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Early radiology 

Early radiology
Early radiology

Adrian M.K. Thomas

and Arpan K. Banerjee

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date: 07 December 2019

The importance of the X-ray machine to the general public is shown by the fact that in 2009 it won the Science Museum’s Centenary Award. The modern Science Museum in London was founded in 1909 and as part of its centenary celebrations it held a public vote on the top ten objects in the museum. One of the icons is the Russell Reynolds X-ray apparatus, which is on display in their ‘Making of the Modern World’ gallery. In January 1896, as a schoolboy, Russell Reynolds (1880–1964) used an early Watson gas X-ray tube mounted on a retort stand similar to the one illustrated to demonstrate Röntgen’s discovery (Figure 2.1). Nearly 50,000 people voted in the poll, and they voted overwhelmingly for the discoveries that have transformed the way we look at our bodies and ourselves. The X-ray machine took the top place, followed by penicillin and then the DNA double helix. We should also reflect on the fact that without X-ray crystallography the discovery of the structure of DNA (which took third place in the vote) would not have happened.

Fig. 2.1 An early gas (ion) X-ray tube mounted on a wooden stand.

Fig. 2.1
An early gas (ion) X-ray tube mounted on a wooden stand.

Image courtesy of Dr Adrian M.K. Thomas.

Early radiology was both difficult and dangerous.1 There was no radiation protection of the X-ray tube or indeed any electrical protection of the apparatus. There were a number of dangers that were intrinsic to early radiology, and these included the dangers of overexposure to radiation, the presence of high-tension cables, and also the chemicals involved in photographic wet processing. It was not until the 1930s that shockproof apparatus became generally available. There is an account of the inquest of a nurse at Wimbledon Hospital in the 1930s who was killed by an electrical shock after being repeatedly warned by the radiographer to keep away from the mobile ward apparatus when an exposure was being made. The unfortunate nurse touched the radiographic apparatus as the exposure was being made and received a fatal shock.

Ernest Wilson (1871–1911)

The story of Ernest Wilson illustrates the dangers that beset the pioneers. Ernest Wilson was for some years a lay assistant (radiographer) at the Electrotherapeutic Department at the London Hospital (now the Royal London Hospital), having joined the department in 1899. Initially all his work involved the use of the fluorescent screen, and this was carried out with no protection. Wilson held a fluorescent screen for many hours each day, exposing his hands in particular to the full effect of the rays. He was ‘not of a robust type’ and had previously suffered from tuberculosis of his neck glands. Within a few months of his starting to work with X-rays his hands showed evidence of X-ray injury (radiation dermatitis) and by 1900 he had developed whitlows at the base of the nails. Initially these were treated by ‘scraping and fomenting’. A series of amputations of the right middle finger were performed, starting in June 1904; these never healed well and there followed chronic suppuration. He took a poignant series of radiographs of his hands demonstrating the progressive changes (Figure 2.2). By June 1910 the stump was very painful and swollen and a further amputation was performed. The specimen showed evidence of epithelioma, which was spreading along the bone. At this period the possibility of the development of epithelioma in such cases was only just being realized. A final amputation of the finger was soon followed by axillary lymphadenopathy with secondary deposits and he died on 1 March 1911 at the age of 40. As Ernest Wilson put it himself, he was not a martyr to science but a victim since a martyr knows what to expect. His name was one of the original 169 names of X-ray and radium martyrs recorded on the memorial in the grounds of St George’s Hospital, Hamburg.

Fig. 2.2 Radiographs of the fingers of the pioneer radiographer Ernest Wilson showing progressive bony loss secondary to radiation injury.

Fig. 2.2
Radiographs of the fingers of the pioneer radiographer Ernest Wilson showing progressive bony loss secondary to radiation injury.

Image donated by the Scott Family. Reproduced courtesy of Dr Adrian M.K. Thomas.

It was on 4 April 1936 that a memorial to the X-ray martyrs of the world was erected in the grounds of St George’s Hospital in Hamburg. The monument is still standing and may be visited. These early X-ray and radium workers suffered greatly from radiation injuries and premature death in the period prior to the understanding of the need for radiation protection and safe handling of radiation sources. In particular, there was little awareness of the cumulative nature of exposure. It was believed that if a radiation worker showed signs of overexposure then what was needed was a period of rest and recuperation. Once the worker had recovered then he or she could safely return to work. This is not the case and radiation doses are cumulative.

