ISOTOPES, IMAGING AND IDENTITY - The History of Nuclear Medicine in Australia and New Zealand

1

FOREWORD This unique and fascinating history of Nuclear Medicine and the formation of the Australian & New Zealand Society of Nuclear Medicine is the culmination of the contributions of numerous society members and an extensive network of industry colleagues. Compilation of this volume commenced several years ago and it has been an honour for my fellow council members and me to have played a part in its ultimate completion and publication.

Isotopes, Imaging & Identity – The History of Nuclear Medicine in Australia and New Zealand outlines the discoveries and achievements of interrelated disciplines within nuclear medicine and the development of various technologies introduced over the years to make nuclear medicine an integral part of patient management today. This book details the formation and expansion of a professional collegiate which became the ANZSNM and of many lifelong friendships including interstate and international cooperative ventures that have underpinned the vital contributions that nuclear medicine has made to medicine, within and beyond Australia & New Zealand.

Paul Richards’ extensive endeavours in sourcing initial material, and compiling and drafting the original manuscript is to be greatly commended. The society wishes to acknowledge our numerous other members and colleagues for their varied contributions. We are particularly grateful for the stories and personal contributions of many notable pioneers and industry giants.

Nuclear medicine is a relatively young health discipline and its significance and benefits are ever more appreciated by today’s increasing and aging population. It is a great privilege to be professionally engaged in this vital discipline with so many who continue to play such a significant role in enhancing the lives of millions of people throughout the world each year.

We hope this book will hold a place of importance in the libraries of ANZSNM members and will be valued by others with any interest in contemporary nuclear medicine, medical history, Australian and New Zealand social history, and other related fields.

I sincerely hope that all readers enjoy and learn from this book and that it brings back happy memories, providing fascinating insight into what has brought the discipline of nuclear medicine and its diverse, but unified, professional collegiate to where we are today.

Through this glimpse of our past, and recognition of contemporary advancements, I believe that our specialty is moving towards an ever increasing role in personalised patient care and an even more exciting future.

– Elizabeth Bailey [BAppSc(MRS) MBA] President ANZSNM Chief Nuclear Medicine Scientist Royal North Shore Hospital Sydney NSW Australia

2

INTRODUCTION This history of Nuclear Medicine and the formation of the Australian & New Zealand Society of Nuclear Medicine briefly looks at pivotal discoveries since the mid nineteenth century, recognises early radium treatments and explores the introduction and use of radioisotopes and development of nuclear medicine in Australia and New Zealand since the start of the twentieth century. From humble beginnings in the eastern states of Queensland, New South Wales, Victoria and Tasmania, this new and exciting field of medicine quickly spread to South Australia, Western Australia, the Australian Capital Territory and to New Zealand. In Adelaide, in May 1969, a professional body of physicians, physicists, technologists, radiopharmacists and nurses, sharing a common interest in nuclear medicine, came together to establish today’s Australian & New Zealand Society of Nuclear Medicine.

Nuclear Medicine The science of nuclear physics followed the discovery of radioactivity over a century ago.

Applications flowing from the work of Becquerel and others include nuclear reactors, nuclear weapons and nuclear medicine. In the field of medicine, diagnostic procedures such as tracer techniques and therapeutic applications like the treatment of cancer by radiation have proved to be highly valuable. Radioactivity of isotopes of elements used as tracers enables scientists to locate them, even inside a living body.

In Australia, in the early 1960s, emerging specialists in nuclear medicine came from backgrounds in radiotherapy, endocrinology and radiology. In contrast to what had occurred in the United States, Australian specialists tended to come from the college of physicians (RACP), rather than the college of radiologists (RANZCR). Similarly, pioneering nuclear medicine technologists were also being drawn from radiotherapy and radiography.

This initial formula of physician, physicist and technologist was a strong combination throughout Australia. Soon they were joined by pharmacists and then, more recently, nurses to build a team of health professionals second to none in the delivery of physiologic medical imaging and therapeutic management of a range of human disease processes in both the public and private sectors of medicine.

At the ‘Atoms For Peace + 50 Nuclear Energy & Science for the 21st Century Conference’, 22 October 2003, at The Watergate Hotel, Washington, DC, Dr Henry Wagner presented the following succinct, but precise, history of the discipline of nuclear medicine.

At the 1954 meeting of the Society of Nuclear Medicine, the invention of the rectilinear scanner by Benedict Cassen from UCLA was presented. This was a motor driven radiation detector that moves back and forth across the body detecting the photons being emitted and producing images such as the distribution of radioactive iodine within the thyroid gland.

Although the technology has improved enormously, the basic principles of nuclear imaging to examine regional biochemistry in the living human body and in experimental animals have remained the same.

At Johns Hopkins in 1958, we built a modification of the Cassen rectilinear scanner, which moved a radiation detector back and forth over the patient’s body. Today we do not use

3

moving radiation detectors, and routinely combine the regional biochemical information with anatomic information from a computed tomography (CT) instrument.

As long ago as 1961, we combined the nuclear medicine images of regional chemistry and function with x-rays on which the nuclear medicine images were superimposed. Thus, even then, clinical decisions were based on the combining of anatomical and biochemical images.

The 1940s and 1950s marked the birth of regional biochemistry in clinical medicine to examine various organs of the living human body and experimental animals. For example, on May 26, 1946 Hertz and Roberts at MIT showed that radioactive iodine could be used in the study of thyroid physiology and define diseases of increased or decreased function of the thyroid, based on measurement of the metabolic activity of the gland. A regional biochemical process defined the disease. If the thyroid was hyperactive, the patient is given a higher dose of the radioactive iodine to diminish its abnormally increased function. The same paradigm is used today and is expanding into many organs and lesions of the body.

The same agents used to identify regional chemical processes can be used in higher radiation doses for treatment. In December 7, 1947, a publication by Seidlin and his colleagues in New York cause a tremendous interest on the part of the press, when they described the use of radioactive iodine treatment in treating functional metastases of carcinoma of the thyroid.

