 |
|
Radiation and Cataracts
Cause or Cure?
John W. Gittinger, Jr, MD
Arch Ophthalmol. 2001;119:112-116.
INTRODUCTION
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.
THE SNYDER LECTURE
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.
WILHELM CONRAD ROENTGEN, PhD (1845-1923)
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.
|
|
|
|
Figure 1. Frau Roentgen's hand with ring.
|
|
|
THOMAS ALVA EDISON (1847-1931)
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
|
|
|
|
Figure 2. 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.
|
|
|
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.
THE WILLIAMS FAMILY
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)
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.
WILLIAM HERBERT ROLLINS, DMD, MD (1852-1929)
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
|
|
|
|
Figure 3. A Rollins' design, which included
a collimator at the top. Adapted with permission from AJR Am J Roentgenol. 1986;147:850-853.
|
|
|
|
|
|
|
Figure 4. Demonstration of a Rollins' instrument.
The model may be Rollins himself.
|
|
|
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:
|
|
|
|
Figure 5. The radium applicator of Scott
and Cordes was placed over closed eyelids.
|
|
|
[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).
|
|
|
|
Figure 6. Brooks' radium applicator was
designed to be inserted under the eyelids.
|
|
|
|
|
|
|
Figure 7. 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.
|
|
|
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.
DAVID G. COGAN, MD (1908-1993)
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
FREDERICK CARL CORDES, MD (1892-1965)
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.
AUTHOR INFORMATION
Accepted for publication April 28, 2000.
Reprints are not available from the author.
From the Department of Ophthalmology, Boston University School of Medicine,
Boston, Mass.
REFERENCES
| |
1. Snyder CL. Our Ophthalmic Heritage. Boston, Mass: Little Brown & Co; 1967.
2. Snyder CL. The Williams brothers and the Roentgen ray. Arch Ophthalmol. 1965;73:749-752.
ISI
| PUBMED
3. DiSantis DJ. Early American radiology: the pioneer years. AJR Am J Roentgenol. 1986;147:850-853.
FREE FULL TEXT
4. Shephard DA. Thomas Edison's attempts at radiography of the brain (1896). Mayo Clin Proc. 1974;49:59-61.
ISI
| PUBMED
5. DiSantis DJ, DiSantis DM. Wrong turns on radiology's road of progress. Radiographics. 1991;11:1121-1138.
ISI
| PUBMED
6. Kathren RL. William H. Rollins (1852-1929): x-ray protection pioneer. J Hist Med Allied Sci. 1964;19:287-294.
PUBMED
7. Rollins W. Notes on X-Light. Cambridge, Mass: University Press; 1904.
8. Rollins W. X-light kills. Boston Med Surg J. 1901;144:173.
9. Codman EA. No practical danger from the x-ray. Boston Med Surg J. 1901;144:197.
10. Brown P. American Martyrs to Science Through the Roentgen
Rays. Springfield, Ill: Charles C Thomas Publisher; 1936.
11. Rollins W. Notes on x-light: the effect of x-light on the crystalline lens. Boston Med Surg J. 1903;148:364-365.
12. Paton L. Cases of posterior cataract commencing subsequent to prolonged exposure
to x-rays. Trans Ophthamol Soc U K. 1909;29:37-38.
13. Macklis RM. Radithor and the era of mild radium therapy. JAMA. 1990;264:614-618.
ABSTRACT
14. Macklis RM, Bellerive MR, Humm JL. The radiotoxicology of Radithor: analysis of an early case of iatrogenic
poisoning by a radioactive patent medicine. JAMA. 1990;264:619-621.
ABSTRACT
15. Clark C. Radium Girls. Chapel Hill: University of North Carolina Press; 1997.
16. Brooks ED. Further uses of the x-ray flash. J Ophthalmol Otol Laryngol. 1911;17:412-415.
17. Linnell EH. A final word in regards to the Roentgen ray flash treatment. J Ophthalmol Otol Laryngol. 1911;17:416-420.
18. Mattice AF. Report of the successful treatment of a corneal tumor with radium,
with remarks on radium in ophthalmology. Arch Ophthalmol. 1914;43:237-253.
19. Franklin WS, Cordes FC. Radium for cataract. Am J Ophthalmol. 1920;3:643-647.
20. Ravin JG. Cataracts, Diabetes, and Radium: The Case of Cassatt:
History of Ophthalmology. San Francisco, Calif: Foundation of the American Academy of Ophthalmology;
1990.
21. Franklin WS, Cordes FC. Radium applicator for cataracts. Am J Ophthalmol. 1921;4:431-432.
22. Allen B. A new radium applicator for the treatment of cataracts. AJR Am J Roentgenol. 1922;9:755.
23. Brooks HL. Radium treatment of immature and incipient cataracts. J Ophthalmol Otol Laryngol. 1925;29:349-357.
24. Cogan DG, Martin SF, Kimura SJ. Atom bomb cataracts. Science. 1949;110:654-655.
FREE FULL TEXT
25. Abelson PH, Kruger PG. Cyclotron-induced cataracts. Science. 1949;110:655-657.
FREE FULL TEXT
26. Cogan DG, Donaldson DD. Experimental radiation cataracts, I: cataracts in the rabbit following
single x-ray exposure. Arch Ophthalmol. 1951;45:508-522.
27. Cogan DG, Donaldson DD, Reese AB. Clinical and pathological characteristics of radiation cataract. Arch Ophthalmol. 1952;47:55-70.
28. Cogan DG, Goff JL, Graves E. Experimental radiation cataract: cataract in rabbit following single
exposure to fast neutrons. Arch Ophthalmol. 1952;47:584-592.
29. Cogan DG, Donaldson DD, Goff JL, Graves E. Experimental radiation cataract: further experimental study on x-ray
and neutron irradiation of lens. Arch Ophthalmol. 1953;50:597-602.
FULL TEXT
30. Cogan DG, Dreisler KK. Minimal amount of x-ray exposure causing lens opacities in the human
eye. Arch Ophthalmol. 1953;50:30-34.
FULL TEXT
31. Hogan MJ. Frederick Carl Cordes, MD. Trans Am Ophthalmol Soc. 1965;63:11-18.
PUBMED
32. Woods AC. Cyclotron cataracts. Am J Ophthalmol. 1959;44(5, pt 2):20-28.
|