Corporal Edward Wallwork RAMC and radiation risks

Unfortunately there were many of the early generation of X-ray workers who suffered injuries from radiation. The illustration (Figure 2.3) shows a wristwatch presented to Corporal Edward Wallwork RAMC by Doctors Ironside Bruce (1879–1921), Stanley Melville (1867–1934), and George Harrison Orton (1873–1947). The presentation of the watch was as a token of appreciation for his work in the X-ray department of the King George Hospital in London from 1915 to 1919. The watch measures 3cm and is engraved on the back. Edward Wallwork was from the Manchester area. All of the three doctors suffered from radiation-induced disease and their names are recorded on the X-ray martyrs’ memorial in the grounds of St George’s Hospital in Hamburg. Ironside Bruce was on the staff of Charing Cross Hospital and the Hospital for Sick Children in Great Ormond Street. Ironside Bruce was very talented and published widely and his well-known book A System of Radiology: with an Atlas of the Normal came out in 1907. The British radiological world was shocked when Bruce died of radiation-induced aplastic anaemia in 1921 at the young age of 42. The outcry resulting from his death resulted in the formation of a national radiation protection committee. George Harrison Orton was a pioneer of radiotherapy and was in charge of the X-ray department at St Mary’s Hospital in London. George Orton was regarded as the last martyr pioneer of radiology. Stanley Melville worked at St George’s Hospital in London and was the President of the British Institute of Radiology in 1934. Both Orton and Melville served periods as co-secretary with Sidney Russ of the newly formed and influential British ‘X-ray and Radium Protection Committee’. Concerns about the safety of radiation continue to this day and medical radiation is now a significant proportion of the population’s exposure to radiation.

Fig. 2.3 The engraved wristwatch presented to Corporal Wallwork by three radiologists who all became radiation martyrs.

Fig. 2.3
The engraved wristwatch presented to Corporal Wallwork by three radiologists who all became radiation martyrs.

Reproduced with permission from the archive of the British Institute of Radiology.

The United Nations was concerned about the responsibilities of the medical profession to limit the medical use of ionizing radiation and issued a statement in June 1957 that is still relevant today. In 1956 the British government under the chairmanship of Lord Adrian had set up a committee on radiation hazards to patients and in June 1957 Adrian was asking for the help and assistance of radiologists through the pages of the British Journal of Radiology. Concerns about medical radiation became more significant as the 1950s progressed in the period after Hiroshima and Nagasaki when public concern about radiation was heightened. In the UK in August 1957 Sir Stanford Cade reviewed radiation-induced cancer in humans and G.M. Ardran advised the radiological community on dose reduction in diagnostic radiology and how it might be achieved. G.M. Ardran and H.E. Crooks also reviewed doses from dental radiography and the effect of radiographic techniques in September 1959. The Presidential Address by L.F. Lamerton for 1958 to the British Institute of Radiology examined the clinical and experimental data for the risks to the individual of small doses of radiation and arguments over the importance of small doses of radiation continue to this day. Basically, is there a threshold for the effects of radiation or is all radiation harmful? This question is still controversial. In April 1959, A.G.S. Cooper and A.W. Steinbeck from Australia reported a case of leukaemia developing in a 3-year-old child following irradiation whilst in utero, and in an adult man following spinal irradiation for ankylosing spondylitis. Concerns about the effects of antenatal radiography had been raised by the Oxford epidemiologist Alice Stewart in 1956. By the 1930s many obstetricians were recommending routing prenatal radiography and the risk of radiation to mother and fetus were generally minimized by the medical profession. It was Alice Stewart2 who correlated cancer deaths in children under the age of 15 to the mother being exposed to radiography in pregnancy. Stewart was investigating the epidemiology of childhood leukaemia, which in 1951 was rising in frequency and a ‘leukaemia epidemic’ was being talked about. Alice Stewart emphasized the obvious fact that life begins at conception and not at birth, and she therefore asked mothers about what happened during their pregnancy, such as ‘Did you have any illnesses in pregnancy?’ and ‘Were you X-rayed?’.2 This research was undertaken at the height of the ‘Cold War’ at a time of increasing concerns about radiation. The Campaign for Nuclear Disarmament was formed in 1958, which was the same year that Alice Stewart’s full study was published. In that year Linus Pauling (the winner of the 1954 Nobel Prize for Chemistry) suggested that nuclear fallout from nuclear testing could have effects on the fetus and result in injury, and for his pains Pauling had to appear before the House of Un-American Activities (HUAC) and it was made difficult for him at Cal Tech, precipitating his resignation. In spite of the evidence there was resistance in the medical profession to a change in practice and whilst there was some fall off in requests for radiography in pregnancy it was not until 1980 that major American medical groups ceased to recommend the practice.

