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The first 50 years of military radiology 1895–1945
European Journal of Radiology 63 (2007) 214–219
The first 50 years of military radiology 1895–1945 Adrian M.K. Thomas ∗ Department of Nuclear Medicine, Princess Royal University Hospital, Orpington, Kent BR6 8ND, UK Received 3 May 2007; received in revised form 4 May 2007; accepted 5 May 2007
Abstract Following the discovery of X-rays in 1895 by Wilhelm R¨ontgen the value to the military surgeon of the new technique was soon realised. The localisation of retained bullets by radiography avoided inappropriate exploration of the wound. The X-rays were first used on casualties from the Abyssinian War of 1896 and the developing radiological technology was progressively applied to military surgery. In addition the needs of warfare stimulated the development of all aspects of radiology. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: X-rays; Military technology; Radiography; Listerian concepts
It was in 1945 that lieutenant colonel Lewis Etter from the Medical Reserve Corps of the United States Army visited R¨ontgen’s laboratory in the University of W¨urzburg [1]. That area of northwestern Germany had been devastated by the recent war, but miraculously the laboratory of the physical institute had survived. It was in this laboratory 50 years earlier that R¨ontgen had discovered the X-rays [2] and in the intervening time, both the practice of warfare and medicine had changed beyond all recognition. That the discovery by R¨ontgen of X-rays would be of benefit to military surgery was realised immediately [3,4]. The end of the 19th century was a period of changing military technology when the older soft lead bullets were being replaced by steel jacketed bullets. During the 1890s, the European powers were equipping their armies with new powerful magazine rifles such as the Martini-Henry and Mauser. The new bullets made only a small entry wound and frequently passed straight through the body. The previously common gaping entrance wounds were no longer seen and surgeons found that exploration for bullets was often far worse than careful observation. The introduction of radiography helped in the development of modern war surgery by locating retained bullets. The army doctors soon saw the value of the X-rays. The older generation of army regimental surgeons were being replaced a generation trained with the Listerian concepts of antisepsis and in Britain were attracted to a professional career in the newly established Royal Army Med-
∗
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ical Corps. The early X-ray tubes were very fragile, however, the apparatus available before 1900 could detect fractures and foreign bodies [5]. 1. The Abyssinian War The first occasion for the use of X-rays in warfare was in the Abyssinian War of 1896 when the ancient kingdom of Abyssinia was invaded by Italian forces. The Italians lost the battle at Adowa on 1st March 1896 and the casualties returned to the base hospitals in Italy by sea. Lieutenant-colonel Guiseppi Alvaro of the military hospital in Naples successfully took radiographs of two soldiers with fractures of their forearm bones [4,6]. These radiographs were made only six months after the discovery of Xrays and clearly show the presence of retained bullets. Colonel Alvaro stated that the new technique “has proved to be a great aid in diagnosis, enabling us to determine with mathematical precision exactly where a foreign body was located.” 2. The Graeco–Turkish War Hostilities broke out in the Balkans in the spring of 1897. The European nations were divided with Germany supporting the Turkish side and Britain, Russia and the French supporting the Greeks. The German Red Cross Society sent a unit to Constantinople [7] and the London Newspaper the Daily Chronicle sent two fully staffed and equipped hospital units to Greece in the charge of the surgeon Francis Abbott under the British Red Cross [8]. The British equipment included a complete X-ray
A.M.K. Thomas / European Journal of Radiology 63 (2007) 214–219
apparatus similar to that used at St Thomas’s hospital in London. Casualties were received from the Battle of Domoko which took place on the 17th May 1897. The X-ray apparatus was operated by Robert Fox Symons and Francis Abbott gave an account of the difficulties experienced. In Phalaerum, a room at the base hospital was set out for the X-ray equipment and Fox Symons had this installed and working by the 1st of June 1897. Casualties arrived soon after and X-ray work continued for about six weeks. There were many difficulties, however the results were successful. Abbott and Fox Symons were able to illustrate their report about their activities with several radiographs and claimed “to record the first skiagrams taken in wartime, as well as to show that even inexperienced hands working can get fair results.” The original prints were exhibited at the first conversazione of the R¨ontgen Society in London (this became the British Institute of Radiology), which took place in London on the 15th of November 1897. Abbott and his team treated about 114 patients with war injuries and Fox Symons probably radiographed about half of them. On the account of Abbott and Fox Symons is interesting because of the account of the use of X-rays under field conditions and it was the first to be available to the British Army and therefore influenced their attitudes in following campaigns. Fox Symons had hoped that it would be possible to use the fluorescent screen rather than the taking plates and that of the foreign body in be looked at in many projections and would obviate