Part 1. Some Seriously Unwarranted Early Optimism
Concerning Fluoroscopic Hazard
Preston Hickey, M.D., of Ann Arbor, was one of the illustrious radiologists of the early period. In 1922 he addressed the American Roentgen Ray Society. He made some points which, in retrospect, should scare us all --- especially with what came to pass.
In his published paper (Hickey 1923) we find the following: "A more liberal use of fluoroscopy in the removal of foreign bodies is also traceable to the army training. No longer is the hand or foot extensively mutilated in long-continued efforts to find a needle or a bullet. Operation under fluoroscopic control is now perfectly safe by the intermittent method, and results in easy removal, with a minimum of laceration of tissues." And:
"The extensive use of the fluoroscope in the manipulation and control of fractures is also a step in roentgenologic progress." And:
"Another outcome of the development of war activities has been the diminution in the size of machines. With the self-rectifying tube and the bed-side type of transformer, the internist is now able to do adequate fluoroscopy and still not encroach on valuable office space. In planning or installation of x-ray outfits in buildings where the price per square foot is high, this constitutes a very important item. Practically very little floor space is needed for the electric part of an x-ray outfit." And:
"It is interesting to note also the large number of internists who have placed fluoroscopes in their offices, not with the idea of specializing in x-ray work, but simply wishing to have conveniently at hand an x-ray control of their physical findings. Here again, the simplified apparatus which has developed from war-time practice is conspicuous."
It would be a gross understatement to say that Dr. Hickey was a bit optimistic about the virtues of these machines getting into the hands of those totally untrained to handle them appropriately. (See Chapter 31, where Leddy, Taft, and West make highly relevant comments many years later.)Part 2. Ardent and Sincere Advocates for the Fluoroscope
Dr. Louis Faugeres Bishop must certainly be cited as the advocate of advocates for fluoroscopic investigation. And he undoubtedly had the expertise to know the benefits in experienced hands. He gave a talk at the Medical Society of the Greater City of New York in 1922 [published].
We single this paper out, not only for its advocacy of fluoroscopy, but because his focus is heavily on the use of the fluoroscope in diagnosis of diseases of the heart. There appeared to be a whirlwind of interest in all aspects of heart measurements, heart motions, and heart disease diagnosis via heart roentgenography and fluoroscopy in the 1920s and 1930s. Many children and young adults received appreciable doses in a variety of large scale studies of cardiac measurements by fluoroscopy.
Dr. Bishop is very critical that in the early years of this century, lots of attention was paid to dimensions of the heart, and x-ray measurements of the size of the heart, but very little attention was given to what he regarded as more important features of heart disease.
We quote Dr. Bishop at page 489:
"It was the custom at that time, if any of you remember, to speak of enlargement of the heart as a matter of importance from a point of view of treatment and to measure the benefits of treatment by supposed reduction in the size of the heart ... Curiously enough the fluoroscopic diagnosis of the activities of the different chambers of the heart and the probable auricular and valvular defects as well as the discovery of congenital lesions was passed over lightly. The idea that this method could compete with the ancient and honorable institution of auscultation and percussion [listening with a stethoscope and thumping on the chest] never entered the mind of even so skillful as worker as Franz Groedel." And:
"Nevertheless, unconsciously they gained a great deal of skill and I remember how often the younger Franz Groedel could independently conclude by sight what his father had determined by history, auscultation, and a general examination of the person. In fact, it is extremely easy to distinguish a mitral heart from an aortic heart and many other important points." And:
Every Doctor's Office Needs One --- a Fluoroscope, That Is
"Fluoroscopy, I venture to assert, will become a routine measure in every physician's office before very long."
We interject here, "Many women can be most thankful that this prediction did not materialize in quite the fashion that Dr. Bishop predicted."
