Ionizing Rays and Cancer in Review

Bertram Speakman Hanson, Emeritus Radiation Oncologist, Royal Adelaide Hospital

This address was delivered at the seventh Foundation Day Ceremony held at Royal Adelaide Hospital on 10 July, 1985.

I suppose you will all have heard of the Welsh divine who announced from his pulpit that he would take as his text ‘The Devil goeth about like a roaring lion seeking whom he may devour’. He proposed, he said, to deal with his subject under the heads: who the devil he is; where the devil he is; and what the devil he is; and what the devil he is roaring about.

I envy the reverend gentleman the certainty he had in knowing the value of what he was to say, for I have no such certainty. But in general terms it would seem best that, required as I am to speak on a historical subject, I should choose something related to ionizing rays and cancer, for my professional life has been concerned almost entirely with these matters, beginning on 1 January, 1930, when I began duty as the first registrar of what was then known as the Radium Department of this hospital.

By that time, of course, X-rays has become old hat, but we can imagine the astonishment and excitement of the world of 1896 when it was reported that Professor Rӧntgen had discovered ‘a new kind of ray’ while he was doing some work with a Crookes tube at the end of 1895. It is said that he did not leave his laboratory  for a week after his discovery, his wife bringing food to him there, and at the end of the week he had worked out the physical properties of his ‘new kind of ray’ to a level much as we know them today.

It was obvious that the unknown ray, named ‘X’ as the conventional and perhaps temporary title of an unknown quantity, had important applications in medicine, and my medical forebears of that time were as quick as the profession always has been to use something new, even if it has not been tested and tried, and as a result the world gained its first so called ‘X-ray martyrs’ who developed aggressively malignant squamous carcinomas of the hands and forearms, and I suggest that the fecundity of those members of the medical profession handling X-ray machines at that time would have been below average. But not all comment was favourable.

A London newspaper classed as ‘revolting’ the thought that a person’s bones could become visible. And applications other than medical were found. There were ‘bottom of the harbour’ types of that time who advertised X-ray proof underclothing for women who feared that gentlemen carrying X-ray machines might reveal their all as they walked about the streets. And there was the fictional detective, as up with the latest as was Sherlock Holmes, who believed that the criminal he was chasing had swallowed the diamond. By some subterfuge he inveigled the villain into entering his laboratory where he suddenly switched on the X-ray machine, and there was the diamond glistening in the region of the man’s caecum. No mention, of course, of the X-ray screen, and in any case a diamond is composed of carbon, and is about as transradiant as a sheet of paper.

News of this astounding discovery soon appeared in the press in Adelaide, but it was some six months before scientific papers reached Adelaide from Europe, and so six months before our first professor of physics, Professor William Bragg, made his first X-ray tube. Until my house was burned down some years ago I had an X-ray picture of a hand made with that tube, the hand of a physics department cadet named Bromley who later became our meteorologist. It was quite a good print, but needed thirty seconds exposure compared with the minute fraction of a second which would be needed today. I believe that this first tube was blown by Mr Rogers who was the university glass blower when I was a medical student; at any rate it was his daughter, Lorna Rogers, who gave me this picture.

What I believe to have been the first commercial X-ray machine in Adelaide was owned by Dr Todd whose slightly ornate two-storeyed house on the corner of Wakefield Street and Victoria Square was recently demolished so that a lawn could be planted and the architecturally pleasant west wall of St Francis Xavier’s Cathedral exposed to view. Dr Todd has acquired from the carriers, Graves Hill and Co the services of a young coachman named Charles Marshall, aged twenty two. When motor cars became practicable Marshall changed from coachman to chauffeur, and I remember his telling me that his first car had a leather belt drive without a differential gear, so that on turning a corner it was necessary to throw out the clutch to allow the driving wheels to run freely.