the need for the slower process of obtaining a dry plate. Fox Symons lists the technical difficulties as including the heavy weight of the coil and accumulators, the fragility of the Crookes tubes and glass plates, the dangers of transporting cases of sulphuric acid for the accumulators, the delicacy and temperamental nature of the apparatus and the general problems of transportation. It was also said that an additional source of difficulty was the superstition of the local inhabitants who looked at the X-ray apparatus and its use has the work of the devil. Fox Symons said that it was difficult to take radiographs when the patient was constantly crossing himself to ward off evil spirits. Of the most serious obstacle to field radiography was the lack of a reliable source of electrical power and this prevented the siting the X-ray apparatus where it would be most useful, which was at Khalkis in the hospital nearest to the front line. Even Phalaerum did not have access to a mains electrical supply and so “HMS Rodney,” a warship of the Royal Navy, was used as the source of electricity to recharge their wet batteries. The casualties were mainly cases of fracture or suspected retained bullets and in several patients the bullets had penetrated the body cavities. The radiographic findings in addition to helping with the immediate treatment of the patient helps to define this new area of military medicine. The nature of war wounds was changing due to the newer high velocity rifles and Abbott wrote to the War Office and said: “The Roentgen rays should always, if possible, be available at the hospital nearest the front in which the wounds can be first properly examined and dealt with. . . .the apparatus is of no use in the field where detection can only be an incentive to premature exploration. The less wounds are tampered with before satisfactory surroundings are reached,
215
Fig. 1. A radiograph of ‘a bullet in the elbow of a native soldier’ taken by major Beevor (from 10).
the better. The modern bullet . . .is practically aseptic and there is no urgency for removal.” 3. The Tirah Campaign In June 1897, there was insurrection in the Northwest frontier of India on the frontier with Afghanistan. A British Army of 10,000 was sent to open the passes. One of the groups was the Tirah expeditionary force consisting of 8,000 British & 30,000 Indian troops under the command of general Sir William Lockhart. Twenty-three field hospitals were established on the Tirah plateau and 900 casualties were treated. There was a long journey to the base hospital at Rawlpindi with slow transport. Surgeons therefore treated wounds earlier and nearer to the front line. Walter Beevor, a regimental surgeon with the Coldstream guards, examined 200 cases with X-rays on the Tirah plateau and later took further X-rays in the hospital at Rawlpindi [9,10] (Fig. 1). The examinations included the leg of general Woodhouse whose leg wound had failed to heal and some weeks later Beevor was able to show the retained bullet. Beevor made a presentation to the United Services Institution in May 1898 which signalled the introduction of field X-ray units into the British Army. It is to be observed that Walter Beevor had purchased his apparatus at his own expense. 4. The River War A British led army was sent from Cairo to the Sudan against the Mahdists whom they defeated at Omdurman on 1st September 1898. The army was led by general Herbert Kitchener. The force was of 20,000 men and equipped with modern weapons. Thomas Cook’s pleasure boats took the army up the Nile as far as the cataract at Aswan. In the battle at Omdurman in daylight, 50,000 Mahdist tribesmen attacked a modern army. They only had spears and primitive guns and the carnage was enormous. The army medical department had learnt from the experience of surgeon-major Beevor ordered a portable apparatus from A.E. Dean to be sent with the expedition; however the apparatus was
216
A.M.K. Thomas / European Journal of Radiology 63 (2007) 214–219
Fig. 2. ‘Science to the rescue. Finding a bullet with the X-ray apparatus at the military hospital, Pietermatitzburg.’ Black and White budget, 1899.
only sent after angry words in the British parliament. The preliminary battle at Berber had already been fought when a member of Parliament about the supply of the X-ray apparatus. The Financial Secretary of the War Office reported that the senior medical officer reported that no case would have benefited if the apparatus had been available. A decision was finally made to send X-ray apparatus. It was put in charge of surgeon major John Battersby [10,11]. He examined about 60 casualties with X-rays at Abadieh near Berber on the upper Nile between July and October 1898. His mud hut at Abadeih became a landmark in the history of radiology and of military medicine [3]. The apparatus had been issued by the war office as part of the regular medical supplies and it was the first use of X-rays in the field by the army medical department. The main difficulty experienced by Battersby was the climate in the Sudan and it was with great difficulty that the apparatus was made to work. Electricity was generated by a soldier using a bicycle. One hundred and twentyone wounded were transferred to Abadeih and in 21 cases the conventional approach could not find a bullet. In 20 of these cases, an accurate diagnosis was made using the X-rays and in the final case the patient was too ill to be examined. Battersby concluded that radiography prevented suffering by unnecessary probing of the wound and in addition to simple radiography, he used the cross-thread localisation device of James Mackenzie Davidson [12] (Fig. 2).