We quote further from Dr. Bishop: "For several years I have examined with the fluoroscope every patient who has come to me. I have at the same time recorded the picture with a film. The fluoroscopic examination which allows me to observe the relative activity of the various chambers of the heart and the pulsations of the large vessels, has furnished me with a real impression of the condition." And:
"Although a series of x-ray plates furnish a permanent record, many people are excluded from the benefits of an x-ray examination entirely on account of the labor and expense involved, thus making it a rather formidable matter. As a result, physicians are deprived of the training which comes only from repeated examinations. In my opinion there is nothing that can take the place of fluoroscopy as a short cut in the diagnosis of cardiac disease ... (to his closing sentence of this paragraph)." And:
"I venture to say at this time, what I do not believe ten years from now any one will deny, that in the detection of minor impairments of the heart the fluoroscope is vastly superior to the stethoscope, and when it is supplemented by the electrocardiograph, at least 30 % of otherwise unknown conditions are added to the factors that must be considered." And:
"Medical students are now receiving an intensive training in the anatomy and physiology of the heart so that facts which are at present known to only a few will be a matter of course to the next generation of physicians. In the interim, it behooves our larger institutions to adopt fluoroscopy as a routine matter because it will reveal a large per cent of unsuspected impairments and will thus save an immense amount of labor in drawing inferences without sufficient data. It will also occasionally reveal a condition of of the abdomen or chest which calls for prompt operative intervention and as a result save life."
One must contemplate the radiation dose to the chest (and breasts) from the following description of Dr. Bishop:
"The fluoroscope gives only a general view of the thorax. When the chest is placed behind the screen and the roentgen tube is charged one sees the shadow of the mediastinum outlined on the clearer borders of the lungs. The heart pulsations are clearly perceived and the respiratory movements are interpreted by the vertical displacement of the heart, by the raising of the ribs, by the outline of the thoracic cavity, and by the raising and lowering of the diaphragm. The anterior and posterior mediastinal spaces are shown by rotating the body of the patient from right to left and left to right. These appear clearly because of the slight density of the tissues and it is easy to observe the outline of the denser organs as well as to discover additional shadows of pathological origin. Finally, examination in the dorsal or lateral positions complete in a very short time a series of observations of the thoracic shadows as a whole."
We surely admire a man who so obviously loves his work, but we might choose a different physician if breast-cancer were to be avoided.
In re-assuring us that some of the shadows seen during the examinations do not interfere too much, Dr. Bishop states:
"The mental process of discounting a distortion of the shadows due to the nearness of the tube in fluoroscopy is much easier than one would suppose. I have records of 2000 such examinations. In each instance I studied the heart with the fluoroscope and subsequently in a teleoroentgenogram. I believe that I have acquired the faculty of mentally discounting the larger shadows of the fluoroscope. At any rate the observation of the heart with the fluoroscope enables me to form an opinion of the condition that is usually confirmed by collateral investigations."
Requires Personal Skill ... But Should Become "a Routine Procedure"
"The one disappointing element in this subject of fluoroscopy is that the question of personal skill comes in and training of the observer is necessary. It is always the ideal of scientific work to substitute some mathematical formula or instrument of precision that will eliminate the personal equation. In cardiology nothing is more popular than the arithmetical formula, but so far it has failed to be useful." And:
"Fluoroscopy, however, is capable of systematic development and of very definite interpretation. It is particularly valuable in proving and disproving a negative diagnosis. Striking instances appear in daily work where pretty good men pronounce a heart normal when the fluoroscopic examination, even to the casual observer, shows enlargement or deformity of the cardiac image." And:
"I particularly advocate fluoroscopy as a routine procedure in the examination of large numbers of patients to determine which are deserving of detailed cardiologic study and which are not."
We would add that this sort of program would certainly add materially to the breast-radiation-doses in the population. But we can be sure that Dr. Bishop was an influence, and that many persons did have fluoroscopy in offices and in hospital practices, and only rarely might the radiation doses be available for us to add to the totals for our Master Tables.
