Battlefield Radiology

Imaging's essential role in warfare

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An early X-ray of a foot

Wilhelm Roentgen discovered the X-ray in November 1895. This invention greatly contributed to innovations in medical warfare. (Radiology Centennial Inc.)

The Wantz Generator, circa 1900, was used for the production of X-rays. (The International Museum of Surgical Science)

According to the famous physicist Albert Einstein, "so long as there are men there will be wars." Because it has not always been possible to avoid war, our focus must, therefore, direct itself in lessening the suffering and loss of life that is an unfortunate byproduct of warfare.

Medicine, on the other hand, is intended to help heal wounds and prevent illness brought on through accident or with intent to harm. Balancing out the scales of radical dictators are the humanitarian inventors who brought progress to help aid the plight of humanity with its incessant demand for war. These pioneers in medicine have risked their own lives by either subjecting themselves to countless, often harmful, experiments or have worked at the battlefront during combat to provide aid to the wounded.

One such area of invention that stands out is the discovery and application of radiology: It has helped change the face of diagnoses and medical intervention within military medicine. The science of radiology has helped turn the tide against unnecessary deformity and/or death by providing medical personnel a window into the anatomy of man, pinpointing areas of illness and/or injury.

A Historical Perspective

The year 1895 was pivotal, serving as a springboard to launch the diagnostic aspects of medicine into a whole new field. A discovery was about to take place, as German physicist Wilhelm Conrad Roentgen, by accident, made a fortunate discovery: a new kind of radiation.

It was not long before that the medical field (i.e., military surgeons) realized the immense benefits X-ray images would serve when used as a diagnostic tool. In the past, injured soldiers had to undergo emergency exploratory surgery, where surgeons would probe the wound in hopes of finding and detracting bullets, shrapnel or shell fragments.

However, the probing method was unsuccessful because bullets frequently took unpredictable paths after entering the body, and attempts to find them by probing proved futile; this was particularly true when the injured parts were too swollen for careful examination, or when manual manipulation was too painful to be borne by the patient. Additionally, despite antiseptic precautions, the insertion of probes, fingers or instruments into a bullet wound could precipitate infection with pernicious consequences (Cirillo, 2006).

Furthermore, X-ray films could help locate bullets embedded in bone, soft tissues and shattered joints by guiding the army surgeons to a more successful – and less invasive – approach of removing the foreign object. Certain injuries, such as 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 fragments – conditions that could not have been otherwise determined in the living body. As a result, surgical experience with joint wounds, such as in the Spanish-American War, showed a remarkable contrast to that of the Civil War in that mortality was practically obsolete, lodged bullets were rare and no amputations were performed for gunshot injuries of the large joints (Cirillo, 2006).

In 1900, Captain William C. Borden published his landmark monograph, The Use of the Roentgen Ray by the Medical Department of the United States Army in the War with Spain (1898), which codified the Army Medical Department's wartime X-ray data.

According to Borden, "The use of the roentgen ray 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 age long method of probing for deep-seated bullets had come to an end as a result of this new technology."

Military medical staffs of all nations partook in the diagnostic application of Roentgen's discovery – from its first appearance to modern-day warfare. A brief timeline will show how radiology was incorporated into the use of military medicine. (See "Radiology in Global Warfare" sidebar on this page.)

What began as stationary radiology locations progressed to mobile radiology units, such as those designed by French physicist Marie Curie, who discovered the elements radium and polonium. And, by late October 1914, the first of 20 radiology vehicles had transported X-ray apparatus to wounded soldiers (Pasachoff, 2006). Finally, radiologic technology became utilized at the battlefront.

Fighting for the Frontline

Despite the numerous advantages that this new discovery offered, it took years until radiology became recognized as an official science and specialty. The new science faced certain obstacles that had to be eliminated in order for it to be more widely accepted as a safe and more accurate diagnostic tool.

