CHAPTER IICURATIVE VALUE OF X-RAYS
In my Little Blue Book on Radium (No. 1000), it is shown that the “emanation” and the “gamma rays” of radioactive substances are being used to great advantage in our hospitals, but that certain dangers to the patient’s normal cells attended employment of these radiations.
It is gratifying to note that successful X-ray treatments are now being given in cases of cancer, rays being produced—under high-tension currents—that are almost identical with the gamma rays of radium.
Moreover, the X-rays have a double value in medicine. In the first place, they are used as an aid to diagnosis, forming those branches of radiotherapy known as radioscopy and radiography. Then they are also used to great advantage in the alleviation or cure of certain maladies. By means of radioscopic or radiographic examination it may be found that there is a tumor in the chest, and as a result of that diagnosis it may be decided to institute treatment(radiotherapy) by means of X-rays or radium rays or the two combined.
The method of employing extremely penetrating X-rays—under high voltage and amperage—seems to have been first used in Germany, during the World War, but was soon developed to a high degree of efficiency in France, England, and the United States, especially by Dr. William Duane, professor of biophysics at Harvard.
As early as 1919, Professor Dessauer, in Germany, produced the penetrating X-rays by means of a high-tension current ranging from 170,000 to 240,000 volts. It was later found, that rays at 200,000 volts became homogeneous, so that a further increase was considered as of no therapeutic value.
In March, 1923, Dr. I. Seth Hirsch, head of the X-ray department of the Bellevue Hospital in New York, gave a drastic treatment—for cancer—of four periods of 16 hours each with the X-rays at 250,000 volts, apparently with satisfactory results. The patient suffered no pain or inconvenience during the treatment with the exception of occasional nausea. A year later an experiment was made in a Philadelphia laboratory where an X-ray treatment of 300,000 volts was used. It seems that alleviationrather than cure has been the result of nearly all cases where cancer had been well advanced.
Other important improvements, meanwhile, were being introduced by the German specialists, during the World War and later, among which was the just mentioned method of giving large tissue-destroying doses, requiring from ten to 15 hours; to this was added careful filtration of the rays, and the invention of theionto—a quantimeter for exact measurements. A number of malignant diseases is reported to have yielded to this new system of massive doses under higher voltage. But Professor Duane has stated that neither X-rays nor the gamma rays of radium should be considered as a permanent cure for cancer.
Until recently the tubes in which X-rays are produced have always been made of glass. The latest discovery is a tube made of fused silica, or vitreosil. Vitreosil permits the passage of the short rays, will stand a much higher temperature than glass, and is much stronger. This means more continuous service from X-rays.
According to Dr. Francis C. Wood, director of the Crocker Institute of Cancer Research of Columbia University, a marked advance in thetreatment of cancer has been made possible by a new type of X-ray tube, the invention of Dr. C. T. Ulrey, of the Westinghouse Company. The new tube has a higher emissive power—in other words, it is as if the candle-power of an ordinary lamp were increased six-fold. It is besides designed for use with higher voltages than have previously been practical in Roentgenology. The result is to reduce the necessary exposure from two or three hours per patient to 20 minutes, and to increase the life of the tubes. Incidentally, the new tube gives a greater proportion of the type of rays that cure certain forms of cancer, and less of the sort that attack healthy tissue.
A revolutionary discovery by Dr. Jacques Forestier, of Aix-les-Bains, France, for which a gold medal was awarded him in 1925 by the French Academy, has made possible a method of exact diagnosis by X-rays heretofore deemed by many workers impossible of attainment.
As is well known, it is not difficult to make an X-ray picture of the bones of the body. They are so much denser than the soft parts of the body that, even with the ordinary photographic plate, it has been possible to photograph them fairly well. By pumping the stomach full of gas or air—which are highly transparent to theX-rays—and then applying the X-ray, it has sometimes been possible to locate the beginnings of cancer of the stomach, and the place of malignant growth.
Another method in common use is to give the patient about a pint of some substance opaque to X-rays, such as bismuth carbonate, thus making it possible to record the passage of the mixture, the outline of the stomach and the intestines thus being made visible. In this way ulcers of the stomach have been frequently located.
Bismuth and similar substances could not be injected into the brain or spinal cord, on account of their poisonous effect on the highly sensitive cells of these regions. Now, thanks to the method discovered by Dr. Forestier, the cavities of the brain and spine can be safely explored, as well as the network of bronchial tubes in the lung—the so-called “bronchial tree.”
