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Fluoroscopy:   Source of a Big Underestimate in Our Breast-Dose Finding

Part 1.   Why We Think Fluoroscopy Has Been Seriously Underestimated

          Many times in the chapters of Section 2, we have demonstrated our policy of trying to arrive at a "credible lower limit" of average annual radiation exposure to the breasts, 1920-1960.

          In this chapter (and the next), we intend to show why we must regard the real contribution of fluoroscopy to breast-irradiation to be far greater than evaluated in our Master Table. We begin with some reminders. In no chapter where fluoroscopy was known to be involved, or considered likely to have been involved, did we ever estimate a fluoroscopic dose to anyone of more than 5 medical rads to the breasts (Chapter 8, Part 2). For general diagnostic fluoroscopy (Chapter 23, Part 3), we assumed that fluroscopy was never done with the beam traveling from front to back, we assigned a breast-dose of only 0.111 rads per average fluoroscopy, we assigned no population-dose at all for children under 15 years of age, and for frequency of fluoroscopic examination, we used data from the 1970s.

          By contrast, some of the reality in approximately the 1920-1960 period was described in 1969 by Charles B. Braestrup, whom we already quoted in Chapter 23, Part 1 (from Shapiro 1990 at page 379):

          "The Wappler fluoroscope, manufactured around 1930-1935, produced 125-150 R/min at the panel. Skin reactions were produced and in some cases, permanent injury. To minimize hazard, a `100 R per examination' limit was set in the New York City hospitals."

          We can not just walk away from those observations of Braestrup. And we can not believe at all that New York City was Neanderthalia, and that all was very different elsewhere in the country. Braestrup reports that (a) skin reactions were produced, and (b) in some cases, there was permanent injury. Visible skin reactions usually mean an absorbed dose of about 200 rads or more in the skin, and permanent skin injuries require even higher doses (see Chapter 29, Part 3).

"The Thing Speaks for Itself"?

          When there was a necessity of limiting each fluoroscopic exam to 100 Roentgens because some people were clearly receiving even more, it might really be a fair statement that "the thing speaks for itself" and that ionizing radiation received in the 1920-1960 period explains the great majority of all the breast-cancers which have been occurring in recent decades.

          Of course, that one source of evidence need not "speak" alone. Dr. Francis Curry has already spoken about the use of photofluorograms and fluoroscopy in a 1950 mass screening-program from which "many people were getting [whole-body] doses big enough to show clinical symptoms" (Chapter 16, Part 1).

          There is much additional evidence to present about the popularity of fluoroscopy and its widespread use by unqualified people, as readers will see. Anyone who denies that medical irradiation has a major role in explaining the breast-cancer problem, really has an obligation to be realistic about fluoroscopy.

Part 2.   The Routine Fluoroscoping of Well-Babies

          We begin with the topic of routine pediatric fluoroscopy, briefly mentioned in Chapter 23, Part 1.

          "Those of you who have been in the field a long time know that it was once the practice of pediatricians to fluoroscope babies and young children every month and when they had the annual checkup. When we questioned this practice, pediatricians would say, `Well, the parents expect it. They think if I don't fluoroscope the patients, they are not getting a complete examination'."

          That statement was made in 1970 by Dr. Hanson Blatz, who was director of the Office of Radiation Control, New York City Department of Health. And there is good reason to believe that pediatric fluoroscopy of well-babies was occurring from one end of the country to the other.

Confirmation from Dr. James Pifer and Colleagues

          Dr. James Pifer and his colleagues have described the case material, radiation factors, and study methods in the investigations of enlarged thymus therapy with x-rays in the Rochester Studies of this problem (Pifer 1963). At page 1358, where they described the circumstances which led certain children to become involved in such therapy, Pifer and colleagues stated the following:

          "... Also, the indications for treatment differed with each radiologist, pediatrician, or general practitioner. Frequently parents insisted that their child be treated. Some pediatricians fluoroscoped all infants routinely, but probably most children treated in private offices had symptoms at presentation which prompted a radiologic examination ..."

          That is an eye-opener of the first magnitude. "Some pediatricians fluoroscoped all infants routinely."

