts to find them by probing proved futile. The greatest benefit derived from the radiograph in the Spanish-American War was that it made possible the localization and surgical removal of lodged missiles without the physical exploration of the original wound so common in all of America's previous wars. Even with antiseptic precautions, the insertion of probes, fingers, or instruments into a bullet wound could precipitate infection with pernicious consequences. "Probably no single measure has done so much to increase the gravity of gunshot wounds as the search for and removal of bullets," Borden opined. "The probing of bullet wounds [sic] should be entirely abandoned except in cases of urgent necessity" [23].
In the Civil War, gunshot wounds of the large joints (hip and knee) were particularly lethal. The low-velocity, soft lead bullets promoted sepsis because they carried large fragments of clothing into wounds, fractured joint bones, and were prone to lodge. Amputation was the rule; conservative treatment had unacceptably high mortality rates.
Joint fractures were especially difficult to diagnose by ordinary means. Radiographs were indispensable in these cases because they revealed the character of the bone lesions and the amount of bone comminution—conditions that could not have been otherwise determined in the living body. As a result, surgical experience with joint wounds in the Spanish-American War showed a remarkable contrast to that of the Civil War (Table 2). Mortality was practically nil. Lodged bullets were rare, and no amputations were performed for gunshot injuries of the large joints.
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Tissue trauma is related not only to bullet velocity, but also to the resistance encountered on impact. Epiphyseal bones consist mainly of a spongy bone that offers minimal resistance, as opposed to the compact bone of the diaphyses. Modern high-velocity bullets drilled clean holes through the articular ends of bone without causing fractures, thereby vastly improving the chances for recovery. Civil War data had disclosed a heightened risk of death whenever the bones of the extremities were fractured in gunshot wounds [24].
The Spanish-American War and the Future of Military Radiology
Even though the Spanish-American War had shown that radiographs were invaluable in military surgery, they were not assimilated into army medical practice until the 1920s. The reasons for the sluggish incorporation of radiography into American military medicine were twofold: restrictions imposed by the limitations of late 19th- and early 20th-century X-ray technology, and the conservative medical attitude of the military.
Long exposure times, fragile cathode tubes, cumbersome apparatus, glass photographic plates, and the need for a reliable source of electricity restricted the dissemination of X-ray machinery to permanent facilities and to hospital ships. At this stage of their development, radiographs were not an unerring guide for surgery. They were difficult to interpret and, on occasion, failed to serve the surgeon's needs. Surgeons skilled at diagnosing fractures on the basis of deformity, abnormal mobility, and crepitus were unwilling to discard bedside observations for the newfangled Crookes tube and Ruhmkorff coil. Medical art—the quick eye, sensitive touch, and experience of the practitioner—still reigned supreme over medical science.
Moreover, the best informed military surgeons of the United States, Great Britain, and Germany advised against the use of radiographs under field conditions for fear that surgeons would be enticed to operate under septic conditions. Indeed, during the Spanish-American War, all wounds subjected to surgery in field hospitals became infected [25]. Even under the best of circumstances, there could be no such thing as a completely aseptic operation. In contrast to his Civil War forebears who operated in pus-stained coats with undisinfected hands and instruments, the military surgeon of 1898 scrubbed his hands, used sterile instruments, and adhered to antiseptic technique. Other essentials of aseptic wound management—rubber gloves, surgical caps, gowns, face masks, and sterile cloth drapings—did not become standard in military operating rooms until World War I.
In 1900, Nicholas Senn [26], the celebrated Chicago surgeon who had used X rays to great effect while operating on board the Relief during the Spanish-American War, recommended that the Army Medical Corps be supplied with portable X-ray apparatus and experts to use them. However prescient, this recommendation was impracticable. It was not until World War I that X-ray technology had improved enough so that X-ray appliances could be used in field hospitals at the front. In contrast to the Spanish-American War, early surgical intervention became the basic principle of World War I surgery, and cooperation between the surgeon and the radiologist was viewed as essential for a successful outcome [27].
