Frau Roentgen's hand with ring.
Edison's vitascope (arrowhead) and an x-ray tube (arrow) with a hand interposed. In a photograph from this era, Edison was shown examining Dally's hand with his vitascope. Adapted from Arch Ophthalmol. 1965;73:749-752.
A Rollins' design, which included a collimator at the top. Adapted with permission from AJR Am J Roentgenol. 1986;147:850-853.
Demonstration of a Rollins' instrument. The model may be Rollins himself.
The radium applicator of Scott and Cordes was placed over closed eyelids.
Brooks' radium applicator was designed to be inserted under the eyelids.
A letter describing the problems in the development of radioactive glasses. Mesothorium was an early name used for what are now known to be isotopes of radium.
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Gittinger JW. Radiation and Cataracts: Cause or Cure? Arch Ophthalmol. 2001;119(1):112–116. doi:10-1001/pubs.Ophthalmol.-ISSN-0003-9950-119-1-esa00018
David Glendinning Cogan, MD, founded the American Ophthalmic History Society to encourage the study of ophthalmic history. This society met for the first time on March 18 and 19, 1988, at the National Library of Medicine. Cogan hosted an annual gathering until his death in 1993, and the group has continued as the Cogan Ophthalmic History Society. Twenty-five members and 13 guests attended the 1999 meeting in Montreal, Quebec.
In 1991, Cogan inaugurated the Snyder Lecture to honor Charles L. Snyder, who for many years was the librarian at the Massachusetts Eye and Ear Infirmary. Snyder's interest in ophthalmic history had led to the publication of a series of essays as the "Our Ophthalmic Heritage" section of the ARCHIVES while Cogan was its editor. Many of Snyder's essays were collected in book form in 1967.1
Frederick Blodi, MD, delivered the first Snyder Lecture. Subsequent lecturers have been Daniel Albert, MD (1992), Andrew Ferry, MD (1993), Frank Newell, MD (1994), H. Stanley Thompson, MD (1995), Ronald Fishman, MD (1996), James Ravin, MD (1997), and Melvin Alper, MD (1998). For the 1999 Snyder Lecture, I explored a topic that has links to both Charles Snyder's historic interests and David Cogan's scientific achievements. It also serves as a cautionary tale at the turn of the 21st century and for this purpose will be recounted here.
The story begins just before the end of the 19th century. In Snyder's words:
On November 8, 1895, Wilhelm Conrad Roentgen, Professor of Physics at the University of Wurzburg, produced in his laboratory a strange and unusual phenomenon—a new kind of ray. Seven weeks later, December 8, 1895, he presented to the President of the Physical Medical Society of Würzburg his first written report, a preliminary communication entitled Eine Neue Art von Strahen. A few days later news of the discovery was published in the German newspapers, and on January 6, 1896, via the London cable, the news was given to the world.2(p749)
Roentgen was experimenting on the discharge of electricity in a partial vacuum when he noted fluorescence on a barium platinocyanide screen in his laboratory. This fluorescence was green, although Roentgen did not recognize this because he was color-blind. The Crookes tube he was using was known to produce cathode rays, which were later determined to be electrons. The fluorescence Roentgen saw was from high-energy photons, which he called x-rays. Roentgen almost immediately discovered that the human body with the exception of bone was partially transparent to these x-rays. In his first communication, he included a radiograph of his wife's hand (Figure 1). Seeing her own bones made Frau Roentgen think of death, a reaction that turned out to be prophetic.
Among the first to act on the news of Roentgen's discovery was Thomas Alva Edison. Edison, at age 49 years, was near the height of his career. He immediately sought to find a practical use for x-rays, employing what biographers have called his greatest invention—the industrial laboratory—to investigate the phenomenon. He built a device he first called the "vitascope" and then "fluoroscope"—thus coining the term fluoroscopy—intended for home use (Figure 2).3,4
Edison soon became aware of the capacity of x-rays to damage the human body. His assistant, Clarence Dally, developed burns on his skin that eventually led to a radiation-induced malignant neoplasm. Dally became the first American martyr to x-rays.5 This so impressed Edison that, when he became terminally ill at the age of 84 years, he refused to have a radiograph taken. He had long since stopped experimental work with x-rays at his wife's insistence.
