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The X-Ray Service in an Army Area Surgical Hospital

Medical Science Publication No. 4, Volume 1

TUESDAY MORNING SESSION
20 April 1954

MODERATOR
COLONEL WILLIAM S. STONE, MC


THE X-RAY SERVICE IN AN ARMY AREA SURGICAL HOSPITAL*

COLONEL HARRY L. BERMAN, MC

Our experience in the Korean conflict tended to crystallize some of our notions about our problems in the field of military roentgenology. We entered this struggle after a decade of singular and conspicuous progress in the science of medicine. The specialty of radiology, being intimately associated with the other branches of medicine, naturally shared in the advances. However, because of the incomplete status of development of our newer military X-ray equipment, our entry into Korea was made with World War II equipment and perhaps with somewhat outdated concepts by many physicians as to the practice of roentgenology.

Since practically all aspects of military roentgenology revolve about equipment, let us consider that item first, including a little about its background. Military field X-ray equipment is designed to produce roentgenograms of satisfactory diagnostic quality, while retaining the features of minimum weight, adaptability to a limited power supply, and sturdiness to withstand the ravages of adverse environmental effects and rough handling. The ideal machine is one in which an extremely rapid exposure may be made, just as in the case of a camera, to minimize the effect of motion and the resultant blurred detail on films.

The time of exposure bears a definite relationship to the number of milliamperes which an X-ray machine delivers. For example, if a certain examination requires an exposure of 100 milliampere-seconds with a given voltage, the same effect is produced by a machine operating at 200 milliamperes for one-half second as by one operating at 25 milliamperes for 4 seconds. It should be quite clear that the chances of motion on the part of a patient, especially a semicomatose one, are much greater with an exposure of 4 seconds than with one requiring a half-second.

However, those machines designed to deliver the higher amperages are excessively heavy, unwieldy units with power requirements far beyond those which field generators can meet. Consequently, for field


*Presented 20 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School. Walter Reed Army Medical Center, Washington, D. C.


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use an X-ray machine within allowable limits of weight and power requirements will have definite restrictions as to output in amperage, and the price paid for that sacrifice is a prolonged exposure time.

At the beginning of World War II it was anticipated that the demonstration of fractures and the localization of foreign bodies would constitute the major portion of the radiological work in the forward areas and that this could be done mainly by fluoroscopy alone. Furthermore, it was expected that film would be in short supply, necessitating resort to fluoroscopy. It was believed too at that time that definitive surgical care would be given in fixed-type hospitals further to the rear, where conventional X-ray equipment including all accessory items would be installed.

The World War II unit was accordingly built to meet the needs of the forward area installation. It was constructed to operate with one tube for both fluoroscopy and radiography. It was capable of a maximum output of 85 kilovolts and 30 milliamperes. This of course was more than adequate for fluoroscopy which is normally performed at 3 to 5 MA. The table is a steel frame which was expected to support a litter for a top (fig. 1). The casette holder could be adjusted so that a fixed grid might be interposed between the part examined and the film. If necessary, the tube could be turned to one

FIGURE 1. World War II field x-ray unit.


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side for the examination of litter patients on the floor or adjusted for vertical radiography of the chest.

Fluoroscopy with this unit is done by swinging the tube beneath the table top, but it is cumbersome and awkward. Patients could not be readily examined in both the horizontal and vertical positions without a time-consuming shifting of the apparatus, and the fluoroscopic screen held in a practically rigid position could not be moved around freely for the examination of different areas.

The unit was a rugged, well-built piece of equipment requiring very little maintenance, and generally it might have served the purpose for which it was intended, as the problem of medical care in the forward areas was originally envisaged. However, subsequent experience proved the fallacy of that concept. The definitive care of the so-called nontransportable patient was instituted in mobile hospitals in the forward area, a practice which was extended in the Korean conflict. The nature of the work there required films which the surgeon wished to see and which could serve a permanent record. Foreign body localization assumed less importance than was expected. Furthermore, there was a demand for routine roentgen procedures, such as barium enemas, gastrointestinal series, etc., none of which were easily performed on the World War II unit. Some of the more enterprising radiologists improvised certain embellishments to facilitate some of the radiographic procedures, but it seemed obvious after the war that the development of a more serviceable unit was in order.

After careful study in the postwar period, it was decided to build two types of field x-ray machines: (1) a small one, light in weight and readily mobile for use in hospitals in the forward areas; and (2) a larger unit containing most of the features of a conventional machine for use in the fixed hospitals in the communications zone.