          That is precisely what Dr. Blatz was telling us had been his experience, too. Well-babies getting fluoroscopy. Regularly. And the information fits the experience of the woman who wrote to me about her own experience as a child in New York. She could remember being fluoroscoped at every visit to the pediatrician from age 4 through age 12. She had no recall of medical attention one way or the other before age 4, as we mentioned in Chapter 23, Part 1.

          Had this pediatric practice left New York State? Indeed it had. We find it on the other side of the country. We will look at the story out west.

More Confirmation, from Dr. Franz Buschke and Herbert M. Parker

          Buschke and Parker published a very low-key bombshell, in the Journal of Pediatrics (1942), entitled "Possible Hazards of Repeated Fluroscopies in Infants." The paper had been read before the North Pacific Pediatric Society, in Seattle, Washington, January 31, 1942.

          The opening paragraph follows:

          "Recently we became aware of the fact that apparently a number of pediatricians include a fluoroscopy in the monthly routine examinations of infants in their care during the first and second years of life. Since we feel that such a procedure is charged with potential hazards, we welcome the opportunity of discussing this problem at your initiative in this group."

X-Rays Like a "Powerful Drug" --- Not "Glorified Photography"

          The second paragraph illuminates a sorry state of affairs in the level of basic information not possessed by the pediatricians --- or even by some radiologists of the time (p.524):

          "It is too often not realized that x-rays, in addition to being a useful diagnostic tool, accidentally and unfortunately represent at the same time a powerful drug. As Dr. Case once pointed out, x-ray diagnostic procedures are still considered by many as a kind of `glorified photography.' Yet every exposure to x-rays actually delivers radiating energy to the body. The output of different diagnostic machines varies within very wide limits, depending upon the milliamperes and kilovolts used, the filtration, the distance between tube and body surface, the time of exposure, and the size of the exposed field. But even many specialized radiologists do not know the actual output per minute of their diagnostic machine."

          Buschke and Parker were advising the pediatricians against the practice of monthly fluoroscopy in the routine examination of infants in their care during the first and second years of life. After studying the radiation output of seven randomly chosen x-ray apparatuses in the offices of "reputable pediatricians selected at random," they drew some conclusions of likely doses to infants irradiated in the manner then current. They wrote (at page 527):

          "If the average rapid fluoroscopy by an experienced and well-adapted examiner takes twenty seconds, about 8.3 R will be delivered at this rate or 100 R during the first year of life. Actually we know from experience that some of the fluoroscopies last considerably longer."

          Fortunately, not all pediatricians were using routine fluoroscopy on problem-free babies. We have found no estimate of what fraction did.

"Even in the Best Places ..."

          In the seven offices visited, Buschke and Parker found that "none of them knew the output of their machine" (p.525). They found one machine which delivered 35 Roentgens per minute at the supposed operation of 5 milliamperes (Ma.) "The physician in charge, however, reported that the amperage is inconstant and that the amperes would change up to 40 Ma. without change of the controls. In such a case, an amount of about 200 r might be delivered to the infant's body in one minute" (p.525). And they also reported (p.527):

          "In another place under the direction of one of the best radiologists we found that the output differed with the operator ... While the physician assumed that he was always fluoroscoping infants with 3 Ma., we found accidentally that one of the technicians when he happened to be at the control would give him 5 Ma., increasing unnecessarily the output from 23 to 38 r. This example again emphasizes that even in the best places there is not sufficient appreciation of the potential hazards, and there is a lack of attention to details with the purpose of minimizing them."

Don't Instruct the Mother While the Beam Is On

          Another indication that Buschke and Parker observed appallingly casual attitudes toward the x-ray beam, is reflected in their third recommendations to the pediatricians (p.532):

          "3. The exposure time should be kept as short as possible. No discussion of the fluoroscopic findings is permitted as long as the shutter is open. This naturally means that an explanation of the screen picture to the baby's mother during fluoroscopy is not permitted."

