The Dawn of the X Ray
X rays were discovered accidentally on November 23, 1895, by the German physicist Wilhelm Roentgen. Roentgen was working in a darkened room, trying to determine whether recently discovered cathode rays could travel through a glass vacuum tube. "Suddenly, about a yard from the tube," recounted Dr. Otto Glasser, Roentgen’s biographer, "there was a weak light that shimmered on a little bench he knew was located nearby. It was as though a ray of light or a faint spark from the induction coil had been reflected by a mirror." Not believing this possible, Roentgen repeated the process, and another faint light appeared, this time looking "like a faint green cloud." Excited, Roentgen soon found the fluorescence was caused by the rays striking a chemically treated screen. After extensive experiments he determined that the rays had a very short wavelength that gave them special penetrating power, enabling them to pass through various substances—including human flesh. Human bones, he found, cast a denser shadow than surrounding soft tissues—a property that would form the basis for the global medical X-ray industry.5
Roentgen published his first article on the phenomenon in late December 1895. By February of 1896 American physicists were using X rays in clinical medicine. One patient—a young boy named Eddie McCarthy—had a broken forearm X-rayed. A young New Yorker named Tolson Cunningham had a bullet removed from his leg after it was located with a forty-five-minute X-ray exposure. Soon University of Pennsylvania professor Henry W. Cattell wrote in Science that "the manifold uses to which Roentgen’s discovery may be applied in medicine are so obvious that it is even now questionable whether a surgeon would be morally justified in performing a certain class of operations without first having seen pictured by these rays the field of his work—a map, as it were, of the unknown country he is to explore."
Within months X rays were used to find a bullet in the brain of a twelve-year-old child, a severed drainage tube in a lung, and to photograph a broken hip joint. By the end of 1896 a Chicago electrical engineer named Wolfram C. Fuchs had performed more than fourteen hundred X-ray examinations, and doctors were regularly referring their patients to "specialists" with the simple, primitive machines they had bought or built themselves.6
Not surprisingly the early X-ray pioneers had little understanding of the potential dangers of radiation. Theyrarely bothered to protect their patients or themselves from overexposure. Machine operators often tested their equipment by placing their hands—time and again—in the beam. With fluctuating power ratios and errant beams, doctors, patients, machine operators, and bystanders alike were exposed. The X rays could even penetrate walls and irradiate people in other rooms.7
And the side effects were not long in surfacing. In 1896 Dr. D. W. Gage of McCook, Nebraska, writing in New York’s Medical Record, noted cases of hair loss, reddened skin, skin sloughing off, and lesions. "I wish to suggest that more be understood regarding the action of the x rays before the general practitioner adopts them in his daily work," Gage warned.8
As the technology was refined and the equipment became more powerful, increasingly serious damage began to surface. A part-time machine demonstrator named H. D. Hawks was forced to quit his job after only four days because his hands began to redden and swell. The skin on his knuckles disintegrated from overexposure, fingernail growth halted, and the hair on exposed skin fell out.9 Hawks’s problems were minor compared with those of Clarence Madison Dally, a glassblower at Thomas Edison’s Menlo Park laboratory and the first American X-ray worker known to have been killed by X-ray exposure. Dally frequently tested the output of radiation tubes by placing his hands directly in the beam. Though he was severely burned in 1896, Dally continued X-ray work for two more years. In 1902 his right arm was amputated at the shoulder to arrest the spread of skin cancer; two years later his left arm was amputated for the same reason. Dally died that October, prompting Edison to discontinue radiation research in his laboratory. By the 1930s so many people had fallen victim to the misuse of X rays that an entire book (entitled American Martyrs to Science Through the Roentgen Rays) was published by Dr. Percy Brown, a Boston radiologist who himself died of cancer in 1950.10
As the demand for X rays expanded, so did the number of people operating the machines. Radiology grew from a specialty of only a few hundred practitioners in 1913 to a burgeoning profession with more than fifteen thousand people in 1981—roughly 6 percent of the nation’s physicians. To become certified radiologists, doctors generally complete a three-year residency following their medical-school training and internship. A one-year fellowship in a specialty may also be taken. They must then pass a national examination before practicing.11 As an elite group of medical doctors with radiation training, they raised the use of diagnostic X rays to the status of a high-powered medical specialty.