In 1961 the Medical Research Council in the UK reported on the hazards of radiation in their second report on the topic and the important Adrian Committee on Radiological Hazards to Patients also reported. The reports were very influential and became ‘required reading for all radiologists’. Lord Adrian gave the opening address to the Annual UK Radiology Congress in 1961 and his views on the hazards of radiation remain relevant to this day. The hazards of medical radiation were now being taken seriously and efforts to reduce doses to patients and operators were made in both diagnostic radiology and radiotherapy and numerous publications appeared. By 1969 Jennifer Matthews from Sheffield repeated a survey of radiation hazards in diagnostic radiology. She found that whilst the staff were aware of radiation risks and used gonadal shields, the numbers of patients radiographed were continuing to rise. This remains true with yearly increases in the use of computed tomography (CT) scanning. However, the risks of any technique have to be balanced against the benefits and not having the CT scan may be more harmful than having the test.

The acronym ALARA stands for ‘as low as reasonably achievable’ and this idea started to develop in the 1950s with the concerns about radiation exposure. In the 1960s the Atomic Energy Commission, required that human exposures be kept ‘as low as practicable’ (ALAP). ALARA was recognized at this time, although there was more concern about controlling radiation exposures to within the dose limits, rather than reducing them to below the limits. Concerns ware also present in the 1970s with the recognition of the development of solid tumours in the Japanese survivors of the atomic bombs from the Second World War and in patients receiving radiotherapy. Whilst tumours may develop with high doses of radiation the effects of small doses are less certain, hence the need to keep doses ALARA, although economic and social factors need to be taken into consideration. A balance needs to be made between the clinical value of an examination and the radiation dose received. For example, a radiograph of a foot to diagnose a fracture or arthritis is reasonable. Using radiology to fit shoes in the Pedoscope that was popular in the 1950s and earlier is not.

Early pioneers

Charles Thurstan Holland (1863–1941)3 (Figure 2.4) was a major figure in early radiology both in the UK and worldwide. Holland worked as a general practitioner in Liverpool from 1889 and following the discovery of X-rays he was approached by Robert Jones (1857–1933) who was a pioneer orthopaedic surgeon. As Holland recollected, ‘In the beginning of 1896 Robert Jones visualized some of the possibilities of radiography in respect to his own work’.3 His first radiograph was made on 29 May 1896 and was ‘My first X-ray. My own hand’. This involved a 2-minute exposure using a 3-inch coil and five Grove cells. He took a total of 261 plates in 1896. Holland radiographed many conditions including foreign bodies, arthritis, fractures, a stillborn fetus (Figure 2.5), ‘mummy bird’, fish to show bones, and a series of hands to demonstrate bone growth. Whilst his images may look basic today the difficulties that he overcame and the skills that he showed cannot be overemphasized. What is remarkable about the pioneers is how many future developments were anticipated. As Holland recalled, ‘There were no X-ray departments in any of the hospitals. There were no experts. There was no literature. No one knew anything about radiographs of the normal, to say nothing of the abnormal’.3 Writing in 1938, R.E. Roberts was able to say that ‘In spite of the inadequate apparatus which was available, and of the lengthy exposures required, some of Holland’s early radiographs of small parts compare very favourably with many of those seen nowadays, taken with much more costly equipment’.3

Fig. 2.4 The pioneer Liverpool radiologist Dr Charles Thurstan Holland as President of the Röntgen Society, 1904.

Fig. 2.4
The pioneer Liverpool radiologist Dr Charles Thurstan Holland as President of the Röntgen Society, 1904.

Reproduced with permission from the archive of the British Institute of Radiology.

Fig. 2.5 A stillborn fetus radiographed by Charles Thurstan Holland in 1896.

Fig. 2.5
A stillborn fetus radiographed by Charles Thurstan Holland in 1896.

Reproduced with permission from C. Thurstan Holland, X Rays in 1896, British Journal of Radiology, Vol. 11, No. 121, pp. 1–24, Copyright © 1938 British Institute of Radiology, DOI: 10.1259/0007-1285-11-121-1. Image kindly supplied by the archive of the British Institute of Radiology.

Thurstan Holland was President of the Röntgen Society (1904–1905) and in 1925 was President of the First International Congress of Radiology, held in London. It is now quite difficult to put ourselves into the mind-set of the pioneers in the 1890s. There was a confidence that we now lack. In his presidential address to the Liverpool and Literary Society in October 1896 Holland could explain that ‘this 19th century of ours is the most wonderful that the world has ever seen’ and ‘In the case of operative we have almost reached the acme of this art. It is difficult to see in what way it can make any further great advances’.4 How wrong he was and the speciality of radiology to which he was to contribute so much was to transform surgical practice.

A letter sent by Patrick Heron Watson of Charlotte Square in Edinburgh to Dawson Turner (1857–1928), the pioneer Edinburgh radiologist at George Square, dated 17 February 1896 (Figure 2.6), enclosed a cheque for five guineas (£5.25) as payment for the ‘photoprinting of the hand with Enchondromata as illustrating the Röntgen process’. Five guineas was a considerable sum of money in 1896. This is possibly the earliest account of a payment for radiological services and is dated less than 4 months after the discovery of X-rays. Dawson Turner was the first doctor to provide radiological services to the Edinburgh Royal Infirmary. Sadly Dawson Turner had to retire early due to the injurious effects of radiation and his name is one of three from Edinburgh to be listed on the Martyrs’ Memorial at Hamburg.

