Fedor Krause: The First Systematic Use of X-rays In Neurosurgery
Fedor Krause: The First Systematic Use of X-rays In Neurosurgery
On February 15, 1896, shortly after Röntgen's report, Cushing wrote enthusiastically in a letter to his mother, "Everyone is very excited over the new photographic discovery. Professor Röntgen may have discovered something with his cathode rays that may revolutionize medical diagnosis." In another letter to his mother on May 10, 1896, he stated "We have at least succeeded in having an X-ray machine put in for which I have subscribed largely and hope the conservative staff will ultimately remunerate us for it."
The first clinical use of x-rays in North America was by Williams and Codman in 1896, which started shortly after its discovery in Röntgen's laboratory. Cushing worked with Codman at the Massachusetts General Hospital with x-rays and then left for John Hopkins Hospital in 1896 with an x-ray tube. In Boston, attempts were made to demonstrate brain tumors by x-rays from 1896 through 1910. Williams, in the first text in North America on radiography, wrote of the technical problems with acquiring useful images: "Tumors in the brain with our present apparatus and inexperience must necessarily offer a great deal of difficulty to detection by the rays" (340).
After his first use of x-rays on November 6, 1896, on a female patient who had sustained a gunshot injury Cushing wrote:
It was in the fall of 1896 that I went to John Hopkins and made the first Roentgenograms that were taken there, with the aid of a decrepit and perverse static machine as big as a hurdygurdy and operated in the same way, by turning a crank. My first paper submitted for publication contained an account of a case of a gunshot wound of the spine showing a bullet which a Baltimorean had planted in the body of his wife's sixth cervical vertebra. I once showed these pictures to Dr. Cole and he expressed himself as astonished that such good plates could have been taken in 1896; but I do not know whether I told him, as I shall now confide to you, that the plates were the result of exposures averaging 35 minutes. And I may add that the pictures which were reproduced were not those of a single experience, for I think the patient was given as many as half a dozen sessions at least, before plates were secured which were sufficiently good for reproduction. Needless to say, she was a most cooperative patient. Subsequently a Will-young coil was purchased which I think had a spark gap of 2 or 3 inches. With this coil and many bottles of rodinol (I do not know if rodinol is anything more than a memory for a few grey beards in this audience), I spent many weary hours for the next year or two in an improvised dark room off from the old amphitheatre at the Johns Hopkins Hospital developing roentgen-ray plates in which no one at the time took any very great interest. Certainly no one of us could have had any possible conception of the increasingly important role of Roentgen-ray was to play in clinical diagnosis and treatment.
Cushing published on the use of x-ray applications in 2 spine cases in 1898.
While Cushing was writing letters home, Krause's work on his use of x-rays for surgery (The Importance of Röntgen's Photogram's for Surgery) had already been published twice in German scientific medical journals in March 1896 (in Deutsche medizinische Wochenschrift and M¨nchener medizinische Wochenschrift). These publications are recorded in the seminal book by Glasser on Röntgen. Concurrently in their 1900 text, An American Text-Book of Surgery for Practitioners and Students, Keen and White stated that their use of x-rays was limited to localization of foreign bodies and fractures in difficult cases. In a chapter, "The Use of the X or Röntgen Rays in Surgery", Keen commented:
The Roentgen method is, of course in its infancy. It has, however, reached already a degree of usefulness that makes it obvious that the necessary apparatus will be an essential part of the surgical outfit of all hospitals, and will be employed constantly in a variety of cases. Those to which the method can now be applied with advantage may be summarized as follows, emphasis being placed on the fact that what is written to-day may require revision or reversal tomorrow, so rapidly are improvements and discoveries taking place. (1191)
With regard to intracranial tumors, Keen indicated that locating them still depended on "localizing symptoms…if they exist; for it must be remembered that in certain parts of the brain a tumor may exist without any localizing symptoms, but with only the general symptoms of headache, vomiting, choked disc, and convulsions" (547). Interestingly this was written in the section not titled with the term "tumor" but under the rubric "Fungus Cerebri, or Hernia Cerebri." However, in the chapter on x-rays some pages later, Keen wrote presciently:
Bony tumors can plainly be seen, and as the method improves it is to be expected that intracranial and intraspinal osteomata may be discovered and located, and possibly even periosteal thickenings due to tubercular, syphilitic, or pyogenic infection…. Penetration is not, however, of the greatest value; the property of differentiating between all ranges of densities is of greater value. Differentiation between the lesser as well as the greater densities is essential to the future development of this method of diagnosis. In order, therefore, that a tube should be most useful for diagnostic purposes, it should be capable of producing and maintaining for any desired length of time any of the various qualities of the Roentgen ray that the operator may desire to employ. (1192 and 1194)
In 1901, Keen remarked, "At first it was thought impossible to discover anything inside of the bony skull, but there are now on record nearly a score of instances in which bullets have been detected within the skull…." (245).
In the 1904 multivolume surgical text (Fig. 2) by von Bergmann, von Bruns, and von Mikulicz, only one comment on x-rays as a diagnostic aid exists in the section on wounds of the head written by Krönlein. In the section on surgical treatment of brain tumors written by von Bergmann, there are no comments on x-rays. Interestingly, Krause was the contributor of the chapter on neuralgias of the head.