The field of nuclear medicine is based on the “tracer principle”, invented by Georg Hevesy, to whom the Nobel Prize was awarded in 1943. His Nobel lecture was entitled, “Some Application of Isotopic Indicators.” Rosalyn Yalow was awarded the Nobel Prize in 1977 for developing the technique of radioimmunoassay, which made possible detection of molecules present in the blood in extremely low concentrations.

Yalow shared the Nobel Prize with Schally and Guillemin who discovered a hormone called somatostatin, an example of a chemical messenger involved in bioenergetics or information transfer. Also in the 1970’s we saw the introduction of minicomputers into nuclear medicine, to improve and quantify the data from nuclear imaging of the body. Today’s biochemical and anatomical imaging would be impossible without the invention of computers.

One of the major fields to benefit from nuclear medicine is pharmacology. As early as the 1960’s, imaging of the blood flow to regions of the lung was used to examine the effectiveness of a drug called, Urokinase, that dissolved blood clots in the lung, a disease that is often fatal. A series of lung scans showing the distribution of blood flow to the lung was examined to provide objective evidence of whether the drug was or was not effective.

An example today is in the assessment of drugs for the treatment of Alzheimer’s disease. In addition to assessing the symptomatic or psychological testing of the patient’s response to the candidate drug therapy, it is of great value to have an objective, quantifiable, regional biochemical signal.

The 1970s saw the birth of nuclear cardiology, which today has become a routine, dominant part of cardiology, another achievement that can be traced back to the “Atoms for Peace” talk

by President Eisenhower. The field is based on an invention by Hal Anger working at UC Berkeley, work sponsored by the DOE. His first scintillation camera was shown at the 1958 convention of the Society of Nuclear Medicine. It measured the photons coming from the body by means of a large stationary scintillation camera. He replaced the Cassen type of scanner in which a detector moved back and forth over the regions of interest, with a large detector that could measure the radioactivity coming from large areas of the body

4

simultaneously. This made possible introduction of a time domain into the examination of the spatial distribution of the tracer.

Technetium-99m, introduced by the Brookhaven National Laboratory, provided the large numbers of photons needed to produce interpretable images of radioactive tracers in the heart. Its physical properties made possible administration of large doses safely to the patients. In 1960, the cover of the catalogue of the Brookhaven National Laboratory advertised technetium-99m generators, at a time when nobody had any idea what it would be used for. Only three years later, Paul Harper, at the University of Chicago, realized that the physical characteristics of technetium-99m were perfect for nuclear imaging. It was metastable, that is, it did not emit particles in the process of radioactive decay, which meant the radiation dose was very low. It emitted photons of the right energy range so that the information could get from the inside to the outside of the body. The combination of the Anger camera and technetium-99m from the National Laboratories made possible the development of nuclear cardiology.

One can obtain images of a radioactive tracer moving into the right side of the heart, then into the lungs, and then into the left side of the heart, and obtain quantitative time/activity curves as the tracer passes from the lungs into the blood vessels. If the patient has an abnormal connection or a shunt between the right and the left ventricle, characteristic time/activity curves are obtained. Today, positron-emitting photons, such as fluorine-18 deoxyglucose, oxygen-15, and nitrogen-13 ammonia are widely used in clinical cardiology and research. For example, one can examine the effect of gene therapy of coronary artery disease in experimental animals in an effort to improve the circulation. Here you can see the combined image at the bottom.

In addition to cardiology, an important use of nuclear medicine techniques today is in the study of the brain. Again, the early studies go back 50 years, when George Moore of the University of Minnesota, used a Geiger-Mueller tube in the operating room to locate deepseated brain tumours that could not be seen visually.

Today, throughout the world, hand-held imaging detectors are used during operations to identify cancerous tissue from non-cancerous tissue. In the brain, as in other organs, the fusing of biochemical (molecular) imaging with structural imaging also goes back to the 1960s. The rectilinear scans of the brain of a patient with a brain tumour were superimposed over an X-Ray of the skull obtained at the same time.

Another example of the use of nuclear medicine in therapeutic drug design and development is in patients with Alzheimer’s disease. Nuclear imaging is used to make accurate diagnoses prior to treatment, and then is used to assess the effectiveness of treatment in serial studies.

Recently, at UCLA and the University of Pennsylvania, radiotracers are being developed that accumulate in the pathological lesions believed to cause Alzheimer’s disease.

On May 25, 1983, we were able to carry out the first imaging of a neuroreceptor in the brain of a living human being. Neuroreceptors are involved in the transfer of information from one neuron to another. We were subsequently able to show that the dopamine receptor decreased markedly with age in normal persons, and that so-called pre-synaptic receptors, called “transporters”, were characteristic of Parkinson’s Disease. One could objectively differentiate normal persons from patients with various types of Parkinson’s disease.

Another major domain of nuclear medicine is oncology, based largely on the findings with positron emission tomography (PET) and an analogue of sugar, fluorine-18 deoxyglucose.

5

Again, returning to 1953, the American Cancer Society wrote, “The number of cancer patients who would have been cured last year could have been doubled by early diagnosis and prompt treatment.” In the early stages most cancers cause no symptoms. Today, cancer is being detected before symptoms occur, often in persons identified as being at high risk of developing cancer.

Clinical examination, anatomical imaging, and histopathology play a major role in medicine today. Histopathology can only examine small samples of tissue that must be removed by biopsy or surgery. Molecular images with techniques, such as PET, examine the entire human body, examining a variety of molecular processes. For example, in patients suspected of cancer one can detect the increased utilization of sugar by the tumours throughout the body; then, one can examine the degree of oxygen-supply to the tumours, or their rate of cell division. All this information can be translated in improved treatment, and monitoring of its effectiveness.

What about the 1990s and the future? One challenge is to increase productivity. Today it takes about an hour for a PET study. Many are trying to reduce the examination time to 10 minutes.

