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1964 Phys. Med. Biol. 9 433

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 Phys. Med. Biol., 1964, Vol. 9, No. 4, 433-456

Review Article

Pictorial Heat Scanning

By K. LLOYDWILLIAMS,M.A., XChir., F.R.C.S.

Middlesex Hospital, London, W.l

9 1. ISTRODUCTION
PICTORLAL presentation of surface temperaturepatternshas become
possible inrecentyears because of the advancesinelectronicsand
detector design provided bytheimpetus of militaryrequirements.
The ability to demonstrate the temperature of large areas of the body
surfaceinashort space of time has aroused medical interest because
of its potential value inshowing variations in static temperature patterns
and variations produced by heat flow and heat transfer mechanisms in
the body.

2. THE PHYSICS OF THERMAL IMAGING

Thermography depends upon the measurement of the temperature of
a surface a t a distance by means of its infra red emission.
I n 1800, Sir William Herschel described in a paper before the Royal
Society, his investigations of the power of the prismatic colours to heat
and illuminateobjects.Hefound that when the light of the sun was
passed through a prism and broken up into primary colours, the greatest
power to heat a mercury thermometer occurred when the thermometer
had been passed beyond theredend of the visible spectrum.He
considered, therefore, that there must be some invisible radiation beyond
the spectrum which he namedinfra-red waves. These infra-red waves
are now known to behavein the samemannerasallelectromagnetic
waves.
Any object a t a temperature above absolute zero emits energy at its
surface in the form of a spectrum of electromagnetic waves of differing
wavelengths and intensities. The particular spectrum which the surface
emits depends upon the absolute temperature of that surface and on its
character, or emissivity. Fig. 1 illustrates the spectrum of emission from
a variety of familiar objects a t differing temperature where the emissivity
has been assumed to be unity (i.e. considering them as black bodies).
According to Wien's Law the maximal emission of radiation occurs a t
a wave length h max. = 3000/T, where h is in microns, and T in degrees
K. Fromthis, it will be seen that ablackbody at 37"~, ( 3 1 0 " ~ )will
emitradiationfrom 4 to over 100 p , withapeak emission a t 9.5 p.
This temperature approximates to that of the human body, and it has
been shown by Cobet and Bramigk (1924) andlaterbyHardyand
P.M.B. 1D
434 K. Lloyd Willianls

Muschenheirn (1934 and 1936) thatthe spectrum of emission of the

humanskin is within 1% of that fromaperfectblackbody at the
temperature of t'heskin.Fig. 2 compares the spectrum of emission
fromablackbody and the skin at the same temperature.Theskin,
whether white or black, is in the thermal sense an almost perfect black
bodyradiator,andpainting or blackening its surface(Barnes 1963,
Lloyd Williams, Cade and Goodwin 1963, Elam, Goodwin and Lloyd
Williams 1963) cannot increase its radiation.

Wavelength in microns
Fig. 1. Spectrum of emissionfor a variety of familiarobjects at varying
temperatures; the emissivity of eachobject has beenassumed t o be
unity. (After BowlingBarnes1963.)

The total radiation from a black body surface is proportional to t'he

fourth power of the absolute temperature. If the skin is a black body
radiator,the Stefan-BoltzmannLawshould be applicable,andthe
temperature of the skin may be determined by measuring its emission.
Bohnenkamp and Ernst (1931) showed that the Stefan-Boltzmann Law
did in fact apply exactly, in thecase of nude subjects, in an environment
 Pictorial Heat Scanning 435

between 18" and 30" C when externalradiation was excluded. It is

obvious that both the emissivity of the skin, and the environmental
temperature will affect the amount of radiated energy.

WAVELENGTH

Fig. 2. Spectrum of emission of a ' Black Body ' at 3 2 " compared

~ with human
hand at similar temperature. (After Hardy 1934.)