(Enlarge Image)
Figure 2.
The title page of von Bergmann and colleagues' 1904 multivolume text to which Krause was a contributor, but not on tumors or x-ray information.
(Enlarge Image)
Figure 3.
Title pages of Krause's textbooks. Note the signature of Krause on the German Volume II released in 1911. The title page of the "Radiography" chapter is shown in English (published in 1909), which was the last chapter of the German Volume I published in 1908.
Krause must have obtained excellent apparatus as his radiographs are amazingly clear for the time. He routinely used x-rays to differentiate the origin and the direction of growth of the tumor:
In discussing newer methods of examination, radiography should be included. Above all other means of diagnosis it furnishes the most useful in tumors with calcareous or bony deposits as, for instance, in exostosis. If the neoplasm has its origin from the lamina vitra and grows toward the cranial cavity, its recognition by means of the X-ray is an easy matter. However, when exostoses originate at the base of the skull, and reach a certain size, they, too, will throw a shadow on the plate which may permit of a diagnosis being made [278]…Neoplasmata of the base of the skull are closely allied to tumors at the base of the brain. New formations originating in these cases from the outer (lower) surface of the dura or from the bone itself grow, as a rule, into the cranial cavity and may give rise to manifestations of cerebral compression as well as to morbid symptoms from involvement of the cerebral nerves. A differentiation as to the structures from which the tumor originated is, from the clinical manifestations alone, frequently impossible. (821)
Krause used the x-ray apparatus on every patient with epilepsy that he treated:
Any injury to the skull may bring on epileptic seizures…. Whenever possible x-ray examination should be made. It frequently is a great aid in clearing up the diagnosis. Even in other forms of epilepsy roentgenography is of urgent need. (479)
Krause stressed proper radiographic technique to avoid artifacts and inaccurate results. The thought process behind Krause's efforts to acquire useful images are apparent in comments in his chapter regarding the base of the skull and the sella-sphenoid region:
Interpretation of the Roentgen plate must be carefully made. The fact that the plate is of some distance from the Turkish saddle influences very largely the conformation of the shadow. Each turn of the head on its vertical axis alters the picture of the cavity, and when to this is added the fact that in acromegaly an enlargement and thickening of the skull is present, it is easy to see that an accurate picture of the contour of the base of the skull is not easily obtained. The shadow should be compared with that of the normal skull, and exposures should be made at stated intervals in order to observe the extension of the pathological process. The examination may be regarded as associated with great difficulties. (279–280)
X-ray Implementation in Neurosurgery
On February 15, 1896, shortly after Röntgen's report, Cushing wrote enthusiastically in a letter to his mother, "Everyone is very excited over the new photographic discovery. Professor Röntgen may have discovered something with his cathode rays that may revolutionize medical diagnosis." In another letter to his mother on May 10, 1896, he stated "We have at least succeeded in having an X-ray machine put in for which I have subscribed largely and hope the conservative staff will ultimately remunerate us for it."
The first clinical use of x-rays in North America was by Williams and Codman in 1896, which started shortly after its discovery in Röntgen's laboratory. Cushing worked with Codman at the Massachusetts General Hospital with x-rays and then left for John Hopkins Hospital in 1896 with an x-ray tube. In Boston, attempts were made to demonstrate brain tumors by x-rays from 1896 through 1910. Williams, in the first text in North America on radiography, wrote of the technical problems with acquiring useful images: "Tumors in the brain with our present apparatus and inexperience must necessarily offer a great deal of difficulty to detection by the rays" (340).
After his first use of x-rays on November 6, 1896, on a female patient who had sustained a gunshot injury Cushing wrote:
It was in the fall of 1896 that I went to John Hopkins and made the first Roentgenograms that were taken there, with the aid of a decrepit and perverse static machine as big as a hurdygurdy and operated in the same way, by turning a crank. My first paper submitted for publication contained an account of a case of a gunshot wound of the spine showing a bullet which a Baltimorean had planted in the body of his wife's sixth cervical vertebra. I once showed these pictures to Dr. Cole and he expressed himself as astonished that such good plates could have been taken in 1896; but I do not know whether I told him, as I shall now confide to you, that the plates were the result of exposures averaging 35 minutes. And I may add that the pictures which were reproduced were not those of a single experience, for I think the patient was given as many as half a dozen sessions at least, before plates were secured which were sufficiently good for reproduction. Needless to say, she was a most cooperative patient. Subsequently a Will-young coil was purchased which I think had a spark gap of 2 or 3 inches. With this coil and many bottles of rodinol (I do not know if rodinol is anything more than a memory for a few grey beards in this audience), I spent many weary hours for the next year or two in an improvised dark room off from the old amphitheatre at the Johns Hopkins Hospital developing roentgen-ray plates in which no one at the time took any very great interest. Certainly no one of us could have had any possible conception of the increasingly important role of Roentgen-ray was to play in clinical diagnosis and treatment.
Cushing published on the use of x-ray applications in 2 spine cases in 1898.