In an interview with Mr. David Dietz, Dr. Forestier said (in part):
“I make use of a French oil called lipiodol. It is a chemical compound composed of poppyseed oil and iodine. The chemical previously had been used as a treatment for certain diseases,such as goiter. But no one had ever thought of using it in X-ray work.
“I noticed that where patients had been treated with lipiodol opaque spots appeared when X-ray pictures were made of the treated parts. It occurred to me, therefore, that lipiodol could be used as a means of making photographs.
“Accordingly, in company with Dr. Sicard of Paris, I began to experiment. We worked with animals until we were convinced of the correctness of our method. When we were sure that it was safe we tried it on human beings. I have used it in more than 5,000 cases in Europe without having a single adverse result.
“The lipiodol is injected into the brain cavity or the canal of the spinal cord or the bronchial tubes and then a regular X-ray photograph is made. The oil renders the injected part opaque to X-rays and they show up as sharp black images in the photographs.
“The method is of particular value when a patient is suffering from paralysis which has been caused by a pressure of a tumor or growth somewhere along the spinal cord. In this case a drop of the oil is injected into the spinal canal at the base of the brain. In a healthypatient it would immediately travel to the base of the spine. But in the paralyzed patient it only travels as far as the point of compression. The X-ray picture therefore reveals the drop of oil as a black spot. The surgeon then knows the exact spot at which to operate in order to find the growth causing the pressure, which in turn results in paralysis.
“In diagnosing the lungs with the use of lipiodol the injection in the bronchial tree enables the X-ray worker to tell at once whether the patient is suffering from diseases of the bronchial tubes themselves, or from diseases of the lung tissue, such as tuberculosis.”
It is gratifying to be able to relate that along with the improvements already described, progress has also been made in the preparation of photographic plates required by the radiographer. Until recently no photographic plate had been made which fully met the requirements of X-ray work, and there was little contrast in X-ray photographs. They were all much too sensitive to the longer (visible) wave lengths, and produced blurring effects.
Early in 1921 an excellent photographic plate, 25 times more rapid than anything previously known, was invented by Dr. Leonard A. Levey, a prominent member of the Roentgen Society. It makes an X-ray photograph of the vital organsof the living body whose movements have hitherto blurred the images on the ordinary photographic plate. Distinct pictures of the heart, lungs and stomach can now be made. Dr. Levey has made snapshot photographs of the heart, lungs and kidneys. All were taken in a flash with the X-rays on the new plate.
Dr. H. Becher has called the attention of Americans to the achievement of Dr. Schleussner, an eminent German authority in photochemical matters, who has succeeded, after years of investigation, in sensitizing photographic plates for X-ray use by an addition of certain organic salts which are absorbed by the grains of silver bromide on the photographic plate. The plate thus formed is very responsive to the soft rays of an X-ray tube. The soft rays are relatively longer than the hard Roentgen rays. One could compare the soft rays to blue-violet light, if their effects on this new photographic plate are used for the comparison. Photographs taken with such plates give very contrasting effects.
On the “Neo-Roentgen plate” the effect of the yellow light was almost nil. For this reason, developing the plate is considerably facilitated, as the plate can be exposed to yellow light and the attendant, who need not be a skilled operator,can examine the plate in a rather brilliant light without necessarily guessing at possible results. The examination of the plate under a ruby light is, therefore, completely done away with. It follows that if the new X-ray plate should come into general use, much clearer X-ray photographs would be possible; the time of exposure could be decreased; an unskilled operator could develop the plate in a room flooded with yellow light. Such improved plates are now being extensively used.
While not attempting to enumerate all the special affections to which X-ray therapy is now being successfully applied, a few uses may be mentioned.
In a preliminary report published in theMedical and Surgical Journal(Boston), Dr. Henry I. Bowditch and Dr. Ralph D. Leonard express the belief that a valuable cure for whooping cough has been found in X-ray treatment of this disease, which has stubbornly resisted most, if not all, of the other remedies applied.
Definite improvement was noted in most of 26 cases of active pertussis (whooping cough) treated with the X-ray, the subjects of which ranged in age from three months to 40 years,with disease stages from one to ten weeks. The physicians added that they could not give any rational explanation of the action through which the X-ray appeared to produce beneficial results. The report said:
“Each patient received three or four applications of the X-ray at intervals of two or three days.”
