P A R T IIX Rays and the Radioactive Workplace
6The Use and Misuse of Medical X Rays
During 1979 congressional hearings on medical and dental X rays, Congressman Albert Gore (D-Tenn.) recalled taking his young daughter to a hospital emergency room after she had inhaled some pillow stuffing. She was having trouble breathing. Recalled Gore: "The first thing the doctor said is, `Let's have an X ray.'" Gore asked the doctor if the pillow stuffing would show up on the X ray. The doctor said it would not. Gore then asked why an X ray was necessary. The doctor said it would be good to have as a base against which to compare future X rays in case some pneumonia developed. Gore decided not to allow the X ray to be taken.
Gore's action was a rare one. In 1979--the year of the accident at Three Mile Island--the American population received over 270 million individual X rays. They constituted the largest single source of human-made external radiation doses to the American public. In 1980 some $6.7 billion was spent on radiology equipment, insurance, and personnel; approximately 300,000 people are currently employed operating medical and dental X-ray equipment. Yet the doses administered by this industry were hardly insignificant. In some cases they may have harmed rather than helped their patients.
There is no question that X rays can perform enormously important medical services, and that their use has made an inestimable contribution to human health. Surgical therapy; treatment of bone fractures; location of various cancers, internal diseases, and malformations--all have become possible with the use of X rays, and all have resulted in the alleviation of pain and the saving of lives on a mass scale. As a result, X-ray diagnosis has rightfully taken its place as a vital and necessary part of medical therapy throughout the world.
The problems arise when the technology is overused and its dangers are not fully appreciated by the medical profession or the public. Every indicator now points to new warnings that caution is advised, and that there are those--particularly pregnant women and their unborn children--who have already suffered from the misuse of this medical miracle.
1. U.S. Congress, House Committee on Interstate and Foreign Commerce, Subcommittee on Oversight and Investigations, Unnecessary Exposure to Radiation from Medical and Dental X-rays, 96th Cong., 1st sess., July 24 and 31, 1979, pp. 86-87 (hereafter cited as 1979 X-ray Hearings).
2. 1979 X-ray Hearings, p. 79.
3. Joseph D. Calhoun, "President's Address," American Journal of Roentgenology 135 (September 1980): 636-646.
4. 1979 X-ray Hearings, p. 71.
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.
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.
Not surprisingly the early X-ray pioneers had little understanding of the potential dangers of radiation. They rarely 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.
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.
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. 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.
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. 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. 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. 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. 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.
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." 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." 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.
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.
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." 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."
Herbert Abrams has added his opinion that improper focusing and shielding may be widespread among untrained X-ray operators. 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.
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.
X Rays in Utero
Though the X-ray industry and its medical proponents emphasize that the doses from diagnostic radiation are small, considerable evidence has surfaced indicating that the health effects can be devastating, particularly to the unborn fetus.
In fact, one of the world's first and biggest radiation surveys was conducted in the mid-1950s on the effects of X rays on unborn children, and it has had an important effect on all debate over safe radiation exposures since.
The study began in 1955, when David Hewitt, a statistician at England's Oxford University, noticed that in the preceding few years there had been more than a 50 percent increase in the number of British children dying of leukemia. His preliminary statistics convinced Dr. Alice Stewart of Oxford's Department of Preventative Medicine to search for a reason. Trained as a pediatrician and epidemiologist, Stewart began crisscrossing Britain, persuading local health officials to interview the mothers of each of the 1,694 children who died of cancer the previous two years. An equal number of healthy mothers and children were used as controls.
As the interviews began to accumulate, a cause for the excess cancers emerged. Stewart and Hewitt sifted through the data and found that twice as many cancer deaths occurred before the age of ten among children whose mothers had received a series of pelvic X rays while pregnant. "It was quite by accident that we bumped into the radiation story," Stewart told us.
The "accident" was not well received by either the medical community or the nuclear industry. An X-ray picture of a fetus in utero had been secured as early as February of 1896--two months after Roentgen's discovery--and it had become common practice to use X rays to detect multiple births or abnormal conditions in the uterus, and to clarify the outlines of the mother's pelvis to aid in delivery. Hewitt's and Stewart's findings jeopardized those practices and threw into doubt the entire foundation of the safety standards for radiation. Such doses from X rays were believed to be safe. At the time their study was issued, it was generally believed that the "threshold" below which radiation exposure was safe was roughly ten rads. The new findings indicated that a single rad of X-ray dosage to an infant in utero could lead to a higher chance of childhood leukemia.
Dr. Stewart soon found herself under a barrage of criticism. She lost her staff and her funding for the Oxford survey. But she continued nonetheless. In 1958, with an expanded data base, she concluded that a fetus exposed in the first three months of development was ten times more likely to develop cancer than an unexposed fetus. The risk increased with the number of exposures, even a single X ray was found to contribute. Stewart also found that X rays to a woman who was not pregnant could also lead to damage in future offspring. Women carry their eggs from birth, and Stewart found the X rays would be particularly harmful if they affected the mothers' ovaries.