Fig. 3. The use of the localisation device of Mackenzie Davidson by Major Battersby (from 11).
technique was not without hazards and two cases of X-ray burns caused by repeated and prolonged exposure were presented. Borden believed that the most important factors responsible for the burns were the duration of exposure and the closeness of the X-ray tube to the patient. 6. The Boer War In 1899, limited campaigns in South Africa started. The initial preparations were inadequate and what was expected to be a brief conflict turned into a full-scale war. The Boer War was the first occasion since the Crimea that the British Army faced an opponent with weapons as modern as their own, and also had the advantage of defending their country against invaders. The war lasted two and a half years. There were 500,000 British troops in South Africa. Less than 6,000 died in battle and over 16,000 died of disease. The Boers lost with about 5,000 killed. The medical arrangements became more complex as they progressed with a system of general (fixed) hospitals and field
5. The Spanish–American War In the Spanish–American War of 1898, there was a limited use of radiography and again this obviated the need for unnecessary probing of the wound. The larger American general hospitals and three hospital ships were supplied with radiographic apparatus [6,13,14]. The American forces had felt that the use of radiography in the field was unnecessary because the bullet wounds rarely required immediate removal and it was also believed that since aseptic surgery was not easy under field conditions, if the radiography could be obtained, then it would only encourage the surgeons to operate inappropriately. Captain William Borden [14] published his document on the use of X-rays with an extensive account of the use of the new technique. The new
Fig. 4. ‘Wounded from the front. Locating a Mauser bullet by X-rays in a London hospital.’ The Graphic, June 16, 1900.
A.M.K. Thomas / European Journal of Radiology 63 (2007) 214–219
217
Fig. 7. ‘Radiographing a wounded shoulder.’ Fluoroscopy as illustrated in 20.
7. The First World War
Fig. 5. ‘An X-ray photograph showing the position of a Mauser bullet in the left shoulder of a soldier invalided home.’ The Graphic, June 16, 1900.
(moveable) hospitals. X-ray apparatus was supplied to general hospitals as part of the essential equipment for the campaign [15] (Fig. 3). Both electrical and radiation protection were still primitive. The general hospitals (but not the field hospitals) had portable X-ray apparatus to allow retained bullets to be detected and fractures to be diagnosed and treated (Figs. 4 and 5). The equipment was supplied with a dynamo to generate power needed for the batteries.
The First World War was war with all its grim tragedy [4] and the large number of casualties put a considerable stress on the casualty clearing or mobile field hospitals [16]. At the start of the war, the X-ray equipment was located in the larger army hospitals behind the front [17]. Initially, it was felt that there was no need for facilities near to the fighting, however, as the war progressed, the confidence of the army surgeons in rapid radiography increased and this was a view held by Marie Curie [18]. In France, Marie Curie developed an X-ray car (voiture radiologique) (Fig. 6) and equipped 18 such cars herself. The engines of these cars could supply the current supply for the X-ray apparatus [19]. Marie Curie also established two hundred fixed radiographic units. As the war continued the need for both radiologists and technicians increased. The French radiologist Antoine B´ecl`ere developed a training school at Val-de-Grace hospital and the French Army opened a school for X-ray technicians. Marie Curie opened a school for female X-ray technicians
Fig. 6. ‘French field hospital – Locating bullet with X-ray machine.’ Stereo-pair, Keystone View Company.
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Fig. 8. ‘First captured German X-ray apparatus, consisting of wooden upright stand, light upright lightweight metallic tubing stand with canvas stretched across’ (from 24).
(manipulatrices) in 1916 and worked with her daughter Ir`ene [17]. At the beginning of hostilities, the European armies were supplied with traditional gas X-ray tubes. During the First World War, more powerful radiographic apparatus became available as the Coolidge tube and the Potter-Bucky diaphragm were introduced. The American expeditionary force was supplied with the best radiographic apparatus available and these modern advances were used fully [4]. Following injury, the casualty was sent to a regimental aid post and then by field ambulance to the casualty clearing station, some miles behind the front. If radiography was required, then the patient was transferred to the X-ray room. Most of the X-ray work was in the detection of retained bullets and a simple apparatus was used [20] (Figs. 7 and 8). The stretcher with the patient was placed on supports above a moveable X-ray tube. The patient was rapidly fluroscoped and using a parallax technique with tube movement, the depth of the foreign body and its relation to the point of entry could be determined quickly and a written report issued [21–23]. The apparatus was powerful enough to diagnose thoracic injuries [24,25] and the use of stereoscopy was common.
