A darkened laboratory with an eery green glow; a photograph of the bones of a woman’s hand published on the front pages of newspapers throughout the globe; mysterious rays that promise to change medicine forever but also cause horrific disease in their champions and pioneers. In this episode, called Bone Portraits, I tell the story of two men — Wilhelm Roentgen, the discoverer of x-rays who would later win a Nobel Prize, and Clarence Dally, the first victim of x-ray radiation. Listen to the thrilling conclusion of our to part series on the dawn of diagnostic imaging! We’ve got all this, plus a double-header #AdamAnswers, in Episode 23 of Bedside Rounds, a tiny podcast about fascinating stories in clinical medicine.

Sources:

• Brown, Percy. American martyrs to radiology. Clarence Madison Dally (1865-1904). 1936.
• Cheng, Tsung. Dilation vs. Dilatation. American Journal of Cardiology. February 15, 1994. Volume 73, Issue 5, Page 421
• Dunlop, Orrin. Deleterious effects of X-rays on the human body. Electrical Review 1896;29:95
• Gagliardi, Raymond A. “Clarence Dally: An American Pioneer,” American Journal of Roentgenology, November, 1991, vol. 157, no. 5, p. 922
• Goodman, et al. Medical Writing: A Prescription for Clarity. P37.
• King, Gilbert. “Clarence Dally — The Man Who Gave Thomas Edison X-Ray Vision.” Smithsonian.com, March 14, 2012.
• Mahroo, et al. ‘Dilatation’ and ‘dilation’: trends in use on both sides of the Atlantic. Br J Ophthalmol. 2014 Jun;98(6):845-6. doi: 10.1136/bjophthalmol-2014-304986. Epub 2014 Feb 25.
• Obrien, Frederick. In Memoriam: Percy Brown, MD. Radiology. December 1950
  Volume 55, Issue 6
• Sansare K, et al. Early victims of X-rays: a tribute and current perception. Dentomaxillofac Radiol. 2011 Feb;40(2):123-5.

Transcript

This is Adam Rodman, and you’re listening to Bedside Rounds, a tiny podcast about fascinating stories in clinical medicine. Last month we had part one of our first two part episode about the dawn of diagnostic imaging, about the assassination of President James Garfield and futile attempt to locate his bullet by listening with a telephone ear piece. And now we have the thrilling conclusion. This episode is called “Bone Portraits,” and is the story of two men, both pioneers and similar in many ways — Wilhelm Roentgen, the discoverer of the X-ray, and Clarence Dally, the x-ray’s first victim..

Wilhelm Roentgen, an unassuming physics professor in Wurzberg Germany, had unusually good vision and was a detailed experimentalist. Both of these he attributed to his red-green color-blindness which forced him to be a keen observer of the world. Well, it turns out that his color-blindness would change the world of medicine forever. He was locked away in his laboratory, located beneath his apartment, on a Friday afternoon in November 1895. Roentgen was experimenting with cathode-ray tubes — think old-fashioned TV sets — to try and identify high energy rays which he thought penetrated the ether. He set up a fluorescent screen placed in front of the tube which would glow green in the presence of the rays. The glow would be faint though, and he needed his laboratory completely dark. He drew the curtains, turned off all the lights, and covered the tube with black cardboard. Satisfied that he had darkened the room enough for his experiments, he flipped a large switch to make sure that he had shielded the tube appropriately. Roentgen was a perfectionist, and no light escaped from the tube. But a faint glimmer from the corner of the room caught his eye. Was one of his tools reflecting light from a hole in the wall? He turned off his tube in preparation to investigate, but then noticed that the glimmer disappeared. Curious, Roentgen lit a match and crept over to his table. The glow was coming from the fluorescent screen, which was sitting haphazardly in a corner of the table. He moved the screen closer to the tube. The glow became a brilliant green. He placed a sheet of cardboard between the screen and the tube, then a 1,000 page book, then an entire bookshelf. None of them diminished the green glow.