In 1962 Stewart's embattled study received powerful confirmation from Dr. Brian MacMahon of the Harvard School of Public Health. A study of 700,000 children born between 1947 and 1964 was conducted in thirty-seven major maternity hospitals in the Northeast. MacMahon compared the children of seventy thousand mothers who had received pelvic X rays during pregnancy with the children of mothers who had not been X-rayed. He found that cancer mortality was 40 percent higher among the children with X-rayed mothers. It was a stunning confirmation of Stewart's findings, a crucial turning point in the radiation controversy, and made essentially inescapable the conclusion that the human fetus was far more vulnerable to miscarriage, malformations, and cancer from X rays than anyone had previously believed possible. In 1963 MacMahon told a Joint Committee on Atomic Energy hearing on bomb fallout in southern Utah that "we must consider very seriously the possibility of cancer production by low doses of radiation such as encountered in x ray diagnosis and even fallout."
Yet two decades after Stewart first published her findings, and fourteen years after MacMahon confirmed them, little had been done to warn the public. A 1976 telephone survey by the New York Public Interest Research Group indicated that women of childbearing age who underwent X-ray examinations were often not asked beforehand if they were pregnant. At 1980 hearings for radiation victims, held in Washington, Dr. Karl Z. Morgan remembered how he and others had "fought for years to pass a recommendation . . . that women in the childbearing age should not be given x rays in the pelvic and abdominal region except during emergency situations and except during the ten-day interval following the beginning of menstruation." The failure of the X-ray industry to comply was, he said, "one of the biggest problems in reducing the harmful effects of radiation."
In 1970, the last year in which the federal government analyzed X-ray records on a national scale, it found that 23 percent of the 3.5 million pregnant women in the United States were exposed to medical X rays--some eight hundred thousand women. In 9 percent of these cases--involving more than seventy thousand individuals--the fetus was exposed to the X-ray beam. Five years later a study of sixty-eight thousand single deliveries in sixteen hospitals during 1969 and 1970 estimated that pelvic X rays were given in 6.9 percent of the cases. Current estimates indicate that pelvic X rays are still given in about 6 percent of all live births in the United States, though some facilities administer them at a far higher rate.
Unfortunately the practice of X-raying pregnant women already has had tangible effects. In January of 1957 Emma Rita Mihal, an Ohio housewife, visited an obstetrician and told him she was pregnant. "But," she remembers, "he insisted that I was not pregnant" and then ordered month-long radiation treatments for endometritis, an inflammation of the lining of the womb. A few weeks after completion of the treatment Mrs. Mihal returned to the obstetrician. The doctor, she said, "took the stethoscope and he listened, and then . . . he turned to me and said, `Mrs. Mihal, you are pregnant.' . . . It was the last thing that man ever told me." Worried about what the radiation treatment might have done to her unborn child, Mihal visited her radiologist. "He took me by the shoulder and he said, `I want you to go home, your baby will be fine.'" But when Kathleen Mihal was born on September 19, 1957, she came into the world with the undersized head of a microcephalic. Radiation burns scarred her back.
Mihal recalled that her doctors "never told me I shouldn't have another child. I did become pregnant again, and here again my other child is greatly damaged, because she has genetic damages. She was very sickly from the day she was born."
Though the Mihals' story was an extreme one, it and other cases ultimately could not be ignored. Additional studies have now linked X-ray doses to women even before pregnancy with significant rises among offspring in Down's syndrome and fatal cancer before the age of fifteen. Finally, in April of 1980, the Bureau of Radiological Health and the American College of Obstetricians and Gynecologists launched a massive public education program warning of the damaging effects of radiation (as well as certain drugs) on pregnancies. The consumer education program is part of BRH's nonpersonnel budget, which was cut in fiscal year 1981 from $6.3 million to $6.1 million. Projections for FY 1982 at the time of this writing put that budget at $5.9 million.
24. DHEW, X-Ray Examinations A Guide to Good Practice (Washington, D.C.: Department of Health, Education and Welfare, 1970), p. 6. The unborn face greater risk of radiation damage than adults receiving the same amount of exposure. The stage of pregnancy determines, in large measure, the type of fetal damage. During the first trimester risks of accidental miscarriage, congenital malformation, and brain damage predominate. From the ninth day through the sixth week of pregnancy, organogenesis--the period of organ and limb development--occurs. The greatest radiation-induced deformities can be produced because of the specialized rapid development and division of cells and tissues. Ear, nose, eye, and structural brain deformities can result.
25. Griffiths and Ballantine, Silent Slaughter, p. 41.
26. Alice Stewart, interview, November 1980.
27. Brecher and Brecher, The Rays, p. 60.
28. Stewart, et al., "Survey of Childhood Malignancies," British Medical Journal (1958), p 1495.
29. Alice Stewart and George W. Kneale, "Radiation Dose Effects in Relation to Obstetrics, X Ray and Childhood Cancer," Lancet 1 (1970): 1185-1187.
30. Brian MacMahon, "Prenatal X-ray Exposure and Childhood Cancer," Journal of the National Cancer Institute 28 (1962): 1173.
31. Fallout, Radiation Standards and Countermeasures, U.S. Congress, Joint Committee on Atomic Energy, Subcommittee on Research, Development, and Radiation, August 20-22, 27, 1963, p. 595.
32. Deborah Van Brunt, Consumer Perspectives on X Rays (New York: New York Public Interest Research Group, November 15, 1976).