Fig. 10. The Watson MX-2 arranged for fluoroscopy using a cryptoscope (hooded fluorescent screen).
Vincent Cirillo has demonstrated the importance of World War I for the development of the speciality of radiology [13]. The army surgeons became accustomed to working in a team with radiologists and this practice continued after the war. The number of radiologists increased and the X-ray equipment became easier to use. World War I legitimised the discipline of military radiology [13]. 8. The Second World War By 1939, good portable apparatus was available. The British Army was supplied with the MX2 [26] which was robust and easy to use (Figs. 9 and 10). This apparatus could be used for radiography and fluoroscopy and was easily crated for transportation. Radiography had developed as a profession and many entered the forces, however numbers available were inadequate and many units were only supplied with radiographers with no medical radiologists. In the US, two radiologists were assigned to each mobile surgical hospital unit [27,28]. The work would consist of fluoroscopy of casualties, foreign body localisation, general duties and radiotherapy for superficial infections including gas gangrene (prior to the introduction of antibiotics). Compared to the first War, the war was more mobile and radiographic units accompanied the field hospitals. 9. Conclusion The military surgeons at the end of the 19th century soon realised the value of radiography in military surgery and innumerable lives were saved in the subsequent 50 years. As military technology developed, so did the technology to treat war casualties. We owe a debt to the early pioneers who initiated the development of military radiology, the need for which is still very much with us. References
Fig. 9. The Watson MX-2 arranged for radiography.
[1] Etter LE. Post-war visit to R¨ontgen’s laboratory. AJR 1945;54:547–52.
A.M.K. Thomas / European Journal of Radiology 63 (2007) 214–219 ¨ [2] R¨ontgen WC. Uber eine neue Art von Strahlen (Vorl¨aufige Mittheilung). Sber Phys-Med Ges W¨urzb 1895;137:132–41. [3] Burrows EH. Pioneers and early years: a history of British radiology. Colophon, Great Britain, 1896:194-219. [4] Reynolds L. The history of the use of the roentgen ray in warfare. AJR 1945;54:649–72. [5] Guy JM. British Military Radiology, 1897–1919. In: Thomas AMK, editor. The invisible light. 100 years of medical radiology. Blackwell Science; 1995. p. 39–41. [6] Alvaro G. The practical benefits to surgery of R¨ontgen’s discovery (diagnostic results in the location of bullets in wounded soldiers from Africa). In: Bruwer AJ, editor. Classic descriptions in diagnostic roentgenology, vol. 2. Springfield, IL: Thomas; 1964. p. 1318–23. [7] K¨uttner H. The importance of roentgen rays in war surgery based on experience in the Greco–Turkish war of 1897. In: Bruwer AJ, editor. Classic descriptions in diagnostic roentgenology, vol. 2. Springfield, IL: Thomas; 1964. p. 1337–45. [8] Abbott FC. Surgery in the Graeco–Turkish war. Lancet 1899;1(80–83):152–6. [9] Beevor WC. The working of the Roentgen ray in warfare. J R Un Serv Instn 1898; 42:1152–1170. In: Bruwer AJ, editor. Classic descriptions in diagnostic roentgenology, vol. 2. Springfield, IL: Thomas; 1964. p. 1346–67. [10] Fyfe HC. The R¨ontgen rays in warfare. Strand magazine, 17. 1899. p. 777–83. [11] Battersby J. The present condition of the Roentgen rays in military surgery. Arch Roentg Ray 1899;3(74–80):89–91. [12] Davidson JM. A method of localization by means of Roentgen rays. Arch Roent Ray 1897;2:64–8. [13] Cirillo VJ. The Spanish–American War and military radiology. AJR 2000:1233–9.
