The practice of medicine during this era was also quite different. The physician of the time had three resources at his disposal as he made his calls on the patient, usually in the home. His mere presence might inspire the patient or family, to produce some salutary effect. The pharmaceuticals in his black bag, though meager, might provide some remedy for the ailment. The same bag contained a few instruments which might also contribute. Finally, the increasing acumen of disease owing to a greater. knowledge about pathology and the germ theory of disease, made the correct diagnosis possible. Often, bleeding or laxating the patient was the only treatment offered due to the limited pharmacoupia available at the time.
Into these times, the discovery of x-ray occurred in late 1895 in Wurzburg at the Physical Institute of the University. The first radiograph of Mrs. Roentgen’s hand was made on December 22nd. The formal lecture and demonstration at the Wurzburg Physical-Medical Society was presented on January 23,1996.
Roentgen immediately realized the significance of his work and its commercial applications. The rest of the world did as well and word of the new discovery spread rapidly. In 1895 the telegraph was well established. The first transatlantic cable was laid in 1865 after Faraday discovered how to properly insulate cable with gutta percha. The Reuters European news agency was founded in Germany in 1849 and did it’s part in disseminating news in Europe and Britain. The Associated Press, founded in 1848, took up the task in the U.S. An interesting side bar to the potential for the rapid dissemination of news was the discovery of radiotelegraphy by Marconi the same year, 1895. The telephone was discovered in 1877, but did not play much of a role in communications at that time. (It may surprise you to know that reliable transatlantic telephony did not exist until 1950.)
The discovery of x-ray found Ohio a largely agricultural state in the midst of a huge industrialization. Northern Ohio saw rapid growth of heavy industry, fueled by commerce on the Great Lakes and iron ore from Minnesota. This particularly affected Toledo, Cleveland, and Youngstown. Akron fast became the “rubber capital of the world.” Columbus was a center for blowing and the manufacture of railroad and farm equipment. Cincinnati made steamboat boilers, machine tools, railroad cars, meat products, and soap. Dayton made paper products, refrigerators, and cash registers.
Medicine in Ohio was a rather disorganized profession, often not looked upon with a great deal of respect. The Ohio State Medical Society was founded in 1848. The early arm was to reduce the number of untrained or ill-trained individuals in the State who were practicing what might be described as medicine. In 1896 a law was enacted that required at least two twelve week courses of study as a requisite to practice. Ultimately, a more satisfactory law required the successful completion of a State Board examination for licensure. After 1900 legislation made a frill four year course of study mandatory. Until that time, Ohio was the repository for a large number of “physicians” with few or no credentials, since our laws were much behind those of our neighboring states. The state of affairs was very clear when the following statement was made by the president of the State Board upon enactment of the law requiring examination. “It is probable that no equal territory contained so many vampires, charlatans, mountebanks, and quacks as did Ohio.” The news of the work of Roentgen came to Ohio at a time when the science of medicine was not so well recognized as we expect today. This led to some interesting practitioners and practices of this amazing discovery.
The public was fascinated with the new x-ray. Ohio, like the rest of the country, found all sorts of people providing access to the “new light.” The “skiagrapher,” as the radiographer of the time was called, was more likely to be a layperson than a physician. No less a scientist than Edison himself provided walk-up fluoroscopy so the public could see their own skeletons. This certainly encouraged all sorts of entrepreneurs to cater to the intense public interest. Physicians early on recognized the impact this would have on the practice of medicine, but the sheer numbers of nonmedical practitioners eclipsed then efforts. One should remember that a fad of the time was to treat a number of ailments with an application of electric current. It was only a simple extra step to attach a Crooke’s tube to the generator to provide x- ray.
Ohio led the nation when Professor Dayton C. Miller of the Case School of Applied Science made the first medical x-ray February 3,1896. He lectured the Cleveland Medical Society on his work on April 3,1896 and immediately was in demand from the medical community to obtain images of broken bones and foreign bodies.