The former, capable of a maximum output of 85 KV and 15 MA, was intended for use in such installations as the Mobile Army Surgical Hospitals and the evacuation hospitals. It first made its appearance in Korea in the latter part of 1951. Up to that time and for some time afterwards the World War II unit was used in the medical installations in Korea and in most numbered hospitals in Japan.

This unit, shown in figure 2, has several features which are a definite improvement over the World War II unit. The table, serving as its own packing case, has a sliding top which can be set quickly and easily in either the horizontal or vertical positions. The tube is easily positioned over the table for radiography or under it for fluoroscopy. The unit has a reciprocating Bucky diaphragm; that is, one which oscillates


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FIGURE 2. 15 MA field x-ray unit.

back and forth. A lightweight portable tube-stand equipped with large casters is part of the set and permits its use as a bedside unit.

In spite of these improvements, it is felt that changing from a 30 MA to a 15 MA machine was a retrogressive step. Benefits to be derived from the increased flexibility of an x-ray machine should not be gained at the expense of the exposure time and at the risk of motion of the patient. If the purpose of the new machine was to demonstrate only fractures or metallic fragments, then it presented no advantage over the old machine. If it was to facilitate the performance of routine and diverse procedures, the prolongation of the exposure time nullified the effects of improvements in equipment. It was almost impossible to immobilize large individuals and irrational or semi-comatose patients for the required time of exposure. The same problem held in the case of head examinations, stereoscopic films, and in gastrointestinal series in which the situation was aggravated by the fact that the stomach and duodenum are normally in motion.

After a 6-month trial the first 2 units in Korea were converted to 30 MA machines by using cable converter kits along with the tube, transformer and control stand of the World II unit. This was a definite improvement and at present constitutes the best we have for


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the forward installations. Although it still leaves much to be desired, considering the type of work done in those hospitals, it is capable of a satisfactory performance.

The larger unit, operating at a maximum of 100 KV and 100 MA, has all the features of it modern, conventional radiographic and fluoroscopic machine (fig. 3). It has a hydromatic motor-driven tilt table, two tubes with rotating anodes-one for fluoroscopy and one for radiography, a fluoroscopic screen with a spot film device, and a movable Bucky diaphragm. It differs from conventional equipment in that its transformer utilizes a gas, sulfur hexafluoride, as an insulating medium, instead of the usual transformer oil. This gas is odorless, nontoxic, noninflammable and has a density about five times that of air. All wires and cables are of the "plug-together" type and can be quickly connected and disconnected. The machine has been designed to reduce weight whenever possible, but it is still too heavy for use in the forward area installations. When used in the field away from a community power supply, it requires a 10 KW generator for a power supply.

It is possible to combine certain items from both field units and thereby have an intermediate machine with a high output in milliamperage, while retaining the features of moderate weight and

FIGURE 3. 100 MA field x-ray unit.


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FIGURE 4. 100 MA field X-ray unit with lightweight table.

mobility (fig. 4). The control stand, transformer and rotating anode tube of the large unit are combined with the lightweight table of the smaller unit. The power requirements of the large unit, namely, a 10 KW generator, remain unchanged. This combination was not tried in Korea. It should have a field test.

Of the accessory items of equipment the most important is that concerned with film processing. This consists of a stainless steel processing tank with two inserts for the solutions and a water-conditioning unit to maintain the temperature of the solutions at 68° F. regardless of the environmental temperature. The film can be dried in a field dryer (fig. 5) after processing.

The chemical processing of films was a very perplexing problem. For reasons difficult to determine, whether because of the complexity of the equipment or the inertia of the technicians, the temperature-conditioning unit did not work. As a consequence, the temperature of the processing solutions varied with that of the environment. The problem was especially acute in the winter and summer when extremes of environmental temperatures occur. Thus, films were too often processed in solutions which were too warm or too cold.


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FIGURE 5. Field dryer.

The processing of films presents a problem from another aspect. Frequently, patients were immediately evacuated after initial examination in the MASH. An envelope of wet, incompletely developed films went with the patient. These were subsequently of little use, although they might have provided important information. There is need for a rapid developing and drying process for field use.

The Land-Polaroid process was tried in Korea but not with especially gratifying results. This equipment makes use of a special cassette with paper instead of transparent film. After exposure of the film, it is placed in an electrically operated processing device and developed for 1 minute, following which the device is opened and the film is immediately available for use. In radiographs prepared by this method, the detail is not too satisfactory in the thicker parts. This method of radiography has great possibilities but requires further study.

No standard stereoscopes of the Wheatstone type were available in Korea. There was a crying need for stereoscopy, especially in the management of battle casualties with head and eye injuries. The


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need was met by using a 90-degree prism obtained from the periscope of salvaged tanks. This represented an inexpensive and economical solution.