Persons are now being identified as being at high risk of developing cancer. Approaches now being developed are to screen millions of persons, identify those at special risk, and then, together with tumour markers, examine those persons who are at very high risk with PET scans so that the foci of disease can be identified at a very early, treatable phase. The goal is to move earlier and earlier into the diagnostic process.

Nuclear medicine, so very much affected by President Eisenhower’s “Atoms for Peace” has reached the prominence and importance in biomedicine that it has today is based on the collaboration between government, academia and the community hospitals, using chemistry and cyclotrons as well as reactors to produce radioactive tracers today, and fluorescent tracers tomorrow. Whole body molecular and structural imaging are now part of the health care systems throughout the world.

Another child of the DOE is the human genome program, which provides maps, or the ingredients, if you like, indicating a high risk of present or future disease in an individual.

Radiotracers help identify the phenotypic expression of these genetic maps. Nuclear medicine, particularly what is now called molecular nuclear medicine, provides incisive, in vivo chemistry and physiology. It rests on an infrastructure of physics and chemistry, and is an effective partner with genetics and pharmacology.

Nuclear medicine provides molecular markers for gene hunts. Instead of using symptoms, such as forgetfulness of impaired movement, one can use molecular markers in genetic studies. We can identify asymptomatic persons at high risk for subsequent disease, such as breast cancer. We can monitor the effectiveness of gene therapy, with reporter genes, that can be administered with therapeutic genes to be able to tell whether the therapeutic gene has been successfully transfected.

Nuclear medicine connects genes, proteins and disease processes, for example, the sickle cell gene that results in abnormal haemoglobin, which results in abnormal destruction of red blood cells. It can target therapy. The studies that we started in 1983 of dopamine, serotonin and other receptors, and transporters, provide targets for drug therapy. If the physician is going to treat the patient with chemicals, he or she should characterize the disease as an abnormal chemical processes.

6

The trunk of the tree of molecular nuclear medicine, regional physiology and regional biochemistry, is based on technology and ideas that began with Dwight Eisenhower’s “Atoms for Peace” talk. The branches extend out into other medical specialties, including cardiology, neurosciences, and more recently to oncology.

The challenges: There are hundreds of potentially useful radioactive tracers that have been shown in experimental animals to be very, very useful. Yet it still takes between five and ten years to get a diagnostic, let alone a therapeutic, agent through regulatory agencies and, subsequently, approval by insurance.

An economic problem is that diagnostic agents do not provide the economic benefit for the pharmaceutical industries that therapeutic agents have. This results in their being hesitant to make the investment needed to meet the requirements of FDA and Medicare. We need to try to simplify regulatory requirements for the approval of diagnostic radiotracers. To validate and show the safety of a procedure that is only given to a patient only once or twice, should be simpler than what is needed for a therapeutic drug that is going to be taken for the rest of the patient’s life. The challenges are to continue to support the basic and clinical research with collaborative efforts, particularly between the DOE and the NIH. And finally, to form teams in a government labs, academia, and industry, working together to solve problems.

ANZSNM Nuclear medicine as a clinical specialty in Australia and New Zealand is now over 60 years old and the Australian & New Zealand Society of Nuclear Medicine is in its fifth decade.

During this period, spectacular changes have seen the humble Geiger detector transform into what today we recognise as the most sophisticated imaging devices in SPECT, PET and Magnetic Resonance Imaging.

One of the most significant milestones in the history of the ANZSNM was the visit to Australia of Drs Henry Wagner (Johns Hopkins University) and David Khul (University of Pennsylvania) in 1968. There is no doubt that their visit sowed the seeds that then grew with the establishment of the Society in 1969. In his recently published book, Henry Wagner said: On the way to an IAEA meeting in Vienna, David Khul and I spent 16 days in Australia on a trip jointly sponsored by the US Atomic Energy Commission and the Australian Atomic Energy Commission. The purpose of our trip was to promote nuclear medicine in Australia. The Australian Government operated a nuclear reactor and radiopharmaceutical manufacturing program that was supplying the country.

Between the two of us, Dave and I delivered 48 lectures in five cities; together in Sydney, Melbourne, and Canberra. I went to Brisbane and Tasmania alone, while Dave went to Perth and Adelaide. One of the principal topics of our lecturers was “Cameras Vs Scanners”. The Anger camera had recently been introduced by Nuclear Chicago and would eventually replace the rectilinear scanner.

Dr Wagner was to return on several occasions to Australia and several Australians also took advantage of honing their nuclear medicine skills at Johns Hopkins University in Baltimore USA, especially during the late 1960s and mid-1970s. However Dr Kuhl was not to return to our shores.

Subsequent technological changes include new and better imaging equipment, computer acquisition and data processing and the introduction of a considerable number of new radiopharmaceuticals. Society members embraced technological changes and have 7

frequently worked at the leading edge of such research and development. However, around ten years ago, more subtle and possibly more challenging internal changes were recognised within the Society itself. As a maturing society within a dynamic field, a progressive broadening of the membership occurred, further expanding the array of professional representation and member interests.

Early pioneers of nuclear medicine were mainly physicians and physicists. Initially, the society only offered full membership to physicians and graduates. But with great foresight, these founders did not seek to restrict the new Australian & New Zealand Society of Nuclear Medicine to their own specific disciplines, but established a professional society that was open to all who worked within the broader scope of nuclear medicine and held appropriate tertiary qualifications. Associate membership was available to non-graduates, which included nucleographers (as they were known at that time) and ‘sustaining membership’ was offered from inception to involve the crucial support industry. As the practice of nuclear medicine subsequently evolved and expanded, the society moved to recognise and embrace other professionals including technologists, pharmacists and nurses, and those involved in research and production, and also suppliers to the nuclear industry.

In 1997, Mrs Heather Hodges from Queensland became the first nuclear medicine technologist to be elected president of the ANZSNM. Her predecessors had been physicians, scientists, radiopharmacists and physicists.