33. Citizens' Hearings, p. 88.
34. "Considerations of Possible Pregnancy in the Use of Diagnostic X Rays," FDA Publication 75-8029, Health Physics in the Healing Arts, 7th Mid-year Topic Symposium, Health Physics Society (Washington, D.C.: DHEW, December 1972), p. 599; J. A. Campbell, "X-ray Pelvimetry: Useful Procedure or Medical Nonsense," Journal of National Medical Association 68 (November 1976): 514-520; K. M. Kelly, et al., "The Utilization and Efficacy of Pelvimetry," American Journal of Roentgenology 125, No. 1 (September 1975): 66-74.
35. Citizens' Hearings, p. 35; Robert W. Gibson, et al., "Leukemia in Children Exposed to Multiple Risk Factors" New England Journal of Medicine 279, No. 17 (October 24, 1960): 906-909.
36. Griffiths and Ballantine, Silent Slaughter, p. 46; A. T. Sigler, et al., "Radiation Exposure in Parents of Children with Mongolism (Down's Syndrome)," Johns Hopkins Hospital Bulletin 117 (December 1965): 374-399.
37. The FDA panel on X-ray pelvimetry approved the following statement on January 26, 1979:
"Pelvimetry is not usually necessary or helpful in making the decision to perform a cesarean section. Therefore, pelvimetry should be performed only when the physician caring for the patient feels that pelvimetry will contribute to the decisions concerning diagnosis or treatment. In those few instances, the reason for requesting the pelvimetry should be written on the patient's chart. This statement does not apply to x-ray examinations for purposes other than measurement of the pelvis."
This statement was subsequently approved and adopted by the American College of Radiology in July 1980.
The American College of Obstetricians and Gynecologists has approved the following statement in June 1980, which is comparable to the panel statement:
"X-ray pelvimetry provides limited additional information to physicians involved in the management of labor and delivery. It should not be a prerequisite to clinical decisions concerning obstetrical management. Reasons for requesting x-ray pelvimetry should be individually established."
FDA's public education campaign "X-Rays: Get the Picture on Protection" includes American College of Obstetricians and Gynecologists and FDA-approved materials on X rays and pregnancy. The information is available free from: X Rays, FDA, Rockville, MD 20857.
38. A revised FDA operating budget of $336 million for fiscal 1982 has been submitted to Congress by President Reagan. This is $16.9 million below the request submitted in January by the previous administration. The new proposed figures are:Fiscal Year Budget Paid Staff Years 1981 $327 million 7,627 1982 $336 million 7,379 Source: FDA Talk Paper, March 10, 1981.
Mammography and Other Problems
Unfortunately, children in utero have not been the only ones to suffer from the misuse of X-ray technology. One major program of X-ray diagnosis--mammography, aimed at tracking down breast cancer in women--has also resulted in disaster. Breast cancer is the leading cause of death among American women between the ages of forty-four and fifty-five. Apparently X rays have contributed to the problem rather than helping to solve it.
An X ray of the breast can reveal tumors in their early stages, and thus can have beneficial results. But because the breast is highly radiation-sensitive, the mammogram itself can cause cancer. The danger can be heightened by the subject's genetic makeup, preexisting benign breast disease, artificial menopause, obesity, and hormonal imbalances. Ironically, because the breast tissue of younger women is denser than that of older women, detection of their cancer through mammography is more difficult, if not impossible, in many cases.
The idea of using X rays to detect breast cancer gained credence in the 1930s. By the 1960s mammography was in common use, and a study begun in 1963 by the Health Insurance Plan of New York (HIP) concluded that mammography could reduce mortality rates among women. In 1973 the American Cancer Society and National Cancer Institute cosponsored the establishment of the Breast Cancer Detection Demonstration Projects (BCDDP). Twenty-seven projects were established with the goal of examining a quarter million women. The project program included instruction in breast self-examinations, an initial clinical history, and a physical examination which included a thermogram (which uses an infrared camera to study body temperatures) and a mammogram X ray. The entire program was repeated each year for five years, with a five-year observation period after screening. By 1976 about eighteen hundred cases of breast cancer had been detected.
But the program took on the aura of a fad. In 1974, after Betty Ford and Happy Rockefeller suffered mastectomies, the interest in methods of preventing breast cancer soared. Rose Kushner, executive director of the Maryland-based Breast Cancer Advisory Center, found that "women all over the country were inundated with information about this life-saving machine, and waiting lists for mammograms were often months long. Omitted from this flood of media coverage, however, was the behind-the-scenes conflict among scientists about the potential danger of exposing healthy breasts to a known carcinogen: x ray."
In January of 1975 Dr. John C. Bailar III published an article in the Annals of Internal Medicine warning that the Health Insurance Plan study, which had prompted so much faith in mammography, had not in fact demonstrated any increase in survival rates among the women under fifty who had been given the X rays. Drs. Irwin Bross and Leslie Blumenson of Buffalo's Roswell Park Memorial Laboratory soon estimated that based on dosage levels, twice as many deaths as cures could result from mammographic screenings. By early 1977 Bross had become an outspoken critic of the program, calling it a "disastrous mistake" that would "produce the worst . . . epidemic of cancer in medical history." At a meeting sponsored by the National Cancer Institute, Bross accused the American Cancer Society and the American College of Radiology of subjecting a quarter million American women to X-ray dosages equivalent "to death warrants with a 15-year delay in the execution." Dr. Rosalie Bertell, a mathematician and an expert in radiation and the causes of cancer, later explained that a basic arithmetical error had been made in the design of the mammography program, which may well have resulted in serious health effects to early participants in the program. Some changes were made after the error was pointed out, she said, but had the program continued as originally planned, it might have caused up to twelve breast cancers for every one it picked up. "A lot of this I blame on the nuclear establishment," she said, "which has gone out of its way to convince everybody that low level radiation is no hazard. The nuclear physicist gives cancer risk per year, whereas health professionals give reproductive lifetime (30 year) or lifetime (70 year) risk. A physician using a physicist's estimates and not noting the timeframe difference will underestimate the risk." The medical profession, she said, was also accepting the word of the weapons industry about the magnitude of the risk per year, even if corrected for longer time spans, letting nuclear physicists determine what doses of radiation were safe, and what were not. Thus, she charged, "the doctors have abdicated responsibility in this area."