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[14] Borden WC. The use of the R¨ontgen ray by the medical department of the United States Army in the war with Spain (1898). Washington, DC: Government Printing Office; 1900. [15] Bruce F. Experiences of X-ray work during the siege of Ladysmith. Arch Roentg Ray 1901;5:69–74. [16] Ernst EC. Reminiscences of roentgenology during the last war, 1917–1919. Radiology 1941;36:421–38. [17] Quinn S. Marie Curie, a life. London: Heinemann; 1995. [18] Curie M. La radiologie et la guerre. Paris, 1921. [19] Lemon F. X-rays in war. Arch Roentg Ray 1914;14:200–3. [20] Anon. Wizardry of the X-ray, how the radiograph tracks down bits of frightfulness. The War Budget 1916;7:15. [21] Hampson W. Localising simply and immediately. Arch Roentg Ray 1914;14:200–3. [22] Borzell FF. Report on a method of fluoroscopic examination with the army bedside unit. AJR 1919;6:454–5. [23] Borzell FF. Localisation of foreign bodies at the front. The nearest point method. The palpating stick. AJR 1919;6:188–90. [24] Rea RL. Chest radiography at a casualty clearing station. London: HK Lewis; 1919. [25] Borzell FF. Some observations on the radiographic findings in a series of chests examined at a base hospital in France. AJR 1919;6:573– 4. [26] Watson portable X-ray apparatus type MX2, instructions for assembly and operation. Watson & Sons, London, undated. [27] De Lorimer AA. Wartime military roentgenology. Radiology 1941; 36:391–403. [28] De Lorimer AA. Requirements for roentgenological services in the field of combat. Radiology 1942;38:590–8.
The first 50 years of military radiology 1895–1945 Adrian M.K. Thomas ∗ Department of Nuclear Medicine, Princess Royal University Hospital, Orpington, Kent BR6 8ND, UK Received 3 May 2007; received in revised form 4 May 2007; accepted 5 May 2007
Abstract Following the discovery of X-rays in 1895 by Wilhelm R¨ontgen the value to the military surgeon of the new technique was soon realised. The localisation of retained bullets by radiography avoided inappropriate exploration of the wound. The X-rays were first used on casualties from the Abyssinian War of 1896 and the developing radiological technology was progressively applied to military surgery. In addition the needs of warfare stimulated the development of all aspects of radiology. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: X-rays; Military technology; Radiography; Listerian concepts
It was in 1945 that lieutenant colonel Lewis Etter from the Medical Reserve Corps of the United States Army visited R¨ontgen’s laboratory in the University of W¨urzburg [1]. That area of northwestern Germany had been devastated by the recent war, but miraculously the laboratory of the physical institute had survived. It was in this laboratory 50 years earlier that R¨ontgen had discovered the X-rays [2] and in the intervening time, both the practice of warfare and medicine had changed beyond all recognition. That the discovery by R¨ontgen of X-rays would be of benefit to military surgery was realised immediately [3,4]. The end of the 19th century was a period of changing military technology when the older soft lead bullets were being replaced by steel jacketed bullets. During the 1890s, the European powers were equipping their armies with new powerful magazine rifles such as the Martini-Henry and Mauser. The new bullets made only a small entry wound and frequently passed straight through the body. The previously common gaping entrance wounds were no longer seen and surgeons found that exploration for bullets was often far worse than careful observation. The introduction of radiography helped in the development of modern war surgery by locating retained bullets. The army doctors soon saw the value of the X-rays. The older generation of army regimental surgeons were being replaced a generation trained with the Listerian concepts of antisepsis and in Britain were attracted to a professional career in the newly established Royal Army Med-
∗
Tel.: +44 1689 863653; fax: +44 1689 863320. E-mail address: [email protected].
0720-048X/$ – see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrad.2007.05.024
ical Corps. The early X-ray tubes were very fragile, however, the apparatus available before 1900 could detect fractures and foreign bodies [5]. 1. The Abyssinian War The first occasion for the use of X-rays in warfare was in the Abyssinian War of 1896 when the ancient kingdom of Abyssinia was invaded by Italian forces. The Italians lost the battle at Adowa on 1st March 1896 and the casualties returned to the base hospitals in Italy by sea. Lieutenant-colonel Guiseppi Alvaro of the military hospital in Naples successfully took radiographs of two soldiers with fractures of their forearm bones [4,6]. These radiographs were made only six months after the discovery of Xrays and clearly show the presence of retained bullets. Colonel Alvaro stated that the new technique “has proved to be a great aid in diagnosis, enabling us to determine with mathematical precision exactly where a foreign body was located.” 2. The Graeco–Turkish War Hostilities broke out in the Balkans in the spring of 1897. The European nations were divided with Germany supporting the Turkish side and Britain, Russia and the French supporting the Greeks. The German Red Cross Society sent a unit to Constantinople [7] and the London Newspaper the Daily Chronicle sent two fully staffed and equipped hospital units to Greece in the charge of the surgeon Francis Abbott under the British Red Cross [8]. The British equipment included a complete X-ray
A.M.K. Thomas / European Journal of Radiology 63 (2007) 214–219