Roentgen was late for dinner that night, and his wife Bertha noticed that he ate quickly, and immediately returned to the lab. She did not ask any questions. That night, and for the next several weeks, Roentgen barely left his laboratory, experimenting obsessively with these strange rays, which he termed X-rays, signifying their mystery. Plus, he assumed a future scientist would come up with a better name. He placed a variety of different metals in between the tube and the screen to see what could block the rays. Only platinum and lead seemed to work. It was while testing this feature of X-rays that he came across their most bizarre property. He held up a small lead disk in front of the fluorescent screen, but instead of just seeing a small black spot, he saw the bones of his hands. He immediately withdrew, and cautiously put his own hand in the rays. His living bones danced on a glowing green screen in front of his eyes. His unusually good vision had brought him to this point, but now he didn’t trust his own eyes. Seeking a more objective source, he replaced the fluorescent screen with a sheet of photographic film, and history was made.

On December 22nd, 1895, Roentgen led his wife Bertha into his lab and made her hold her exposed hand in between the tube and a photographic plate for 15 minutes. The subsequent image, a bone portrait now famous around the world, showed her skeletal hand with her wedding ring on the fourth finger. Roentgen quickly penned a paper, “On a New Kind of Rays,” and sent it off to be published in the December 28th edition of his local scientific journal. In the meantime, he sent copies of the photograph of his wife’s hand to friends. One of these copies ended up in the hands of a daily paper in Vienna, which ran the picture on the front page. Within days, news had spread all over the world. There was some initial skepticism — the New York Times dismissed Roentgen’s “alleged discovery” as an artistic hoax — but the medical applications of these new X-rays were obvious. Before the ink was barely dry on his journal publication, tinkerers, photographers, and doctors all around the world had purchased their own tubes to recreate his experiments. 

Across the ocean, America’s most prominent inventor Thomas Edison immediately saw the promise of these new X-rays. Roentgen had embodied the scientific ideal of meticulous observation and research, but Edison had weaponized this process to make the world’s first research and development laboratory. He filled his lab in New Jersey with young “muckers,” who were encouraged to innovate, experiment, and tinker, always with an eye to marketable products. Like the hackers in Silicon Valley in the 70s, the muckers and their tinkering would change the world. And the mucker Edison most relied on was Clarence Dally.

Clarence Dally was then 30 years old, trained as a glassblower like his father before him. His skill at making hand-blown bulbs had helped Edison conquer electric light, and after Roentgen’s discovery, Edison put Dally to work experimenting with these new X-rays. Like Roentgen, Dally was a detailed experimentalist, and he quickly became Edison’s expert on x-ray technology.

When Bertha Roentgen first looked at the photograph of her bones, she withdrew exclaimed, “I have seen my death!” Her words could not have been more prophetic. As quickly as x-rays spread over the world, murmuring of the disturbing news of their effects started. By August of 1896, a Mr. Hawkes of New York City wrote into the journal Electrical Review describing how his experiments with the x-ray had cracked and burned the skin on his hands, finally leading it to slough off all together. His eyes likewise had become bloodshot. 

The journal called for more cases, and a trickle turned into a torrent. Common themes emerged — blistered skin, bloodshot eyes, wounds that would not heal. My favorite case comes from Dr. Elihu Thomson of Boston, who decided to experiment on himself to measure the effects of X-rays on the human body. You can read his first hand accounts in the shownotes. Thomson, having read previous reports, decided to test on the most expendable part of his body, his left little finger above the knuckle, which he placed directly on the x-ray source for 30 minutes a day. For the first nine days, nothing much happened, but then he noted that the skin blistered, the nail stopped growing, and finally his skin sloughed off. With continuous exposure, the skin did not grow back, leaving a scarred finger full of granulation tissue. 

Despite these murmurings, Dally continued his mucking unperturbed. Working diligently on his x-ray tubes, he tested each new iteration on himself, holding his non-dominant left hand in the rays. His work would be unveiled at the 1896 National Electric Light Association in New York City in April, the first widespread exhibition of X-ray technology for the American public, only months after the New York Times had first described Roentgen’s discovery.  In the Grand Central Palace, which was right near the original Grand Central Station, thousands of ordinary New Yorkers saw the future for the first time. Just try and imagine what it must have been like. You were ushered into a darkened waiting room. After your eyes adjusted, you were handed a glove and a large coin to grasp. A small wooden cabinet waited in front of you, beckoning to place your hand inside. You might recognize a viewer similar to that of a kinetoscope, which had popped up in fairs along the boardwalk, showing moving pictures for the first time. But this time, after glancing down through the viewer to the screen underneath, you saw an amazing sight — through the glove, the coin was visible — and your bones underneath. The effect on the public was immediate. The skeleton had been a symbol of death for a reason — prior to these x-rays (or roentgenograms as they were then being called), you could only see a skeleton after someone had died. But now this had been supplanted with “bone portraits,” showing the living skeleton underneath. Arthur C. Clarke’s would later write that any sufficiently advanced technology is indistinguishable from magic. Even fifty years before, this new fluoroscope would have been dismissed as such. The world was changing, and the x-ray was one of its horsemen. It’s not hard to see how Roentgen mania spread after these demonstrations, and why the growing warnings about the dangers of x-rays went mostly unheeded. By the way, there’s a famous picture of Edison and Dally, which I’ve placed on the website, where you can see Edison looking through the fluoroscope through Dally’s hand. 