So much for equipment. Now I should like to say a few words about the problem of radiation protection. Initially there was considerable laxity on the part of all personnel with respect to protection from radiation. There was a tendency ascribed to expediency to crowd auxiliary services, such as x-ray, laboratory, pharmacy and admitting room, into as compact a space as possible. As a result, a large number of people were being constantly exposed to radiation while performing their normal duties. I saw a roentgenologist reading films seated 3 feet away from an x-ray machine in constant use. Recently he wrote me that his white blood count was low. The practice on the part of technicians of standing close to an x-ray machine while making an exposure, was very common. Occasionally, one saw a small piece of lead, set for some strange reason about 3 feet from the floor, behind which the technician stood during an exposure.

Although sheet lead was available in Korea, its use for protection barriers was negligible until its importance was stressed. Towards the end of 1952 the situation in this regard showed considerable improvement. The hazard of radiation to personnel must be constantly emphasized and unremitting attention must be devoted to appropriate protective measures. Figure 6 demonstrates a desirable arrangement of an x-ray department for a field-type hospital.

FIGURE 6. Arrangement of x-ray department in tent for field use.


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The problem of protection raises the question as to the location of the x-ray department in the forward area hospitals. Its best location is near the admitting room, so that it lies along the normal flow of patients through the hospital. Protective lead or sand-bag barriers should be interposed between the x-ray machine and personnel who must be in its vicinity. Where these cannot be provided, a minimum of 10 yards on all sides should separate the x-ray department from the other parts of the hospital. As a mandatory minimum for the x-ray personnel the presence of a protective barrier as shown in figure 6 is essential.

Many of the problems relative to protection and technic stemmed from the fact that no trained roentgenologists were assigned to the Mobile Army Surgical Hospitals. It is an accepted fact that x-ray films and roentgen studies generally are better in a hospital with a roentgenologist than in one without. Initially it was felt that no roentgenologist would be needed because of the fact that the patients were all traumatic in type, and it was desired to keep the number of nonsurgical personnel at a minimum. In a sense, this is a reversion to the broken-bone, metal-fragment brand of roentgenology of olden times, but the need for having a minimum of personnel may be an overriding consideration. During the latter part of 1952 competent roentgenologists were assigned to the MASH's and undoubtedly contributed substantially towards an improved standard of roentgenology. Most hospitals used them in the combined status of roentgenologist and admitting officer or officer in charge of the preoperative ward. The MASH commanders generally preferred to rotate their surgical personnel through the preoperative ward and not have a full-time roentgenologist. They felt that they would like to have a consulting roentgenologist visit them from time to time to discuss their diagnostic and technical problems.

There was an adequate supply of generally competent, well-trained enlisted technicians. Most of these came from the conventional hospitals in the United States, where the handling of acute casualties is done infrequently. In the training of our technicians more emphasis should be placed on the work under field conditions and on practice with simulated casualties.

In the latter part of 1952 a field x-ray unit was installed in the clearing station of the 40th Infantry Division as a test to see if needless evacuation for minor injuries and some minor medical conditions might be reduced. The addition of this unit to a division clearing company creates certain additional logistical and technical problems for that organization. Whether or not the benefits to be gained will compensate for those problems has not been determined. The question requires further study.


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Roentgenological studies in the management of the various wounds and injuries treated in the forward area hospitals contribute a great deal more than the mere demonstration of fractures and metallic fragments. The localization of small fragments of bone and metal in the brain is extremely important to the neurosurgeon, but this cannot be done without good films. The localization of foreign bodies in and about the eyes can be made with a pair of good stereoscopic films without recourse to special equipment, such as the Sweet localizer, but stereoscopic films of a severely wounded man cannot be made with a machine requiring a long exposure time. The care of chest wounds with intrathoracic hemorrhage, pneumothorax and hemopericardium requires films showing good detail. Similarly, free air and blood from ruptured abdominal viscera cannot be detected on films of poor quality. Such diagnoses are a far cry from the days of fracture and shrapnel roentgenology, and yet without this knowledge the surgeon is greatly hampered. Many other examples could be cited to show the place of roentgen studies. They need not be recounted here, but it suffices to make mention of this fact in order to point out that diagnoses are made when the index of suspicion has height and breadth.

Our forward area hospitals am now capable of performing surgery of a prodigious nature. Its diagnostic support in the field of roentgenology requires appropriate examinations, technically well prepared and competently interpreted. We have certain problems requiring further study. Our aim is to provide all the means possible to assist the surgeon.