Fig. 2.6 A letter sent by Patrick Heron Watson of Charlotte Square in Edinburgh to Dawson Turner enclosing a cheque for five guineas as payment for radiological services. Dated 17 February 1896 it may be the earliest financial transaction radiological services in existence.

Fig. 2.6
A letter sent by Patrick Heron Watson of Charlotte Square in Edinburgh to Dawson Turner enclosing a cheque for five guineas as payment for radiological services. Dated 17 February 1896 it may be the earliest financial transaction radiological services in existence.

Image courtesy of Dr Adrian M.K. Thomas.

Defining the normal

Defining what is normal might seem straightforward; however, it is actually quite difficult. The new rays gave us a different view of the body and interpretation of the shadows had to be made with care and, as Charles Thurstan Holland, the pioneer radiologist from Liverpool said, there were no experts, no literature, and no knowledge of the normal, to say nothing of the abnormal. In defining normal appearances in radiography the work of Alban Köhler from Germany and Sebastian Gilbert Scott from England is important.

In the case of the Nelson incident (described later), the radiological abnormality was obvious. However, other abnormalities that are of forensic importance are considerably subtler. The shadows cast by the new rays discovered by Röntgen could often be confusing and until the normal was defined the medico-legal use of radiographs as evidence could only be limited.5 The question, though, as to what is normal is not as simple as it might first appear. Traditional anatomy had been learnt in the dissecting room or in the operating theatre and the new living anatomy shown on radiographs required a new appreciation and understanding of anatomy and its many variations. Since earliest times variations from normality had been recognized, particularly in the animal kingdom. Before radiography the knowledge of human congenital anomalies, apart from gross and visible anomalies, was limited to those found by anatomists at dissection. If the nature of normality is not appreciated in clinical practice there is a danger of medical intervention for non-existent conditions. For example, a lack of understanding of the normal anatomy and physiology as shown on radiography led to ‘fantasy surgery’ for dropped organs (visceroptosis and floating kidneys) and chronic intestinal stasis.6 The position of a kidney lying down is different from that standing up and both are normal. There is also a wide variation in the shape and position of the stomach and when standing up part of the stomach may lie in the pelvis. Ann Dally has reviewed the story of surgery for ‘displaced’ organs and for chronic intestinal stasis as a cause for a large variety of symptoms. The subject of chronic intestinal stasis was reviewed by Alfred Jordan in 1923 and he called it Arbuthnot Lane’s disease, dedicating the book to him as ‘The Father of Stasis’. Jordan provided the radiological evidence for Lane’s surgical practice and his book is full of examples of colonic and duodenal stasis. It is easy to be critical of those in the past while being blind to our own failings. The significance of the abnormalities that we find on modern medical imaging is often not obvious, particularly on magnetic resonance imaging (MRI). More tests are being performed on patients and an increasing number of coincidental abnormalities are found of uncertain significance to the patient’s presenting complaint. The term ‘Ulysses syndrome’ has been coined for the practice of intensive investigation of coincidental abnormalities that are not related to the patient’s primary condition. Whilst the adventures of Ulysses as described in The Odyssey by Homer are interesting, his aim was to return home to his wife.

Alban Köhler (1874–1947)

The majority of congenital variations were undiscovered before the advent of modern medical imaging and the numbers of such variations increase as imaging becomes more sophisticated. It was largely due to the work of Köhler (1874–1947) of Wiesbaden in Germany that these variations of anatomy were first described. Köhler is best remembered today for his description of avascular necrosis of the tarsal navicular bone, which he described in 1908. Köhler was a founder member of the German Röntgen Society and became its president in 1912. The Lexikon der Grenzen der Normalen und der Anfänge des Pathologischen im Röntgenbilde 7 was published by Köhler in 1910 and went through a number of German editions and received the highest Röntgen award in Germany, the ‘Rieder Gold Medal’. The book was enormously influential and became an immediate classic. Instead of reproducing radiographs, the book was illustrated using line drawings, and the illustration shown is of congenital abnormalities of the patellae (Figure 2.7). The book was translated into English in 1931, appearing as Röntgenology: The Borderlands of the Normal and Early Pathological in the Skiagram,8 with a second edition appearing in 1935. In the preface to the second English edition, the great American radiologist James T. Case indicated the usefulness of the book ‘to physicians and lawyers whose work brings them in contact with problems on legal medicine’.9 Case wrote that ‘how many foolish actions would be avoided and unjust decisions righted by a sufficient dissemination of the knowledge of developmental appearances in the radiogram’.9 He then described a ridiculous damage suit over an alleged fracture of the spine, allowed as a just claim in a high court of law. The deciding testimony was that of a surgeon who declared the radiograph clearly demonstrated a fracture, whereas in reality it was a long-standing hypertrophic osteoarthritis with huge osteophytes almost uniting the lumbar vertebrae into one bony mass; and what the surgeon interpreted as a fracture was in reality only a small island of calcification just separating two of the opposing bony outgrowths. In this instance, faulty evidence based on ignorance led to a serious miscarriage of justice. The radiological community therefore owes a huge debt to the pioneer work of Alban Köhler.