Over the next five years, Dally and the muckers continued to refine Edison’s x-rays, experimenting with filters and churning out medical grade machines. In September 1901, Dally traveled to the Pan-American Exposition in Buffalo, New York, to display the latest models of Edison’s medical x-ray machine. There, another American president, William McKinley was about to give a speech when an anarchist shot him twice in the abdomen. Just like the case of poor James Garfield and Alexander Graham Bell a decade before, the surgeons could not locate the bullet. Edison immediately phoned Dally and instructed him to set up the X-ray machine to prepare for the president. However, despite the considerable advances over the past five years, x-rays still took over an hour to develop, and the president’s surgeons felt his condition was far too unstable for this extended session. They opted for watchful waiting instead. Unfortunately, the president worsened, and then died before the week was out.

Shortly after Edison started to work on X-rays in 1896, he noticed that his eyes were bloodshot, and that his vision had worsened, and he recused himself from any more work with the technology. Dally continued unabated, however, and by the time of McKinley’s assassination, he was starting to show the toxic effects of radiation exposure. His skin had prematurely wrinkled, his hair and eyebrows and fallen out, and the skin of his left hand was badly burned and ulcerated. Dally took long breaks with hopes that his skin would heal, but just like Dr. Thomson had observed, healing came slowly, if at all. A faithful mucker to the end, when the pain became unbearable to use his left hand, he started to use his right hand to test the tubes and slept with his hands in cold water hoping for relief. Edison felt responsible for the young man, and took Dally to the best doctors on the East Coast. Skin grafts were attempted, but they would not take to the radiation-scarred tissue. Eventually, he had his left arm amputated. Later in 1901, his right hand also began to ulcerate, and four fingers were removed. By 1903, his right arm had been amputated as well. Edison kept him on the payroll long after he could no longer work, and promised Dally he would support his family. Ulcerated skin cancer spread across his entire body, and by 1904 he died in excruciating pain. He was 39 years old. 

Dally’s death scarred Edison, and he stopped all work on X-rays. He told New York World:

I did not want to know anything more about X-rays. In the hands of experienced operators they are a valuable adjunct to surgery, locating as they do objects concealed from view, and making, for instance, the operation for appendicitis almost sure. But they are dangerous, deadly, in the hands of inexperienced, or even in the hands of a man who is using them continuously for experiment.”

Years later, when Edison was 84 and suddenly collapsed, he rebuffed his doctors and adamantly refused to be X-rayed, dying peacefully at home four months later.  

Dally died of X-ray’s effects only 8 years after their discovery, the first martyr to Roentgen’s rays, but he wouldn’t be the last. Over the next decades, most of the original tinkerers and experimenters with x-rays died quite horrifically of their effects. A probably apocryphal story tells of a dinner at a radiological society in 1920 where the main course — chicken — was poorly received, since most of the radiologists present were missing at least one hand. Dr. Percy Brown, another earlier radiologist, would release a book called American Martyrs to Science through the Roentgen Ray in 1936, including the stories of 30 early scientists and doctors in its 300 pages, starting with Dally. Within a few years of its publication, he began to suffer from the effects of repeated radiation exposure, and underwent over 50 operations until he too joined the ranks of martyrs to X-rays. As for Wilhelm Roentgen, he stopped working with X-rays soon after their discovery, though they would define the remainder of his career. And in 1901, when the first prizes funded by Alfred Nobel were awarded, Roentgen became the first Laureate in physics..