There was no understanding of the risks of exposure and it is startling to see early photographs of procedures being performed with everyone standing about without any sort of protection. Many of the early pioneers in radiology lost their extremities and even their lives because of this ignorance. Dr. George Iddings began practice in Cleveland in 1897. Within ten years he had to discontinue his career due to severe injury from exposure, having damaged his hands, face, and left breast. It is of particular interest that the first reference I can find, in Ohio’s literature of the time, is a review of injuries which the author attributes to x-ray. N. Scott Stone, MD, of Cleveland, in The Transactions of the Ohio State Medical Society in 1897 reported a total of 69 injuries in an approximate total of 20,000 examinations. The data came from across the United States. This was a very carefully written article, which included a large table. Skin reactions from erythema to vesiculation were carefully documented. Epilation was also noted and Stone recognized that a delay of several days often occurred before the findings became manifest. There was no correlation as regards the type of machine utilized to generate the energy. The exposure times were also documented and he found only a limited relationship. It should be remembered that there was no available standardization of tubes or generators and it is a bit startling to see exposure times of up to three hours noted. This was an excellent observation of the acute reactions of the skin and its appendages and it was only later, with the passage of time, that the long term effects became known. He noted that the severity of the injury was related to the proximity of the part to the anode or platinum electrode. The final comments were particularly interesting. Stone did not speculate upon the actual physiological cause of the injury, but left that inquiry to the electricians. He referred to the comments of Professor Blake, who made the following observations which were reported in the Electrical Journal, December 1, 1896: “Injuries are rare when proper precautions are taken. Injuries are limited to the skin and the deeper tissues are not affected. Bones are not affected. Short exposures are best and should not exceed one hour at 10 inches from the terminal. If trouble occurs from short exposures, don’t do any more.7’ When one considers the infancy of the science, it is remarkable how many correct conclusions were drawn. Serious errors can be attributed to the fact there was no long term experience with the new discovery.
In 1899, a second reference to the use of x-ray was noted in the Transactions of the Ohio State Medical JournalThis article by William Jordan, BS of Cincinnati is entitled “The Use of Roentgen Rays in Surgery.” He indicated that exposures are now measured in seconds, rather than minutes, denoting rapid improvement in the apparatus utilized. The primary use of radiography was for fractures and other orthopedic problems. The diagnosis of caries of the spine was facilitated. One of the most frequent indications was for the evaluation of foreign bodies, particularly bullets. There was lively discussion regarding the possibility of trickery in the images. Numerous questions were posed as to whether a practitioner could trust the images and the “skiagrapher.” Reference was made to a $10,000 dollar malpractice award, made in a Chicago case, regarding an x-ray image. There seemed to be concern as to the role of the image in the management of the patient. (Times have not changed!) The therapeutic value of the x-ray was discussed and a case was cited of a railroadman afflicted with tuberculosis of the knee. Three exposures of the joint were made, owing to difficulties with the equipment. The exposure times were quite long.
Following the last diagnostic exposure, he returned to work and became asymptomatic. Perhaps this was Ohio’s first therapeutic application.
In the 1904 edition of the same journal, the first clearly intended application of radiotherapy was reported. Myron Metzenbaum, MD of Cleveland reminded the audience of the work of Madam Curie and the physical properties of radium. He presented the case of a 57 year old woman who had a “lupus” on her supraorbital ridge. This was treated with conventional x-ray with the loss of her eye and incomplete control of her disease. He applied radium locally and noted rapid improvement in the lesion. Two additional applications seemed to resolve the tumor. He wondered if radium could be used to make “skiagraphs.” He demonstrated images produced in that manner and these were deemed unsatisfactory. (Clearly he did not recognize the phenomenon of Compton absorption.) He declared that there was too much skin reaction and a very poor image as well.
Local medical journals in major cities began to report significant interest in the new discipline, but much of the interest was tempered with skepticism. In Cleveland, Dr. Walter Hill expressed an interest in x-rays and was advised by his professor of medicine that it was “a passing fancy.” He persevered and became the Lakeside Hospital radiologist in 1904. Dr. Walter LeFevre, also of Cleveland, began his practice in 1902 and actually manufactured much of his own equipment. In association with the Gebauer brothers, he discovered that tungsten was much better for the anode. He was ready to manufacture tubes when Coolidge developed the first predictable tubes that provided constancy to the exposure.
In Cincinnati, the therapeutic uses of x-ray were being explored by Dr. William Taylor. He reported on the improvement of pain in nine cases of rheumatism. Dr. Percy Shields, Professor of Dermatology at one of the predecessors of the University of Cincinnati, treated epitheliomas. He also treated carcinoma of the tonsil and larynx. In 1905, Dr. Albert Freiberg, later the Professor of Orthopedics at the University of Cincinnati, lectured on how invaluable x-ray was becoming in his specialty. At the conclusion of his presentation, Dr. Joseph Ransohoff, Chair of Surgery at the Medical College of Ohio, admitted the difficulty in adequate interpretation of radiographs. He advised as to the usefulness of x-ray in the evaluation of stones in the urinary tract. He also made the cogent observation that it was important to visualize them in more than one perspective. The images used in his presentation were provided by Dr. Freiberg, indicating early cooperation among colleagues. By late 1905, the name of Dr. H. Kennon Dunham began to appeal’ in the literature. He lectured in electrotherapeutics at the Medical College of Ohio. He was intensely interested in x-ray and was one of the pioneers in developing instrumentation for the accurate measurement of radiation and standardization of exposure. He early recognized the need for reproducibility of radiographs to facilitate their clinical usefulness. He collaborated with Dr. Samuel Allen, a physicist, to that end. He also felt that the use of x-ray should be a paid of medical education. A course of 24 lectures, split between physics and diagnostics, was offered to medical students in 1907. This was one of the earliest efforts in American medical education to teach radiology. Allen participated in the development of intensifying screens, cine radiography, and stereoscopic imaging. He became internationally known for his expertise in the use of x-ray in the diagnosis of tuberculosis and studied the therapeutic application of x-ray in the treatment of tuberculous adenopathy.