Again, to quote Snyder:
Before the year 1896 ended the incredible number of 1044 articles on the x-ray, or roentgen ray, as it was soon known, appeared in the medical and scientific journals. One of the papers, A Case of Extraction of a Bit of Copper from the Vitreous Where X-Rays Helped to Locate the Metal, was read by Charles H. Williams before the American Ophthalmological Society at its meeting on July 16, 1896. This paper related the first successful use of the roentgen ray in ophthalmology.2(p749)
To learn more about Charles Williams, MD, and his brother Francis, one of the first American radiologists, read Charles Snyder's essay "The Williams Brothers and the Roentgen Ray."2 Portions of the final paragraphs are worth repeating here:
Charles Williams continued in ophthalmology until his death in 1918. . . . However, it was one quite small piece of work he did that resulted in there being something of a monument to him on every busy street corner.At about the time he and his brother Francis were working on the roentgen ray, he served as a special consultant to the New York, New Haven & Hartford Railroad. The railroad was dissatisfied with its signal light system and called Charles in for his opinion. The problem was one of what color to use for the cautionary signal. . . .Williams made a protracted study of the problem, even riding in the engine cabs at night. His suggestion was to use the color that is often referred to as chrome yellow. In time the color was adopted by all the railroads in this country and by many railroads abroad. In the 1920s, when highway traffic engineers were faced with the problem of automobile traffic congestion, they borrowed the already well established color code system of the railroads—red for stop, green for go, and Charles Williams' yellow for caution.2(p752)
Charles Williams continued in ophthalmology until his death in 1918. . . . However, it was one quite small piece of work he did that resulted in there being something of a monument to him on every busy street corner.
At about the time he and his brother Francis were working on the roentgen ray, he served as a special consultant to the New York, New Haven & Hartford Railroad. The railroad was dissatisfied with its signal light system and called Charles in for his opinion. The problem was one of what color to use for the cautionary signal. . . .
Williams made a protracted study of the problem, even riding in the engine cabs at night. His suggestion was to use the color that is often referred to as chrome yellow. In time the color was adopted by all the railroads in this country and by many railroads abroad. In the 1920s, when highway traffic engineers were faced with the problem of automobile traffic congestion, they borrowed the already well established color code system of the railroads—red for stop, green for go, and Charles Williams' yellow for caution.2(p752)
The name Williams should be familiar to many ophthalmologists. Francis and Charles were the sons of Henry Willard Williams, MD, the prominent New England ophthalmologist whose name is perpetuated in the endowed professorship Cogan once held that is occupied by the chair of the Department of Ophthalmology at Harvard.
The narrative now passes to Henry's son-in-law and Charles and Francis' brother-in-law, William Herbert Rollins, DMD, MD.6(The date of the Snyder Lecture on which this article is based—June 19, 1999—was the 147th anniversary of William Rollins' birth in Charlestown, Mass.) Rollins practiced as a dentist, but also held a medical degree from Harvard. His interests were broad; he made contributions in horticulture and genetics and studied astronomy, photography, and radio communications. He used his home as a laboratory and spent considerable personal funds on his investigations, an estimated $30 000 on his studies of x-rays alone.
He preferred to call x-rays "x-light" and published 180 "notes" between March 1896 and February 1904, sometimes several in 1 week.7 One of these articles with the dramatic title "X-light Kills" appeared in the Boston Medical and Surgical Journal (the precursor to the New England Journal of Medicine) in 1901 describing his experiments with 2 guinea pigs.8 Radiologists denied the deleterious effects of their beloved x-rays.9
Rollins designed and built sophisticated devices that contained features well in advance of their day: collimators and radio-opaque casings (Figure 3). If he had decided to become a manufacturer of x-ray equipment, it has been suggested, then the history of radiology in America would have fewer sad chapters (Figure 4).10
Perhaps because of the ophthalmologists in his family, he considered the eyes. In his 1903 "Notes on X-light: The Effect of X-light on the Crystalline Lens," he refers to his brother-in-law, Francis Williams, MD, the radiologist, and reports the case of an unidentified man "less than forty years of age" who had been exposed to x-light "to a considerable extent since 1896" who had developed cataracts.11 Rollins wrote, "Through correspondence with investigators, who at different periods have worked with x-light, I have learned of a number of cases where the eyes have grown prematurely old during the investigations."11(p364)
He also offered suggestions on how to avoid unnecessary exposure of the eyes to x-rays. "That I have escaped injury has been due to an early recognition of the dangerous nature of x-light, and to having taken the precautions recommended in earlier papers."11(p364) Instead, Rollins' warnings went all but unheeded, and the hands and lives of many early radiologists were lost. At radiology meetings during the 1920s, banquet menus shunned roast meat, as most radiologists wore gloves, and thus could not easily cut their food.