By the 1930s, the danger of radiation exposure had been well-described, and improved technology and radiation badges had dramatically cut down the risk for both technicians, doctors, and patients. Unsafe practices persisted however; if you talk to anyone who was a child in the 1950s, they’ll tell you about how shoe stores used to have fluoroscopes so you could see how your bones fit your new shoes. And the conversation about safe radiation exposure is ongoing today, especially as new types of bone portraits are repeated ad infinitum on patients, often unnecessarily. Those annual dental x-rays you’ve been getting? Yeah, not a thing by the ADA’s own recommendations for your average patient, and might maybe have something to do with the fact that your dentist owns her own x-ray machine.

In any event, the next time you have a bone portrait made, take a moment to thank Wilhelm Roentgen’s uniquely good eyesight, Clarence Dally’s sacrifice, and both of their curiosity, industry, and experimentation.

That’s it for the show! But wait, there’s more — it’s time for this month’s #AdamAnswers! Dr. David Serota couldn’t help himself — he has TWO questions this month. And because I’m feeling a super generous mood coming on, I’m gonna tackle both. 

First up, he tweets: Dilation vs. dilitation: difference? And fortunately I can answer this one definitively: yes, there is a difference — you should be saying dilation. Dilatation and dilation basically mean the same thing, and don’t let anyone tell you differently. The basic difference is that dilatation is the proper Latinism; that is, conjugated like it would be if we all spoke Latin. Fortunately, we speak English, and there’s a perfectly good, shorter, and less pretentious word in dilation. An interesting study looking at the frequency of the two words in medical literature from 1800 onwards shows that dilation has recently overtaken its hoity-toity cousin as of 1990 or so, so at least I’m not alone in this one. And in case your use of “dilation and curettage” gets you in an argument, I’ve got all the sources — including a text book on proper medical communication — in the show notes.

BAM, knocked that one out! What do you have next for me, Dr. Serota? Well, he asks, “Why do nurses write notes in the third person and doctors in the first?”

So first some background — in my experience, and when talking to some of my nurse friends, it does indeed seem that many nurses document in the third person, though certainly nursing is not a monolithic profession. This can be “pseudo third-person”; that is, just regular old first person but cutting off the word I, as in, “Responded to call at 10 PM; patient was awoken by a scary dream.” Or it can read like a absurdist novel: “This nurse responded to the patient, who informed this nurse that he dreamt he was stuck in a Twinkie” 

Doctors also document in the third person passive when writing procedure notes. So something like, “the patient’s ribs were cracked, and surgical things were done inside the chest. The chest was then closed” You can tell I’m not a surgeon. 

But at least in my experience, doctors are far more likely to document their interactions with patients and their families in the first person. So something like, “I spoke to Mr. Henderson this morning, who informed me of his increasingly frequent dreams of being consumed as a dessert snack.”

Dr. Serota, I love your question — because I have absolutely no idea why this difference in documenting might be, or whether it even truly exists, and it looks like this hasn’t really been studied. One of the great unsolved medical mysteries if you will. I did find some literature on the use of first and third person in field notes in ethnographies, and how differences in these styles related to the observer becoming part of the narrative. And while I suspect this might be part of it — I know I’m much more likely to document in the first person when it’s an intense conversation that I am a part of, like a goals of care conversation — like much written on this subject, this is only conjecture. So if you’re an anthropology student looking for a thesis — I got one for you! And you can thank Dr. Serota.

Sorry I couldn’t do better Dr. Serota. Do you have a question about medicine that you want to be partially answered so you can be disappointed when you listen to the next podcast? Well, I’m your man! Tweet at me @AdamRodmanMD for the next #AdamAnswers!

That’s it for the show, thanks for listening! This two part episode was inspired by the book Naked to the Bone by Bettyanne Kevles, about the history of medical imaging. I highly recommend it! There’s also a PBS special from the 90s based on the book. If you want more Bedside Rounds, all of our episodes are on the website at www.bedside-rounds.org, or on iTunes, Stitcher, Google Play, or wherever fine podcasts are found. I’m on Twitter @AdamRodmanMD, and on Facebook at /BedsideRounds, so drop by and say hi! I occasionally tweet interesting things. All of my sources are in the show notes.

And of course, as always while I am actually a doctor and I don’t just play one on the internet, this podcast is intended to be purely for entertainment and informational purposes, and should not be construed as medical advice. If you have any medical concerns, please see your primary care provider.