The society also established specific geographical groups of members, the State Branches; and then equipment user groups also developed. These groups were open to all members of the Society on an equal footing. More recently, groups have developed which reflect specific professional interests within the field of nuclear medicine. These are the Special Interest Groups (SIGs), which now represent technologists, nurses, physicists and pharmacists.

Today’s membership of the ANZSNM is wide and varied.

Various sources, from which this book has drawn, include available archival material and communications with several eminent pioneering professionals directly associated with the establishment of nuclear medicine and the society and its activities over the last five decades. Official publications of the society, ‘Nuclear Medicine News’, ‘ANZSNM Newsletter’ and ‘ANZ Nuclear Medicine’ and the ‘Spectator’ of the Australian & New Zealand Association of Physicians in Nuclear Medicine (ANZAPNM, established in 1969), were particularly valuable. The Australian & New Zealand Society of Nuclear Medicine Technologists (ANZSNMT, established in 1974) became a special interest group (SIG) of the society in 1992. Other vital sources included the ‘Pioneer Witness Seminars’ that were held in Melbourne, Adelaide, Sydney and Perth. These brought together pioneers representing all professions within the nuclear medicine community (including physicians, physicists, radiopharmacists, technologists and nurses). From New Zealand, ‘The Blue Book’ and thumbnail sketches of departmental histories were provided by several pioneering physicists and physicians.

References 1. ‘Atoms For Peace + 50 Nuclear Energy & Science for the 21st Century’ Conference, 22 October 2003, The Watergate Hotel, Washington, DC.

8

Chapter 1

FUNDAMENTAL DISCOVERIES A ‘New Light’ Two great advances in basic physics became known during the closing years of the nineteenth century. One was the discovery of X-rays; the other, understanding the electron.

Both arose from the study of electric discharges in gases at low pressure.

The German physicist Plucker concluded in 1859 that fluorescence was due to something radiating from negative electrodes or cathodes. These ‘cathode rays' were closely studied during the remainder of the nineteenth century. The English physicist Crookes published the results of a series of researches on the subject in 1879.

Crookes showed that cathode rays were emitted normally to a cathode surface and could be deflected by a magnet. When he focused the rays to a point, sufficient heat was developed to melt glass or platinum foil. He concluded rightly, that the rays consisted of negatively charged particles. But although his experimental results were indisputable, the conclusions he drew from them were vigorously contested. Most German physicists thought that the cathode rays were a wave motion similar to light and that there was no propagation of matter.

Hertz, working at Bonn, was seeking an experimental proof of Maxwell's theories of the nature of electricity and magnetism, and he took up the study of discharges in a vacuum.

Hertz found that cathode rays could pass through a thin film of gold or aluminium placed in their path. After his death in 1894, his pupil Lenard continued his work. Lenard made a tube with a thin aluminium window and succeeded in bringing cathode rays into the outside air.

He found that they still produced fluorescence, but that the rays would not travel far through air at atmospheric pressure. Lenard said that the cathode rays passed through his hand, which was almost certainly an observation of X-rays produced where the cathode rays struck the window of the discharge tube. But he failed to notice that it was a different kind of ray.

Sir William Crookes often made the observation that photographic plates which happened to be stored near his tubes became fogged and this must have been caused by X-rays. On one occasion, he returned some plates to the manufacturer as unsatisfactory. Many workers must have produced X-rays accidentally while studying cathode rays, but it was Roentgen who observed their presence and realised that he was dealing with a ‘new kind of ray’.

Although humans have been exposed to radiant energy as a part of our environment since prehistoric days and have since studied many properties of this radiation (principally those visible to the eye), official acquaintance with what is rather generally classified today as ‘nuclear radiation’ began with newspaper accounts in early January 1896 of a "sensational scientific discovery."

German physicist, Wilhelm Conrad Roentgen (1845-1923) reported that, in his researches with a Hittorf-Crooke's tube, he had observed a new form of radiation that was capable of penetrating wood, tinfoil, human flesh and other opaque objects. He referred to these rays as ‘X-rays’, with "X" denoting the unknown factor; and this ‘temporary’ name stuck.

9

The fascinating history of X-Rays goes back to 8 November 1895, when, at the Institute of Physics in the University of Wurzburg, Bavaria, Roentgen first observed this new radiation.

By 28 December he had submitted a preliminary report. When, in January 1896, the context of Roentgen's discovery, reduced to a small paragraph, was flashed around the world, it caused a sensation comparable with that resulting in recent times from the announcement of the atomic bomb.

A detailed description of Roentgen's discovery was given by Sylvanus P. Thompson, late Professor of Science and Principal of Finsbury Technical College, himself an enthusiastic Xray research worker and President of the British Roentgen Society, at a meeting held on Friday 5 November 1897, at St Martin's in London.

There is no doubt that Roentgen’s discovery of X-Rays is considered as one of the greater moments in history. However, the knowledge from which this advance in science was made could be found in the momentous work of a number of previous investigators.

In 1837, Faraday, in England, identified dark spaces in electrified evacuated bulbs and he pioneered experiments with induction coils. It was also Faraday who, in 1853, referred to the positive electrode as the ‘anode’ and the negative electrode as the ‘cathode’.

In 1851, Ruhmkorff, in Russia, produced his self-named coil. Geissler then discovered that an electric current produced vivid colours when passed through a tube containing rarefied or thin gases.

Sir William Crookes, in England, was the man who laid the foundation upon which it can be said that X-Rays were discovered. In transcripts of the Royal Society, in 1874, Crookes stated that cathode rays could be brought to a focus by curving the cathode.1 He accordingly replaced the flat cathode with a concave one. In 1879, Crookes actually constructed a tube with a plate of platinum at the focus to display the heating effects of focused cathode rays.

X-Rays must have been produced in abundance when the vacuum of his tubes was high enough to give a pale green fluorescence.