Resistance by "the Unbeliever," as Reported by Buschke and Parker

          The smaller the child, the more worried were Buschke and Parker about preventing excessive exposure from fluoroscopy (p.525):

          "... For the majority of diagnostic procedures used in general practice, the lack of appreciation of these potential hazards is regrettable but probably not a cause of major concern because these procedures in adults and older children are usually limited to fairly small portions of the body. If the small body of an infant is exposed to the same kind of radiation, a comparatively much larger volume of body is irradiated. This risk is naturally increased if such fluoroscopies are done repeatedly in infants at short intervals. For this reason it seems necessary to give even more attention to details of the fluoroscopic procedure with infants in order to eliminate or minimize the possible detrimental effects." And:

          "We will meet, and as a matter of fact have repeatedly met, the objection that never has any damage been observed by those who have used this procedure throughout many years. But as we have already pointed out, the possible effects of doses under consideration here are much more difficult to demonstrate and, it is true, by their very nature can be anticipated only by implications from our general knowledge of radiation biology and from comparison of doses delivered with those used for other therapeutic purposes. If we wait until damage is proved beyond the doubt of the unbeliever, irreparable harm may have been done [emphasis added]."

What Kind of "Irreparable Harm"?

          Buschke and Parker never mentioned breast-cancer (or any other sort of cancer) as the focus of their concern. They wrote this paper in 1942, long before MacKenzie's paper of 1965. Their worry in 1942 about routine fluoroscopic doses was centered on injury to the gonads and to the future descendants of the irradiated children (p.527-532). "The doses in question here are well within the range in which such damage might be expected," they warned at page 528. They were concerned about radiation-induction of inherited "disease entities ... such as diabetes, susceptibility to tuberculosis, cleft palate, certain diseases of the central nervous system, etc." (p.529). And they observed (p.530):

          "To most clinicians all arguments based on genetic considerations appear somewhat as fairy tales. This is due to the fact that definite conclusions in the field of genetics can be reached only by statistical evaluation of a vast number of observations throughout many generations. Obviously therefore conclusions in regard to human pathology can be reached only in analogy to those obtained by animal and plant experiments."

An Interesting Contrast in Attitudes

          In Chapter 28, Part 7, we reported some sweeping assertions in the 1960s about the alleged safety of high-dose mammography --- at a time when clear warnings about the actual state of ignorance would have been appropriate.

          Here, we are very pleased to call attention to the wisdom of Buschke and Parker, who showed a very different policy toward acknowledging ignorance and uncertainties. Clearly, they tried hard to warn the medical profession about "irreparable harm" which can be caused by appeasing "the unbeliever."

          Buschke and Parker met repeated objections to their warnings about radiation, from physicians who had never personally observed any damage clearly connected with fluoroscoping babies within their own limited practices (p.525), or who demanded absolute proof of delayed harm from nearly impossible epidemiologic studies (p.530). In our opinion, such physicians must have received an inadequate medical education. Otherwise, they would have accepted the potential reality of some important consequences which can not be proven within a personal practice or even by any real-world epidemiologic studies. Moreover, if they had realized how really hard it is to establish lasting truths in matters of medicine and health, they would have questioned the alleged fact that there was no hazard to the babies from fluoroscopy.

          The need to allow for nasty surprises, in the form of unidentified long-term consequences, is well illustrated by the fact that Buschke and Parker apparently did not even imagine the menace of radiation-induced breast-cancer. They were pleading for reduced radiation exposure on other grounds.

Some Advice to Women and Their Families

          You are going to hear soothing words many times about many marvels:   "Never has any damage been observed by those who have used this procedure throughout many years."

          We can offer this advice:   When you do hear this, distance yourself from the source, and have a hard look at the type of evidence offered in support of the statement. Will you gain enough, by making the extra effort? Not always. But you may want to consider one illustration of real benefit, presented in Part 3.

Part 3.   What Harm Could the "Unbelievers" Do?
             A Quantitative Analysis

          Sometimes, a few numbers can tell a story not easily related in thousands of words. This is one such occasion.

          We will do an "if-then" exercise to answer the question:   What harm could the "unbeliever" pediatricians have done, by the routine fluoroscoping of well-babies? We will limit the analysis to radiation-induced breast-cancer. Of course, we are using the term "unbeliever" as Buschke and Parker did (Part 2), to denote pediatricians who refused to believe that there might be delayed hazards from such repeated fluoroscopies.