Fig. 2.7 Congenital abnormalities for the knees (bipartite patellae) as illustrated by Alban Köhler in 1910.

Fig. 2.7
Congenital abnormalities for the knees (bipartite patellae) as illustrated by Alban Köhler in 1910.

Originally published in Köhler, A., Lexikon der Grenzen des Normalen und der Anfänge des Pathologischen im Röntgenbilde, Lucas Gräfe & Sillem, Hamburg, Germany, Copyright © 1910. Image courtesy of Dr Adrian M.K. Thomas.

Sebastian Gilbert Scott

Dr Sebastian Gilbert Scott was the director of the radiological department of the London Hospital and was interested in medical jurisprudence and in skeletal variations. His influential book Radiology in Relation to Medical Jurisprudence was published in 1931.10 By the 1930s many claims for compensation were being made in the UK at common law or under the Employer’s Liability and Workmen’s Compensation Acts of 1905 and 1925. Scott held the view that large sums were being paid out each year that would not have been awarded if there were more awareness of skeletal variations and other conditions that made accurate diagnosis difficult, even for experienced radiologists. By the 1930s evidence of bone injury in medico-legal cases was almost entirely dependent on the radiographic appearances and the evidence of the radiologist was frequently the decisive factor in such cases. The misinterpretation of a supernumerary ossicle as a fracture would result in the payment of a large sum in compensation. The correct interpretation of the radiograph was therefore essential and the radiologist had to be familiar with the skeletal variations that may simulate a fracture. Scott pointed out that improvements in radiographic technique, instead of making that task easier, had made interpretation more difficult because of the increased detail that was then attainable. This trend has continued to contemporary times. Modern MRI and CT scans show much more detail than with earlier generations of scanners and the possibility of an improper interpretation increases with the complexity of the system.

In the UK in 1927 there were a total of 458,419 accidents to workmen that involved payments under the Workmen’s Compensation Act with a total of £12 million.10 Scott describe the case of a man with a congenital anomaly of the clavicle who had a series of imaginary accidents and had been able to successfully make a series of bogus claims to insurance companies.

In the 1930s the Medical Defence Union in the UK, which provided professional insurance for medical practitioners in cases of medical negligence, advised its members that in every case of fracture or suspected fracture a radiograph should be obtained. If the patient objected to a radiograph being obtained, then such a refusal should be obtained in writing. If this were not obtained than the Medical Defence Union might refuse to defend the case.

Scott emphasized the need for specialist interpretation of radiographs since there were many pitfalls and difficulties in image interpretation and these were illustrated in his book. Adequate training in image interpretation was therefore essential. By the 1920s there had been considerable developments in radiology and it was becoming recognized as a distinct medical speciality. The radiologist was defined as a qualified doctor with specialized training and in possession of a recognized qualification. The first qualification in the UK, and probably the world, was the Diploma in Medical Radiology and Electrology (DMRE), which was awarded by the University of Cambridge from 1922.

Scott also recommended the use of standard views in radiography. Standard views made image interpretation easier and facilitated comparison between radiographs taken by different radiologists and departments. If radiographs were not taken in standard positions then accurate comparison was made difficult. In the 1920s and 1930s standard radiographic views were developed, culminating in the publication of Positioning in Radiography by Kathleen C. Clark in 1929. The adequate identification of the radiograph was essential to avoid dispute and as adhesive labels were not acceptable the side marker was applied using a lead letter placed on the film before exposure.

Scott discussed in detail aspects of medico-legal work for radiologists. The radiographic report for medico-legal cases required special care in writing. Each statement in the report should be carefully considered with ambiguity avoided. The radiologist should keep strictly to the radiographic findings and not stray beyond his area of expertise. Radiographic imaging is an integral part of the medical process and provides a permanent record of the patient’s condition.

The work of the pioneers Alban Köhler and Sebastian Gilbert Scott has been continued by Theodore Keats from Charlottesville, Virginia. His well-known Atlas of Normal Roentgen Variants That May Simulate Disease first appeared in 1973 and is currently in its ninth edition, and is a modern classic.11 Its presence in most if not all radiology departments is witness to its value.