But how did Crookes get the idea for making a Crookes-tube? This question was answered some years ago by Marshall Brucer M.D. who wrote Vignettes in Nuclear Medicine and researched the life and times of Sir William Crookes.2 William Crookes (1832-1919) was from a large family reasonably placed in society. His father was the court tailor on Regent Street in London. Crookes entered the Royal College of Chemistry and, by the time he was 19, had read his first paper to the London Chemical Society on the remarkable parallelism between sulphur and selenium.

From this time, photography, spectrometry and finally metrication of any kind became his passions. To earn money, he became editor of the Liverpool and then, in 1856, London photographic journals, which were then primarily publications in practical chemistry.

He purchased the copyright to the ‘Chemical Gazette’ and, as editor published the first issue of the renamed ‘Chemical News’ on 10 December 1859. For the next thirty years practically everything that went on in Science passed under Crookes' eyes. Editing was only a part-time 10

pursuit, as he maintained an extremely sophisticated laboratory for his research within his own home.

On 5 March 1861, after experimenting with impure selenium he announced the discovery of a new element 'Thallium' (from ‘thallous’: a green budding twig).

Following the death of his brother, Crookes became dangerously engaged in spiritualism, so much so that his scientific peers considered reading him out of the scientific society. This was a turning point in Crookes' career and, as a means of scientific endeavour he threw himself into research to purge the hurt he had encountered from his colleagues. From this work came an introduction to the atomic age.

Following demonstrations to the Royal Society in 1873, 1874 and 1875 of a sensational instrument he called the ‘radiometer’, Crookes continued experimentations. The radiometer consisted of four disks of pith (black on one side; white on the other) that were attached to four arms suspended on a steel point, so as to revolve horizontally. All of this was enclosed in a glass globe evacuated to the highest obtainable vacuum. The arms revolved when exposed to visible light. The rate of revolution was proportionate to the intensity of the incident radiation.

A number of scientists of the day, including Crookes, then started to develop experiments with electricity through gases in glass vacuum tubes. Other such notable scientists included Faraday, Julius Plucker and Johann Hittorf, famed for his shadow experiment of 1869. In one experiment, Hittorf put an obstruction between the cathode and glass wall of the vacuum tube. The obstruction cast a very sharp-edged shadow on the glass wall. He concluded that whatever was coming off the cathode must have been travelling in straight lines and was similar to waves of light in the luminiferous 'aether'.

Crookes improved Hittorf's experiment by placing the anode asymmetrically, so as to leave the path of the cathode-ray beam free to strike the glass wall. In its path he had placed a hinged, mica, Maltese cross.

During the early 1870's, Crookes' fanatic drive for precision in measuring the atomic weight of thallium led to the invention of the ‘Radiometer’. The Radiometer was converted into a ‘Crookes-tube’; then to dozens of modifications. Practically every physics laboratory in the world had at least one.

A most memorable event in the history of Science occurred on 8 November 1895, when a new light, never before known to humans, was first observed. Professor Wilhelm Conrad Roentgen observed a faint, flickering, greenish illumination on a piece of cardboard he had painted with a fluorescent chemical preparation. In a carefully darkened room, from which every known kind of ray had been scrupulously excluded, he saw a line of dark shadow on the faintly luminous surface. Roentgen’s Crookes-tube was stimulated internally by sparks from an induction coil, but was carefully covered by a shield of black cardboard that was impervious to every known kind of light, even the most intense. In that darkness, especially arranged to see luminous phenomena, nothing was visible but these previouslyunrecognised rays evidently emanating from the Crookes-tube and penetrating the cardboard shield.

11

Roentgen traced back the shadow to the object that caused it and verified the source of the rays to be the Crookes-tube. These newly-discovered rays, which were invisible until they fell upon a chemically painted screen, were found to have a penetrative power previously unimagined. They penetrated cardboard, wood and cloth with ease and even went through a thick plank and a book of 2,000 pages to light up the luminous screen placed on the other side. But metals such as copper, iron, lead, silver and gold were found to be less penetrable.

Strangest of all, while flesh was very transparent, bones were fairly opaque. So, interposing his hand between the source of the rays and his luminescent cardboard, Roentgen saw the bones of his living hand projected in silhouette upon the screen. A great discovery was made.2 When Roentgen first came upon this new light, so powerful that it could pass through opaque objects, he told his good friend Boveri, "I have discovered something interesting, but I do not know whether or not my observations are correct." Except for this remark, he talked to no one about what he had found. For days he locked himself in his laboratory and, without sleep or food, worked out his experiments again and again.

Roentgen first reported his findings in a paper, ‘A New Kind of Ray’, which he presented to the Physical Medical Society of Wuzburg. His paper was published almost immediately, at the end of the Society's 1895 ‘Transactions’. The news of this new discovery electrified the world. Perhaps the best known X-ray of all time is that of Roentgen’s wife’s hand captured on photographic film (figure 1). Newspapers around the globe printed a host of X-ray images of the hands and feet of living persons and extolled the mysterious power of those strange rays which could "see" through almost anything.

Media saturation provoked common scepticism, fear and public ridicule. A Bill was introduced into the House at Trenton, New Jersey, prohibiting the use of X-rays in opera glasses at theatres and, in England, a firm "made prey of the ignorant women by advertising the sale of X-ray proof underclothing."

Roentgen's scientific contemporaries weren't completely without scepticism either, but there were also strong believers in the value of his discovery. The majority of the medical fraternity could vividly foresee how the sufferings of mankind might be lessened by the use of these new rays.

Figure 1. An X-ray image on photographic film of the hand of Roentgen’s wife, Anna Bertha. It is perhaps the most famous Xray image of all time.