The "If-Then Scenario" per Million Female Infants

          o - 1.   Start with 1,000,000 female infants.

          o - 2.   Do the pediatric fluoroscopy each month for 24 months with an average dose of 8.3 Roentgens of exposure per exam. This means a total exposure in the first two years of life of 24 x 8.3, or just about 200 Roentgens. These figures come from measurements by Buschke and Parker, who say the average dose per exam was probably higher than 8.3 R because the duration probably exceeded 20 seconds (Part 3).

          o - 3.   While Buschke and Parker suggest that most of these fluoroscopies were done with the beam entering the back, we can be sure that some were done with the beam entering laterally or from the front. Nonetheless, we will assume that all were done with the beam entering the back --- which reduces the hazard to the breasts.

          o - 4.   Elsewhere in this book (in Chapter 23, for example), we use a factor of 0.037 to convert Roentgens to breast-dose in rads, for back-to-front beams. Because of the very small body-size of babies, this factor will underestimate the breast-dose. Nonetheless, we will use it without any adjustment. So for these infants, we will approximate a breast-dose of (200 R x 0.037 rads per R), or about 7.4 rads during the first two years of life.

          o - 5.   The conversion-factor (from dose to breast-cancer), comes from Chapter 39 --- the Master Table, Column V. It's origin is explained in detail by Chapter 40. The conversion-factor for age-1 and age-2 is:

92.74 radiation-induced breast-cancers per 10,000 person-rads.

Extra Cancers of the Breasts =

  (7.4 rads per person) x (1,000,000 persons) x  92.74 breast-cancers 
                                                10,000 person-rads  

"I Never Saw Any Damage in My Own Practice"

          The lesson of the "if-then" scenario is the ratio --- 1 out of 15 --- not the absolute number (68,628). We have no way of estimating the absolute number without knowing how many million female infants experienced the full regime of well-baby fluoroscopy over the years. We do know that the maximum number "enrolled" by pediatricians in such a regime each year could not possibly exceed the number of females born per year, which was about 905,000 per year in the USA during the 1920-1960 period (from the Master Table, Column A).

          Women are quite upset that 1 in 9 of them are currently going to experience breast-cancer. Our "if-then" scenario indicates that those "unbeliever" pediatricians who scoffed at the Buschke-Parker advice created a situation where they could be responsible, among their former patients, for a lifetime rate of breast-cancer which is about 1 in 15. Of course, the "unbeliever" pediatricians never personally saw any damage at all.

          Can we justify a statement that women and their families owe an enormous debt of gratitude to pioneers like Buschke and Parker, who probably reduced the number of well-babies who received routine fluoroscopies? Obviously, the answer is, "Yes."

Part 4.   An Additional Expert
             Who Reported Hazards and Tried to Prevent Them

          Carl B. Braestrup, of the Physics Laboratory of the Department of Hospitals of the City of New York, was persistent in the early years in attempting to limit the hazard of exposure both to patients and staff. Some of his relevant comments in a talk before the New York Roentgen Society in April 1941 (published in 1942) are presented below.

A Certain Fluoroscope Called "A Lethal Diagnostic Weapon"

          Describing his experiences with many, many fluoroscopes, Braestrup stated (pp.210-211):

          "During the past years we have measured the R [Roentgen] output of large numbers of fluoroscopes, using the settings at which they are normally operated [emphasis added] ... and have found a very wide variation ... Attention is called particularly to test B-116, where the R per minute at the panel was 127, that is, an erythema dose would be reached in about three minutes. Such a unit could be classified as a lethal diagnostic weapon and yet there are many of these still in use [emphasis added]. This particular one was changed to reduce the output, and the results are shown in test B-129."

          We recommend that readers hold these observations of Braestrup in mind as we later describe (Chapter 32) how the virtues of fluoroscopy were extolled in a "blitzkrieg" campaign for more fluoroscopy in the decades of the 1920s and 1930s, and beyond. Responsible people like Braestrup and others seemed to face the attitude:   "First use, then learn."