A few other cases of radiation-induced cataracts were reported. Leslie Paton, MD, in 1909, described the case of Miss MN, aged 32 years, who had received x-ray treatment for lupus on both cheeks.12 She presented with posterior subcapsular cataracts that reduced her visual acuity to counting fingers at 3 feet OD and counting fingers at 4.5 feet OS. Paton noted, "A good deal of attention at present is being directed to glass-worker's cataract, and it would be of great importance if members would bring forward any personal observations bearing upon this subject, particularly with regard to opacities in the lens resulting from exposure to heat, bright light, x-rays, or to radium."12(p38)
Soon after Roentgen discovered x-rays, naturally radioactive elements were recognized, and Marie and Pierre Curie coined the term radioactivity. One of the elements they discovered, radium, soon found its way into medical therapeutics. This "Curie-therapy" was applied to malignant neoplasms and even was used in patent medicines, notable among which was Radithor.
Macklis chronicles the rise and fall of Radithor and reports observations on its dosimetry.13,14 During the 1920s, this preparation was hawked by William J. A. Bailey though his Bailey Radium Laboratories. Bailey was born in Boston, Mass, in 1884, graduated from Boston Public Latin School, and attended Harvard College, but never graduated. One of his enterprises, the Carnegie Engineering Corporation, promised to deliver a $600 mail order automobile to anyone who sent a $50 deposit. For this deception, he was found guilty of fraud and spent 30 days in jail in 1917.
Radium was considered a panacea (and a potent aphrodisiac). Bailey sold cases of Radithor to physicians who then could resell them for a 500% profit. More than 400 000 bottles of Radithor were distributed worldwide in the late 1920s.
The millionaire industrialist Eben Byers fell out of the top berth of a Pullman party train while returning from the Harvard and Yale game in 1927, injuring his arm. He took Radithor, found it much to his liking, and soon was sending cases of the nostrum to his friends—even administering it to his racehorses. The resulting radium toxicity condemned Byers to a horrible death, and the publicity surrounding his demise led to Radithor's being removed from the market in 1931.
A similar fate awaited the "Radium Girls"—the watch dial painters whose work-related injuries served as another indicator of the adverse effects of radiation.15 One consequence of World War I was the popularity of the wristwatch, which was more convenient to wear when crawling through trenches than the traditional pocket watch. Between 1917 and 1920, a group of young women painted luminescent dials on watches manufactured in Orange, NJ. (This area of New Jersey was a radiation hotbed. Edison's industrial laboratory was in West Orange, and the Bailey Radium Laboratory was in East Orange.) The Radium Girls practiced a technique known as lip pointing(pulling the end of their brush through their lips to bring the bristles to a point), resulting in their ingestion of large doses of radium-containing paint that led to their disfigurement and death.
The commercialization of radium has parallels in its medical use. Treatment of cataracts by radiation proceeded despite the existence of a literature that should have excited caution. In a "symposium" in 1911—by which is meant in this instance 2 articles—in the Journal of Ophthalmology, Otology, and Laryngology, E. D. Brooks, MD, of Kalamazoo, Mich, and E. H. Linnell, MD, of Norwich, Conn, describe their results, including treatment of 20/40 amblyopia (did not help, but cleared up the patient's otorrhea) and "narrowing of the visual field" ("For lack of a better diagnosis, I called it detached retina . . . ").16,17 Two cataracts were also treated, with improvement in the visual acuity, from 4/200 to 7/200 and 1/200 to 5/200, respectively.
Brooks suggested that the improvement in vision was actually an effect on the retina, not the lens. He concludes:
On the whole I am much pleased with the results of this method of treatment. If it never did another thing for me more than it has done, I have made enough people happier and taken in enough money to pay for the tube and apparatus, so that I would feel that there had been a positive gain from its use.16(p425)
In 1914, Albert Mattice (while describing the successful treatment of a corneal tumor with radium) mentions that:
The action of radium upon lens opacities themselves was nil, though in one case of cataract caerulea of star form in the anterior cortex the opacity fell to pieces and disappeared entirely after five sittings of one hour weekly, the tube being applied directly to the sclera.18(p245)
A major contribution to the literature on the treatment of cataracts with radiation was the article of Walter Scott Franklin, MD, and Frederick Carl Cordes, MD, in the American Journal of Ophthalmology in 1920.19,20 The young Cordes had recently joined the practice of Franklin, then the chair of ophthalmology at the University of California Medical School (subsequently renamed the University of California at San Francisco when other California state medical schools opened). This was Cordes' first publication.