Other Major Advocates for Fluoroscopy,
Particularly in Relation to Studies of the Heart
If other advocates were not so eloquent as Dr. Bishop, they were nonetheless enthusiasts in recommending more fluoroscopic studies. Some prominent ones were:
J.G. VanZwaluwenberg: A plea for more use of the fluoroscope in examination of the heart and great vessels. American Journal of Roentgenology 1920, Vol. 7: 1-6.
Charles Martin: An enthusiast for extensive fluoroscopic studies of the heart. American Journal of Roentgenology 1921, Vol. 8: 295-315.
Gonzalo Martinez: Spoke of the advances in heart and great vessel diseases because of fluoroscopy. American Journal of Roentgenology 1921, 8: 491-496.
Rolla G. Karchner and Robert H. Kennecott: Fluoroscopy of heart steadily growing because the method is so precise for heart measurements, American Journal of Roentgenology 1922, Vol. 9:305-314.
Clarke, T. Wood, 1924, "The value of gastrointestinal x-rays in the diseases of children." Archives of Pediatrics, December 16, 840-844.
The enthusiasm here is for fluoroscopy of the gastro-intestinal tract in children, rather than for the heart. The plea suggests that a thorough gastrointestinal examination by the roentgen ray is a valuable adjunct to the clinical examination and blood, stool, and stomach analyses in the clearing up of gastrointestinal abnormalities in children. Clarke felt that the same roentgenoscopic [fluoroscopic] attention to the child's abdomen is indicated, such as that which is becoming more universally accepted as a routine procedure for the adult.
Other Roentgen Exposures for Which
Population Doses are Difficult to Assess
- In 1925, W.W. Wasson wrote "Radiography of the Infant Chest, with Special Reference to the Progression of the Chest and Determination of the Normal," Radiology Vol. 5, November: 365-398. We cite Wasson's justification for his study of infants. He had developed what he considered a technique for roentgenography of the adult chest, which he considered portrayed quite accurately the minute structure of the adult lung. The same technique was adapted to infants, and Wasson felt that the same principles held true.
Therefore, he launched a study "of the infant at birth before any changes in the lung have taken place." Then he roentgenographed babies during the first two weeks after birth, "and every four weeks thereafter until they were three months of age, then every three months until one year of age, and every three months thereafter unless conditions warranted more frequent roentgenograms. The chest is roentgenographed in the anteroposterior and lateral positions, usually recumbent, at both inspiration and expiration. The series at present includes 56 babies [emphasis added] varying from a few weeks to three years of age. The series is also supplemented by group studies of varying ages and by a considerable post-mortem series."
While these studies did not include roentgenoscopy, the two types of roentgenograms used are the worst in terms of exposure to the breasts. And there were many, many shots taken over time at ages of great sensitivity to breast-cancer induction.
This was an era when "studies" of heart and great vessels each involved examination of hundreds, and even over a thousand persons, by roentgenoscopic and/or roentgenographic methods to acquire data for the "normal." We are not being judgmental about issues such as informed consent. Rather, our problem with these studies is that they do not fall anywhere into a defined group from which we can readily ascertain the population radiation dose to the breasts, which surely occurred, and can not be overlooked.
- In the 1920s, George E. Pfahler, the very eminent Philadelphia radiologist, decided he needed some measurements on liver size in the normal state: 1926, "The Measurement of the Liver by Means of Roentgen Rays Based upon a Study of 502 Subjects," American Journal of Roentgenology and Radium Therapy, Vol.16 (6): 558-564.
We let Dr. Pfahler describe his study himself:
"No accurate roentgenological measurements seem to have been made previously to indicate what measurements may be accepted as standard or what may be considered even relatively normal. Therefore, with the hope of determining the practical value of such measurements and with the hope of establishing at least a relatively normal standard, I have been making routine measurements in every abdominal examination in my private laboratory, and have had made at two of the hospitals (Medico-Chirurgical and the Polyclinic Hospitals, of the Post-Graduate Medical School of the University of Pennsylvania) with which I am connected, 324 similar examinations upon subjects who are in general good health, but who came to our clinics because of some minor accident such as a broken wrist, or ankle, etc. From this group I believed I could obtain a more accurate estimate of the normal for various ages, height, weight, and thickness than could be obtained from a study of any group of students or nurses who would be likely to show much less variation."