Kathleen Clark (1898–1968) and radiographic standardization

In the 1930s there was a gradual standardization of radiographic projections, which was to culminate in the publication of Positioning in Radiography by Kathleen C. Clark in January 1939. The book is a radiographic classic and remains in print to this day.

The Society of Radiographers had been set up in 1920. Letters had been written from the new society to non-medical assistants in the various X-ray departments in the UK inviting applications for membership. Those who been in active practice for over 10 years were given membership without examination; however, all other applicants had to take a new examination. The first regular group of students was entered for examination in January 1922. There were 45 students of which 20 passed and were duly awarded the certificate of the Society (the MSR). Miss K.C. Clark had completed her training course at Guy’s Hospital in London in 1921 and she passed this first ever qualifying examination held by the Society of Radiographers. She worked initially at the Princess Mary’s Hospital in Margate before moving to the Royal Northern Hospital in North London.

Clark was very aware of the lack of adequate training for radiographers and so she founded a school of radiography at the Royal Northern Hospital. This school became a model for schools of radiography elsewhere in the world. In 1935 she became co-founder and principal of the Ilford Radiographic Department at Tavistock House in London where she was involved in instruction and research into radiography and medical photography. Under her guidance the department developed a worldwide reputation. She was president of the Society of Radiographers from 1935 to 1937 (and also the first woman president) and is shown wearing the chain of office in Figure 2.8.

Fig. 2.8 Miss Kathleen Clark, president of the Society of Radiographers, 1935–1937.

Fig. 2.8
Miss Kathleen Clark, president of the Society of Radiographers, 1935–1937.

Reproduced with permission from the Society and College of Radiographers.

The first edition of her classic book Positioning in Radiography was published in 1939.12 The book is the standard work of reference for radiographers and has been through many editions. Many radiographers will have heard of ‘Kitty Clark’ and have used the textbook.

Positioning in Radiography is a very important book for several reasons. Firstly, it standardized the radiographic projections and so similar projections were made in all hospitals. Clark was keen to standardize both the radiographic positioning and the exposure values. Secondly, the book is very artistic. The illustrations do not come across as cold and entirely objective scientific images. It is therefore not surprising to read that the artist Francis Bacon acknowledged Positioning in Radiography as a crucial source and it was his favourite medical textbook. Lawrence Gowling indicated that Bacon repeatedly borrowed from the photographs in the book for his work and pages torn out of the book were found in his studio. The images of the body that Francis Bacon painted have an almost radiographic quality and there is the impression that multiple layers of the body are seen at the same time and that one is not just looking at the skin surface.

K.C. Clark was awarded the MBE in 1945 for her services to radiography, particularly for her work on mass miniature radiography of the chest. She was committed to fostering cooperation and contact between radiographers throughout the world and was a driving spirit behind the formation of the International Society of Radiographers and Radiological Technicians (ISRRT). The photograph from 1964 (Figure 2.9) shows three important radiographers, K.C. Clark, E.R. Hutchinson, and Marion Frank. Ernest Ray ‘Hutch’ Hutchinson was president of the Society of Radiographers from 1959–1960 and Miss Marion Frank from 1967–1968. Kathleen Clark is on their right. All three were committed to international radiography and were involved in the formation of the ISRRT. The ISRRT is an organization composed of 71 national radiographic societies from 68 countries and now representing more than 200,000 radiographers and radiological technologists. K.C. Clark remained as principal at Ilford until 1958 and as consultant in radiography until 1964.

Fig. 2.9 Three radiographers: Kathleen Clark, Ernest Hutchinson, and Marion Frank.

Fig. 2.9
Three radiographers: Kathleen Clark, Ernest Hutchinson, and Marion Frank.

Image donated by Kathleen Clark. Reproduced courtesy of Dr Adrian M.K. Thomas.

British Authors

A profession is defined by a number of parameters, one of which includes having a literature. One of the most significant events of the 1930s was the publication of A Text-Book of X-ray Diagnosis by British Authors, the highly influential multiauthor textbook covering all aspects of medical imaging. Diagnostic radiology came of age in this decade and this book celebrated the knowledge that had been obtained in the previous 40 years. The editors were Ernest W. Twining, C. Cochrane Shanks, and Peter Kerley, and the first edition was published in 1938. The book was expensive and volume 1 alone cost 50 shillings (£2.50). The standard that was set was quite outstanding and no other country produced anything that could compare, either in printing or in the illustrations. The book was required reading for generations of radiologists studying for examinations. It was the view of the radiologist Bill Park that during the lifetime of this book, the role of the radiologist advanced from a type of ‘aircraft spotter’ to that of an established clinical diagnostician. It was partly due to the contribution of this book that there was this fundamental change in attitudes. The final edition of the book was the fourth edition (edited by Cochrane Shanks and Peter Kerley following the untimely death of Ernest Twining) with volume 6 appearing in 1974. In our world now dominated by cross-sectional imaging we should remember those who worked with X-rays alone and who laid the foundations of the specialty of radiology. As a chest radiologist, Peter Kerley would have found MRI and CT quite fascinating in the details that they reveal of anatomy and pathology in the chest.