The medical establishment gradually responded to the criticism. In August of 1976 the National Cancer Institute set interim guidelines for X rays at the screening centers, warning that "we cannot recommend the routine use of mammography in screening [women without demonstrable symptoms] ages 35 to 50." In 1977 the federal government recommended that women below the age of fifty be X-rayed only if they or a member of their immediate family had a history of breast cancer. The American Cancer Society has suggested that women under thirty-five be given mammographies only if there is clear evidence of a need for it.
Nonetheless the controversy continued. Leonard Solon, director of New York City's Bureau of Radiation Control, worried in 1976 that inadequate training was leading to faulty administration of mammograms. In 1977 the BRH found that roughly 35 percent of the mammograms being taken had technical problems affecting their usability. Bross warned that "the irresponsible or incompetent use of x ray" could not be stopped if health agencies waited for the medical profession to give the word. "If one million women each receive 1,000 millirem of x rays, between 50 and 200 can be expected to develop breast cancer as a result," he said. "The risk for radiation-induced breast cancer is higher than for all other radiation-induced cancers, including thyroid, lung, leukemia, and bone tumors."
Though infants in utero and women have proved extremely sensitive to X rays, the problem is not restricted to them. In the early 1960s one of the largest radiation-related population studies ever done was begun at Johns Hopkins University. Known as the Tri-State Leukemia Survey, the study covered some six million subjects in New York, Maryland, and Minnesota who had undergone diagnostic X rays. By 1972 results of an analysis by Dr. Bross and Nachimuthu Natarajan indicated that children with chronic diseases were also at special risk from low levels of X ray. The study also lent crucial confirmation to the problem of in utero X rays, showing that children of mothers X-rayed during pregnancy suffered 1.5 times the leukemia rate as children of mothers not X-rayed. In certain selected sub-categories of children, exposed groups are 5 or even 25 times as likely to develop leukemia as is the general population. Dr. Rosalie Bertell, in examining the data, added that "young adults with asthmas, severe allergies, heart disease, diabetes, arthritis and so on, were about 12 times as susceptible to radiation-related leukemia as were healthy adults." She measured the equivalence in effect of X ray and natural aging. Although the aging acceleration had been recognized as radiation-related, the effect had gone unmeasured. Nor had there been a full accounting for what X rays might be doing to the gene pool. "I think we need to face up not only to the long-term effects on the individual of exposure to radiation," she warned, "but on the long-term effects to the species."
In May 1977 the outspoken Bross coauthored an article in the Journal of the American Medical Association, blaming doctors for excess cancers and increased risks of genetic damage because of misuse of X rays. Within weeks he was notified that federal funding for his work on the Tri-State Survey was being terminated. The National Cancer Institute, which supported the survey for a decade, put two of Bross's best-known opponents on its review committee. Said Bross: "We became the most recent victims of a pattern of censorship and repression that has been going on in the United States ever since the furor over fallout from weapons."
39. J. D. Boice, "Risk of Breast Cancer Following Low-Dose Radiation Exposure," Radiology 131 (June 1979): 589-597; G. W. Beebe, et al., "Studies of the Mortality of A-bomb Survivors, Report 6, Mortality and Radiation Dose, 1950-1974," Radiation Research 75 (July 1978): 138-201; F. A. Mettler, "Breast Neoplasms in Women Treated with X-rays for Acute Postpartum Mastitis," Journal of the National Cancer Institute 43 (October 1969): 803-811.
40. S. Shapiro, et al., Changes in Five-year Breast Cancer Mortality in a Breast Cancer Screening Program, presented at the Seventh National Cancer Conference (Philadelphia: J. B. Lippincott, 1973), pp. 663-678.
41. Winifred F. Malone, "National Cancer Institute Guidelines for Mammography," presented at Ninth National Conference on Radiation Control, Seattle, Washington, June 19-23, 1977, p. 51.
42. 1979 X-ray Hearings, p. 115.
43. John C. Bailar, "Mammography, A Contrary View," Annals of Internal Medicine 84 (1976): 77-84.
44. I. D. Bross and Leslie Blumenson, "Screening Random Asymptomatic Women Under 50 by Annual Mammographies: Does it Make Sense?" Journal of Surgical Oncology 8, No. 5 (1976): 437-445.
45. I. D. Bross, "Written Statement Submitted for the NIH/NCI Consensus Development Meeting on Breast Cancer Screening, September 14-16, 1977, at the Invitation of Dr. Donald Frederickson," p. 1.