The exams appear to have been postero-anterior roentgenograms, not fluoroscopy. Studies such as these leave a legacy of persons carrying a radiation dose which is obscurely recorded, but which still contributes to the production of breast-cancer.
- In 1925, L.R. DeBuys and E.C. Samuel wrote, "Growth of the Heart, Roentgenographic Observations." American Journal of Diseases of Children, 30:355-358.
This is a continuation of an earlier study of the shape of the heart at various ages. The authors wished to convince themselves of the correctness of their earlier impressions, and have therefore extended their studies up to the thirty-ninth month after birth.
They took roentgenograms within the first twenty-four hours after birth and thereafter every three to six months out to 39 months. Only true antero-posterior roentgenograms were considered acceptable. They made 623 observations on 400 persons, extending over the entire 39-month period. No fluoroscopy was involved.
Incidentally, from the point of view of breast-cancer, their exams were the worst, in terms of dose to the breasts. This work is from the Department of Pediatrics of Tulane University.
- In 1928, Edith M. Lincoln and Ramsay Spillman wrote, "Studies on the Hearts of Normal Children II. Roentgen-Ray Studies," American Journal of Diseases of Children, Vol. 28: 791-810.
Lincoln and Spillman state: " Many studies of this kind have been made on adult hearts. The literature on the size of children's hearts is not abundant, and a considerable amount of the work was done on small groups and on children in clinics who did not have obvious organic heart disease." And:
"The study was made over a period of seven school years and was based on yearly roentgenograms of 246 of the same group of normal school children ... All the roentgenograms were made with the child in a standing dorsoventral position, at a distance of 6 feet. The exposures varied from three-eighths to three-fourths of a second, with the central ray passing approximately through the fourth dorsal vertebra..." These children ranged in age from 2 years to 13 years.
The taking of the x-ray postero-anterior is of lesser harm with respect to breast irradiation. We would like to say here that we realize fully that a small series of children so studied is not going to have an impact on national breast-cancer rates. The aggregate impact of innumerable studies of children and adults by fluoroscopy (which was not done in the Lincoln study) may not be insignificant --- depending upon how many studies and how much time was spent under the fluoroscope. We have no access to such information for the relevant period, so that if the net dose is an appreciable increment, there is no way to add it to the Master Tables.
- A good example of our concern is the work of Robert O. Moody, Roscoe Van Nuys, and W.E. Chamberlain of Berkeley, California (Moody 1923, 1928). Their two reports are cited here of roentgenoscopic and roentgenographic studies first of 600, and then of 1,200 healthy students at the University of California. These investigators were conducting extensive studies of the anatomical features (size, etc.) of internal organs. We do not get an estimate of the radiation dose, but with roentgenoscopic studies being done, this is an issue of some importance. If many studies of this sort were being casually done, the person-rads to the breast and other tissues could be significant for our concerns. One cannot have many studies of 1,800 young persons, 400 young persons, 1722 roentgenograms of 246 normal children, etc. without adding to the radiation exposure of the population during the relevant period of our study. The numbers of cases we report here are by no means inclusive --- we have no idea of the number of similar studies that may well have gone unreported.
Cinematography in Studies of the Heart
A "close relative" of roentgenoscopy, in one sense, is the use of cinematography. In the American Journal of Roentgenology and Radium Therapy, 13: 508-509, 1925, work in France by Lomon and Comandon is cited, "The Roentgenologic Cinematograph." We quote a paragraph from a summary of this article:
"The practical use of cinematography in recording the cardiac contractions is described in some detail. Aside from the immediate value of such pictures, there is also the future use of these in watching the changes in heart contractions at stated intervals; comparison of these pictures may be of much value in following the condition of certain cases. In the method described, 25 roentgenograms can be made per second." The article states that under the conditions used, erythema results only after 20 seconds of exposure. "Because of the extreme heat and tension on the tubes," the writers established 5 seconds as the maximum exposure. In this time, at least 2 complete cardiac cycles were obtained. "From 17 to 18 images per second seem to give the best results, although 25 per second are possible."