The fact that the skin is a perfect black body emitter enabled Hardy
to suggest in 1934 that the temperature of the skin could be measured
bydeterminingtheamount of infra-redradiatedfrom the surface,
and comparing it withtheradiationfromablackbody a t aknown
temperatureandinthe sameenvironment. Many workers havesub-
sequently shown this tobe an efficient way of measuring skintemperature.
(Hardy 1934, Bedford and Warner 1934, Lloyd Williams, Lloyd Williams
and Handley 1960).
Severaldetectorsareavailable for measuringinfra-red radiation, of
which thermistors, the Golay cell, and the Schwarz thermopile are the
best known. They have the advantages compared with contact methods
of speedy response, non-interference with the surface to be measured,
and the ability toaverage the temperature over a small area, which tends
to compensate for variations in local capillary control. Because radiation
can be measured a t a distance, a scanningmechanism can be constructed,
436 K. Lloyd Williams

which will look sequentially at areas of the body surface, and present
temperature contours in a pictorial form.
Confusion has arisen between direct infra-red wave measurement and
infra-redphotography.Infra-redphotographyexploitsthe differences
in the absorptive and emissive properties of surfaces, and depends upon
the reflection of infra-red waves from the surface photographed. These
very short infra-red waves are generated by an out'side source, such as
thesun or lamps, which is muchhotterthanthebody.The waves
radiated from the body, due to its temperature, are longer, and minute
in quantity. They are insufficient' in amount to register on photographic
emulsion, which is in any case insensit'ive to wavelengths longer than
1.2 p.

3. THE HISTORYO F THERMAL SCANKINGDEVICES

Sir John Herschel, son of the Sir William mho first described the exis-
tence of infra-red waves, report'ed in 1840 his at'tempts to make these
waves visible. He covered strips of paper with lampblack, and soaked
t'hem in alcohol. On exposure to radiation the alcohol evaporated more
rapidly from the parts of the paper which received the stronger radiation,
so that these parts appeared lighter in colour. Sir John's invention was
developednearlya century later by Czerny in 1929, to give the first
practicalsystemfor seeing heat waves,called ' Evapography '. The
system was further developed bythe BairdAtomicCompanyin the
United States, and was first used in clinical medicine by Lawson in 1957.
Differences intemperature of about 2"c could be detected,butthe
images were blurred,particularly wit'h rapidlychanging temperature
patterns, and the response t'ime was slow.
Becquerel (1843), a contemporary of Sir John Herschel's, discovered a t
about the same time, that thephosphorescent after-glow which occurred
when certain materials had been excited with visible or ultra-violet light
could be stimulated or quenched by subsequent irradiation with infra-red.
Once again a century was to elapse before a practical heatviewing system,
basedonBecquerel'sdiscovery, was constructed. I n 1949, Crbach,
Nail and Perlman described two methods of making thermal pictures,
which they calledcont'actthermography ' and ' projectionthermo-
graphy ', In the former, a luminescent material is applied to the surface
underobservation,andilluminateduniformlywithultra-violetlight.
Temperature patterns are demonstrated by the quenching of luminescence,
in proportion to the infra-red radiation fromthe surface, and temperature
discrimination is of the order of 2Oc. When measuring skin temperature,
the method has disadvantages, e.g. it is difficult to apply aneven layer of
phosphor, there is the possibility of skin sensitivity, and the temperature
discrimination is not good enough.
I n ' project'ion thermography ' an image of the object under observation
is focussed on a phosphor screen by means of a suitable optical system,
 Pictorial Heat Scanning 437

andthe screen is uniformlyexcitedbyultra-violetlight.Projection

thermography is far less sensitive than the contact method, and both
methods suffer from t'he general disadvantage of negative-image systems,
in that high averageintensity of the picturesreduces visual discrimination.
The possibilities of ' seeing by heat ' with all the implications of seeing
in darkness and through camouflage, and detecting aircraft and missiles,
were not lost on the military authorities. A great deal of effort has been
expendedon developing more sensitiveinfra-reddetectors, and more
sophisticated scanning systems, in the United States, Soviet Union and
Great Britain in the last 30 years, but much of the resulting information
hasremained classified for long periods. Two maingroups of modern
image-forming devices exist, based ontwo different types of infra-red
detector (Cade 1961). Firstly,temperature sensitive devices such as
thermist'ors and thermocouples, and secondly,photosensitive devices,
which may be photo-conductive or photo-emissive.The temperature
sensitive devices respond to a wide spectrum of wavelengths, but their
response is relatively slow. X scanning mechanism based on a thermistor,
at'emperature-sensitiveresistor composed of nickel,cobalt and mag-
nesium oxides inthe form of athin flake mountedonasapphire
background, mas designed for milit'ary purposesby the Barnes Engineering
Company in the Cnited States. It was first tried out clinically by Lawson
in 1957 and described officially byAstheimer and Wormser in 1959.
The present version of this scanner is claimed to measure better than
0.5'c, but a scanning time of 12 minutes is necessary to achieve maximum
resolution.Recently, modifications have been made, which produce
good thermal resolution over an area as large as the chest wall, in three
minutes.
The second group of detectorsarethe thermosensitivedevices, of
which the photo-conductive ones have been used for scanning. Much of
thefundamental researchonthesedetectors,particularly on indium
antimonide, was done in England at the Royal Radar Establishment,
Malvern (Goodwin 1957, Petritz 1959, Goodwin 1961, Goodwin and
Jones 1961). The main advantage of these detectors is their enormous
speed of response and sensitivity. The military requirements were for
detectors working in the very short wavelengths: as this is the region of
maximum emission from arocket, or a jet engine.Unfortunately,the
maximum emission of radiation from the humanbody is a t 9.5 p, whereas
the uncooled indiumantimonide cell developed for militarypurposes
responds only to 6.5 p. The amount of energy emitted by the human
body,available for measurementby theindiumantimonide cell, is,
therefore, only a small proportion of the total energy radiated. However,
as fig. 3 demonstrates, although the cell can only see a very small amount
of the totalenergy emitted by the body, the portion of the graph represent-
ing the radiation detected by the cell is at the steepest part of the curve.
Hence, there is relatively a greater change of energy per unit of tempera-
ture than occurs if measurement is made over the whole curve. It follows
438 K. Lloyd
Williams