46. Citizens' Hearings, p. 85.
47. Diane Fink, "Letter of Screening Guidelines to Breast Cancer Center Directors," August 1976.
48. "Modification #1, Operational Memorandum #6," Breast Cancer Detection Demonstration Project, National Cancer Institute, May 5, 1977.
During a 1977 lecture Dr. Richard G. Lester of the University of Texas Department of Radiology discussed the statistical limitations of the screening program. There is a sharp increase in the incidence of breast cancer among women between the ages of forty to forty-five. The BCDDP program established the screening program at age thirty-five because proponents "believed, despite the fact that it was more recognized that the HIP Study showed no improvement in survivorship under the age of 50, that techniques had improved enough so that such an improvement would be demonstrated."
In October 1975 the National Cancer Institute initiated three committees to review the use of X-ray mammography for women under age fifty. One group, headed by Dr. Lester Breslow of UCLA, was to estimate the benefits of adding mammography to history and physical examination in the HIP breast-cancer screening project. The Breslow report, presented in July 1976, recommended that routine mammographic screening in women less than fifty years of age be discontinued; the amount of radiation in mammography for women in all ages be standardized at the lowest level possible for diagnostic quality; and additional randomized clinical trials involving women under fifty be carried out to more clearly define the value of mammography in relation to other means of detecting breast cancer.
A second group, under the direction of Dr. Louis Thomas, a NCI pathologist, reviewed the pathology data from the HIP survey. The third group, under Dr. Arthur Upton, was asked to lead a group evaluating the relation between the benefit and risk of mammographic screening for the detection of breast cancer. The Upton report found that although the risk of a mammogram increasing an individual's risks of developing breast cancer was small, the total risk to a large population of healthy women was not justified.
49. Leonard Solon, "The Options: New York City Mammography Regulations," presented at the Eighth National Conference on Radiation Control, Springfield, Illinois, May 2-7, 1976, p. 241; M. J. Homer, "Mammography Training in Diagnostic Radiology Residency Programs," Radiology 135, No. 2 (May 1980): 529-531.
In a letter to the American Journal of Roentgenology ("National Conference on Breast Cancer: Adequacy of Mammography Training," 133, No. 1 [July 1979]: 161) Dr. Marc J. Homer of the New England Medical Center Hospital stated: "Not too long ago I prepared for my oral boards in radiology. Though subjects as esoteric as congenital hypophosphatemia and the Mounier-Kuhn syndrome were covered . . . I was never required to learn mammography. Though last year I saw more breast cancers on my viewbox than all the colon, stomach, and kidney cancers combined, I never had to interpret a single mammogram as a resident . . . Anything less than a resident learning the technical and interpretative aspects of mammography is inadequate and will only serve to keep mammography as a `second class radiology examination.'"
50. Ronald G. Jans and Thomas R. Ohlhaber, "Breast Exposure: Nationwide Trends--Progress to Date," presented at Ninth Annual National Conference on Radiation Control, Seattle, WA, June 19-23, 1977, p. 222.
51. Bross, "Written Statement," p. 2.
52. I. D. Bross and N. Natarajan, "Leukemia from Low Level Radiation: Identification of Susceptible Children," New England Journal of Medicine 287 (1972): 107-110; S. Graham, et al. "Methodological Problems and Design of the Tri-State Leukemia Survey," Annals of the New York Academy of Science, 107: 557-69 (1963).
53. Citizens' Hearings, p. 83; R. Bertell, "Radiation Exposure and Human Species Survival," Environmental Health Review, June 1981, pp. 43-52.
54. I. D. Bross and N. Natarajan, "Genetic Damage from Diagnostic Radiation," Journal of the American Medical Association 237 (May 30, 1977): 2399; and U.S. Congress, House Interstate and Foreign Commerce Committee, Hearings on Effect of Radiation on Human Health, January-February 1978 (Vol. I): p. 995.
Why So Many X Rays?
Proponents of atomic power and weaponry have long been concerned that indications that small doses of X rays may be harmful would reflect badly on the viability of atomic reactors and the safety of bomb testing. Dr. Stewart's initial study, for example, was the first major epidemiological indication that low-level fallout could be far more dangerous than the currently accepted limits. In fact, even as late as 1979, during the accident at Three Mile Island, nuclear proponents were arguing that exposure levels from the plant were comparable to a single X ray, and thus safe. But Dr. Stewart's study, and a host of others, had indicated that even a single X ray could have disastrous effects on an infant in utero and other susceptible members of the community. As Dr. Allan Reiskin, professor of radiology at the University of Connecticut, told a congressional subcommittee in the wake of the accident, "these comparisons are inappropriate because they fail to recognize dramatically different distribution of radiation energies, different dose rates, different types of radiation, and different types of population that are irradiated."
Another reason for an excess of X rays may be that they add to the income of doctors and medical institutions. X-ray equipment is costly and as the state of the art quickly changes, older but still usable models become obsolete. Doctors who invest thousands of dollars in X-ray machines may well be inclined to use them more than absolutely necessary in an attempt to recoup their investment. Perhaps the technology most vulnerable to this kind of financial consideration is the new "computerized axial tomography scanning" machine--the CT scanner. This device was introduced in 1973 and can perform precise examinations of the brain and, more recently, the whole body. It contains an X-ray tube and an electronic detector situated on a circular track. While rotating, the scanner can take thousands of radiographs in a few minutes and create a computer-processed cross-section view of the patient's body on a video screen. A visual slice can be taken of any body part.