Let us consider this procedure. An erythema dose would have been in the neighborhood of 300 R of skin exposure. The authors say 20 seconds produce an erythema, but therefore they limited exposure to 5 seconds. So we have a skin exposure of 75 R. For an anterior entry of the beam, this would be a dose in the neighborhood of (0.693 rads/R x 75 R), or about 52 rads to the breast. This would have to be regarded as "a new dimension" in doses associated with roentgenography, although not so rare with roentgenoscopy. Since this publication was in 1924, we shall be interested in the future to try ascertaining just how frequent such exams might have become in the United States in the many decades which followed.Part 3. Fluoroscopy as a Major Problem Refuses to Disappear
There existed so much good work in the 1920s, the 1930s, and the 1940s by people like Leddy, Braestrup, and Blatz, it seemed reasonable to believe that fluoroscopy, the outstanding hazard of radiology, would at least not be the problem in the second half of the 20th Century that it had been for the first half of the century.
But that simply did not happen and is not happening today. A large part of the problem of fluoroscopy is its enhanced use in techniques of medicine and surgery in the diagnosis and treatment of blood vessel disease and heart disease. It simply requires no disclaimer concerning the very wonderful advancements in surgical therapy which have characterized the second half of the 20th Century, especially with the life renewal of children with otherwise lethal, or severely crippling congenital heart problems.
Unfortunately, we need to be concerned that we are building into our society future breast-cancers as a result of the chest-dose to the female children undergoing the surgery. Who would not be happy to accept decades of full happy life in exchange for the risk of a later cancer? We need to be concerned since we may not see the ultimate decline in breast-cancer rates that would otherwise accompany the elimination of such practices as thymus irradiation.
The evaluation of the status of population exposure from high dose individual exposure in connection with cardiovascular therapy and other radiation sources will be a focus of the study of breast-cancer risks being generated in the 1960-2000 period, as a follow-on to the study of the current breast-cancers occurring by the thousands as a result of the radiation exposure during the 1920-1960 period.
Just as a matter of keeping our eyes on the problem, let us examine the order of magnitude of doses which can be involved in this second half of the 20th century. We look at Table 9, page 312 in the UNSCEAR Report of 1977. Table 9 is described as
"Mean Energy Imparted to Patients During Radiological Investigations of the Heart and Larger Vessels."
Method of Study Area Time Filter Dose per Procedure cm^2 minutes mm Al Roentgens Fluoroscopy 200 1.5 0.5 7.5 to 10 Radiography Direct 1200 0.5 0.25 to 0.5 Lateral 800 0.5 0.50 to 1 Tele 1200 0.5 0.3 Kymography Direct 720 1.0 8 Lateral 720 1.0 12 Electrokymography 50 10 1.0 25 Angiocardiography 1200 1.0 0.5 Heart Catheterization 100 22 1.0 30-232 Heart Catheterization, with 400 22 3.0 21 Image Intensifier Cine 400 22 3.0 12.5
It is clear that the field of diagnosis and therapy of heart and vessel disease will need an on-going careful look with respect to the issue of breast-dose to patients, nurses, technicians, and physicians.Part 4. What Can Be Done about Radiation Dose in Fluoroscopy
Versus What is Done
Gofman and O'Connor (1985) discussed in detail some excellent work which demonstrated the possibilities of lowering seriously excessive doses in fluoroscopy. The fact that this good work was being done in the late 1970s and early 1980s testifies to the ongoing aspect of less-than-satisfactory progress in dose management in fluoroscopic procedures. Considering the earlier lack of appreciation of the cancer-producing ability of low doses of ionizing radiation, it occasions no surprise that relatively little attention was given to the possibility of extensive lowering of radiation doses in fluoroscopy.