Many of these cases have not been observed sufficiently long to determine the final result. Nevertheless, “it is evident to us that there resulted a definite improvement in these patients which cannot be explained by mere accident.... It does not seem likely that [the beneficial result] is due to any direct bactericidal property of the X-ray.
“We feel warranted in classifying a small percentage of these 26 cases under the heading of “prompt cures.” By this we mean that after two or three applications of X-rays, covering a period of six days, the spasms and whoops entirely disappeared and the patients were clinically well, except for, possibly, a very slight cough.
“The bulk of the cases, however, we have classified as relieved. This group consists of perhaps 70 percent of the total. By relieved we mean that there has been a gradual diminution in the number of spasms.
“There is a small percentage of cases, perhaps 10 to 15 percent, which apparently were not relieved. In this group are included one moribund case and one rather difficult feeding case.
“While our evidence so far is not sufficient to warrant any definite conclusions, we have the feeling that the X-ray at the present time may be of more value in the treatment of pertussis than any other form of treatment, including serum.”
An Italian physician, Dr. Antonio Pais, of Venice, has since 1916 been successfully treating malaria by means of X-rays. This treatment is, however, not employed as a substitute for quinine, but merely to reinforce its action. The X-rays are directed toward the region of the spleen, and the effect is to reduce its enlargement. At the same time the composition of the blood is modified. The success obtained by Dr. Pais has, according to theBibliothèque Universelle et Révue Suisse(Lausanne), been so great that the Italian Government decided to introduce his method of treatment into the military hospitals.
Since the war the treatment has been studied by Prof. B. Grassi, who made a report, at anItalian scientific meeting, in which he declared the action of X-rays upon chronic malaria to be “truly marvelous.” TheBibliothèque Universellesays, regarding earlier treatments:
“The attempt was made by them to destroy the parasite contained in the spleen. But it is now known that the X-rays employed for therapeutic action have no effect upon micro-organisms, although they may be injurious to the elements of the blood. In the method devised by Dr. Pais, the X-rays are employed to stimulate the functioning of the spleen, of the marrow, and of the lympathic elements by means of slight but prolonged excitation; they are employed in infinitesimal doses—homeopathically, so to speak. Thus the result is absolutely different as well as the method.”
Dr. James B. Murphy demonstrated that accompanying cancer grafts on immune animals there occurs a general increase in the circulating lymphocytes and hyperplasia of the lymphoid tissue. When the lymphoid tissue of immune animals was destroyed, the immunibility was annulled. Two methods of increasing the lymphocytes have been found, namely, diffuse small doses of X-rays, and dry heat. Mice with lymphocytosis induced by these agents show Increased resistance to replants of their own tumors. The results afford ground for hope ofhuman application. (Reported inScientific American Monthly, January, 1920, page 96.)
It has been found that actively growing tissue, whether normal or pathological, is the most susceptible to X-rays, and it is comparatively easy to sterilize a number of species of animals without otherwise injuring them. (Prof. James W. Mayor,Science, September 23, 1921.) C. R. Bardeen found that X-rays prevent worms from regenerating lost parts. Observations of the effect of exposure to X-rays on the fertility of animals were described in a paper by Prof. L. H. Snyder of the North Carolina College of Agriculture. Exposure of male rats to X-rays, he said, had rendered them sterile at the end of two months, the animals regaining fertility when no longer subjected to the rays.
If not handled with due caution and skill, X-rays may do more harm than good, provoking malignant growths as well as retarding their development. As early as 1911, Otto Heese published a record of 54 cases of cancer caused by means of improper handling of these powerful rays.
In the early days of X-ray therapy the nature and effects of these radiations were wholly unknown. Operators did not hesitate to testand adjust their tubes by throwing the shadow of their hands on the flouroscope. X-rays do not make objects visible to the human eye, and to see the effects of them it is necessary to interpose a special screen between the eyes and object through which the X-rays are to penetrate. The cardboard screen is coated with a fluorescent substance, such as barium-platinum-cyanide, or calcium tungstate. This screen is best placed in one end of a black wooden or pasteboard box, against the other end of which the eyes are placed when in use.
This screen under the influence of X-rays becomes luminous and enables one to see shadows or silhouettes of objects of denser material interposed between the eyes and the X-ray tube, when the tube is in operation.