The CT scanner can be enormously useful--and also enormously expensive, costing up to $1 million to buy and $500,000 per year to maintain. A body scan can cost $250 (CT radiation therapy can run as high as $36,000 per patient) and by the early 1980s more than two million Americans were undergoing CT examinations each year. Unfortunately the radiation doses are not inconsiderable, ranging as high as forty-five hundred millirems for some scans.
The question must inevitably arise as to whether the machines once bought might be overused for financial reasons. That question has also arisen in the field of dental X rays. The average skin dose per dental X-ray film is about 910 millirems, nearly triple the whole body dose from background radiation. Though the dose to the bone is much lower--four millirems--a full mouth series can involve sixteen or more individual X-ray films and can deliver a substantial dose of radiation to the mouth. A 1976 telephone survey of five hundred New York dentists by the New York Public Interest Research Group found that 89 percent of them ordinarily included a full set of full-mouth X rays during a patient's first visit to the office. Nearly half the dentists repeated X rays of the mouth at least once a year. According to radiological health specialist James L. Walker, many dentists "feel that the dental x-ray is a tiny, tiny exposure and it's not really a hazard."
Unfortunately, many of the technicians administering dental X rays are no better trained than those working in doctors' offices. And though lead "bibs" have been recently introduced to protect patients in some dentists' offices, sensitive organs such as the thyroid, salivary glands, active bone marrow, and lymphatics are still being exposed. Scatter radiation may also affect other parts of the body, including the gonads, a particularly important problem among children.
Experts at the 1981 National Council on Health Care Technology Conference on Dental Radiology agreed that dentists rely too much on X rays. Conference participants concluded that X rays should be administered only when clinically indicated, i.e., after the patient's mouth has been visually examined and there appears to be a definite need for more information.
Another form of exploratory X ray under scrutiny is the use of chest X rays to find cancers and tuberculosis. As early as 1965 the Public Health Service called for an end to routine chest X rays as a means of detecting tuberculosis. PHS argued that tuberculosis was on the decline and that 95 percent of the people with active TB had been identified without X-ray screening. PHS also learned that chest X-ray units--many of which were mobile, moving around in vans--produced higher levels of exposure than other radiological equipment, and that a large segment of the population was receiving unnecessary amounts of radiation with little return. Nonetheless X-raying of children with mobile units continued essentially unabated until 1972, when the PHS again called for an end to the practice, this time in conjunction with the American College of Radiology and the American College of Chest Physicians.
Chest X rays remain a part of many routine health physicals and screening programs aimed at finding heart and breathing diseases. Serious questions have been raised by the Medical College of Pennsylvania about their effectiveness in promoting early treatment of lung cancer. But in 1977 thirty-seven million chest X rays were performed in hospitals across the country. In February of 1978 President Jimmy Carter approved a directive recommending, among other things, that routine X-ray screening of patients who showed no particular symptoms should be discontinued, except in specific circumstances of high disease risk because of social or economic factors.
In April of 1979 the Joint Commission on Accreditation of Hospitals announced that it no longer required or recommended routine laboratory or X-ray examination upon admission to the hospital. In February of 1981, as part of the Reagan reductions in domestic expenditures, the federal government saved four million dollars and perhaps numerous lives by eliminating its program of routine chest X rays for some 160,000 government employees in thirty-seven agencies.
But X rays continue to be prescribed and shot all over America in what Irwin Bross has described as a "mindless" fashion. Ironically, one of the chief contributors to this ongoing exposure is the American insurance program. Medical malpractice liability varies from state to state. Numerous insurance companies require an X ray before they will reimburse a patient for treatment. The Social Security Act requires an X ray to be submitted as proof of need for chiropractic treatment.
Perhaps the worst problem resides in the medical malpractice laws. These vary from state to state, but in general they are a strong incentive to doctors to give numerous X rays far in excess of real medical need, in the hopes of establishing a record with which to defend themselves in case of a lawsuit. This "defensive medicine" can be carried to extremes. Dr. John McClenahan, a Pennsylvania radiologist, describes the syndrome thusly: " If a tennis player suffers elbow pain after a truck scratched the fender of his car, a radiologist will be called on to take pictures of not only the elbow, but of a shoulder . . . a forearm, a neck, chest and, after the diarrhea ensuing as the result of stress imposed by the accident, of the patient's entire gastro-intestinal tract." Though radiologists and doctors may find such treatment excessive, few would risk losing an expensive lawsuit by refusing to use it. A 1973 survey by the Federal Commission on Medical Malpractice found that more than half the doctors polled admitted to engaging in some form of defensive medicine, and four years later an American Medical Association poll found 75 percent of the doctors contacted were ordering extra X rays to protect themselves from lawsuits.
55. 1979 X-ray Hearings, p. 10.
56. K. Z. Morgan, "The Need for Radiation Protection," Radiologic Technology 44, No. 6 (1973): 385-395; OTA, Policy Implications of the Computerized Tomography (CT) Scanner (Washington, D.C.: Office of Technology Assessment, August 1978), pp. 15-20.
57. Michael Goldstein, "CT Benefits and Cost in Therapy," Journal of the American Medical Association 244, No. 12 (September 19, 1980).