The American Roentgen Ray Society met in Cincinnati for the first time on October 3-5, 1907. The use of x-ray attracted most of the medical specialty’s interest and the speakers were representative of that fact. Two speakers from Cincinnati were the previously mentioned Drs. Frieberg, an orthopedist and Allen, a physicist.
The rapid expansion of the technology and the widespread applications to clinical medicine, both diagnostic and therapeutic, continued to be documented in local and national publications. Both state and local medical society newsletters are ample evidence of interest. The practice of x-ray imaging was a mix of hospital based and private office work. Most of the therapeutic applications were found in the private setting. By this time, every major city in Ohio offered x-ray services, as did many of the smaller communities. The educational efforts of the aforementioned societies had an effect and the quality of the images rapidly improved. Reference was often made to physicians who trained in the new specialty in the East and returned to Ohio to begin practice. The actual birth of Radiology as a specialty was beginning.
Wide usage of x-ray flourished in the period from 1905 to 1910, albeit not without controversy. One of the biggest problems was: Who would be the “skiagrapher?” Hospital electricians, photographers, and physicians all competed for control of the laboratory. In a relatively short time, however, recognition of the dangers of careless use and the injuries gave control to the physician. Hospital medical staffs were still a bit skeptical of the value of x-ray and administrators were reluctant to provide much space to the effort. Early x-ray laboratories were usually a one-room affair; and, a small one at that. Single individuals, such as Dr. Sidney Lange at the Cincinnati Jewish Hospital and Dr. Walter Hill at Lakeside in Cleveland, were early hospital radiographers. In a fairly short time, nearly every major hospital acquired such a practitioner. The vast majority were physicians with a special interest, who chose to perform the service. There were very few training programs anywhere in the world for radiology.
The Spanish American War and World War I brought into focus the value of x-ray in casualties. The use of portable units on the battlefield cemented the benefits of radiography in surgeons’ minds. The widespread application was aided by the use of early contrast media. Dr. Lange diagnosed a carcinoma of the esophagus by using a mixture of corn meal mush and subcarbonate of bismuth as early as 1910. Agents to visualize the gall bladder soon followed and the new specialty was now on its way. In the early 1920’s, the specialty was seeing its first division, into diagnosis and therapy. Most practitioners still performed both services.
Radiology grew gradually and soon there were practitioners in nearly every community. World War II provided impetus, as had the previous world conflict, and it also provided an entirely new discipline. The Manhattan Project was the beginning of nuclear medicine. The first chairman of a separate department of Radiology at Case Western Reserve was Dr. Hymer Friedell. He had served on the Manhattan Project and probably performed the first nuclear medicine procedures in the country. The Armed Forces Schools provided training for many radiologists during the war and those newly minted specialists returned to private practice following the conflict. Many of these men and a few women formed the nucleus of the formal training programs that began to develop in the early fifties. Dr. Ben Felson told us many a story of his adventures in the Army. Most of Ohio’s academic programs started about this time and the process of accreditation for training began in earnest during this period as well. Currently, Ohio has eight training programs in diagnostic radiology and four programs in radiation oncology.
Progress has been extraordinary since the fifties. The addition of computers has made our specialty one of the most progressive and rapidly changing in all of medicine. In my own practice lifetime alone, I find that at least one half of my workday is spent using technology that was not taught during my residency in the late sixties. The last twenty-five years have been quite a ride for us all.
I have enjoyed the time spent researching this project and I hope that you have enjoyed this brief history. I need to thank medical librarians Betty Broaddus at the University of Cincinnati and Maggie Yax at Wright State University for their help.. Special thanks to Dan Singer for material provided from Toledo, and George Belhobek from Cleveland. I am particularly grateful to Stanley Lucas for the treasure trove of material he provided from his previous history of radiology in Cincinnati. A final thank you my wife, Vickie – my editor and best critic.
Burton G. Must, Jr., M.D.
Former OSRS President