Mobile Fluoroscopic Units:   In Surgery and at the Bedside

          Braestrup expressed great concern about the mobile units used in hospital radiology. He stated the following (p.213):

          "Of the various types of radiologic equipment, the mobile unit probably has been responsible for more radiation damage than any other piece of apparatus. These accidents have in most cases occurred while the mobile unit was used for fluoroscopy by surgeons, who apparently did not realize the high output obtained at short distances [emphasis in the original]. Measurements show that at the shortest possible distance, about 8 cm., the R per minute is as high as 1000 without filter at 85 kv. and 5 ma. [milli-amperes]. To avoid these excessive doses it is recommended that all mobile units be provided with fixed cones or a frame arrangement preventing the target-skin distances from being less than 30 cm (12 inches). In addition, the aperture should be provided with a fixed filter of not less than 1.0 mm. Al." And:

          "A considerable amount of bedside radiography is done in the larger hospitals, and it is therefore important to consider the protection of the operator of the mobile unit. Tests show that the average stray radiation at the technician's position, 1.5 meter from the tube, is about 0.0044 R per 100 ma.second exposure [milliampere-second exposure]. It is advisable to rotate the technicians doing mobile work, or have them wear lead rubber aprons."

          Braestrup's very basic recommendations about the mobile fluoroscopy units were necessary --- even though medicine in 1941 was about 40 years into the Roentgen era. What does the need for such advice imply about casual use of fluoroscopy by unqualified people --- and the massive, never-recorded doses which may have been delivered by fluoroscopy to female breasts in the 1920-1960 period?

Measurements of "Stray" Radiation from X-Ray Equipment

          Braestrup did measurements for "the average ray-proof tube" to establish how much stray radiation would be received by by-standers at a distance of 1 meter from a patient's midline, at right angles to the central beam. He reported his findings as follows (p.209):

          "In evaluating the significance of the tube protection, it should be borne in mind that the direct stray radiation --- that originating from the tube --- is only a small part of the total stray radiation received under actual operating conditions. Measurements show that the scattered radiation from the patient is many times as high as the direct stray radiation from the average ray-proof tube." And he provided a startling demonstration of this in his Table 5, entitled "Comparison of Direct and Scattered Stray Radiation":

    Field          Type of Stray     Stray Radiation at 1 Meter         
   Diameter          Radiation          Roentgens per hour         Ratio
0 (lead placed      Only Direct               0.01                  1.0 
 in aperture)                                                           

       8          Direct+Scattered            0.03                  3.4 

      35          Direct+Scattered            0.72                 80.0 

Exposure of the Radiologic Staff, Nurses, Orderlies, Parents, and Residents

          Braestrup warned about irradiation of non-patients, as follows (p.212):

          "Unfortunately, it is not always possible for the staff to remain behind protective barriers during the exposure. Patients, particularly babies, often have to be supported or held while the x-ray tube is energized, dental units are used without protective screens, and the cystoscopist is exposed to secondary radiation ... This amount of stray radiation makes it advisable for members of the radiologic staff never to expose themselves to scattered radiation if the work can be entrusted to nurses and orderlies who are not normally exposed to the rays."

          The reader might be outraged by this apparent concern for the radiologic staff but not for nurses and orderlies. We think Braestrup's words give the wrong impression of what he meant. In reality, the philosophy which has pervaded radiology departments is simply that the procedure is going to get done, so someone in addition to the patient may have to take a dose in the process. Members of the radiology staff get dosed every day in their work. By contrast, the nurses or orderlies who bring a patient down to the radiology department only rarely would get a dose in the manner suggested by Braestrup. Others have suggested strongly that parents should do the holding of babies and children when necessary in the x-ray department.

          Did these exposures actually occur in our hospitals? They most certainly did, and for many decades. We can vouch for such exposures having occurred in the hospitals of the University of California, San Francisco, and of Stanford University. In the former, Professor Helen Gofman, as a resident in pediatrics during the years of World War Two, held infants who were receiving radiation. She related that the reason given was that the department was short of staff. In the Stanford case, a radiation technician stated that she commonly held infants who were to be x-rayed because she did not expect to have children. Her reasoning was that the younger nurses and technicians might still be planning a family and therefore should not receive the radiation.

One More Type of Unrecorded Breast-Irradiation

          In this way, many young women in their 20s, 30s, and 40s received a radiation dose to their breasts during x-ray procedures, without it being recorded. When they held the children and others needing help, they very rarely had film badges or dosimeters. Their radiation dose does not find its way into our Master Table. So this represents one more source of dose underestimation in our analysis.