The first obstacle that radiography faced was transportation and power supply when using the equipment in the battlefields. Unfortunately, early X-ray units were bulky and delicate. Both the tubes and the glass photographic plates were fragile, making the whole apparatus difficult to transport.

However, the most serious obstacle was the lack of a reliable electrical power (www.uihealthcare.com). The new technology's 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 hospital ships (Cirillo, 2006).

Soldiers would have to wait to be medically treated for certain injuries, such as the removal of bullets, until they were transported to more permanent medical facilities away from the battleline; this, in turn, increased the risk of bleeding, infection and pain for the soldier.

In addition, radiographic equipment needed to be more lightweight, less complex, more portable, cheaper to maintain, less likely to break and less affected by the climate. Another obstacle that radiographic images faced was its need for precision as a diagnostic tool. Initially, early radiographs did not provide an unerring guide for surgery; they were difficult to interpret and, on occasion, failed to serve the surgeon's needs (Cirillo, 2006).

As a result, 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 or Ruhmkorff coil.

Medical art – the quick eye, sensitive touch and experience of the practitioner – still reined supreme over medical science. Until the images could be clearer and more precise, medical practitioners could not rely on them and, as a result, these physicians continued to opt for more traditional diagnostic methods. The surgeon needed more information, such as the size of the retained object, its position and its depth in the tissues.

Through 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 in evaluating difficult cases that arose during the war (Cirillo, 2006).

In the end of reviewing numerous cases, Borden believed radiographs have made the probing for bullets a thing of the past. According to Borden, "The superiority of the R?ntgen 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 roentgen ray, show clearly how impossible it would have been to determine the position of the missile by means of a probe." With continued improvements, Borden believed that radiological equipment would continue to prove itself an invaluable diagnostic tool for the military surgeons.

The third obstacle in the utilization of radiography involved safety on two levels. The first problem was the discouraging findings that these "harmless" rays of light were leaving a path of injury and death in their wake.

At 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 U.S. Army Medical Department was the first military organization in the world to report that painful burns resulted directly from exposure to X-ray radiation (Cirillo, 2006).

In time, however, people began to recognize the deadly results of unprotected, prolonged and repetitive exposure to X-rays. (Ironically, most X-ray martyrs were radiologists and other medical professionals.) In fact, in 1939 a monument was erected in Hamburg, Germany to honor those who had died from exposure or whose deaths were hastened by X-rays. One hundred and sixty-nine names were engraved on the stone at that time; by 1959, this number had escalated to 352. The terrible deaths of these men and women from many countries alerted the profession to the dangerous potential of X-rays (www.uihealthcare.com).

Eventually, guidelines were established to protect the patient, as well as the X-ray tech. For instance, shorter exposure times and the use of lead walls, lead aprons and monitoring devices for radioactivity have made this field safe, compared to its initial introduction into the medical field.

Another safety issue involved the military surgeon's potential inappropriate use of this new technology. Some countries initially discouraged the use of readily available radiographs at the battlefront because they did not want to encourage surgeons to immediately operate in an environment that may not be sterile enough to prevent problems with wound infections.

Instead, they felt that the surgery should take place at a stationary field-based hospital, which could provide a safer and more sterile environment. Even the most adept military surgeons of the United States, Great Britain and Germany were advised against the use of radiographs under field conditions for fear that surgeons would be enticed to operate under septic conditions. For instance, in the Spanish-American War, all wounds subjected to surgery in field hospitals became infected; even under the best circumstances, it was impossible to perform a completely aseptic operation, thereby risking the lives of the soldiers even further (Cirillo, 2006).

This conservative approach hindered battlefield radiology until better methods of aseptic techniques and guidelines were developed for the mobile battlefield hospitals.

Finally, the last obstacle in the successful of battlefield radiology was the theory that that the field be recognized as a specialty, with proper training and education provided.

