The pioneers of radiotherapy

Röntgen's discovery of X-rays in November 1895 had a tremendous impact on the practice of medicine. To him we owe the birth of a new and complete medical discipline: radiology, in its diagnostic and therapeutic specialties.

The origins of diagnostic radiology have been well elucidated and the chronological sequence of its advance is well established. For example, it is not disputed that it was Röntgen himself who recorded the first X-ray image of internal anatomy. However, the origins of therapeutic applications are less well known and surrounded by controversy. Some of the early attempts at its therapeutic use of X-rays did not have a logical justification to support them because our knowledge of the biological nature of X-ray effects took much longer to develop than it did to sprout. the idea of the therapeutic application of these rays. For this reason, some of the pioneers that will be presented below are not considered by many to be the precursors of radiotherapy. The historical literature on these early attempts can be restricted to four people: Emil H. Grubbé, Leonhard Voigt, Victor Despeignes, and Leopold Freund.

Emil H. Grubbé, a German emigrant in Chicago, claimed to have performed the first X-ray treatment on January 29, 1896, while he was a medical student. The patient suffered from a recurrent carcinoma of the breast. The first known document on this event is an article that Grubbé himself wrote for the Chicago Congress of Radiology 37 years later. He also reported that just one day after that first treatment, a second patient was treated for lupus vulgaris. There are no original records of these treatments, nor did his doctors record any improvement in the patients. Both passed away within a month. It is striking that these cases were not previously described by Grubblé himself when he already published publications dealing with radiotherapy at the beginning of the 20th century.

In chronological order we would later meet the German doctor Leonhard Voigt. He informed the Hamburg Society of Physicians that in February 1896 he had treated a patient for inoperable nasopharyngeal cancer using X-rays in 30-minute sessions applied twice daily, for a total of 80 sessions. Voigt observed a reduction in the patient's pain, which allowed him to reduce the dose of morphine he regularly used. There is no original clinical report of the treatment or identifying data of the patient. Voigt did not provide technical details of the treatment. There is also no clear data on the justification of the treatment.

There are publications from that time on in vitro and animal studies on the bactericidal effect of X-rays. Most of them concluded negative results. However, between April and June 1896, Lortet and Geund, two doctors from Lyon, inoculated the skin of guinea pigs with tuberculosis bacteria. Part of them were irradiated in said area of the skin with X-rays for one hour daily. The rest of the guinea pigs developed the disease, as expected, but the irradiated ones did not. This finding was inspired by Victor Despeignes, Dean of the Lyon Faculty of Medicine, who was probably the author of the first article on radiotherapy published on July 26, 1896. In the article he describes the case of a 52-year-old patient with a advanced stomach tumor that is treated with X-rays from day 4 to 12 of that same month. The patient was treated twice a day for half an hour. The equipment that was built with a 6-cell battery, an induction coil and a vacuum tube, similar to the one used by Röntgen himself.

At the end of the treatment Despeignes recognized a "considerable improvement" in the patient's condition as the size of the lesion was reduced. The patient died 12 days later and the autopsy showed no reduction in the size of the lesion. The size reduction assessed by Despeignes was most likely due to a severe skin reaction, since the equipment used could not work at regimes greater than 20 kVp and therefore its effect beyond the first few millimeters of depth should be negligible.

We can say that not even a year had passed since the discovery of X-rays and therapeutic trials such as those described had already proliferated. However, these cases lacked a clear justification and the technical information and the evolution of the patients was scarce. It was in November 1896 when we can find the best justified and described application to date: the Viennese dermatologist Leopold Freund treated a 5-year-old girl who suffered from a hairy nevus that covered her entire back. Freund was 28 years old and had been practicing dermatology since he had graduated a year earlier. He thought that he could remove the hair from the girl's back using X-rays because of a story he had read in a newspaper. It described how an engineer had lost his hair after continually experimenting with this radiation.

Freund began the treatment on November 24, 1896. It was carried out with an X-ray apparatus that was located in a photography research institute in Vienna. He gave one session a day and each one lasted two hours. He performed a first series of ten sessions only on the upper half of the back. At the end of the treatment, he noticed that the hair was beginning to fall out and days later the irradiated skin was shaved and only a slight dermatitis was visible. Freund had doubts as to whether the observed biological effect was due to the X-rays themselves or to electrical currents produced by the high voltage of the generator. He began a second series of treatments that covered the rest of the back, but now, to check the origin of the hair removal, he protected the patient from the electric field with aluminum foil. To compensate for the effect of radiation absorption by the sheet, he decided to increase the number of sessions to twenty-one. He again got hair removal from the treated area, but also caused an ulcer in the lower back that took six years to heal, leaving a scar. Freund was presenting the results of the follow-up of this patient until 1937. Later he contacted the patient again when she was 64 years old. She herself presented herself at the institute where she had been treated. All of the skin on her back was shaved and no radiation damage was found beyond the lumbar scar. The patient was followed up to 75 years after treatment.

In addition to the description of this case, Freund made numerous publications dealing with radiotherapy, among which may be included the first book on the subject.

Considering the detail of the description of the first treatment carried out by Freund, the justification of the same and the extensive bibliography that he generated, it is not surprising that many authors on the subject consider Freund as the authentic pioneer of radiotherapy. It should be noted that he was even nominated for the Nobel Prize in Medicine by the professor of dermatology at the University of Vienna Ernest Finger in 1906, who sent an extensive ten-page letter of nomination extolling the work that Freund had done and the repercussions that could be expected to have. in the future of medicine. However, the prize that year was shared by Camillo Golgi and Santiago Ramón y Cajal in recognition of his work on the structure of the nervous system.

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