A general article published 30 January 1896 in ‘The Nation’ said in part:-

.....the importance of this discovery in its application to surgery as an aid to diagnosis in cases of disease or fracture of the bones is apparent. The photograph would reveal immediately and unmistakably the nature of the disorder without the long and often painful examination which the patient is now obliged to endure. In a case of complicated fractures another photograph can be taken after the

12

bones have been set in order to ascertain whether the dislocation has been properly reduced or the broken parts have been rightfully replaced. The exact location of a bullet or the splinter of a shell can also be easily found without the use of a surgeon's probe. In all probability the progress can be perfected and modified so as to photograph the heart, lungs, liver and internal organs and thus determine their precise condition.

Such acclaim made Roentgen famous overnight. He was showered with honours, though he sought none and turned down many. As a result of his demonstration before Kaiser Wilhelm 11, Emperor of Germany and King of Prussia, he received a high Prussian decoration. A government decree bestowed upon him the title of ‘Excellency’, boulevards and streets were named for him, and monuments were erected in his honour.

In 1901, the first Nobel Prize for Physics was awarded to Professor Wilhem Conrad Roentgen for his discovery of X-rays. This was the only monetary gain he received from his great discovery, and even this well-earned prize money was given by him to the University of Wurzburg ‘to support scientific research’.

After about five years or so of intense work following up and further establishing his 1895 discovery, Roentgen's career became more and more hidden from the public eye. He devoted much of his time to teaching, which was always a foremost activity for him.

Roentgen refused to patent any part of his discovery and rejected indignantly all ‘commercial’ offers.

His wife's chronic illness and ultimate death in 1919 cast a shadow over his professional life.

World War 1 and its immediate aftermath threw additional burdens on him. Roentgen died on 10 February 1923 at the age of 78 with a carcinoma of the rectum, which had remained unsuspected to the very last. He is buried at his wife's side in the family grave in Giessen.

HERR PROFESSOR DR ROENTGEN, I PRESUME Scene: The Town Hall of Worchberg, in 1896.

Enter a gentleman dressed in cape and top hat.

Official: May I help you?

Gentleman: My name is Wilhelm Conrad Roentgen. I am here to enquire about the status of my application for the new machine which I submitted to the health systems agency of Greater Worchberg.

Official: Yes, Doctor Roentgen; we received your application and have examined it in great detail. There are, however, many questions left unanswered.

Dr Roentgen: Yes, I found it as quite difficult for me to complete your application.

Official: Well, Doctor Roentgen; we anticipate that your new machine will cause many problems. You claim that your new ray permits physicians to look inside the human body and to evaluate bones prior to surgery. We feel that there may be some slight merit to your invention. However, to consider this a medical necessity and expend huge capital sums will raise the cost of the medical care here in Worchberg. In addition to the equipment think of the personnel needed to run each of these units. We would also have to purchase X-ray plates and record these images and then store this information.

13

Dr Roentgen: But, just think of what this X-ray means to patients. For the first time we may diagnose fractures intelligently; and I am working on a new application of my ray that will permit a doctor to look inside the chest and abdomen and visualise the stomach, colon and others areas of the body. Diseases may be found earlier, when they can be corrected.

Official: Even if those procedures were possible, and they have certainly not been proven so as yet, we can't do very much about those diseases, so why find them earlier. If we do find these diseases we will only have a proliferation of surgical procedures and other ancillary medical tests. We must consider that our budget is limited and we must put our health care dollars into more useful areas.

Dr Roentgen: But think of – Official: If we don't limit the use of the new modality each and every hospital will then want one of your units. What will happen to the cost of medical care then. If you are correct and your unit will allow physicians to see other parts of the body, not just bones then no doubt there will be a third and fourth generation X-ray unit. How can we stop this proliferation, no Dr Roentgen the agency will only approve one of your units for the greater Worchberg area. If we don't place these restraints on the unit then the use of the X-ray will increase and everyone with a headache or a stomach-ache will demand to have an X-ray.

Dr Roentgen: Just think of the improved patient care with my X-ray.

Official: The Worchberg HSA has decided that X-ray is still an experimental modality. We will not have our third-party payers reimburse any hospital for the use of X-ray on any part of the body but bones. Uses in the stomach, chest must be considered experimental and will not be reimbursed. I also would like to caution you to prevent your unit from falling into the hands of private practitioners. Who knows how many private X-ray offices would spring up if we did not include physicians’ offices as part of our certificate of need legislation? Perhaps you could find some other use for your new ray. Try shoe-stores.

Natural Radioactivity On 24 February 1896, only a few months after Roentgen's announcement, Henri Becquerel (1852-1908), a distinguished French physicist with equally distinguished physicists as father and grandfather, first reported his observations of natural radioactivity from pitchblende, an ore considered valuable because it was also associated with gold and silver.

On Monday, 20 January 1896 the regular meeting of the French Academy of Sciences featured a demonstration of Roentgen's new photography by Henri Poincare. The Roentgen story had been leaked to the press two weeks earlier, as Roentgen didn't read his first paper until 23 January 1896. But the newspaper article had been well written and most physicists had a Crookes tube available for a quick check. Poincare had verified the news story immediately. His confirmation of the story's validity was published that day in ‘Comptes Rendus’.

Henri Becquerel attended the meeting (as had his father Edmond before him, and his grandfather Antoine before him). The subject matter was of intense public interest and the distinguished occupant of the chair in physics at the Musee d' Histoire Naturell had to know what all this newspaper talk was about. Henri held the chair at that time (as Edmond and Antoine had before him, and his son Jean would also after Henri died).

14

Becquerel's analysis and report on 24 January 1896 were apparently triggered to a certain extent by Roentgen's discovery. Becquerel had noted that, as in the case of X-rays, air would be ionized by ‘emanations’ from his pitchblende ore. This was later found to be because of radiation from uranium and the minute quantities of radium and polonium in the ore.

In July 1896, Pierre and Marie Curie (1859-1906 and 1867-1934), a husband and wife team in France, announced the concentration of the small fraction of radium in this ore, thus discovering a very highly-radioactive material.

