Methods of Localization [excerpt]

     An Emergency Case.—But stepping aside from the consideration of exact methods with a full equipment at hand let us take an emergency case and see what can be improvised to locate a bullet before a primary operation. Suppose a man is shot point-blank in the abdomen and must be treated where few surgical and no X-ray facilities are at command. An operation is decided on. The wound will be opened, cleaned, and sutured. The bullet is “probably” lodged in the muscles of the back, where it may become encysted and do no harm, but it is desirable to know where it is and ascertain its relations to the operation. Granted that there is no X-ray apparatus at the bedside, there [242][243] are several in the city, and a truck can move one as fast as a horse can draw a cart. While preparing the patient, telephone one that can be moved most quickly, and in fifteen minutes or a half hour it can be at the operating-table.
     But none of the surgeons have any localizing instruments and do not know how to use any. They have not studied localizing technics. They are in haste to get at the wound and care little for the bullet. Nevertheless, it will delay only a moment to find it, and then during the operation it can be taken out. Let the surgeon go ahead with his preparations. Let the anæsthetizer begin. Tell an assistant to connect up a tube. As soon as the muscles relax run the tube over the abdomen five inches from the skin and light it up. Let an assistant drop under the table with the fluoroscope and find the shadow of the bullet, which is undoubtedly near the back. When found have another nurse move the tube so that it is vertical over the bullet, being directed to the proper position by the watcher with the fluoroscope under the table. Then let the nurse lay on the abdomen a pair of artery forceps and move them till the fluoroscope shows that the bullet-shadow is rimmed by one of the handles. Then have the nurse slip any long metal instrument with a small tip under the back and shift it till the fluoroscope finds the tip in the same line as the shadow of the bullet. The job is nearly done now. It has taken only while the surgeon is washing his hands, and has delayed nothing. Let the assistant at the fluoroscope still, for a second more, sight the line of the shadows as above. Let the nurse shift the tube a foot or so horizontally. How much has the shadow of the bullet left the line of the front and back markers? If very little, the bullet is very near the back. If very much, it is nearer the front wall than was supposed. The watcher with the fluoroscope can judge the approximate depth by the comparative amount of movement out of the line. Then all is ready. Remove the tube; note that the bullet is in the line between the front and back markers at an estimated depth from the back; let a nurse register the location; and proceed with the surgical treatment of the case. As sterilized instruments were used the operating field has not been interfered with, and the time required has been part of the general preparations. The absence of complete apparatus has not presented an insurmountable obstacle to localization. Having found the site of the bullet the question of its removal can be discussed in the light of exact knowledge instead of ignorance.
     In these directions it has been assumed that an operation was planned. The records of war (and some of them are stated in our chapter on X-rays in military surgery) do not greatly encourage such [243][244] operative interference. The sad result of but a few months ago is eloquent with lessons to optimistic surgery which has boasted its science above medicine. We simply point out that if an operation is impending the bullet can be found by the above impromptu technic, and if no interference is designed the same technic can at a convenient time be used minus the anæsthesia to locate the bullet without harm or disturbance to the patient, simply for the satisfaction of knowing where it is.
     An X-ray examination is not a desperate resort in extremis as many of the public judged it to be from the Buffalo bulletins. At this late day we see in sorrowful retrospect that the question of immediate localization was of the utmost insignificance. But friends of surgery will regret that the X-ray question was not handled with candor to the public and with the decision of competent X-ray knowledge. So far as we have conversed with lay (and the same is true of medical) remarkers on the keenly disappointing case two impressions made their way into the general mind: (1) that an X-ray examination would have been so severe a shock or ordeal that the President could not have endured it; (2) that the bullet was not located because none of the surgeons in the case knew how to do it, and an outside expert was refused from over-confidence or prejudice or to avoid an exposure of said ignorance. The author, however, has no personal comment or criticism to make on these wide-spread impressions. He does not know the true facts. Nor does the official medical report of the case made public on October 19, 1901, appear to throw additional light on the subject. The vital surgical question on September 6th was one of noninterference and not of X-rays per se, and this being so it would have been well to have adopted a different attitude toward the great popular anxiety as to an X-ray diagnosis; an anxiety fostered by repeated surgical statements that “the X-rays would have saved Garfield.” After the probe has been used it is too late to employ conservatism. X-rays then are like locking the stable door after the horse has been stolen.
     Without in any respect implying that human skill could have changed the event in the stunning tragedy that closed our President’s career, yet, if mistake occurred, close study of the lesson is the best way to profit by it.