P A R T II
X Rays and the Radioactive Workplace
The 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.