that although there is less energy to measure, there should be greater

temperaturecontrast.
I n t h e last few years the sensitivity of photo-conductivedetectors
has been greatly increased bytheintroduction of minuteimpurities
into the material. As the limit of sensitivity is set by the background
' noise ' or thermal agitation of electrons in the material, and as theelec-
tronagitation is diminished by cooling, refrigeration of cells has
considerably increased their sensitivity by increasing the ' signal-to-noise '
ratio. In the case of N-type indium antimonide, however, the increase
in sensitivit'y produced by cooling with liquid nitrogen has been at the
expense of a decrease inspectralrangeto 5.4 p , Some cells, suchas
copper and gold-doped germanium, will respond out to 20 p but require
refrigeration to at least - 2 3 0 " ~ . Thisnecessitates cooling withliquid
hydrogen or liquid helium, which is not a practical proposition for clinical
use. The P-type copper-doped germanium cell responds out to 9 p with
nitrogen refrigeration but is not, as yet,commercially available.

0 I I 5 IO 20 30 40 50 60 70 80
l l l I 1.1 l I I I
P E R C E N T OF ENERGYBELOWAGIVENWAVELENGTH

WTOTAL 3 € U T 4 W A T T S cm-'

W i z € x K T " W A T T S Cm" M I C R O N "

FOR x 2 . 5 x M A X , n =%WHERE p , x
C
P X MAX

Fig. 3. Relationship betweenwavelength and emitted energy for a black

body at the temperature of the human body. (By courtesy of R.
Bowling Barnes.)

A scanning system based on a cooled indium antimonide detector was

first used clinically by Lawson in 1958 andlaterby LloydWilliams,
LloydWilliams andHandley,in 1961. Thesensitivity is claimed to
be 0.5"c, and the scanning time is 30 seconds for a field of view as large
as the chest wall.
 Heat Pictorial Scanning 439

To summarize: I n t h e twoscanningsystemsincurrent clinical use

conversion of radiant energy from the object to an electrical signal is
achieved by either a photoelect'ric or a temperature sensitive transducer.
If fast scanning is needed, detectors with a low electrical noise level and
a very fast response time are essential. Of these, the indium antimonide
photo-conductive cells operated at the boiling point of liquid nitrogen
appear to be most suitable. An amplifier with a voltage amplification of
about' a million is needed before the feeble signal from the detector is
strong enough to operate a recording device.
Optical systems can be either reflective or refractive but owing to the
wide range of wavelengths employed and the relatively high dispersion
and poor transmission of infra-red lenses, refractiveoptics arenot
favoured.Nirrors for infra-redsystemsarealwayssurface silvered
because glass is opaque to infra-red radiat'ion. Reflective optical systems
consist usually of a flat scanning mirror and a spheroidal or ellipsoidal
collector which focuses the radiation from the object onto the sensitive
surface of the detector.
Recording the image. A number of ways have been attempted. The
electrical signal can be made to modulate a glow tube and this can be
photographedon polaroid film. Presentationona television tube has
been attempted. Direct presentation means that bothpicture element and
temperature discrimination have to be degraded. It is possible to build
up an image on a persistence tube such as a Permacon, and thenvisualize
this onatelevisionmonitor. It is also possible to record on magnetic
tape at a slow scanning speed and play the tape back faster so that' the
image can be demonstrated on a television monitor.

