SOME LESSONS OF THE SPANISH WAR
REDUCED MORTALITY AMONG THE WOUNDED-EXPOLORATION WITH X RAYS
There are revelations of much popular interest as well as professional value in a report which has been prepared by W. C. Borden, captain and assistant surgeon, U.S.A., under the direction of Surgeon-General Sternberg on the use of Röntgen rays in the late war with Spain. One of the most striking or these facts is that the mortality among the wounded who were under treatment was much lower than in any other similar conflict in half a century.
The percentage of deaths among the injured French in the war of 1859 with Italy was 17, of the Prussians who invaded Denmark in 1864 about 15 1/2, of the English in the Crimea in 1854-56 over 15, of the Union soldiers in the American Civil War nearly 13 (12.96 to be exact), and in three or four modern European conflicts from 10 to 12 per cent. The percentage among the American troops in the Cuban war was only 6.64.
When a comparison is made between the Civil and Spanish wars, according to the region in which the wounds were inflicted, it appears that the chief improvements which are discernible were in the results of injuries in the chest or the extremities. In the Civil War the mortality was 27.8 per cent among men wounded in the chest, whereas in the Cuban war it was only 11.6 - less than half as great. The diminution in deaths from injuries to the upper extremities was from 6.54 to .20 per cent, and in the lower extremities from 13.8 to 1.6 per cent. In other parts of the body there was little difference. Indeed, there was a slight increase in the mortality from wounds In the neck and spine, instead of a decrease. The percentages for the neck in the Civil and Cuban wars were 15 and 22 respectively, and for the spine 55 1/2 and 66 1/2.
EFFECT OF THE MODERN BULLET.
Captain Borden is willing to concede that part of the gain which has been made is due to the modern style of bullet. This is much smaller than the old musket ball, is coated with a thick layer of brass or nickel steel, which gives the projectile greater rigidity, and it is sent at a higher velocity. One consequence of this change is that the modern bullet travels a much straighter course than the old one, whether it be bone or soft tissue that it encounters. Another is that it almost invariably goes entirely through the man, instead of lodging inside. However, when the projectile is fired at verylong range it is more likely to lodge. This was frequently the case in the Santiago campaign. Again, if the bullet first strikes some other object outside the soldier, and ricochets, much of its force will be spent, and it may lodge. Such bullets are usually more or less deformed, and will even be discovered with the butt end foremost.
But the writer of this report insists that the lessened mortality is also due to some extent to improved surgical methods. In the Civil War surgeons knew practically nothing of the relations between suppuration and blood poisoning on the one hand and bacteria on the other."Asepsis" and "antisepsis" had not found their way into practice or the dictionaries. Nowadays the surgeon aims to prevent the infection of wounds, and if they are infected proceeds to kill the germs that make mischief there. It has been pretty well demonstrated that a modern bullet carries in a few bacteria, but not enough to do harm. Nature immediately sets up a warfare on these few germs, and quickly isolates or kills them. Hence, it is the wisest policy not to interfere with the wound by probing or by efforts to remove a lodged bullet. These latter proceedings are pretty sure to aggravate the trouble and produce infection.
AGAINST PROBING WOUNDS IN THE FIELD.
Captain Borden quotes a number of European authorities on this point, and the careful pursuance of the let alone policy in the Cuban war by American surgeons still further demonstrates the soundness of the reasoning. In the field hospital the facilities for sterilizing instruments are so poor that it is wise to leave the bullets in, either to stay permanently or for removal under more favorable circumstances, than to take them out, unless there are special and urgent reasons for immediate extraction. The new system of military surgery, then, recognises the fact that in the vast majority of cases bullet wounds are uninfected and applies "occlusive," or closing dressings thereto. Where the septic character of the injury is patent, however, antiseptics are freely used, But even so an operation is avoided as far as possible. Amputations are not resorted to as frequently as formerly. Now the modern bullet fractures a bone into finer bits than the old one did, and thus produces what in one sense is a worse state of affairs. Hence the reduced mortality which was observed in the recent war indicates that "conservative" surgery deserves at least a part of the credit.
Shrapnel consists of bullets inclosed in a shell fired from a cannon. These have a low velocity and a large calibre, and theoretically ought to cause more mischief than a Mauser bullet. But the experience of 1898 establishes pretty conclusively their comparative harmlessness. On the whole, it is wise to let them alone if they lodge and apply occlusive dressings. The wisdom of non-interference was forcibly illustrated, again, in cases of injury to the spinal cord and brain. The Röntgen rays proved thai the symptoms in the first of these instances were due not to the pressure of the lodged bullet on the cord, but to the original shock. The other case is that of a raw Nebraska soldier who was wounded in the forehead in Manila about two years ago. For a day or two he was unconscious and paralyzed. Then he suffered acute pain. But in five weeks he was practically recovered, and at last accounts was going around with that bullet in his brain.
PLAN OF X-RAY EXPLORATION
But while the utmost caution must be observed about removing bullets, it is necessary that the surgeon should be able to locate them. The metal probe is dangerous. The telephonic probe fails to give the desired results. But the Röntgen ray explores the body with safety and certainty, and is an essential of the army surgeon's outfit. The vacuum tube may be excited by either a "static" machine or a battery. An induction coil capable of giving a spark across a 6 inch gap is powerful enough to work the tube. Ten cells of the Edison-Laiande type will supply sufficient current. As between the battery and static machine, there seems to be little choice. The former is more portable and compact perhaps, and yet it requires more frequent attention than the heavy, fragile and cumbersome static machine. Still, even the latter must be guarded from dust and dampness.
Visual exploration with the fluoroscope is not always satisfactory, because the eye is not sufficiently keen to catch the differences in opacity at great depths. A radiograph is better because it is cumulative in its record of impressions. Hence it is almost invariably employed in surgical diagnosis. Special plates are used for this work,the highest sensitiveness and the greatest thickness of coating being desirable. The thicker the film on the negative the more marked will be the contrast of light and shade. The length of exposure varies according to the thickness of the part explored. But with the vacuum tube distant ten inches, the time required for the hand or forearm is from one to two minutes, for the shoulder and chest ten minutes, the knee nine, and the head, hip Joint and pelvis twenty.
Burns are of very rare occurrence if the apparatus is in good working condition. Captain Borden says that only two cases were reported, and these resulted where, owing to the failure of the instruments to give the desired results, exposures were made on three successive occasions, each time for twenty or twenty-five minutes. No doubt a diseased or debilitated system would be more susceptible than another to this sort of injury. But if the apparatus is in the proper order no harm is to be anticipated.
Source: New York Tribune January 27, 1901, page 13.