X-Rays Use and Abuse BY JAMES F. BRAILSFORD HIS year
we celebrate the diamond jubilee of the dis- covery of X-rays on November 8, 1895, by Wilhelm Konrad Roentgen. He was fifty years of age at the time and Professor of Physics and Director of the New Physics Laboratory in the University of Wurzburg. In the late evening of November 8, 1895, alone in his laboratory with a simple unit he had devised to operate a Crookes' tube, he switched on the electric current, and found that, though he had excluded all visible light from the apparatus and tube, the salt commonly used in research on the spectrum, barium platinocyanide, fluoresced in the dark. He proved that the rays were coming from the tube, that they were effective the long distance of the room, that they could readily penetrate paper, cardboard and books, but as the substances tried increased in density, the rays were increasingly absorbed. Having the standard labora- tory wooden box of weights, he interposed it between the encased tube and the barium platinocyanide—which, to form a screen, was painted on cardboard. With the tube in action in the dark he was able to see the varying densities of the weights within the box.
This might have remained as an interesting experiment in a physics laboratory. .But Roentgen was a genius. He put his hand between the tube and the screen and saw the bones within the hand—it was a simple matter to substitute a photographic plate for the screen and obtain a permanent record—a radio- graph—a phenomenal discovery of the greatest importance.
The news of the discovery was made known to the world in January, 1896, and excited world-wide interest and activity; for not only did Roentgen give an account of his discovery. and his experimental evidence of the nature of the rays, but he supplied full details of the simple inexpensive equipment so that anyone who cared could repeat his results. How different it might have been had he been covetous of the money or the power which were there for the asking! Within a few days of the announcement of the discovery, doctors, physicists, photo- graphers and other interested persons, with apparatus costing less than £5, had taken radiographs of the living human hand, and published them in the local lay and medical press. The instantaneous reaction was that this was a means whereby we might spare the patient pain, for it would enable us to see evidence of foreign bodies, like needles or bullets, damage or disease, without causing the patient any pain. It was this reaction which Roentgen and his beloved wife claimed as their greatest reward, though the rewards included the Iron Cross, the Nobel Prize, the Gold Medal of the Royal Society, the Wilrzburg MD, and distinctions from learned societies all over the world. As he had prciphetically stated in his Rectorial address the previous year, 'If some phenomenon which has been shrouded in obscurity suddenly emerges into the light of knowledge, if the key to a long-sought-after mechanical com- bination has been found, if the many links of a chain of thought are fortuitously supplied, this then gives to the discoverer the exultant feeling that comes with a victory of the Mind, which alone can compensate him for all the struggle and effort, and which lifts him to a higher plane of existence.'
Disciples of Hippocrates, however, saw in the use of X-rays the possibility of great abuse—its easy substitution for the careful, painstaking clinical examination of the patient by which all notable contributions to medicine had been made. Accordingly they opposed the use of X-rays and hindered their application. But the most important deterrents were the dangers to which the X-ray workers were subjected. Many pioneers developed painful X-ray burns which led to amputa- tions, or death from malignant disease; others died from elec- tric shock, for when these deterrents were largely removed by the provision of shock-proof protective units, doctors, with little or no training in radiology, employed it as their Hippocratic teachers had rightly predicted—as an easy substitute for clinical examination of the patient, who is correspondingly neglected. Even today the fundamental knowledge is not appre- ciated that disease may be manifest on careful examination of the patient. though the radiographic appearances of the patient are normal; and that when the patient has fully recovered, the radiograph may show for the remainder of the patient's long, healthy life spectacular shadows of no significance to his well- being. When his condition is neglected and only the shadow is treated—a not uncommon practice today—the life of the patient may be jeopardised. I have reported the case of one patient who sustained an unnecessary operation because the radiograph showed the shadow of a lock of hair over the shoulder which was mistaken for a tuberculous cavity in the lung. Often the shadows which excite major surgical attention are merely evidence of a former episode—a kind of scar from a previous focus of disease—but a doctor who has seen a radio- graph before he has seen the patient is very apt to be biased. The shadows may even be used to justify the risks of major surgery.
For these reasons I opposed mass radiography. That it will show cases of active tuberculosis previously undetected merely argues that clinical examination was absent or careless. The progressive employment of mass radiography since the National Health Service was introduced and the increasing number of cases found can reasonably be taken as an indication of the degeneration of clinical medicine. Fortunately, with improvement in housing and the standard of living, the death rate from tuberculdsis is very rapidly diminishing.
A further reaction to the discovery was that published in the British Journal of Photography in July, 1896, under the head- ing 'Roentgen Work for Profit.' Roentgen refused to make any profit. I wonder what he would say to present activities, when everything connected with X-rays brings profit to all save perhaps the taxpayers. The marked improvement in X-ray films and their processing should permit of simpler and less expensive electrical equipment, but examination of the costs of X-ray departments in the State hospitals will reveal that millions of pounds are being spent on more and more expen- sive units. And a very large percentage of the radiographic examinations are unnecessary; some may actually be harmful. The legal authorities have been taught by the doctors that failure to get an X-ray is an indication of neglect; but from a long experience I would say that in such cases it is the produc- tion of a radiograph that ought to be so regarded, for often it ,means that the condition of the patient has been neglected.
One further reaction must be noted. In the early years follow- ing the discovery it began to, be recognised that X-rays could do harm to the human body. In the enthusiasm to obtain radio- graphs of the denser parts of the body, the head and trunk. radiation was applied which burnt the skin and destroyed the hair-growing follicles. Permanent baldness became a recognis- able post-radiation phenomenon. Then, as already indicated. the workers insidiously developed intractable agonising burns which only amputation could relieve; death still resulted from malignant disease. As; with all agents capable of damaging the body, X- and other radiation, instead of teaching us to avoid it, as it had been, proved to be a definite cause of cancer, was hailed as a possible cure. Roentgen must not be given the credit for the propagation of this gospel. Since it was propounded, radiation has been exploited in every conceivable direction as if it was a panacea for all forms of malignant disease. Personnel has been enormously recruited, departments elaborately ex- tended, X-ray, radium and isotope installations have been ostentatiously developed to the stage of a Frankenstein night- mare, voltages have been increased to the millions, all kinds of filter devices have been tried, millions of experiments have been carried out to cause cancer in animals, but after sixty years of this 'progression' we have found in radiation no cure for malignant disease.
Doctors have not all realised to the full that all advances in medicine, be.they X-rays, radium, etc., anaesthetics, antibiotics, hormones or surgical techniques, call for greater and not, as is too often evident, less discipline before and during their use. The early successes were dependent upon the exercise of every care and skill; the failures—and they are formidable—are due to lack of these precious essentials. They have learnt, no doubt due to demands of patients and their relations, that they can do anything and everything with the human body, but they have not learnt what is so much more important—when it is better to leave it alone.
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