58. OTA, Policy Implications, p. 39.
59. DHEW, Population Exposure to X rays U.S. 1970 (FDA) Publication 73-8047 (Washington, D.C.: Food and Drug Administration, November 1973), Appendix III; ICRP, Protection of the Patient in X-ray Diagnosis, Publication No. 16 (New York: Pergamon Press, 1970).
60. Deborah Van Brunt, Consumer Perspectives.
61. Susan Lockamy, "X-Rays: Many Tidewater Dentists' Machines Exceed FDA Levels," Virginian-Pilot, August 20, 1979.
62. S. Julian Gibb, "Radiation Risks in Dental Practice," prepared for the Council on Dental Materials, Instruments, and Equipment, American Dental Association, p. 12; Panati and Hudson, Silent Intruder.
63. Washington Star, July 2, 1981; National Council on Health Care Technology, Conference on Dental Radiology, Arlington, Virginia, June 29-July 1, 1981.
64. Valerie Britain, "Mass Chest X Rays Are on the Way Out," FDA Consumer, February 1973.
65. W. Weiss, et al., "The Philadelphia Pulmonary Neoplasm Research Project, Thwarting Factors in Periodic Lung Cancer," American Review of Respiratory Diseases 3, No. 30 (March 1975): 389-397.
66: Federal Register, February 1, 1978, pp. 4377-4380. Recommendation #3 of "Radiation Protection Guidance to Federal Agencies for Diagnostic X Rays": "Routine or screening examinations in which no prior clinical evaluation of the patient is made, should not be performed unless exception has been made for specified groups of people on the basis of a careful consideration of the magnitude and medical benefit of the diagnostic yield, radiation risk, and economic and social factors. Examples of examinations that would not be routinely performed unless such exception is made are: a) chest and lower back x-ray examinations in routine physical examinations or as a routine requirement for employment; b) tuberculosis screening by chest radiography; c) chest x rays for routine hospital admission of patients under age 20 or lateral chest x rays for patients under age 40 unless a clinical indication of chest disease exists; d) chest radiography in routine prenatal care; e) mammography examinations of women under age 50 who neither exhibit symptoms nor have a personal or strong family history of breast cancer."
67. "X'ing Out Unneeded X Rays," FDA Consumer, April 1981, p. 19.
68. I. D. Bross, "An Action Program to Protect the Public Against the Mindless Use of Diagnostic Radiation and Other Technology," June 17, 1977.
69. 1979 X-ray Hearings, p. 162; U.S. Congress, House Interstate and Foreign Commerce Committee, Subcommittee on Oversight and Investigations, Report on Unnecessary Exposure to Radiation from Medical and Dental X-rays, Committee Print 96-52, August 1980, pp. 3-7.
70. John McClenahan, "A Radiologist's View of the Efficient Use of Diagnostic Radiation," presented at the Seventh Annual National Conference on Radiation Control, Springfield, Massachusetts, April 27-May 2, 1975, p. 72.
71. Medical Economics, September 30, 1974, p. 75; "Fear of Lawsuits Boosts MD Bills," Buffalo Courier, March 29, 1977.
X rays and other forms of radiation have been used in medicine for purposes other than taking diagnostic pictures. In the early days of radioactive science it was widely believed that radium had immense curative properties, in large part because its rays affected tissue growth. Injection of radioactive materials into some tumors and growths can reduce and destroy them; radiation can also be used to destroy cancerous cells in the body, and arrest the spread of the disease. Great care must be taken to ensure that all the cancerous growth is destroyed and that none of the surrounding tissue is harmed. The size, type, and location of the cancer dictates exactly the form of therapy used.
But the use of radiation as a medical treatment has often been misunderstood and abused. Large amounts of radium, used as a source of gamma rays, have been used to treat lupus, eczema, psoriasis, and other skin diseases, and for removing benign skin tumors and moles. Such radiation treatments were administered from the 1920s through the 1950s, and were also deemed acceptable for treating enlarged thymus and thyroid glands, enlargement and inflammation of tonsils and adenoids, deafness due to hypertrophy of lymphoid tissues around eustachian tubes, ringworm of the scalp, cervical and other types of inflammation, tuberculosis of cervical nodes, asthma, whooping cough, and even breast problems after birth. Throughout the 1950s American children and adults were even allowed to have their feet X-rayed in shoe stores to determine their proper size. The practice may well have damaged millions of people's feet, and scatter radiation from the relatively cheap machines may have done other damage as well.
Some of the more primitive applications of radiation persist. In 1981 we discovered pamphlets from two operating Montana "health spas" advertising the benefits of radon gas in curing "arthritis, sinusitis, migraine, eczema, asthma, hay fever, psoriasis, allergies, diabetes and other ailments." The pamphlets claimed that by sitting in abandoned mine shafts and breathing radioactive gases, people's pain will disappear, joints will loosen, and skin lesions will heal. Unfortunately, the pamphlets do not mention that it has been well established for at least a decade that radioactive gas in uranium mines is a cause of a fivefold increase in lung cancer among miners.
The toll from misdirected medical uses of radiation through the decades is impossible to fully document. But there have been tragic victims. One, a man named Joe Victor, told his story at the 1980 Citizens' Hearings for Radiation Victims in Washington. "I was burned by x rays on my face," he told a packed hearing room. "I have had more than twenty operations to remove the irradiated and malignant skin that the radiation caused . . . I will be disfigured for the rest of my life."