apparatus similar to that used at St Thomas’s hospital in London. Casualties were received from the Battle of Domoko which took place on the 17th May 1897. The X-ray apparatus was operated by Robert Fox Symons and Francis Abbott gave an account of the difficulties experienced. In Phalaerum, a room at the base hospital was set out for the X-ray equipment and Fox Symons had this installed and working by the 1st of June 1897. Casualties arrived soon after and X-ray work continued for about six weeks. There were many difficulties, however the results were successful. Abbott and Fox Symons were able to illustrate their report about their activities with several radiographs and claimed “to record the first skiagrams taken in wartime, as well as to show that even inexperienced hands working can get fair results.” The original prints were exhibited at the first conversazione of the R¨ontgen Society in London (this became the British Institute of Radiology), which took place in London on the 15th of November 1897. Abbott and his team treated about 114 patients with war injuries and Fox Symons probably radiographed about half of them. On the account of Abbott and Fox Symons is interesting because of the account of the use of X-rays under field conditions and it was the first to be available to the British Army and therefore influenced their attitudes in following campaigns. Fox Symons had hoped that it would be possible to use the fluorescent screen rather than the taking plates and that of the foreign body in be looked at in many projections and would obviate the need for the slower process of obtaining a dry plate. Fox Symons lists the technical difficulties as including the heavy weight of the coil and accumulators, the fragility of the Crookes tubes and glass plates, the dangers of transporting cases of sulphuric acid for the accumulators, the delicacy and temperamental nature of the apparatus and the general problems of transportation. It was also said that an additional source of difficulty was the superstition of the local inhabitants who looked at the X-ray apparatus and its use has the work of the devil. Fox Symons said that it was difficult to take radiographs when the patient was constantly crossing himself to ward off evil spirits. Of the most serious obstacle to field radiography was the lack of a reliable source of electrical power and this prevented the siting the X-ray apparatus where it would be most useful, which was at Khalkis in the hospital nearest to the front line. Even Phalaerum did not have access to a mains electrical supply and so “HMS Rodney,” a warship of the Royal Navy, was used as the source of electricity to recharge their wet batteries. The casualties were mainly cases of fracture or suspected retained bullets and in several patients the bullets had penetrated the body cavities. The radiographic findings in addition to helping with the immediate treatment of the patient helps to define this new area of military medicine. The nature of war wounds was changing due to the newer high velocity rifles and Abbott wrote to the War Office and said: “The Roentgen rays should always, if possible, be available at the hospital nearest the front in which the wounds can be first properly examined and dealt with. . . .the apparatus is of no use in the field where detection can only be an incentive to premature exploration. The less wounds are tampered with before satisfactory surroundings are reached,
215
Fig. 1. A radiograph of ‘a bullet in the elbow of a native soldier’ taken by major Beevor (from 10).
the better. The modern bullet . . .is practically aseptic and there is no urgency for removal.” 3. The Tirah Campaign In June 1897, there was insurrection in the Northwest frontier of India on the frontier with Afghanistan. A British Army of 10,000 was sent to open the passes. One of the groups was the Tirah expeditionary force consisting of 8,000 British & 30,000 Indian troops under the command of general Sir William Lockhart. Twenty-three field hospitals were established on the Tirah plateau and 900 casualties were treated. There was a long journey to the base hospital at Rawlpindi with slow transport. Surgeons therefore treated wounds earlier and nearer to the front line. Walter Beevor, a regimental surgeon with the Coldstream guards, examined 200 cases with X-rays on the Tirah plateau and later took further X-rays in the hospital at Rawlpindi [9,10] (Fig. 1). The examinations included the leg of general Woodhouse whose leg wound had failed to heal and some weeks later Beevor was able to show the retained bullet. Beevor made a presentation to the United Services Institution in May 1898 which signalled the introduction of field X-ray units into the British Army. It is to be observed that Walter Beevor had purchased his apparatus at his own expense. 4. The River War A British led army was sent from Cairo to the Sudan against the Mahdists whom they defeated at Omdurman on 1st September 1898. The army was led by general Herbert Kitchener. The force was of 20,000 men and equipped with modern weapons. Thomas Cook’s pleasure boats took the army up the Nile as far as the cataract at Aswan. In the battle at Omdurman in daylight, 50,000 Mahdist tribesmen attacked a modern army. They only had spears and primitive guns and the carnage was enormous. The army medical department had learnt from the experience of surgeon-major Beevor ordered a portable apparatus from A.E. Dean to be sent with the expedition; however the apparatus was
216
A.M.K. Thomas / European Journal of Radiology 63 (2007) 214–219
Fig. 2. ‘Science to the rescue. Finding a bullet with the X-ray apparatus at the military hospital, Pietermatitzburg.’ Black and White budget, 1899.