8 4. DESIGNPROBLEMSI N MEDICAL THERMAL SCANNINGDEVICES

I n December 1963, aSymposium was heldin New York under the
auspices of the New York Academy of Sciences, to discuss the value of
" Thermography in Medicine ". Though in some ways premature,
it didserve to crystallize the medical requirementsinthe design of
scanning equipment, and point to the avenues of medicine which could
be usefully exploredwiththermography.
Design requirements determinedfrompresent clinical experience
seem to be for twoseparatetypes of thermographs.Thefirstshould
have a thermal resolution better than 0 . 2 5 ' ~with a resolution element
of 118th of an inch square covering a field of view a t least 24 in. by 12 in.,
inorder to demonstrate ' static ' temperature differences. A scanning
time of 2 to 3 minutes is acceptable. The second requirement is to measure
rapidly changing heat patterns in the body. Here almost instantaneous
picturesarerequiredandtheacceptablethermalresolutioncan be
degraded to 0*5"c,thoughbothspectral resolution and field of view
should be the same as before. In bothcases a permanent record is needed
of low cost,togetherwith an apparatus which is robust, reliable and
440 K. Lloyd
Williams

reasonably priced-a pretty tall order, when one considers the amount of
energy available to be measured from a small area of the human body.
The construction of a detailed thermal picture in a few seconds implies
the recording of signals of the order of wattsat t'he rate of many
hundredspersecond.Thismeans that the essential parameter around
which all else must be designed is the noise equivalent power (XEP =
power of the signal which is just equal to inherent noise measured in a
bandwidth of one cycle persecond) of the detector cell. It is possible
to scan mechanically at rates which greatly exceed the attainableelectrical
performance, and anyincrease in scanning speed will have to be achieved
either with multiple detectors, which the separateamplifier syst'ems needed
will make expensive, or by the use of detectors which measure further out
to the peak emission of the body's radiation, when background radiation
will become aproblem.Superficially,it'might seem that the problems
which arise in the design of scanners are similar to those of television
scanners.Both producepictorialimages, butthe physicalprinciples
and design problems are quite different.
In the case of the infra-redscanner the two chief requirementsare
(1) to resolve smalltemperature differences existingbetween adjacent
parts of the body surface, and ( 2 ) to produce a complete picture of a part
of the body in atime which is short compared to the body's natural
thermalvariations. Since the accuracy of any measurementincreases
with the time which that measurementtakes, it is clear that the two
chief requirements of thermal scanners are diametricallyopposed and the
essence of design is, therefore, the selection of the optimum compromise
from the thermal, spatial and financialpoints of view.

Q 5 . MEDICALAPPLICATIONS OF HEATSCANNING
A Canadianbreastsurgeon, Ray Lawson,working atthe Royal
Victoria Hospital, Montreal in 1957, was the first to use pictorial heat
scanning medically. He coined the name ' Thermography ' for the new
technique. Hehaddemonstratedthatcertain cancers of thebreast
exhibited a rise in the overlying skin temperature, and he argued that if
one could scan the chest thermally one might be able to detect these
cancers at an early stage, when treatment would be most effective. Using
theBaird Atomic Cos EvapographandlatertheBarnes Engineering
Thermoscan, and finally a cooled antimonide photo-conductive scanner,
he was ableto produce heatpicturesdemonstratinggraphically the
temperatures he had noted with a thermocouple.Hisworkhassubse-
quently been confirmed both here and in America.
Skintemperaturemeasurementshavealwaysproved asnareand a
delusion in clinical practice because it is impossible to establish a base
line. Isolated skin temperature readings mean nothing; skin temperature
is not a constant figure, but a reflection of a dynamic equilibrium between
heat production and heatloss where both factors are varying withinwide
 Scanning
Heat
Pictorial 44 1