Henri Becquerel received the Nobel Prize in 1903.

Twelve years after the death of Becquerel on 25th August 1908, William Crookes wrote the obituary of his old friend for the Royal Society. He described the excitement in 1896: [I] visited Henri Becquerel's laboratory one memorable morning when experiments were in progress which culminated in the discovery of the 'Becquerel rays’ and of 'spontaneous radioactivity’. Uranium salts of all kinds were seen in glass cells, inverted on photographic plates enclosed in black paper, and also the resulting images automatically impressed on the sensitive plates. Becquerel was working on the phosphorescence of uranium compounds after isolation; starting with the discovery that sun- excited uranium nitrate gave out rays capable of penetrating opaque paper and then acting photographically. He had devised another experiment in which, between the plate and the uranium salt, he interposed a sheet of black paper and a small cross of thin copper. On bringing the apparatus into daylight the sun had gone in, as it was put back into the dark cupboard and there left for another opportunity of isolation. But the sun kept persistently behind clouds for several days and, tired of waiting (or with the unconscious prevision of genius), Becquerel developed the plate. To his astonishment, instead of a blank as expected, the plate had darkened under the uranium as strongly as if the uranium had previously been exposed to sunlight; the image of the copper cross shining out white against the black background. This was the foundation of a long series of experiments which lead to the remarkable discoveries which have made 'Becquerel rays' a standard expression in science.

Photographic images of uranium had been seen previously. Forty years earlier, William Crookes had been editor of one of the first photographic journals. He remembered that, in 1857, a French photographer, Niepce de St Victor, had reported the storing up of energy by uranium. A sheet of paper impregnated with uranium nitrate and exposed to light would affect a photographic plate in the dark. This phenomenon was then considered to be a simple chemical reduction of silver salts. However, in reminiscing in 1910, in a speech to the past presidents of the Chemical Society, Crookes considered the first autoradiograph (and all Becquerel's pictures were autoradiographs) to be his own.

By the end of 1899 five elements were known to be radioactive.

The Curies The oppression of the Polish people by the Russian government of the Tsars caused Marie Sklodowska, a gifted young chemist to escape to France. Despite her youth, she had already obtained high academic honours. But she found it difficult to obtain employment and suffered extreme poverty while studying for a degree in Paris.

15

In the course of her work at the Ecole Polytechnique, where Becquerel headed the physics department, she met Pierre Curie, a French Scientist and personal friend of Becquerel who was engaged in experimental work in physics. Becoming friends through the common interest of their work, the two scientists married. Thus was formed one of the historic and fruitful partnerships of science, broken, unfortunately, eleven years later in 1906 by the tragic death of Pierre Curie in a street accident.

As the Curies were extremely poor, they carried out their experimental work in makeshift laboratories in damp underground rooms and in leaking shanties. Nevertheless, they obtained results that were to transform science and medicine.

The Curies' discovery was the result of Marie's belief that the ore pitchblende might contain another more active substance than uranium, which had been described several years earlier by Henri Becquerel.

By 1898, Marie Curie had isolated two previously unknown and radioactive elements, 'polonium' which she named after her native country, Poland; and radium, in response to its intense radioactivity. The Curies received many honours in recognition of their great pioneer work. Madame Curie was twice awarded the Nobel prize; jointly with her husband in 1903 and again in 1911.

In ‘Australian Doctor’, 30 June 1995, Dr George Biro précised her life and times that culminated with her remains being moved to the Pantheon, to become the first women in history honoured in this way.

MARIE CURIE LIT UP THE WORLD WITH HER STUDY Imagine a derelict shed with a bitumen floor and a cracked skylight that lets in the rain. It was a dissecting room, but is no longer fit for corpses - stifling in summer and freezing in winter.

Outside in the courtyard, a woman battles with a huge, heavy iron-rod; stirring a large cauldron brimming with a boiling volatile liquid. Occasionally, she stops to pour the liquid into a jar. When all the jars are full, she joins a man inside. Marie and Pierre Curie toiled like this for years.

Born in 1867, Marie (Manya) Sklodovska was the youngest daughter of well-educated Polish patriots.

Marie's mother was dying from tuberculosis. Only much later did Marie understand why her mother never kissed her.

Russia ruled their part of Poland. Her father, a physics professor, was demoted when the Russians found him quietly teaching his Polish students their own language. He lost his life savings just when Marie was about to enrol at the Sorbonne in Paris. So Marie first worked for five years to support her elder sister Bronya while the latter studied medicine. After graduating, Bronya in turn helped Marie. In 1893, living on tea, bread and butter, Marie topped her class and got her masters.

For her wedding to another physicist, Pierre Curie, she chose a dark suit which would not show the stains of lab work.

It was an exciting time in physics. Soon after Roentgen's discovery of X-rays, Antoine Henri Becquerel found that uranium emitted mysterious rays and penetrated solids. For her doctorate, Marie explored other sources of radiation, which she named ‘radioactivity’. Marie found that the radiation emitted by pitchblende (the main ore of uranium, mined in Bohemia) far exceeded that expected from its uranium. Hence, she said pitchblende had to contain traces of another very radioactive, but still

16

unknown, element. In fact, the Curies discovered not one, but two new radioactive elements (both breakdown products of uranium): polonium (named after Poland) and radium. Radium was one million times more radioactive that its parent, uranium.

It took several years to realise that the Curies' gamma rays were identical to Roentgen's X-rays. But to isolate radium was another matter. So poisoned was the atmosphere in the derelict dissecting room that the Curies' notebooks are still dangerously radioactive. Pierre's hands became so scarred that he could not even knot his tie. He was treated for a malignancy.

In 1901, the Curies lent their friend Becquerel a tube of a radium derivative. After carrying it in his pocket for only six hours, Becquerel found it had burned his skin, just like a burn from X-rays. This triggered interest in radium's therapeutic effects.