Early departments

John Macintyre and the Glasgow Royal Infirmary

John Macintyre (1857–1928)12 was born in Glasgow and graduated in 1882 from the University of Glasgow. In 1885 he was appointed as medical electrician to the Glasgow Royal Infirmary and as assistant surgeon in 1886 with an interest in diseases of the ears, nose, and throat. After the discovery of X-rays in 1895, Röntgen sent a copy of his paper to various scientists around the world, including Lord Kelvin (1824–1907) who was one of the most famous physicists of that period. Kelvin passed the paper to J.T. Bottomley who contacted Macintyre and they then both worked together on demonstrating the new discovery. The letter that Lord Kelvin wrote to Röntgen on 17 January 1896 is preserved in the Deutsche Röntgen Museum (Figure 2.10); however, the radiographs that Röntgen had sent to Kelvin have been lost. In January 1896 Macintyre lectured at the University of Glasgow on ‘The New Light—X-rays’ and then on 15 February 1896, Bottomley, Lord Blythswood, and John Macintyre gave a presentation to the Philosophical Society of Glasgow. Macintyre obtained the permission of the managers of Glasgow Royal Infirmary in March 1896 to set up an X-ray department, which was the first in the world. He was actively working on radiography and made the first demonstration of a renal stone, which was verified at surgery. The first issue of the journal Archives of Clinical Skiagraphy (the forerunner of the British Journal of Radiology) contained no less than three papers by Macintyre. He made his famous demonstration of the cineradiological study of the frog leg to the Royal Society of London in 1897 with a series of images to display the movement and reported his findings to Röntgen.

Fig. 2.10 The congratulatory letter that Lord Kelvin wrote to Wilhelm Röntgen on 17 January 1896 following the discovery.

Fig. 2.10
The congratulatory letter that Lord Kelvin wrote to Wilhelm Röntgen on 17 January 1896 following the discovery.

Reproduced with permission of the German Röntgen Museum.

It was in 1897 that the famous electrical department opened at the Glasgow Royal Infirmary and rooms were fitted up with appropriate modern apparatus. What is quite remarkable is that wires were carried from the department to all the wards of the hospital to avoid the need to carry heavy apparatus. Electricity was supplied either by the 250V mains supply from Glasgow Corporation or from the department’s own generator. Patients could either attend the department or could be examined in the wards or operating theatres, since these were all wired for electricity. The department provided both electrical (electrotherapeutic) and radiological services. The radiological services included plain film radiography, radiotherapy, foreign body localization, and stereoscopic radiography. What is always so very interesting is to see how very contemporary the concerns of Macintyre and the other pioneers were. In 1903 Macintyre stated that the new building from 1897 was being fully used and that the staff number had been increased to get through the large number of cases! The Electrical Pavilion had been built as large as possible in 1897 and by 1903 the demands upon it were far in excess of what could be accomplished. They had two medical officers, an unqualified assistant, and a staff of nurses. The role of the radiological nurse can be seen as crucial right back to the earliest days of radiology departments and is not a recent addition. By 1903 the Electrical Pavilion was taking 2000 radiographs each year and performing many fluoroscopic examinations. Macintyre felt that the most important introduction to the hospital was the electrotherapeutic department. In 1903 Macintyre was also looking forward to the rebuilding of the hospital and was hoping, as many generations of radiologists were to do in subsequent years, for still greater facilities. Macintyre was president of the Röntgen Society in 1900 to 1901 and he died on 29 October 1928 in his home city of Glasgow.

The early radiology departments arose from a variety of sources. Many hospitals already had electrotherapeutic or electrical departments and so acquiring X-ray apparatus was a straightforward progression, and such was the case at the Royal London Hospital and St Bartholomew’s Hospital. Photography was well developed by the 1890s and was provided to the public by chemist shops (community pharmacists). Since these chemists were used to photography and the techniques needed, it was relatively easy for them to also acquire X-ray apparatus and provide a radiography service. Examples of this include the Royal Victoria Infirmary in Newcastle-upon-Tyne where local chemists were invited into the hospital to radiograph patients. Since many early departments originated in electrotherapy departments it was an obvious progression to practice radiotherapy. The early radiologists practised both diagnosis and therapy and it was not until the 1930s that the split into the professions of radiodiagnosis and radiotherapy was formalized in Britain; in continental Europe the two branches of radiology were to be closely linked for much longer.