While Cushing was writing letters home, Krause's work on his use of x-rays for surgery (The Importance of Röntgen's Photogram's for Surgery) had already been published twice in German scientific medical journals in March 1896 (in Deutsche medizinische Wochenschrift and M¨nchener medizinische Wochenschrift). These publications are recorded in the seminal book by Glasser on Röntgen. Concurrently in their 1900 text, An American Text-Book of Surgery for Practitioners and Students, Keen and White stated that their use of x-rays was limited to localization of foreign bodies and fractures in difficult cases. In a chapter, "The Use of the X or Röntgen Rays in Surgery", Keen commented:
The Roentgen method is, of course in its infancy. It has, however, reached already a degree of usefulness that makes it obvious that the necessary apparatus will be an essential part of the surgical outfit of all hospitals, and will be employed constantly in a variety of cases. Those to which the method can now be applied with advantage may be summarized as follows, emphasis being placed on the fact that what is written to-day may require revision or reversal tomorrow, so rapidly are improvements and discoveries taking place. (1191)
With regard to intracranial tumors, Keen indicated that locating them still depended on "localizing symptoms…if they exist; for it must be remembered that in certain parts of the brain a tumor may exist without any localizing symptoms, but with only the general symptoms of headache, vomiting, choked disc, and convulsions" (547). Interestingly this was written in the section not titled with the term "tumor" but under the rubric "Fungus Cerebri, or Hernia Cerebri." However, in the chapter on x-rays some pages later, Keen wrote presciently:
Bony tumors can plainly be seen, and as the method improves it is to be expected that intracranial and intraspinal osteomata may be discovered and located, and possibly even periosteal thickenings due to tubercular, syphilitic, or pyogenic infection…. Penetration is not, however, of the greatest value; the property of differentiating between all ranges of densities is of greater value. Differentiation between the lesser as well as the greater densities is essential to the future development of this method of diagnosis. In order, therefore, that a tube should be most useful for diagnostic purposes, it should be capable of producing and maintaining for any desired length of time any of the various qualities of the Roentgen ray that the operator may desire to employ. (1192 and 1194)
In 1901, Keen remarked, "At first it was thought impossible to discover anything inside of the bony skull, but there are now on record nearly a score of instances in which bullets have been detected within the skull…." (245).
In the 1904 multivolume surgical text (Fig. 2) by von Bergmann, von Bruns, and von Mikulicz, only one comment on x-rays as a diagnostic aid exists in the section on wounds of the head written by Krönlein. In the section on surgical treatment of brain tumors written by von Bergmann, there are no comments on x-rays. Interestingly, Krause was the contributor of the chapter on neuralgias of the head.
(Enlarge Image)
Figure 2.
The title page of von Bergmann and colleagues' 1904 multivolume text to which Krause was a contributor, but not on tumors or x-ray information.
Krause's Use of X-ray Apparatus
(Enlarge Image)
Figure 3.
Title pages of Krause's textbooks. Note the signature of Krause on the German Volume II released in 1911. The title page of the "Radiography" chapter is shown in English (published in 1909), which was the last chapter of the German Volume I published in 1908.
Krause must have obtained excellent apparatus as his radiographs are amazingly clear for the time. He routinely used x-rays to differentiate the origin and the direction of growth of the tumor:
In discussing newer methods of examination, radiography should be included. Above all other means of diagnosis it furnishes the most useful in tumors with calcareous or bony deposits as, for instance, in exostosis. If the neoplasm has its origin from the lamina vitra and grows toward the cranial cavity, its recognition by means of the X-ray is an easy matter. However, when exostoses originate at the base of the skull, and reach a certain size, they, too, will throw a shadow on the plate which may permit of a diagnosis being made [278]…Neoplasmata of the base of the skull are closely allied to tumors at the base of the brain. New formations originating in these cases from the outer (lower) surface of the dura or from the bone itself grow, as a rule, into the cranial cavity and may give rise to manifestations of cerebral compression as well as to morbid symptoms from involvement of the cerebral nerves. A differentiation as to the structures from which the tumor originated is, from the clinical manifestations alone, frequently impossible. (821)
Krause used the x-ray apparatus on every patient with epilepsy that he treated:
Any injury to the skull may bring on epileptic seizures…. Whenever possible x-ray examination should be made. It frequently is a great aid in clearing up the diagnosis. Even in other forms of epilepsy roentgenography is of urgent need. (479)
Krause stressed proper radiographic technique to avoid artifacts and inaccurate results. The thought process behind Krause's efforts to acquire useful images are apparent in comments in his chapter regarding the base of the skull and the sella-sphenoid region:
Interpretation of the Roentgen plate must be carefully made. The fact that the plate is of some distance from the Turkish saddle influences very largely the conformation of the shadow. Each turn of the head on its vertical axis alters the picture of the cavity, and when to this is added the fact that in acromegaly an enlargement and thickening of the skull is present, it is easy to see that an accurate picture of the contour of the base of the skull is not easily obtained. The shadow should be compared with that of the normal skull, and exposures should be made at stated intervals in order to observe the extension of the pathological process. The examination may be regarded as associated with great difficulties. (279–280)