When Dr Todd decided to purchase an X-ray plant, Marshall was sent to Melbourne and bought a W Watson and Sons machine which he brought back with him in the Melbourne express, stored in the luggage rack above his head. The express arrived then, as I think it still does, at about nine o’clock in the morning, and Marshall took the machine to Victoria Square, installed it during the morning, and that afternoon made his first picture, that of a patient who had somehow managed to get a needle embedded in a shoulder region. With the slight malice he felt for the medical men of that era he several times told me of what he regarded as the inane remark of one of them who said what a marvellous picture it was, for it even showed the eye of the needle. When Dr Todd died Marshall kept on an X-ray service for the medical profession from the house in Victoria Square, taking the pictures and providing a diagnosis of some sort. But as other X-ray machines became available in medical rooms the hierarchy of the British Medical Association decided that it was not good enough that a self-educated man should purport to provide a diagnostic service which had become so important and the profession was instructed not to patronise him further. It was Mr Marshall’s understanding that the three principal arbiters of his destiny were Dr Ben Poulton, Sir Joseph Verco and Mr Henry Newland, and he said, again with that touch of malice, that within a month of the prohibition each of them had come separately to him with a plate saying ‘I really should not be doing this but what do you think about this picture’? Without the slightest training in anatomy, pathology or physiology, he had a superb memory which helped him through. He could be stern with young doctors of the ‘ ‘ouse surgeon’ level as he called them, but I was his friend, so he dealt gently with me, and I have been grateful on several occasions when reporting, say, on a chest film and when I had written my report he would say ‘what do you think of that right apice, sir?’ and there would be a small abnormality of the lung apex I had overlooked, but which he had seen.

In 1915 the solidarity of the medical profession was greater than it appears to be today, and the injunction was so obeyed that Charles Marshall could no longer live on his income from private practice and he was compelled to give it up and accept a post as radiographer at the Adelaide Hospital (though the position did not have that title in those days). Thus began a long and admirable service for the hospital.

I do not know the site of the X-ray Department at that time, but in 1925 it appeared to be well entrenched in the old administrative block, a red brick building with a row of hitching posts in front of it, and approximately where the present administrative block is situated. House surgeons’ bedrooms were on the floor above. When I first knew it the apparatus was primitive by modern standards, but to Mr Marshall it must have seemed luxurious when compared with his equipment of earlier times. The tube of those days was suspended above the patient’s couch, with bare wires running from each end of the tube to the generator. One had to be careful to keep away from the wires when the tube was energised, and I have seen an elderly woman, a doctor’s mother, get an unpleasant shock when a strand of her hair blew in the breeze and touched a live wire running to one of these early machines. Marshall described the difficulty in getting good films with a tube which varied in output from moment to moment. If ever a man’s work was his hobby this applied to Charles Marshall. Radiography was not a brisk business at that time, and he would often be found with his staff of two in his department, sitting on patient examination couches waiting for work. But when a patient carrying an X-ray request form came in it was he who first leaped to his feet; for him nothing was so important and so interesting in life as the production of technically perfect X-ray film.

The exponential rate of evolution of everything medical is known to all of us, and X-ray equipment has been no exception. After Marshall’s time there was the boon of the shockproof tube, then the tube with a rotating anode which permitted a pinpoint target to be used for the electron beam without melting the anode, and which thus secured sharper definition of detail on the film; and now there is computerised axial tomography which allows the production of the most beautiful pictures of almost any organ in the body. In radiography the old days were certainly not the good old days, though at the time they had the absorbing interest of a pioneer craft.

The history of radiotherapy in the Adelaide Hospital before my time is unknown to me. In 1929 the hospital owned six needles of vanadium steel, each containing ten mg of radium element, inadequately filtered for modern radiotherapy. They were, I believe, largely used in the gynaecological department. There were also two radium ‘plates’ used for skin application. These pieces of apparatus were all under the care of the honorary radiologist who, however, was not more than their custodian, for the gynaecologist would send down for the needles and later return them from the operating theatre and the honorary dermatologist would send to the department a patient carrying a form requesting that a radium plate be applied to the designated lesion for a period of minutes appropriate to the diagnosis he had made. This treatment was given by Mr Marshall and his staff.

There was also a six inch sparkgap mechanically rectified X-ray machine used for radiotherapy and mostly in the treatment of dermatoses. The rectification caused a clatter of sound so noisy that speech level had to be raised if it were to be heard.

From 1929 the story of radiotherapy in Adelaide Hospital is closely linked with that of the Anti-Cancer Campaign Committee of the University of Adelaide, later to become the Anti-Cancer Foundation of that university, and more recently the Anti-Cancer Foundation of the Universities of South Australia.