The 2 San Francisco ophthalmologists reported 31 cases treated with radium: the applicator was held in place over closed eyelids for about an hour, twice a week for 4 weeks and then once weekly "until the process is stationary." They observed that 84.3% showed improvement, which was more frequent in the 21 private than the 10 clinic patients—a difference they attributed to the difficulty in obtaining radium (an expensive substance) for the outpatient department. They concluded:
Radium is of proven value in the treatment of incipient cataracts.. . . Altho [sic] the vision cannot be brought to normal in many individuals, the ultimate outcome is superior to an aphakic eye such as is obtained by surgery and does not subject the patient to the surgical risk of such a procedure.19(p646)
In 1921, Franklin and Cordes described a "Radium Applicator for Cataracts"—noting that, since the publication of their previous article, "numerous inquiries have been received concerning the exact construction of the radium applicator"21(p429) (Figure 5). They state that:
[T]he results with cataract continue to be consistent with those described in our previous paper. We have used the same applicator in other ocular diseases, as tuberculosis of the conjunctiva, vernal catarrh, and certain obscure conjunctival and corneal lesions. Most of these have shown a decided improvement.21(p430)
The number of patients treated for cataracts with radium during the 1920s is unknown: devices such as one developed by Bundy Allen, MD, in Iowa City were developed to prevent skin burns (Figure 6).22 H. L. Brooks, MD, of The Clinic, Inc, in Michigan City, Ind, published his personal series of 9 cases in 1925.23 The discussant of this article, Fred B. Lewis, MD, of Buffalo, NY, appends a letter describing attempts to manufacture radioactive lenses for glasses so that the eyes could be exposed to therapeutic low-dose radiation for prolonged periods (Figure 7).
Despite these reports of success, mentions of radiation treatment of cataracts in the medical literature cease. It may be that the publicity in the lay press given to Eben Byers and the Radium Girls may have lessened both the public's appetite and most physicians' enthusiasm for such treatments.
The next chapter begins with a bang: the atomic bomb. By the late 1940s the cataractogenic effects of ionizing radiation on the lens were apparent both in workers on cyclotrons and in atomic bomb victims.24,25 Cogan played a major role both in identifying atomic bomb cataracts in Japanese survivors and then in demonstrating, experimentally and in humans, the pathology of radiation-induced lens changes. His series of 6 articles documented that, instead of benefiting from irradiation, the lens is one of the most sensitive tissues in the body to radiation injury.26-30
In 1959, Frederick Cordes was the subject of an affectionate festschrift"on the occasion of his 67th birthday" that, like his articles on the treatment of cataracts with radium, was published in the American Journal of Ophthalmology. He had served without pay as chair of the Division and then Department of Ophthalmology at University of California at San Francisco for 25 years. He started the residency program there and founded the Proctor Foundation. He served as president of both the American Ophthalmological Society and the American Academy of Ophthalmology and Otolaryngology. In an obituary, Hogan described Cordes as a man who "made mistakes, but they were honest mistakes" and also as something of a hard taskmaster.31
In a presumably unintentional irony, the first article in his festschrift was "Cyclotron Cataracts" by Alan C. Woods, MD.32 Woods stated, "It has been known almost since the discovery of x-rays that undue exposure to ionizing radiation frequently resulted in the late development of characteristic cataracts."32(p20) He goes on to describe his study of cyclotron workers and their cataracts.
What can be learned from these events? Even careful physicians may delude themselves as to the effectiveness and safety of treatments, especially when adverse effects do not appear for many years. Warnings tend to be discounted—perhaps more often when there is an economic benefit to ignoring them. The truth will eventually win out, although it may take the participation of both the public and physicians. The scientific method well applied leads to great advances, and practitioners of this method, such as William Rollins and David Cogan, are beacons of enlightenment on the rocky shoals of scientific medicine.
Accepted for publication April 28, 2000.
Reprints are not available from the author.