limits. It is because skin temperature is infinitely variable that man is

able to live as a free organismin anever changing environment. However,
under standardized clinical conditions, although an isolated measurement
of skintemperature is of little value:comparisons of temperature in
identical contralateral areas will demonstrat'e departures from bilateral
symmetry, or provide an indicstion of the rate of flow of heat, and these
are fundamental criteriafor physiological purposes.
I n order tounderstand how skintemperaturemeasurements can
be used as aphysiological tool we need to know the normal heat regulating
mechanisms of the body. I n essence this consists of an insulat'ecl covering
surroundedby a halo of watervapour.Through the insulatedlayer
passes aheat exchangesystem of blood vessels. The calibre of these
vessels is under the control of the central temperature regulating cent're
by means of t'he sympathetic nervous system. The muscles of the blood
vessel walls are, in addition, responsive to local stimulibot'hphysical
and metabolic, and also to circulating hormones such as noradrenaline.
X further means for cooling the body surface is by the evaporation of
sweat, the secretion of which is also under the control of the temperature
regulatingmechanism. Heat loss by sweating does not occur below
3 0 " and?
~ therefore, the main avenues of heat loss below this temperature
areradiationand convect'ion.Control of thisheat loss is effected by
sympathetic vasoconstriction of the blood vessels of the skin.Under
environmental conditions which evoke reflex vasoconstriction any
abnormality which interferes with this response produces a local tempera-
ture differential which will be greater in the presence of maximal vaso-
constriction.Barnes (1963) hasremarked thatthe skin temperature
patterns in the cooled state reflect the vascularity and fat distribution of
theparticularindividual,andthattheseareprobablyfairlyconstant
for that particular individual, a sort of thermal fingerprint.
Cnder controlledenvironmentalconditions any twoidenticalsym-
metrical skin areas of the body are at the same temperature (Sheard &
Williams 1940, Foged 1932, Freeman, Linder & Nickerson 1937).
Thermography can demonstrate departures from this thermal symmetry
in a rapid andeasily intelligible form.
Departuresfrombilateraltemperaturesymmetrymaytheoretically
be caused by:
( a ) Structural abnormalities of vessels
( b ) Abnormalities of vascular control
(c) Local effects on vessels
( d ) Changes in thermal conductivity of the tissues, or
( e ) Increased heat production in the tissues.

( a ) Structural Abnormalities of Vessels. Congenital fistulae, or tumour

vessels (which may not respond normally to the physiological stress of
cold) may produce localized hot areas of the overlying skin. Alteration
inthe calibre of blood vessels by thrombosis or arteriosclerosis may
442 K. Lloyd Williams

diminish heat flow from other parts of the body. R'everse flow in veins
where valves are incompetent may be demonstrable as departures from
thermal symmetry.
(b)Abnormalities of VascularControl. Suchabnormalitiescould be
expected to show as temperature differences. Thus the effects of heat or
cold on vessels, or vasomotor abnormalityresulting from sympathetic
irritation, denervation, or changes in vasomotor control produced directly
or reflexly, may alter temperature patterns.
( c ) LocalEffectsonVessels. Tissue metabolitescanlocallyoverrule
the generalizedvasoconstriction of vessels dueto cold andthus give
rise to ' hot ' areas. Local heat produces vasodilation, as does the raised
local metabolic rate occurring inrheumatoidart'hritis,thyrotoxicosis
and abscesses. Trauma to tissues may produce local vessel abnormalities
eithervasodilation or vasoconstriction,withconsequent changes in
thermalpatterns.
( d ) Changes in ThermalConductiuity. Suchchanges may arise where
the normal insulating layer has been removed, as after Thiersch grafting
and radical mastectomy, or where it has been altered by change in the
consistency of the tissue, as after infiltration by carcinoma.
( e ) Local Increase in Heat Production. This in theory may be due to
increasedmetabolism of the part, or altered efficiency of metabolism
where less energy and more heat is produced. It is found with abscesses,
some tumours, rheumatoid arthritis and leads to local hot spots '.
Apart from such changes in bilateral thermal symmetry, a fast scanner
can demonstrate changes in heat flow. For example, it can show altera-
tions in skin temperature produced by the action of drugs on peripheral
vessels, or the effects of reflex vasoconstriction in response to cold.
It is not yet known what practical value thermography will have in
clinical medicine, but the following are some of the possible applications
discussed at the New York Symposium:
( 1 ) SuperjcialCancer. Most of the discussion was on cancer of t'he
breast,andit now seems established thatmanymammary cancers
exhibit a rise in the temperatureof the overlying skin and can be demon-
stratedthermographically(Lloyd Williams et al. 1961, Lawson and
Chugtai 1963, Gershon-Cohen andHaberman 1964). Fig. 4 shows an
advancedcancer of thebreast.Xtt'emptsare being madein America
andinthiscountry,todeterminewhetherthermal scanning could be
used asa screening test in breast cancer.However, not allcancers
are ' hot ' and,unfortunately, some benignconditionshavearaised
temperat'ure, which may ma'ke interpretation difficult. Thereappears
to be some evidence that the degree of temperature rise overlying a
cancer of the breast reflects the activity of the underlying tumour, and
t'here is a statistically significant relationship between the temperature
 Pictorin1 Hent Scctnning 443

Fig. 4. Photograph and Thermograph of advanced cancer of the right breast.