Part 5.   Fluoroscopy and the Self-Injury of Non-Expert Physicians

          In 1937, Dr. Eugene Leddy of the Mayo Clinic wrote an editorial entitled "The Dangers of Roentgenoscopy:   Summary and Recommendations" which appeared in the American Journal of Roentgenology and Radium Therapy. Although the editorial concentrates on the self-injury of physicians from doing fluoroscopy (roentgenoscopy), it also conveys a great deal about the frequent use of fluoroscopy nationwide, often by general practitioners and surgeons. Dr. Leddy was well qualified to write such an editorial, in view of his study of radiation-injured physicians (Leddy 1936), which we will also describe.

Examinations of Patients "Generally Include Roentgenoscopy"

          At page 924, Leddy stated:   "In fact, roentgenologic methods of diagnosis are so important that no investigation of a patient is considered complete without roentgenologic examinations, which generally include roentgenoscopy. These studies often are carried out by a general practitioner or surgeon in his office because of lack of facilities for expert study nearby or because the physician sees no need to refer the patient to a roentgenologist. In many localities it is cheaper and more convenient `to have some pictures made' in `an x-ray laboratory' operated by a layman than it is to have the appropriate examinations made by a roentgenologist."

"... Careless, Indifferent, or Even Ignorant Use of the Roentgenoscope"

          Leddy worried in the 1937 editorial that conditions were getting worse, not better:   "From data available from the Bureau of Census and from manufacturers, it has been impossible for me to find out the number of roentgen machines in use in this country. But various estimates which have been given to me indicate that perhaps 2 to 5 per cent of all physicians in this country have roentgenologic equipment of some kind in their offices. When one considers the number of diplomates of the American Board of Radiology in contrast to the number of physicians and others who `do a little x-ray work' one can estimate roughly the magnitude of the risk of injury that those in this latter group run from casual and nonexpert roentgenologic procedures. With such a great number of roentgen machines in use, one wonders whether injuries by roentgen rays will not be even more common in the immediate future than they were in the tragic days of the pioneers in roentgenology." And:

          "It is well known that the majority of physicians who suffered injuries which sometimes led to their death sustained these injuries in the course of roentgenoscopy [fluoroscopy]. The story of the tortures endured by physicians who had extensive roentgen burns has been often and well told. One needs but to read the masterpiece by Brown, `American Martyrs to Science through the Roentgen Rays,' to appreciate the tragedy likely to follow the indiscriminate, careless, indifferent or even ignorant use of the roentgenoscope."

Ten Years of "Shockingly Little" Literature on Protection against Radiation

          Leddy's editorial expressed fear about injuries in the future: "Because the American literature of the past ten years contains shockingly little about protection against radiation in roentgenoscopic procedures, I am fearful about injuries in the future and hope that they may be minimized by the work of suitable committees."

          And once again, he reported on the complete ignorance among a number of physicians who used the fluoroscope:

          "In my studies on the causes of roentgen injuries among physicians it was brought out that many of them did not realize that the changes in the skin of their hands were due to roentgen rays, and they exaggerated the already existing injury by their treatment."

Leddy's Study of Physician Injuries and Their Meaning

          In a 1936 paper, Leddy reported on the Mayo Clinic's experience with physicians who came to the Clinic for advice on, or treatment of, roentgen-ray dermatitis. The number was steadily growing:

                       Number of Physicians Seeking
5-Year Time Period     Advice for Roentgen-Ray Dermatitis
    1919-1923                        7
    1924-1928                       13
    1929-1934                       35

    Total                           55

          Leddy had a great interest in learning how these injuries occurred. What did he find?

"A Good Strong Dose" from the Office Clerk

          Eight of the 55 physicians seeking advice or treatment had been injured while themselves undergoing roentgen therapy for benign dermatoses, such as eczema, psoriasis, acne, or pruritus [persistent itching]. These are among the leading skin conditions which were commonly treated with roentgen rays (Chapters 33 and 34).

          Only one of the eight was treated by a radiologist. In that case, the physician had been treated by a radiologist for a benign condition, with good results. But then he insisted that the radiologist repeat the treatment too many times, and an injury had resulted.

          One other physician prescribed his own treatment:   He asked his office clerk to give him "a good strong dose." She did. An ulcer resulted. The six other physicians in this group were treated by some doctor who had a roentgen-ray machine and `did some x-ray work.' In no case was the treatment given by a qualified dermatologist.