At the end of World War II, as a handsome young Marine, Victor underwent radiation therapy for a facial rash called "barber's itch." When the rash recurred in 1947, he again underwent therapy. Five years later an X-ray technologist told him he thought Victor had been overexposed. And when he visited a radiologist at a Veterans Administration hospital in Boston, Victor was bewildered when "doctors congregated around me. The one in charge asked the others a lot of questions about how they would diagnose my problem, and then he turned to them--I'll never forget it, he was very dramatic about it--and said, `This is what happens when you guys are careless with x rays.'"
Later Victor called the radiologist who had treated him and was told not to worry. But within ten years of his "treatment," Joe Victor developed skin cancer on his nose, chin, neck, and eventually on his chest. Huge pieces of flesh had to be removed from his face. Though skillfully done, the reconstruction was patchy, discolored, scarred, and incomplete. His nose was reshaped, his upper lip partly cut away, and he was left unable to close his mouth. Scars left on his neck resembled those of a burn victim, and his chest was permanently disfigured. "I considered getting married," Victor testified. "But aside from the problems my condition created in relationships with women, I was also worried that all this radiation would affect any kids I had. I would be afraid they would be deformed.
"What's happened, to put it bluntly, is that my life's been ruined," Victor added. "They tell me in the hospital now how I'm so well adjusted. But you never really adjust."
At the time Joe Victor was irradiated for a skin rash, faith in radiation as a diagnostic aid and medical cure was nearly boundless. X-ray therapy for a wide range of noncancerous illnesses of the head, neck, and upper chest during childhood has, according to some studies, resulted in a significant excess of both malignant and benign thyroid tumors. X rays used to treat illnesses related to the thyroid directly have also resulted in that sensitive gland's being exposed. Because much of the treatment was done in private doctors' or radiologists' offices, there are no firm records on how many people received such treatment and who they were. But the National Cancer Institute estimated the number to be as high as four million.
Meanwhile the use of radioactive substances to treat a wide range of diseases--and particularly cancer--is becoming increasingly sophisticated. There continues to be widespread debate over the advisability of such therapy, and the possibilities of natural, alternative cures. There has also been some tragic fallout.
In the late 1970s James L. Kline of Hagerstown, Maryland, suffered an overdose of radiation which was given him as a precaution after the surgical removal of his prostate gland. The radiation burned away his buttocks and destroyed his right hip, leaving him, in the words of his lawyer, "hopelessly and totally disabled." Bedridden since May 1978, Kline recently won a two-million-dollar malpractice settlement.
Despite Kline's case and a growing controversy over the uses and abuses of radiation, portions of the medical profession remain enthusiastic. "Recent advances in radiation therapy allow the maximum potential cure with the minimum of side-effects, such as nausea, vomiting, skin reactions and scarring," says Dr. Luther W. Brady, Jr., of Philadelphia's Hahnemann Medical College and Hospital. "With a growing number of early cancer patients, radiation therapy techniques are emerging that are as viable now as radical therapy."
But the question remains whether this early enthusiasm for yet another use of radiation may someday result in a long list of tragic, unexpected side effects, as has the use of medical X rays.
72. Brecher and Brecher, The Rays, pp. 137-160.
73. E. L. Saenger, et al., "Neoplasia Following Therapeutic Irradiation for Benign Conditions in Childhood," Radiology 74 (June 1960): 880-884; L. H. Hemplemann, et al., "Neoplasms in Persons Treated with X-rays in Infancy: Fourth Survey in 20 Years," Journal of the National Cancer Institute 50, No. 3 (September 1975) 519-530; NAS, A Review of the Use of Ionizing Radiation in the Treatment of Benign Diseases (Washington, D.C.: National Academy of Sciences, September 1977).
74. Karl Z. Morgan and J. E. Turner, Principles of Radiation Protection (New York: John Wiley & Sons, 1967), p. 49.
75. Merry Widow Health Mine (P.O. Box 3444, Basin, MT 59631), pamphlet; and Sunshine Health Mine (Box E, Boulder, MT 59632), pamphlet.
76. Citizens' Hearings, p. 80
77. B. J. Duffy and P. J. Fitzgerald, "Cancer of the Thyroid in Children: A Report of 28 Cases," Journal of Clinical Endocrinology and Metabolism 10 (October 1950): 1296-1308; T. Winship, "Symposium of Thyroid Tumors: Carcinoma of the Thyroid in Children," Transactions of the American Goiter Association, 1951, p. 364; T. Winship and W. W. Chase, "Thyroid Carcinoma in Childhood, a Report of 275 Cases," Surgical, Gynecology and Obstetrics 101 (August 1955): 217-224; E. M. Uhlmann, "Cancer of the Thyroid and Irradiation," Journal of the American Medical Association 161 (1956): 504-507.
78. Margaret H. Sloan, "Thyroid Irradiation Followup Studies," presented at the Ninth Annual Conference on Radiation Control, Seattle, Washington, June 19-23, 1977, p. 369.
79. Chip Brown, "Maryland Cancer Patient Gets $3 Million in Malpractice Claim," Washington Post, February 26, 1981. The award was eventually lowered to $2 million. Loretta Tofani, "Malpractice Award Is Cut to $2 Million," Washington Post, February 27, 1981.
80. Lawrence Galton, "New Victories for Radiation Therapy," Parade Magazine, March 1, 1981.
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