The Army Medical Department's success with radiographs during the Spanish-American War had unforeseen consequences for foreign military radiology. It awakened the Spanish Army Medical Service to the need for modernizing its technology. Spain did not use X-ray machines during the War. Several years later, Spanish medical officers—citing America's success with radiography in the recent conflict—petitioned Madrid to install X-ray apparatus in all military hospitals that would likely be used as general or base hospitals in future wars [28].
The Army Medical Department's Radiology Division
During the interval between the Spanish-American War and World War I, only the largest military hospitals were equipped with X-ray apparatus, and the Army Medical Department had no X-ray specialists. Medical officers were given only limited instruction in radiology; there was no intention of creating experts. The Army labored under a mistaken belief that most medical officers could become proficient in the use of X-ray equipment and the interpretation of radiographs without any special preparation. (Traditionally, medical officers were expected to be adept in a variety of areas that would later become medical specialties.)
With the impending entrance of the United States into World War I, the American Roentgen Ray Society, the first organization in the United States devoted to radiology (established 26 March 1900 as the Roentgen Society of the United States) [29], recognized that steps had to be taken immediately to overcome the shortage of qualified military radiologists. Surprisingly, America's success with radiographs in the Spanish-American War had less influence on the thinking of the society's leadership than the knowledge that their European counterparts—especially the French—had been providing invaluable radiologic service to their countries since hostilities began in 1914. An editorial in the American Journal of Roentgenology stressed that American roentgenologists were bound by humanity and patriotism to do no less [30]:
Military preparedness includes efficiency of the medical department, and medico-surgical efficiency is not complete at the present time without roentgenological aid....Europe has shown that it can be done and how it can be done, but it is idle to suppose that a trained staff of roentgenologists can be produced at a moment's notice to go to the front or that the necessary roentgen equipment...can be furnished in an equally short time, unless competent measures are taken in times of peace to be prepared for war.
In March 1917, Lewis G. Cole [31], president of the American Roentgen Ray Society, appointed a Committee on Preparedness to determine the most efficient way to bring the Army Medical Corps up-to-date in radiology. The committee initiated a meeting with members of the Surgeon General's office from 11 to 23 June at the Cornell University Medical College in New York to present their plans for training medical officers and enlisted men (X-ray technicians). The committee's proposal was adopted, and schools of military roentgenology, under the control of the War Department, were opened in Boston, New York, Philadelphia, Baltimore, Pittsburgh, Chicago, Richmond, Chickamauga (GA), Kansas City, and Los Angeles. Classes began promptly in July, shortly after the United States entered the war [32].
In the classroom, localization of foreign bodies in situ was the most important subject, and laboratory manikins with concealed metallic objects were used effectively to demonstrate the required techniques (Fig. 5). Lectures by medical officers who had firsthand experience in the evacuation hospitals in France emphasized that wherever surgery was done, radiology was done too; therefore, close cooperation between the surgeon and the radiologist was of paramount importance [33].
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On 10 July 1918, acting on the advice of Colonel Arthur C. Christie, an accomplished radiologist and future president (1921) of the American Roentgen Ray Society, Surgeon General William C. Gorgas established the Division of Roentgenology in the Army Medical Department. It was a stroke of good fortune that Colonel Christie, an efficient medical officer who was also an able administrator, was placed in charge of the division [34].
World War I was the driving force behind the development of radiology as a medical specialty in the United States. Army surgeons who had become accustomed to working as a team with radiologists continued the habit after the war. The number of physicians who specialized in radiology increased exponentially. Even returning doughboys, who had gained an appreciation of radiographs overseas, demanded them when they were confronted with illness. X-ray technology became, in today's jargon, more "user friendly" with the introduction of the Coolidge hot filament tube and the invertion of X-ray film that replaced the heavy, fragile glass plates of the gas-tube era. In short, World War I legitimized military radiology.
Conclusion
Even though they revolutionized the diagnosis of war injuries, radiographs were not quickly assimilated into military medical practice after the Spanish-American War. Military radiology languished until World War I, when the American Roentgen Ray Society played a pivotal role in the Army Medical Department's development of radiology as a medical specialty.
A common assumption, freighted by presentist assumptions, is that new technology is rapidly incorporated into medical practice. However, factors other than scientific usefulness played decisive roles in determining how, when, and by whom new technologies such as X rays were used.
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