Dr. Kenneth Taylor and colleagues (1979) did a study of 30 radiological facilities in Ontario, Canada, where they found that excessive dose-rate and excessive total time accounted for a huge range in entrance doses for several common fluoroscopic examinations. Their key findings on dose-rate follow here.
Before: Facilities using high fluoroscopic exposure-rates obtained no better diagnostic quality than the facilities using low dose-rates.
After: The radiologists were just as satisfied with the diagnostic images after Taylor and colleagues lowered dose-rates as they were before.
Intensifying Screens: Excessively high dose-rates were closely associated with the use of older cadmium-sulfide intensifier screens; in terms of reduced dose-rate, cesium iodide types were preferable.
Fluorography: With modern image intensifiers, the radiologist can take a 70 to 100 mm film rather than a larger radiograph during fluoroscopy. Taylor and co-workers found that a common cause of high doses was the use of full-sized film, when the 70 mm to 100 mm picture from the image-intensifier system produced satisfactory diagnostic information.
Proper Maintenance of Fluoroscopy Equipment
There are several special tests which Taylor and colleagues used in checking the output of x-ray equipment. Some of these tests, now available through radiological physicists, show up serious additional sources of unsuspected and unnecessary exposure to patients.
As we shall relate, a patient can receive more dose while the fluoroscope is "off" than while it is "on," if its decay performance has been checked in only routine ways.
In their work, Taylor and colleagues found that one of the important features requiring measurement was the waveform of the x-ray yield as a function of time. In one machine, a malfunctioning milliampere stabilizer resulted in a continuous increase in milliamperage --- and therefore in x-ray dose to the patient --- during the course of an exposure. In another, too high a temperature for the tube filament was used, which resulted in an initial high peak exposure, followed after the first second by falling temperature and dose, thanks to control circuits. But even though the fluoroscopist stopped the exposure at 4 seconds, the x-ray yield continued, due to the gradual discharge of the high-voltage circuit. The dose did not fall to zero until 12 seconds after "termination."
As Taylor states (1983, p.656):
"The initial spike and the long decay should not have been present and more than doubled the dose to the patient. Furthermore, the radiation emitted during the tail could not be seen because the television tube is automatically blanked at the termination of fluoroscopy. Thus the patient was being irradiated without the radiologist's knowledge. Usual methods of quality control that measure steady-state conditions do not detect these transients. These transients are commonly found in fluoroscopy but are seldom investigated. The long decay can be eliminated by using higher mA and lower Kv or, better, by discharging the high tension circuit with a load resistance that is automatically connected into the circuit at the end of fluoroscopy. Ironically, the conscientious radiologist who might use high kV and a series of 2-second exposures would in fact deliver to the patient three times the radiation in the `off' periods as in the `on' time." And:
"This is a serious problem, since half the machines in clinical use studied in our survey had one or both of these faults present." [Emphasis added.]
If half the facilities in a survey in Toronto, Ontario, Canada --- an advanced center --- were showing such equipment defects, it is clear that we were, at least in 1983, far from having eliminated serious overdoses in the highest-dose part of radiological practice, namely fluoroscopic procedures. It is clear that this situation needs evaluation in detail and suggests that greater use needs to be made of the services of qualified radiologic physicists. It is fortunate that such individuals are available to maintain some quality control in this area.
The Critical Importance of Beam Size
The risk from fluoroscopic examinations need not necessarily be higher than from the routine films of the same examination. If the beam size during fluoroscopy can be kept small, the area fluoroscoped is small, and hence the risk from small-area fluoroscopic exams can be lower than the risk from larger-area films taken of the same region.Part 5. In Fluoroscopy It Appears We Win Here, and Lose There
We hope that Taylor's sage advice in 1983 has made a large impact on diagnostic use of fluoroscopy, and it would be good to be re-assured that this is the case. But we recently learn that while practice is quite good in Radiology facilities in institutions, recent reports indicate that all may not be well in departments which now have their own fluoroscopic equipment, which they operate, without adequate training in radiation safety requirements.