In 1926 the Federal Health Council, a forerunner of the NH&MRC wrote to the commonwealth government to recommend that a ‘radium bank’ should be formed for loan of radium to the States. The government agreed, and without any reference to parliament its Minister for Health, Sir Neville Howse VC, bought ten gm of radium at a cost of £100,000. When criticised later in Parliament Sir Neville excused himself for his secrecy by saying that this was the greatest single order of radium ever given and that he had feared an artificial price rise if he had call tenders.

The radium was packed in the form of needles, tubes and plates, and it was known that the Adelaide Hospital would receive a proportion of this on loan, and parcels of needles began to arrive in 1929. A further amount as a soluble carbonate was available to go into solution and provide the radioactive gas ‘radon’ or, as it was named in those days ‘radium emanation’. But there was no organisation in existence which could manage this new-found wealth of therapeutic material.

In June, 1928, Dr F S Hone wrote to the Council, University of Adelaide, to draw attention to the inroads of cancer, and to suggest that the university should take steps to combat this group of diseases. As a result the Anti-Cancer Campaign Committee was formed. Its first Chairman, Mr Alex Melrose, persuaded twenty of his grazier friends to contribute £100 each, the commonwealth and State governments each gave £5,000 and later a committee chaired by the lord mayor raised some £5,450 by public subscription; at periods of about five years subsequent lord mayors have set up a committee to raise funds from the public, providing, with bequests which were mostly few and small until recent years, the funds which kept the university committee going.

By mid-1929 honorary staff had been appointed to what was called the Radium Department and a nurse and a clerk with salaries paid by the [Anti-Cancer Campaign] Committee began work on 15 July, 1929. It is a commentary on our level of ignorance at that time that Dr Stanley Verco appointed Honorary Deep X-ray Therapist and Dr H A McCoy, Honorary Radium Therapist, a division of interests strangely suggesting that these two generators of ionizing rays had separate functions. Although by no means enemies, these two men were also not friends, and the radium registrar had to walk a tight rope at times to keep the clinical peace between them. Dr Verco had little to do at first, as he had no deep X-ray plant to work with.

By 1 January, 1930, case notes of a sort became practicable with my appointment as registrar paid by the Anti-Cancer Campaign Committee and some three months later a deep X-ray plant was bought and installed and a technician appointed, again at the expense of the committee. It was said that much argument had occurred before a decision was taken to purchase Siemens constant potential plant. Dr Verco, anxious to start with the sort of machine he had in his private rooms, and so one which he understood, took one side, while a strong minded surgeon argued for the more modern constant potential equipment. The surgeon, frustrated at not getting his own way, eventually said that Dr Verco was on dangerous ground in recommending the purchase of a machine from a company in which he had a financial interest, but then left the meeting and hurried to his sharebroker to sell his own shares in the company which was agent for the machine he himself was proposing. Of course neither was swayed by financial concerns, and the story may be apocryphal. I think that it was Professor Kerr Grant’s approval for the constant potential machine which eventually decided its purchase.

By the late 1940s the theoretical advantage of high voltage therapy units was under discussion, and in England an impressive group of radiation physicists had drawn up specifications for a four million electron volt X-ray unit designed to produce rays more powerful than the ‘hardest’ of the rays from radium and in much greater quantity. Strongly advised by their physicist, Mr B W Worthley, the Anti-Cancer Campaign Committee, realising that a government could hardly agree to buy so expensive a unit which was still only on the drawing board, decided to appeal to the public for money to buy such a machine for the hospital. But what with raising the funds and arguing over which of the two new and experimental plants to buy, together with government delay in building the East Wing to accept it, it was March, 1957, before the machine was installed in specially designed accommodation and the first patient was treated. Too large to pass down passages the new apparatus entered its home through an incomplete outside wall which was then completed around it.

Within three months the new linear accelerator was no longer an experimental plant but already the workhorse of the department. So important was it that I asked permission to speak to the board about the need for a back-up plant should the accelerator break down, suggesting a cobalt beam unit which, although a little less powerful and much slower, would deal with those patients most urgently in need of megavoltage therapy. I must have been in good voice for at the end of my oration one of the board members, Mr Edgar Dawes, asked me whether one cobalt unit was adequate, and I was quick to reply that we would limp along with one, but that two would be twice as good. When these two machines eventually arrived, for several proud months the Royal Adelaide Hospital had more megavoltage capacity than had all of the hospitals in Melbourne and Sydney combined.  May I say for Metropolitan-Vickers, and especially for our physicist, Mr John Tooze who looked after it, that original linear accelerator served the hospital magnificently for over twenty five years, and when it was retired recently it was by a long margin the oldest of its type still in existence in the world.