only sent after angry words in the British parliament. The preliminary battle at Berber had already been fought when a member of Parliament about the supply of the X-ray apparatus. The Financial Secretary of the War Office reported that the senior medical officer reported that no case would have benefited if the apparatus had been available. A decision was finally made to send X-ray apparatus. It was put in charge of surgeon major John Battersby [10,11]. He examined about 60 casualties with X-rays at Abadieh near Berber on the upper Nile between July and October 1898. His mud hut at Abadeih became a landmark in the history of radiology and of military medicine [3]. The apparatus had been issued by the war office as part of the regular medical supplies and it was the first use of X-rays in the field by the army medical department. The main difficulty experienced by Battersby was the climate in the Sudan and it was with great difficulty that the apparatus was made to work. Electricity was generated by a soldier using a bicycle. One hundred and twentyone wounded were transferred to Abadeih and in 21 cases the conventional approach could not find a bullet. In 20 of these cases, an accurate diagnosis was made using the X-rays and in the final case the patient was too ill to be examined. Battersby concluded that radiography prevented suffering by unnecessary probing of the wound and in addition to simple radiography, he used the cross-thread localisation device of James Mackenzie Davidson [12] (Fig. 2).
Fig. 3. The use of the localisation device of Mackenzie Davidson by Major Battersby (from 11).
technique was not without hazards and two cases of X-ray burns caused by repeated and prolonged exposure were presented. Borden believed that the most important factors responsible for the burns were the duration of exposure and the closeness of the X-ray tube to the patient. 6. The Boer War In 1899, limited campaigns in South Africa started. The initial preparations were inadequate and what was expected to be a brief conflict turned into a full-scale war. The Boer War was the first occasion since the Crimea that the British Army faced an opponent with weapons as modern as their own, and also had the advantage of defending their country against invaders. The war lasted two and a half years. There were 500,000 British troops in South Africa. Less than 6,000 died in battle and over 16,000 died of disease. The Boers lost with about 5,000 killed. The medical arrangements became more complex as they progressed with a system of general (fixed) hospitals and field
5. The Spanish–American War In the Spanish–American War of 1898, there was a limited use of radiography and again this obviated the need for unnecessary probing of the wound. The larger American general hospitals and three hospital ships were supplied with radiographic apparatus [6,13,14]. The American forces had felt that the use of radiography in the field was unnecessary because the bullet wounds rarely required immediate removal and it was also believed that since aseptic surgery was not easy under field conditions, if the radiography could be obtained, then it would only encourage the surgeons to operate inappropriately. Captain William Borden [14] published his document on the use of X-rays with an extensive account of the use of the new technique. The new
Fig. 4. ‘Wounded from the front. Locating a Mauser bullet by X-rays in a London hospital.’ The Graphic, June 16, 1900.
A.M.K. Thomas / European Journal of Radiology 63 (2007) 214–219
217
Fig. 7. ‘Radiographing a wounded shoulder.’ Fluoroscopy as illustrated in 20.
7. The First World War
Fig. 5. ‘An X-ray photograph showing the position of a Mauser bullet in the left shoulder of a soldier invalided home.’ The Graphic, June 16, 1900.
(moveable) hospitals. X-ray apparatus was supplied to general hospitals as part of the essential equipment for the campaign [15] (Fig. 3). Both electrical and radiation protection were still primitive. The general hospitals (but not the field hospitals) had portable X-ray apparatus to allow retained bullets to be detected and fractures to be diagnosed and treated (Figs. 4 and 5). The equipment was supplied with a dynamo to generate power needed for the batteries.
The First World War was war with all its grim tragedy [4] and the large number of casualties put a considerable stress on the casualty clearing or mobile field hospitals [16]. At the start of the war, the X-ray equipment was located in the larger army hospitals behind the front [17]. Initially, it was felt that there was no need for facilities near to the fighting, however, as the war progressed, the confidence of the army surgeons in rapid radiography increased and this was a view held by Marie Curie [18]. In France, Marie Curie developed an X-ray car (voiture radiologique) (Fig. 6) and equipped 18 such cars herself. The engines of these cars could supply the current supply for the X-ray apparatus [19]. Marie Curie also established two hundred fixed radiographic units. As the war continued the need for both radiologists and technicians increased. The French radiologist Antoine B´ecl`ere developed a training school at Val-de-Grace hospital and the French Army opened a school for X-ray technicians. Marie Curie opened a school for female X-ray technicians
Fig. 6. ‘French field hospital – Locating bullet with X-ray machine.’ Stereo-pair, Keystone View Company.
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Fig. 8. ‘First captured German X-ray apparatus, consisting of wooden upright stand, light upright lightweight metallic tubing stand with canvas stretched across’ (from 24).