\I’hitr is hot and black cold. Sote that the ~rholeof the right breast is
hotter than the left and that the areolar is the hottest part. Sotice,
also, that three of the satellite nodnles which are undergoing necrosis
are cold.
111 K . Lloytl \\'illiams

risv ant1 the Iwognosis. Jloreovcr the administration of agents affecting

the tumour will. on occasion. alter the tcmptmtnrcoverlying that tumow
(Lloytl \\.illianw P / rrl. l!Mil. Handlcy l!)(iL'. Lloyd \\*iIliams P / r r l . 1 !)W).
(L') & r m s . I,n\\-son. Jlotlek ant1 \\'d)stw (I!)fil) u ~ r cthe first to
she\\- that tlcatl ant1 tlevitalizctl tissues diminish the cw1ission of infra-rctl
nntl that thcl*mogra~)hs re c.apal)Ie o f giving an c ~ d yass(wl11ellt of
the tlcpths of a Imrn. 'I'his w o r l l t l l)(> of gwnt surgic.al il11l)ol'tiltl(~(~a s it
noaltl allou. carlit>resc.ision and grafting of t h ( w injuricx V-nfol~tullatcly,

Fig. 5 . Photograph and Thermograph of a firrwork h r n of thigh. Thc areas

whcrc thc hum is deepest are I)lnck (cold) in the Thermograph. (Courtesy
of the 13urns Kartl, St.. 3Iary's Hospital, Rorhampton.)
 Picforirrl HPnt Scrrn?ting 145

Fig. 6 . (:\) Tlwrmograph of breastsin a patienttwomonthspregnant,.

(R) Thermograph of pntient on thc oral Contraceptive Knovid. ( 1 % ~
courtesy Dr. Richard 13rasficlt1, JIrmorinl Hospital. Sew Yorkt C.S.A.)
446 K. Lloyd l\’illiams

Fig. 7. Tlwrmograph of chest wall and aldomrn of n prrgnant patient a t full

term showing an anteriorly placed placenta. (Ry eollrtcsy of ,T. Crcwllon-
Cohcn, Einstein llctlical Center, Sorthern Division,Pllilntlclphia, h . ,
L-.S.ZL)
 Scanning Heat Pictorial 447

contaminationwith dirt and chemicals is common in burns and may

lead to a change in emissivity which can confuse the picture. Undoubtedly,
a great deal more clinical work needs to be done before the value of
temperature scanning can be assessed, but it would seem to have con-
siderable potentialities in this area. Fig. 5 shows a firework burn of the
thigh.
(3) RheumatoidArthritis. It appearsestablished thatthe rise in
temperature of an affected joint provides a useful measure of the activity
of the disease, and a useful criteria of the effect of therapy. The hot
joint can be detected thermographically and if the thermographs can be
calibrated to produce a quantitative recording, then serial thermographs
may become a useful record of the progress of the disease.
(4) Diseases sf Bones. ;Many active processes in bones such as
inflammation and malignant tumours, anddeposits in bones from cancers
a t differentsiteshave been demonstratedin thermographs. Again
there is insufficient clinical experience to know whether this observation
will be valuable medically.
( 5 ) Pregnancy. Pregnancy causes an increaseinbreast temperature
which is usually symmetrical, as does the administration of hormones
which produceapseudo-pregnancy state.Theoralcontraceptive pill
falls into this category, Fig. 6 compares a breast scan of a patient two
monthspregnantwithapatientonoralcontraceptives.Attemptsare
now being made to correlate thermographic changes in the breast with the
cyclical changes which occur in the breast in the menstrual cycle. The
placentahas been shown thermographically; fig. 7 shows an anterior
placenta a t term. The ability to locate a placenta by this means would
haveconsiderable advantage,asthemethodcannotharm embryonic
cells, unlike the x-rays and radioactive isotopes currently used for this
purpose. Though the idea is attractive, it is not yet known how often a
placenta is visible, nor whether a placenta placed on the posterior wall of
theuteruscan be demonstrated.
(6) Peripheral Vascular
Disease. Here the use of thermography
seems to havedefinite promise as a physiological tool. Atrestthe
temperature of a limb is largely dependent upon the heat brought to it
from other organs by means of its blood supply. Its temperature, there-
fore, can be used as an assessment of the efficiency of that blood supply.
A sharp falls occurs at the site of a sudden vascular block. Restoration
of the blood supply will returnthethermalpictureto normal.The
openingup of collateral vessels following a block can be visualized,
and it may be possible to assess the optimum site for amputation in the
presence of vascular insufficiency by this means. Fig, 8 shows the limbs
and feet of a patient with intermittent claudication of the left calf due
to a block in the superficial femoral artery before and after anilio-femoral
by-pass graft. Heat scanning has the advantage of showing up a vascular
bed as large as a whole limb, and can demonstrate not only structural
narrowing of the vessels but also the effect of drugs or mechanical agents
448 I<. Lloyd \\'illiams