The value of a physics service in a radiotherapy department is obvious, and from its earliest time expert physics advice was provided by Professor Kerr Grant. With the courtesy which it was his nature to show, he responded to all the requests of the clinical people, but his help was mostly asked for such things as to search for a mislaid radium needle or to prescribe the thickness of lead sheet which should be pinned to a wall to provide sufficient protection from some source of ionizing rays within the room. The radon service, that is to say, the capture of radon gas from a radium solution and its sealing in hollow needles and tubes, was at first rather literally in his hands. The soluble radium carbonate provided for this purpose was sealed in a glass vial, and accompanying instructions suggested that the vial should be crushed with forceps under water. Whether Professor Grant did not have a sufficiently long pair of forceps, or whether he preferred his own approach to the problem of getting the radium salt into solution is not known, but for one reason or another he departed from the recommendation of the Commonwealth X-Ray and Radium Laboratory and decided to break the vial under water by dropping on it a metal rod. The operation was successful in that the vial was broken, but unsuccessful in that the bottom of the flask was also broken, and the professor was left catching the liquid in cupped hands, calling plaintively for a new flask to be brought. Surprisingly little radium was lost.

Research is obviously an important function of an organisation such as the Anti-Cancer Foundation and from the early 1930s research projects have been supported; at first small in number and without great ambition, but now important and involving a cost of some $800,000 per annum. Twenty five years ago an attempt was made to develop a world cancer research centre. There was a group of men who lunched together in Paris once a week including an engineer, a journalist, a priest, lawyers and among others an old and revered radiotherapist to whom I am indebted for the earlier part of this story. At one luncheon the journalist proposed for discussion the thought that if six of the world’s richest nations were to devote 0.5% of their respective arms’ budgets to cancer research, the would remain vis-à-vis each other just as strong as they had been, and an enormous sum would be available to set up a research institute. The group thought well of it and went to de Gaulle who in turn invited Sir Alexander Haddow, at the time president of the International Union Against Cancer, to come from London and discuss the suggestion with him.

A frisson of interest passed through the governments of the designated countries, but research does not win votes, and the proposition remained in the various pending baskets. One year later the International Union Against Cancer called a large part of its council to meet in Stockholm to see whether the whole matter could be taken up again. I mention the venue because it shows how little our distance from Europe is realised on that continent. At that time I was serving on the Council of the International Union and when I left Adelaide some two weeks after receiving the invitation, I had no papers dealing with the meeting. On joining a plane from London to Stockholm I asked Professor Ralston Paterson, travelling to the same meeting, what he knew about the proceedings, and he said that he had news for me, I was speaking. It turned out that I was expected to say what research was being done in Australia and New Zealand (I represented Oceania on the council), what further research could be undertaken and how much it would cost. As you will see from this the union tended to act from an unpractical idealism, but I must admit that many very fine intellects were involved with it. My own contribution was to ask for a massive crash programme to investigate the incidence of cancer in Papua New Guinea. It was known that cancer of the mouth was common there, and there was a suggestion that women of at least some tribes fed their babies from one breast, and it was the other breast which developed cancer. The hope was that the plan of cancer incidence among a primitive people might be compared with the incidence among the same people after they had adopted a western type of civilisation, and that it might be possible to indict environmental differences to explain the cause. In the end the whole plan went out without a whimper; the six countries each decided to contribute $100,000 per annum, Australia joined them as later did two countries, and the International Agency for Research into Cancer was set up with its headquarters in Lyons.

In any case the plan was impractical; it takes a long time to train a research worker, and the proposed world centre would at first only have taken workers from other centres, and initially the total amount of cancer research would have been little increased.

Thus comes to an end what has been a disjointed mention of a few past happenings, and one which does not go into depth in any of them. The bare bones of my discourse can be fleshed out from existing documents in many cases, and what I have tried to do is to record little snippets of recent history which are not widely known, and many of which will not be found in writing.

May I conclude by thanking you for the honour you have done me by asking me to speak, and particularly to speak in this centenary year of the Medical School, a hundred years in over half of which I have had some continuing personal relationship with the Royal Adelaide Hospital.