In 1993, Kathleen A. Greer, Associate Editor of "Advance for Radiological Science Professionals," prepared a report of some discouraging findings on this subject.
The report cites a presentation by James B. Spies, M.D. of Sibley Memorial Hospital in Washington, D.C. and Louis K. Wagner, Ph.D., a professor at the University of Texas Medical School in Houston. Their report was "Radiation Injuries During Fluoroscopy: An Unrecognized Risk," presented at the annual meeting of the Society of Cardiovascular and Interventional Radiology in October 1993. These doctors were addressing reports of injuries to patients during fluoroscopy in facilities where there was a lack of training and where patients received either high-dose or lengthy fluoroscopic exposure. The facilities considered to be inadequate are fluoroscopic equipments being used in cardiology, urology, neurology --- regarded by Drs. Spies and Wagner as "just a sampling of other specialty groups performing fluoroscopy."
"Our current concern is that there may not be an awareness of the potential for radiation injury, but it [the potential] exists," Dr. Spies said.
"There is little evidence of radiology personnel involved in fluoroscopy procedures in which radiation burns occurred, but there is documentation of such injuries, primarily during cardiology procedures," Dr. Spies said.
As Yogi Berra, the famous baseball player of the New York Yankees, said: "Deja Vu All Over Again."
It is discouraging to be hearing the same kind of reports we were speaking of earlier for the 1920s, 1930s, 1940s. The genie leaks out of the bottle in the most inauspicious ways.
It is our opinion that the status of fluoroscopy, as a threat for breast-doses which could increase breast-cancer appreciably, is an open question in this second half of the 20th century. These illustrations cropping up, of fluoroscopy in some institutions being able to cause radiation burns and hair loss without anyone even knowing that a problem exists, are disturbing in the extreme. The problem may not be large, but that surmise requires evidence, not wishful thinking.
# # # # #
1931: Roentgenology Fights for Recognition ... and against the "Dishonest
In 1931, Professor Dr. George Fedor Haenisch of the University of Hamburg, Germany, was honored by the American Roentgen Ray Society to deliver the Annual Eugene Caldwell Lecture. His title: "Roentgenology as a Specialty." (American Journal of Roentgenology, Vol.26, No.6: 821-833, December 1931.)
At that time, roentgenology was fighting hard for its recognition as a medical specialty, rather than as a bunch of "picture-takers." But other types of physicians liked doing their own roentgenology. Pediatricians, general practitioners, surgeons, and many others --- as related in Chapters 31 and 32. Unqualified users of "the ray" did not even know they were harming themselves, let alone their patients. Dr. Haenisch's lecture suggests that the scene was similar in Germany. We quote from it:
"The harm, however, which resulted from a too rapid expansion of the art and the consequent faulty, insufficiently prepared training, was not the worst ... Much more disastrous was the fact that incompetent and dishonest elements grasped this specialty. These, in some instances, were unscrupulous physicians who were guided merely by the expected pecuniary advantages and who, unhampered by clinical and roentgenological knowledge and experience, `sold x-ray pictures,' paying the referring physician rebates or commissions, or tempting him by allowing a percentage of the fee. In other instances laymen, with or without the connivance of dishonest physicians, saw in the purchase of x-ray apparatus a get-rich-quick scheme at the expense of innocent patients ... In passing I may mention that there existed unscrupulous individuals who unloaded poor apparatus on the inexperienced physicians."
Not a pretty picture. In addition, there were the eternal "turf wars" within universities and hospitals. Dr. Haenisch described them, too (at p.828):
"Opposition against the independence of roentgenology is however not confined to the universities alone. While many large hospitals have recognized the advantages of a central roentgen department under the direction of an independent specialist ... representatives of other specialties believe they must have their own roentgen laboratories so as to avoid a separation of the roentgen examination from the clinical examination as a whole."
And nearly 65 years after this lecture, non-expert users of "the ray" are still a problem (summary in Chapter 42).