(manipulatrices) in 1916 and worked with her daughter Ir`ene [17]. At the beginning of hostilities, the European armies were supplied with traditional gas X-ray tubes. During the First World War, more powerful radiographic apparatus became available as the Coolidge tube and the Potter-Bucky diaphragm were introduced. The American expeditionary force was supplied with the best radiographic apparatus available and these modern advances were used fully [4]. Following injury, the casualty was sent to a regimental aid post and then by field ambulance to the casualty clearing station, some miles behind the front. If radiography was required, then the patient was transferred to the X-ray room. Most of the X-ray work was in the detection of retained bullets and a simple apparatus was used [20] (Figs. 7 and 8). The stretcher with the patient was placed on supports above a moveable X-ray tube. The patient was rapidly fluroscoped and using a parallax technique with tube movement, the depth of the foreign body and its relation to the point of entry could be determined quickly and a written report issued [21–23]. The apparatus was powerful enough to diagnose thoracic injuries [24,25] and the use of stereoscopy was common.
Fig. 10. The Watson MX-2 arranged for fluoroscopy using a cryptoscope (hooded fluorescent screen).
Vincent Cirillo has demonstrated the importance of World War I for the development of the speciality of radiology [13]. The army surgeons became accustomed to working in a team with radiologists and this practice continued after the war. The number of radiologists increased and the X-ray equipment became easier to use. World War I legitimised the discipline of military radiology [13]. 8. The Second World War By 1939, good portable apparatus was available. The British Army was supplied with the MX2 [26] which was robust and easy to use (Figs. 9 and 10). This apparatus could be used for radiography and fluoroscopy and was easily crated for transportation. Radiography had developed as a profession and many entered the forces, however numbers available were inadequate and many units were only supplied with radiographers with no medical radiologists. In the US, two radiologists were assigned to each mobile surgical hospital unit [27,28]. The work would consist of fluoroscopy of casualties, foreign body localisation, general duties and radiotherapy for superficial infections including gas gangrene (prior to the introduction of antibiotics). Compared to the first War, the war was more mobile and radiographic units accompanied the field hospitals. 9. Conclusion The military surgeons at the end of the 19th century soon realised the value of radiography in military surgery and innumerable lives were saved in the subsequent 50 years. As military technology developed, so did the technology to treat war casualties. We owe a debt to the early pioneers who initiated the development of military radiology, the need for which is still very much with us. References
Fig. 9. The Watson MX-2 arranged for radiography.
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A.M.K. Thomas / European Journal of Radiology 63 (2007) 214–219 ¨ [2] R¨ontgen WC. Uber eine neue Art von Strahlen (Vorl¨aufige Mittheilung). Sber Phys-Med Ges W¨urzb 1895;137:132–41. [3] Burrows EH. Pioneers and early years: a history of British radiology. Colophon, Great Britain, 1896:194-219. [4] Reynolds L. The history of the use of the roentgen ray in warfare. AJR 1945;54:649–72. [5] Guy JM. British Military Radiology, 1897–1919. In: Thomas AMK, editor. The invisible light. 100 years of medical radiology. Blackwell Science; 1995. p. 39–41. [6] Alvaro G. The practical benefits to surgery of R¨ontgen’s discovery (diagnostic results in the location of bullets in wounded soldiers from Africa). In: Bruwer AJ, editor. Classic descriptions in diagnostic roentgenology, vol. 2. Springfield, IL: Thomas; 1964. p. 1318–23. [7] K¨uttner H. The importance of roentgen rays in war surgery based on experience in the Greco–Turkish war of 1897. In: Bruwer AJ, editor. Classic descriptions in diagnostic roentgenology, vol. 2. Springfield, IL: Thomas; 1964. p. 1337–45. [8] Abbott FC. Surgery in the Graeco–Turkish war. Lancet 1899;1(80–83):152–6. [9] Beevor WC. The working of the Roentgen ray in warfare. J R Un Serv Instn 1898; 42:1152–1170. In: Bruwer AJ, editor. Classic descriptions in diagnostic roentgenology, vol. 2. Springfield, IL: Thomas; 1964. p. 1346–67. [10] Fyfe HC. The R¨ontgen rays in warfare. Strand magazine, 17. 1899. p. 777–83. [11] Battersby J. The present condition of the Roentgen rays in military surgery. Arch Roentg Ray 1899;3(74–80):89–91. [12] Davidson JM. A method of localization by means of Roentgen rays. Arch Roent Ray 1897;2:64–8. [13] Cirillo VJ. The Spanish–American War and military radiology. AJR 2000:1233–9.
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