Unfortunately the health of radiologists declined dramatically with the expansion of their trade. In 1946 a statistical study of obituaries in the New England Journal of Medicine by Dr. Helmuth Ulrich found the leukemia rate among radiologists to be eight times that of other doctors.12 In 1956 the National Academy of Sciences (NAS) supported those findings in a report that concluded that radiologists lived 5.2 years less than other doctors.13 In 1963 a study by Dr. E. B. Lewis found a significant excess of deaths from leukemia, multiple myeloma, and aplastic anemia among radiologists, and two years later two Johns Hopkins researchers discovered a 70 percent excess of cardiovascular disease and certain cancers among radiologists as opposed to the general population, and a 730 percent rise in leukemia deaths.14 In 1981 Dr. Genevieve Matanowski, who is directing the continuation of the Johns Hopkins study, wrote that there is additional evidence that radiologists also suffer an increased risk of contracting multiple myeloma, and an increased chance of death from strokes and heart disease.15
And though they have become the human guinea pigs of the X-ray industry, radiologists unfortunately are not the only people administering X rays. In fact many medical practitioners obtain their M.D. certificates and go on to use X-ray machines extensively in their practices without even rudimentary training in radiology. Dr. Herbert Abrams, professor of radiology at the Harvard Medical School, has warned that the problem "can be traced to medical schools, where all too often one finds too few radiologists on the faculty, too little support of the department, too little time in the curriculum and too few radiology clerkships." The result, he warns, "may be a graduating class with limited knowledge of what radiology can do."16 Indeed, Dr. Karl Z. Morgan, founder of the profession of radiation health physics, has stated: "If you ask many of these doctors what is a roentgen or a rad, they are not even able to give you the definition."17 Surveys have shown, in fact, that nonradiologists who provided their own X-ray services ordered twice as many X rays as those doctors who referred patients to trained radiologists expert in the field, with a more complete understanding of the technology and its dangers.18
And if doctors are largely ignorant of the potential health effects of the X-ray machines in their offices, often the roughly 150,000 people who actually operate them understand the dangers even less. As of 1981 less than a third of the states in the U.S. required licensing of X-ray machine operators, and even those programs are by no means uniform. Most of the licensing only pertains to full-time X-ray equipment operators and does not cover people who operate the machines part time. Only California, of all the fifty states, requires that all X-ray machine operators be specially trained.19
Meanwhile the vast majority of the people administering X rays may not really know what they are doing. Congressman Bob Eckhardt, chairman of the House Subcommittee on Oversight and Investigations, found it "particularly disturbing, if not outright frightening . . . that in many states any person can walk off the streets and operate machines which are capable of inflicting great harm upon those exposed to them."20 Daniel Donohue, president of the American Society of Radiologic Technologists, has echoed the sentiment. After assisting in a training program he found that many prospective X-ray machine operators "were told never to adjust the controls of the equipment, but to increase the time of exposure when they X-rayed a larger patient. Many were told to experiment on their patient and to try different techniques . . . to learn how to use the equipment." Some, Donohue added, had been instructed "not to limit the beam of radiation in the area of interest." The technique of limiting tissue exposed is now seen as a basic safety practice in medical radiology.
Donohue found the experience deeply disturbing. "Most of these operators—which included nurses, medical assistants, secretaries, receptionists—who were employed and expected to perform radiological examinations as part of their job requirements were not provided radiation monitoring devices to determine their accumulated dosage, and were unaware that a potential hazard existed for either themselves or their patients."21
Herbert Abrams has added his opinion that improper focusing and shielding may be widespread among untrained X-ray operators.22 And a nationwide evaluation by the Bureau of Radiological Health (BRH) has borne out that fear. In 1975 the BRH found that 63 percent of the noncredentialed operators tested failed to properly restrict the X-ray beam to the size of the film for a given examination and thus unnecessarily overexposed the patient. Forty percent of the credentialed technologists taking that same test failed. In some cases exposure levels varied from patient to patient by a factor of two thousand.23
In August 1981, under intense pressure from portions of the radiation health community, Congress passed a law requiring the states to establish federally approved programs for the training and licensing of radiological technologists. The programs are to be in place by 1985.