Fig. 8. Tlwrmograph of legs and feet of a patient with intermittent clardica-

t,ion of theleft calf. Xrteriogram showed a Mork in the snp(>rfirial
femoral a r t r r - . ( X ) shows patient on admission. (13) sl~owspaticwt
nftcr ileo fvrnornl b y - p s s graft. S o t r that left foot is now hottcr than
right.
 Picforinl H m t Scrcnn.ing 449

upon t h e calilwe of pcriphcral rcsscls. (Fig. !) shows the effectsof smoking

a cigarette on a susceptible intliviclnnl). If these heat pictures c~onld bc
madc qnantitativc by t h r inclusion within the scan of a scrirs of black

Fig. !). Effect of smoking a cigarette on the temprratnrr of thc fingers in R

sweeptilde individual. ( A ) Right hands of two individuals, upper hand
control. Hefore smoking. ( H ) =\ftrrhoth had smokrd ! c*igarc%e.
Frame time 20 seconds. (C) Thermograph taken A minntc n f k r smoking
wllolc cigarette. Framc timc. 20 seconds.
P.M.B. IE
450 K. 1,loyd Williams

Fig. 10. ( A ) T,ce cl(.vntcd and coolctl with ice. I)ilatcdvaris filled wit,h
' hot ' Mood leaking hacl< intoitfromincompetentprrforationsin
anterior upper third of calf. ( H ) Shows heat tlit'f'rlsing from incompctcmt
long saphenous vein. (C) Xppnrcnt clinical perforator in medial part of
calf,shownto be * blow out ' on long sapllrnorls hy application of
prosimal tourniqwtt at, arrow.
 Pictoricrl Heat Scnnning 451

Fig. 1 1 . Tl~ermopraphslloninp the cfkrt of rooling tlw InicItlIc. portion of an

arm \\.it11 i w . Sotircthat n w i n . tlw l)radIial and radinl artery now
become \~isil)lv. Compar(. with hantl and nppc*r arm \vlwrc. nocooling
has 1)ecm ~ ~ s r t l .(Aftvr l<owling Ihrtws, I ! W . )

body emitters at known temperature, then the pictures wonld hccome

meaningful as a phrsiological mcasurementJ of heat flow, and might have
considerablc importance in .r.ascular disease.
7. Vnricose Veins. \Then valves in w i n s arc inefficient, they map allow
warm blood fromtheinterior of a limb t)o run hark intothe cooler
superficial reins dcmonstrat.ing their presence as hot arcas on a thermo-
graph. Fig. 10 demonstrates this effect in a cast of varicose veins.
452 K. Lloyd Williams

Cooling the surface of a limb may allow demonstration of structures

deep to the skin,such as arteries and veins which conduct' their heat into
the cooled tissues. Fig. 11 shows veins and the brachial and radial artery
demonstrable after surface cooling which were not visible in the uncooled
limb.Super-coolingwith ice may increase thethermaldiscrimination
in the pictures and rapid serial pictures will show the spreading of heat
into the tissues.