Medico-legal radiology

Sir Arthur Schuster and the Nelson incident

It was at Nelson, a small Lancashire textile town, that the first diagnostic use of X-rays took place outside of a physics laboratory or hospital department for forensic purposes. Sir Arthur Schuster FRS was one of the first scientists to receive a copy of Röntgen’s first communication and he was one of the first to point out the medical possibilities of X-rays and their practical significance.13 Schuster had been born in 1851 in Frankfurt am Main in Germany and was a mathematical physicist. He was professor of physics at Owens College (now part of the University of Manchester) and he quickly saw the value of the discovery. On 23 April 1896 at 20 North Street in Nelson, Elizabeth Ann Hartley had been shot by her husband Hargreaves. Hargreaves Hartley was 27 years old and was apparently a jealous young man. He had accused his wife of infidelity and then on 23 April 1896 he shot her four times, the bullets entering her head and neck. The bullets injured her jaw, ear, and neck, and caused severe injuries. The medical practitioner in Nelson, a Dr W.G. Little, had worked at Owens College and therefore sent for Professor Schuster. Unfortunately Schuster was unwell and he therefore sent his two assistants to Nelson in his place. The delicate radiographic apparatus was taken to Nelson since the patient was too ill to be moved from her home. The first X-ray plate took an hour to complete and the second took about 70 minutes. The proceedings were observed by Dr Little, the mayor of Nelson, and the town clerk, and the plates were returned to Manchester for processing. Professor Schuster then telegrammed Dr Little saying that whilst the procedure had been successful there was some doubt about the location of the fourth bullet. When he had recovered from his illness Professor Schuster went to Nelson and took another radiograph. The final glass plate was probably placed underneath or behind Mrs Hartley’s skull and Schuster was finally successful in locating the fourth bullet. Unfortunately, Mrs Hartley was too unwell to undergo surgery and she died on 9 May 1896. Professor Schuster subsequently gave a demonstration in the Lecture Room of the Technical School in Nelson of the radiographic techniques used. His subject for the demonstration was a Mrs Taylor of Boundary Street, Colne, who had a fragment of a broken needle retained in her hand for two years. The plate was developed by the photographer Mr J.L. Hopper of Pendle Street in Nelson. The exposure lasted about 5 minutes and the plate took around half an hour to develop. Whilst the Nelson incident is of interest, as Brogdon points out, since no treatment was possible and the patient died then this case ‘can be considered an early manifestation of our tendency to use elaborate procedures and the newest technology, whether or not it will influence the outcome’.14 However, the incident did illustrate the capabilities of the new technique and showed what would be possible in the future. Sir Arthur Schuster died in 1934 as one of the most famous professors in the Department of Physics and Astronomy at Manchester University.

Border control

That radiography could be used in areas other than the medical was obvious, including its use in customs and border control and this continues today. Fluoroscopy of suspect packages using the cryptoscope was being undertaken as early as 1897. The cryptoscope was a hooded fluorescent screen that could be brought to the eyes and which examined suspect packages placed in front of an X-ray tube. The technique was illustrated in the French periodical L’Illustration of 3 July 1897. The trade card illustrated was issued by Cacao Blooker. The front of the card illustrated a respectable woman with the name of the company as a series of apparently meaningless lines. The reverse of the card shows the cacao tin and more meaningless lines. When the card is transilluminated the name of the company is revealed and the contraband in the respectable lady’s hand luggage is revealed. The apparatus that is now used for looking for items hidden under clothing and in luggage has reached a considerable degree of sophistication.

Postal security

There is now a considerable sophistication in examining the mail with radiography employed to look for letter bombs or illicit material sent through the postal service. In the UK many companies are on still on alert after a letter bomb campaign in early 2007 with explosives placed in party poppers in jiffy bags. Businesses need to have a mail security plan and maintain vigilance. Selected businesses may require special precautions with the use of a large-capacity cabinet postal X-ray scanner for checking letters, courier deliveries, parcels, and handbags.

X-ray surveillance

We now have available portable digital radiographic equipment, which can be used by police, military, customs, prisons, and building security managers for security checking unattended bags and suspicious packages. Other uses include bomb disposal, the search for narcotics and hidden contraband, searching behind walls for bugs/weapons, vehicle panel/tyre inspection, and non-destructive testing. In Chapter 4, Figure 4.4 shows an image from pre-1900 on a trade card of life as predicted in the year 2000 and is not so far from the truth. The policeman is looking through the wall to see the criminals robbing the safe. We can now obtain images of illicit goods and hidden items in trucks and vehicles and weapons concealed under clothes are revealed.


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