Fluoroscopic Self-Injury:   "Shocking, Although Hardly Surprising"

          "Aside from the 10 physicians who suffered injuries while undergoing roentgen treatment, the other 45 sustained injury from using the roentgenoscope in their practice. Almost always this consisted in reducing fractures or removing metallic foreign bodies under roentgenoscopic control. A few physicians had used the roentgenoscope in examining the chest in tuberculosis surveys or had sustained their injuries while conducting gastrointestinal roentgenoscopic examinations. Of these 45 physicians, 44 were not radiologists. The only radiologist who was injured had been a pioneer in the work, and at the time he was subjected to excessive irradiation the possibility of injury therefrom had not been considered" (Leddy 1936). And:

          "It is shocking, although hardly surprising, that out of a total of 45 physicians who were injured by using their own roentgen-ray machines, 44 were not radiologists. As has been stated, they were either surgeons who used roentgen rays in their work or general practitioners who used the roentgenoscope to facilitate the examination of patients."

Some Implications of Dr. Leddy's Statements

          Although Dr. Leddy's focus both in 1936 and 1937 was on self-inflicted injury of physicians who were not trained in proper use of the fluoroscope, it seems realistic to infer from what he wrote that such users would also have exposed their patients (and staff) to much higher doses than necessary. And Dr. Leddy indicated that the non-radiologists "doing a little x-ray work" greatly outnumbered the radiologists.

Part 6.   Stories Which Qualified Roentgenologists Told Each Other:   1943

          In 1943, Alfred DeLorimier and colleagues gave a paper at the 43rd annual meeting of the American Roentgen Ray Society. It was entitled, "Protective Features Provided with the United States Army Field Roentgenoscopic Equipment." The paper elicited a lively (published) discussion, from which we provide some illuminating comments and stories.

The Doctor and the Dentist Who Went Shooting Together

          Dr. Robert Taft, of Charleston, South Carolina, discussed the paper at p.659:

          "... I am glad to say that the pendulum has swung in the right direction in regard to roentgen-ray protection and I am delighted to see papers of this kind presented. There is only one thing wrong about a presentation of this kind. It does not get to the right men [emphasis added]. The members of the American Roentgen Ray Society know something about roentgen-ray protection. Where these papers ought to be given is back home in our local medical societies where men are fooling with small roentgen machines without knowing what they are doing." And:

          "I have only to quote briefly a paper of our esteemed colleague, Dr. Pfahler [ one of the giants of early radiology ], from the American Dental Journal a number of years ago. Very briefly, if I remember the story, a physician and a dentist went out shooting. There was a minor accident. One of them got a small shot in his finger. They came back and proceeded to remove it fluoroscopically under the dental roentgenographic machine, as a result of which both of them had to have so many fingers amputated that the dentist had to quit dentistry and the surgeon had to give up surgery." And:

          "Those things go on happening and I know of many cases that have happened after Dr. Pfahler wrote that paper."

"The Beautiful Nurse with Her Toe on the Foot Switch"

          At the same discussion, Major Theodore S. West commented about misleading advertisements for x-ray equipment:

          "Colonel DeLorimier and his associates have made a great contribution in this investigation of roentgen-ray hazards. I have been greatly interested in the matter of roentgen-ray protection for many years, and it is my belief that many of the younger roentgenologists do not fully appreciate the hidden dangers of the agent with which they work, and they are inclined to expose themselves to an unsafe amount of radiation. And:

          "... I heartily agree with Dr. Taft that this work of Colonel de Lorimier's should be broadcast to the medical profession at large, and not be presented only to roentgenologists who are at least supposed to realize the dangers. Roentgenologic apparatus is now being purchased and used by an increasing number of physicians who had not had adequate training or instruction, and who do not appreciate the dangers." And:

          "Advertisements for apparatus seem rather to emphasize the innocuousness of the roentgen ray. I recall a picture in one of the recent journals showing the patient cozily snuggled in bed, the mobile roentgen unit in position, the kindly doctor along side, and the beautiful nurse with her toe on the foot switch. No protective apron or gloves, not even a reasonable distance protecting anyone from the scattered radiation." Time for a Better Brochure?