During the interval between the Spanish-American War and World War I, only the largest military hospitals were equipped with X-ray machines, and the U.S. Army medical department had no X-ray specialists. Medical officers were only given 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 in the interpretation of radiographs without any special preparation.

It was not until the U.S. entered World War I that the newly established American Roentgen Ray Society, the first U.S. organization devoted to radiology, recognized that steps needed to be taken to overcome the shortage of qualified military radiologists. However, through the persuasion of Colonel Arthur C. Christie, an accomplished radiologist and future president (1921) of the American Roentgen Ray Society, on July 10, 1918, Surgeon General William C. Gorgas finally established the Division of Roentgenology in the Army Medical Department (Cirillo, 2006).

In addition, the Army established classrooms that taught individuals how to properly prepare as radiologists, as opposed to the earlier form of training, which was rather unreliable and non-hands-on. Students studied the localization of foreign bodies in situ, and laboratory mannequins with concealed metallic objects were used effectively to demonstrate the required techniques. Also, the students attended lectures held by medical officers who personally experienced the evacuation of hospitals in France. In the end, it's clear that World War I was the driving force behind the development of radiology as a medical specialty in the U.S. (Cirillo, 2006).

Through good fortune, a symbiotic relationship arose from the battlefields of devastation and waste. Suddenly, army surgeons became accustomed to working with radiologists and continued the practice after the war. Also, the number of physicians who specialized in radiology grew exponentially, which resulted in the development of schools and radiology programs worldwide (Cirillo, 2006).

In Conclusion

Countless inhabitants of all nations have suffered the horrors of war. Preventing wars is a trying ordeal, one that holds no simple solutions, as is obvious by today's political situation. Unfortunately, there will be war, there will be suffering, there will be injury and there will be death. However, in the face of such hopelessness, when used constructively, science and medicine can help to ease the devastation created by war.

One area where science and medicine made a positive impact was in the discovery and use of X-rays in warfare. Through research and discovery, these great scientific breakthroughs changed the face of medical treatment, in particular surgical intervention at the combat level.

According to Marie Curie, "The use of the X-rays during the war saved the lives of many wounded men; it also saved many from long suffering and lasting infirmity. We must not forget that when radium was discovered, [nobody] knew that it would prove useful in hospitals. The work was one of pure science. And this is a proof that scientific work must be done for itself, for the beauty of science, and then there is always the chance that a scientific discovery, [such as radium], may become a benefit for humanity."

In conclusion, the use of radiology in military medicine has not only saved the lives of soldiers, but those of civilians, as well. Through its initial trial and errors, the science and application of radiology has fine-tuned itself into a safe, controlled and reliable diagnostic tool. Radiologic technology has provided us with a window for diagnosing illness and injury, prompting early detection, prevention and, subsequently, less invasive surgical interventions.

References:

1. War Quotes - Famous Quotes - Famous Sayings. Accessed online at http://quotations.home.worldnet.att.net/war.html.
   
2. The Trail of Light: The Medical Museum: University of Iowa Health Care: The Trail of Invisible Light: A Century of Medical Imaging. Accessed online at http://www.uihealthcare.com/depts/medmuseum/galleryexhibits/trailoflight/00wordfromdrapkin.html.
   
3. Conner JTH. Beyond the Ivory Tower: The Victorian Revolution in Surgery. Accessed online at http://www.sciencemag.org/ cgi/content/full/304/5667/54.
   
4. Cirillo VJ. The Spanish-American War and the Future of Military Radiology. Accessed online at http://www.ajronline.org/ cgi/content/ full/174/5/1233.
   
5. Pasachoff N: Marie Curie – War Duty. Accessed online at http://www.aip.org/history/curie/war1.htm.
   
6. Beginning of Military Radiology. Accessed online at http://www.radiology-museum.be/English/Collection/Military.asp.

—Abraham T. Machado is a student at Miami Dade Community College and is studying to become a radiographer. Questions and comments can be sent to editorial@rt-image.com.