9 6. POSSIBLE ERRORS AND SPL-RIOUS RESULTSIN THERMOGRAPHS

Patients cannot be examined unless they are unclothed. Immediately
on exposing the body to a lower ambient temperature, quite rapid skin
changes occur which mayamountto j 0 c withinfifteenminutes. It
may take over two hours before thermal equilibrium is achieved between
the body and its surroundings, which istoo long for clinical practice.
It follows that even in the absence of disturbing influences thermographs
show only average temperature patterns over an interval of time. Only
an instantaneous thermograph could be free from this averaging effect
and a thermograph which takes several minutes may embrace temperature
differences, due to the general cooling of the patient, which are of the
same order of magnitude as those which it is desired to det'ect arising
from pathological conditions. It has been found advantageous, therefore,
under clinical conditions to accept a compromise of 15 minutes exposure
to an ambient temperature of around 20"c before thermography. This
gets over the initial rapid changes in skin temperature, and as long as the
scanningtime is nottoo long,providesarelatively steadythermal
backgroundagainstwhichtemperatureasymmetrymay be assessed.
It may well be that with greater experience some other standardizing
technique may beevolved.
Needless to say, air movementcan have quite dramatic effects on local
skin temperature. Fig. 1 2 shows the effect of moving air from a fan in
cooling onehalf of amoustache by 1 +"c. Localsources of infra-red
radiation, such as radiators or even jugs of hot water, can ' illuminate '
the object and lead to spurious interpretation of the thermograph.
At room temperature a change of lo/, in the emissivity of the skin
produces a changein the radiatedenergy equal t'o that caused by a change
~ temperature. This is a variation of the same degree of
of about 0 . 7 " in
magnitude as that involved in many clinical studies. Therefore, unless
we know the emissivity of the skin to be constant to within l:/, (which
we donot knowunderpathologicalconditions), it is meaningless to
attemptto readtemperaturestoasmallfraction of a degree. It is
probable thatthe skin is not a blackbody below 6 p. Below 3 p
the skin is transparent t'oinfra-red,asveinsbeneath the surface
aredemonstrablebyinfra-redphotography ; fortunately, t'hisarea
does not concern us as the body does not emit naturally below this wave.
length. Fig. 13 illustrates this point by demonstrating reflection spectro-
scopy in the infra-red.
 Pictorin1 H w f Scn,nnin,g 453

Fig. 12. 1'::Irly thcwnograph showing manwith a moustache. The left side
of the morlstachr has bccn coolctl l;"c, comparedwith the right, by
air currents prodwecl hy R fan at somc distance from the srll)jcct.

T t is obvious t h a t morc research needs to be done on the emissivity

of the skin nndcr normal and pathological conditions.
3Tany of these possil)ilitics for the nsc of thermography i n medicine are,
of course. spcculativc. I t is one thing to show up a cancer of the hreast
thcr~~1ogral'hicalIy.it, is quitc anoth(v t>o~ S S C S St.hc c . l i n i c d vnluc o f such
an obwrvation. 'I'hrrc has not. as yet. been (.nough clinical c q w i e n c c to
cvaluatc the tcchniquc.
3Iorc sophistic-attd cqrlipmwt is nccdctl to nwasllrv small transient
temperatllrt~s.and its valuc~for clinicxl purposes is complct,ely clcpcndent
on thc ability of thc apparatus to prodrle(~ itlenticd pictllrcsof t]he samc
clinical cwntlition on diffiwnt ocwwions so that. anyc*hangei n the pictures
can be positirclyrelatedto changcs i n thcpathology. S o t only arc
stantla.rt1cnvironmcntal conditions ncctlecl with caontrol o f room tempera-
ture. hnmitlity and an avoidance of draughts i n ortlcr to take arcnratc
thermographs. ))ut. tiwrr is also I I ~ Y Y I to cstnblish a stantlard tcc*hniqrw
of talcing pictures so that the resultant,thermogra.phs w i l l he suital)ly
c.oml'aral~lt~.
l h p i t t . t h ( wtliflic.l1ltics, thermography swms to 1)osscss great, promise
as a physiologic.aI tool. I t at least, has the funtlamc~ntal advanta.ge o f t]rrle
non-tlwtruc.tive testing.
454 K. 1,loycl \\‘illiams

Fig. 1 3 . I’ict1lrt.s tnlten withtlw . I’yrosc*;ln’ by t i l t . rc.fict.ttvl ratlintion of a

medical infra-red lamp. ‘ I ’ h t ~ pit+trlrtbsw w tnktw i n narrow ware Imnds
l y rtst’ of interferencefilters. ( A ) 5-5.5 Inicrons. ( B ) &-b6 mit*rons.
( C ) 3 - 3 5 microns.Thisdcmonstrntt~s rt.flt.t-tion spwtroscopy in tht.
infra-red and shows that the absorptive propertit’s of thc skin ilre not
identical in tlwsr ware-lxmds.
 XcanningHeat Pictorial 455

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