          Major West continued:   "I have recently seen several cases of severe roentgen burns resulting from the use of the fluoroscope for guidance in setting fractures or extracting foreign bodies. The victims in four of these cases, were physicians who `didn't realize the danger'." And:

          "It seems to me that it is the responsibility of the radiological societies to make an attempt to educate the profession at large on this matter. Perhaps a brochure on the subject could be published by the combined societies, and, in cooperation with the manufacturers of roentgen-ray equipment, given to every purchaser of a roentgen-ray apparatus. This may be a big order, but I believe it is our job to see that some such work is done."

Part 7.   The Meaning of All This Regarding Our Underestimation of Dose

          We should think a great deal about these remarks provided by men of experience, as we consider the possible true doses which patients, on the average, were getting from various fluoroscopic procedures in the 1920-1960 period. It is absolutely clear, in our opinion, that we must regard the real contribution of fluoroscopy to breast irradiation to be far greater than evaluated in our Master Table.

          We believe, but can not prove, that the real annual average breast-dose from diagnostic fluoroscopy alone, probably exceeded everything evaluated in the Master Table for 1920-1960.

          o - From Dr. Braestrup (Part 1), we have established that fluoroscopic exams gave such high doses that a limit of 100 Roentgens per exam had to be set by the City of New York. The Wappler fluoroscope manufactured around 1930-1935 produced 125-150 Roentgens per minute at the panel. Braestrup considered certain types of fluoroscopes to be "a lethal diagnostic weapon" (Part 4).

          o - From Dr. Leddy (Part 5), we have established that "no investigation of a patient is considered complete without roentgenologic examinations, which generally include roentgenoscopy." Such a statement indicates that fluoroscopy must have been exceedingly common. Also from Leddy, we established that non-radiologists who used these machines greatly outnumbered the specialists in radiology.

          o - It would seem foolish indeed to believe that the frequency of fluoroscopies was only whatever was recorded in the 1920-1960 period. Whose crystal ball is good enough to divine the real frequency during years when just about any physician could purchase and use a fluoroscope with no need to measure the doses or report the number of fluoroscopies to anyone?

          o - From Drs. Blatz, Pifer, Buschke and Parker (Part 2), we have established that an unknown fraction of pediatricians gave routine fluoroscopic examinations to healthy babies during each routine check-up ... and that sometimes parents insisted on it. Our "if-then" analysis (Part 3) indicated that radiation-induced breast-cancer would be delivered --- decades later --- to about 1 out of every 15 female babies who actually received the 2-year regime described by Drs. Buschke and Parker.

          o - From the experts cited in this chapter, we have established that, in general, the general practitioners, pediatricians, and surgeons who used fluoroscopy did not appreciate the dangers. It is realistic to infer that their patients received radiation doses which were much higher than necessary.

          o - How did all this come about? In the next chapter, we will describe the blitzkrieg and "promotional hype" for fluoroscopy in the 1920s, 1930s, and beyond.

# # # # #

1925:   A Leading Figure in Radiology Warns about the Amateurs

          "Physicians who have made a life study of roentgenology or radium therapy are familiar with the dangers involved, and in many instances have suffered for their early ignorance of these dangers." And:

          "In recent years, among the general profession and the untrained enthusiasts who have purchased roentgen-ray machines or radium there is an astounding sense of security, and a profound ignorance of the dangers involved. They seem to think that the dangers have all passed and that now these powerful agents are made safe for anyone to use. The diagnostic value of the roentgen ray ... and the therapeutic results ... and the enthusiastic propaganda of commercial salesmen have created a great demand for and a wide distribution of these machines." And:

          "As a result, many institutions, many physicians, and even laymen have installed such equipment. They have given much more consideration to the financial investment than to the mental equipment necessary to do justice to the patients or themselves. As a result the health and lives of both the patients and the operators are jeopardized." And:

          "Warnings have been sounded repeatedly, but especially have we urged caution during the recent years. We still have the memories of the damages done twenty and twenty-five years ago, but in the hands of the untrained or careless, the dangers are a hundred times as great today. In the hands of the well-informed, trained and careful, these agents are almost perfectly safe."

o - Excerpts from an editorial entitled "The Dangers in Roentgenology and Radium Therapy," by Dr. George E. Pfahler, in the American Journal of of Roentgenology and Radium Therapy, Vol.13: 276-277. 1925.

      In the remaining paragraphs, Dr. Pfahler recommended that local radiological societies teach the unqualified, and that states require a special license to permit any physician to use roentgen rays in diagnosis or treatment.

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