5. Otto Glasser, Dr. W. C. Roentgen, 2nd ed. (Springfield, Ill.: Charles C. Thomas, 1958), p. 36.
6. Ruth Brecher and Edward Brecher, The Rays: A History of Radiology in the United States and Canada (Baltimore: Williams & Wilkins, 1969), pp. 9, 16, 63, 64.
7. Joel Griffiths and Richard Ballantine, Silent Slaughter, (Chicago: Henry Regnery Company, 1972), p. 39; Charles Panati and Michael Hudson, The Silent Intruder: Surviving the Nuclear Age (Boston: Houghton Mifflin, 1981), pp. 3-43. X rays are produced by bombarding a tungsten target with high-speed electrons in a vacuum tube. They are invisible to the human eye, but they may be captured as a visible image on film. The making of film records of internal body parts by X-ray exposure is called radiography; the film image, a radiograph. Advances in equipment design capability and procedures led to radiation’s rapid growth in the medical field after 1920. Refinements—limiting source size, providing radiation shields and high voltage protection, and disposing of excess heat—allowed the number and types of radiologic examinations to increase. Present-day X-ray films and intensifying screens provide physicians with high-quality images of bones and internal organs, while delivering much less radiation to the patient. Today, films are coated with chemical emulsions to enhance their sensitivity to X rays. The more sensitive a film, the smaller the dose of radiation needed to produce an image. Some of the newer sophisticated films are in the experimental stages or not yet widely used. Intensifying screens are thin sheets of plastic or cardboard coated with a substance that emits blue light when struck by X rays. This acts with the X rays to produce an image of a bone or internal organ with less radiation exposure. Rare-earth metals are used in the most sensitive intensifying screens.
8. Brecher and Brecher, The Rays, p. 88.
9. Electrical Review, 1896, p. 250.
10. Percy Brown, American Martyrs to Science Through the Roentgen Rays (Springfield, Ill.: Charles C. Thomas, 1936), p. 37.
11. Brecher and Brecher, The Rays, p. 211.
12. Helmuth Ulrich, "Incidence of Leukemia in Radiologists," New England Journal of Medicine, January 10, 1946, Vol. 234, pp. 45-46.
13. NAS, Pathologic Effects of Atomic Radiation, Publication No. 452 (Washington, D.C.: National Academy of Sciences, 1956).
14. E. B. Lewis, "Leukemia and Ionizing Radiation," Science, 125(7255): 965, May 17, 1957. (The absence of chronic lymphatic leukemia deaths lead Lewis to suggest that the excess deaths were due to radiation exposure or some other factor acting in a similar manner.) Raymond Seltser and Phillip Sartwell, "The Influence of Occupational Exposure to Radiation on the Mortality of American Radiologists and Other Medical Specialties," American Journal of Epidemiology (January 1965): 2-22.
15. "Job Hazards of Radiologists Studied," Washington Star, February 23, 1981; "Radiologists Take X-ray to Heart, Disputed Study Suggests," Medical World News 22, No. 6 (March 16, 1981): 36.
16. Herbert L. Abrams, "The ‘Overutilization’ of X rays," New England Journal of Medicine 300 (May 24, 1979): 1213-1216.
17. Citizens’ Hearings, p. 93.
18. 1979 X-ray Hearings, p. 75.
19. Arizona, California, Florida, Hawaii, Kentucky, Montana, New Jersey, New York, Vermont, West Virginia, and Puerto Rico have operating programs for licensing X-ray technologists. Delaware, Georgia, Indiana, Iowa, Michigan, and Minnesota have enabling legislation to begin licensing programs.
20. 1979 X-ray Hearings, p. 69.
21. 1979 X-ray Hearings, p. 8.
22. Abrams, "‘Overutilization’ of X rays," p. 1213.
23. DHEW, Bulletin of the Bureau of Radiological Health, Supplement no. 1 (Washington, D.C.: Department of Health, Education and Welfare, July 1976); U.S. Congress, Senate Committee on Commerce, Science and Transportation, Radiation Health and Safety, June 16, 17, 27, 28, 29, 1977, p. 49. The Bureau of Radiological Health is following up on facilities with readings above or below the average doses for certain examinations and has reported significant drops in patient doses. Use of gonad shielding is part of the educational programs for both medical and general audiences.