Finally, in 1902, after four years of effort, the Curies isolated one-tenth of a gram of radium from eight tonnes of pitchblende. Marie and Pierre shared the 1903 Nobel Prize in Physics with Becquerel. The world cheered.

A farmer wanted to put radium into his chicken feed so his hens would lay hard-boiled eggs. An academic said radium-fertilised soil would yield more and tastier crops. Pierre and Marie could have taken out patents and become rich, but passed on their findings for others to apply.

Life was looking up when, in 1906, Pierre was run over by a lumbar wagon. Marie worked on despite this bereavement, the first symptoms of radiation sickness and the insults of the French. As a foreigner and a woman, she never won over the French authorities. Very reluctantly, they awarded her Pierre's professorship and asked her to give his lectures at the Sorbonne. Marie was the first woman to do so.

She found that the luminous substance she and Pierre had called radium was actually a salt of radium. But Marie finally did isolate radium itself. She produced the first international standard of radium. The ‘curie’ became a unit of measurement of radioactivity.

In 1911, Marie won her second Nobel Prize (this time for chemistry), but still the French Academy of Science would not admit the ‘foreign woman’.

When World War I came, she invented mobile X-ray vans (‘little Curies’) to locate shrapnel in wounded troops. She trained 150 people as X-ray technicians, raised money to equip the vans and even drove one herself.

By the end of the war, her 20 vans and 200 radiology posts had examined more than one million men.

In 1921, Marie went to the US, where President Harding presented her with one whole gram of radium (worth $100,000) for medical use in Europe.

Marie's eldest daughter, Irene, worked with her on the medical applications of radioactivity. Warsaw set up a radium institute, with Marie's sister as director.

It was radium, the element to which she had devoted her life, that killed Marie. When she died in 1934 of leukaemia and aplastic anaemia, her body joined Pierre's at a cemetery. But this year the French 3 moved her remains to the Pantheon. Finally, Marie Curie rests with the foremost sons of France.

Radium Following her isolation of plutonium in July 1898, Marie Curie was soon to isolate another radioactive element (radium) some two months later. It had been apparent that the biologic 17

effects of the radiations emanating from radium were witnessed by Becquerel, and were to eventually cause Marie and her daughter Irene's ultimate deaths from leukaemia.

Radium occurs in small quantities in many different minerals found in different parts of the world and also in the water of various mineral springs. For practical purposes it is extracted from pitchblende.

In 1901, Becquerel was travelling to a lecture in London with a sample of his colleagues' radium in his vest pocket. After his return to Paris he consulted a physician about the reddened area on his abdomen beneath the pocket.

In his 1910 publication: ‘Medical Electricity and Roentgen Rays’, S. Tousey reported: 0.2 gram of radium (of high activity) carried in the pocket of a flannel shirt for six-hours produced an ulcer without any pain and which took over a month to heal. This had been preceded by erythema which developed after a fifteen-day period of incubation. This accident was a personal experience of Becquerel. An accident of the same nature occurred to Mme Curie; and M. Curie, Dr Oudin, and M. Giesel have made experiments upon themselves and 4 upon animals.

The first medical applications of radium came only a few years later. During this period, radium therapy consisted most commonly of the application of a radium preparation applied as directly as possible to a local lesion and leaving it in contact for selected periods of minutes, hours, or days, according to the radioactivity employed and the extent of the tissue changes desired.

Celluloid needles were coated with radium of various strengths and inserted into the substance of tumours. This would cause sloughing of tissue to enable extrusion of a tumour en masse. Such needles were left in place for up to 3-4 days depending on the radium activity that had been applied to the needle. It was observed that cancer cells were more susceptible than normal cells to the influence of radium. However, the effect appeared to be confined to tumour cells within a half-inch radius of each needle. Carcinomas of the breast, and especially large tumours, were targeted in this way. Under a general anaesthetic, the breast was punctured in a number of different places to obtain the desired effect of reducing the tumour and curing the disease.

British Scientific Investigations While the discovery of natural radioactivity was emerging in France, English scientists were beginning to identify the constituent components of atoms. Thompson identified the electron in 1897 as a negatively-charged particle with a mass almost 2,000-times smaller than the lightest atom, hydrogen. He postulated that the electron might be a constituent of atoms, indicating that the atom was not indivisible, as Dalton had suggested a century before.

The divisibility of atoms had been suggested by an intuitive English physician, Prout, in 1816. He had hypothesised that the basic building-block of all elements might be an entity identical to the hydrogen atom.

In 1911, Rutherford demonstrated that the principal mass of an atom was concentrated in a dense, positively-charged nucleus. Then, with Soddy, Rutherford ascribed radioactivity to a process involving the spontaneous disintegration of atoms. Together with the Curies and 18

Villard, Soddy and Rutherford were able to identify (by behaviour in magnetic fields) three distinct types of radioactive emissions: 1. positively-charged alpha particles, identical to the helium nucleus, 2. beta particles, consisting of negatively charged electrons, and 3. non-particulate and highly-penetrating electromagnetic gamma-ray emissions.

Following general acceptance by the wider scientific community of Rutherford's atomic model, it seemed clear that these emanations had their origin in the nucleus of the atom.

Irene Curie and her husband, Frederic Joliot, were the first to demonstrate that nuclear bombardment could induce transmutations of some light elements to radioactive forms of other elements. In a short article in ‘Nature’, on 10 February 1934, they announced their discovery: Our latest experiments have shown a very striking fact: when aluminium foil is irradiated on a polonium preparation, the emission of positrons does not cease immediately when the active preparation is removed. The foil remains radioactive and the emission of radiation decays exponentially as for an ordinary radioelement. We observed the same phenomenon with boron and magnesium.

They had discovered that the bombarded boron had been transmuted into radionitrogen-13, and the aluminium into radiophosphorus-30.

With the discovery of ‘artificial radioactivity’ the ‘classical period’ of nuclear medicine ended.

Nuclear Fission X-Rays and naturally radioactive substances were the principal radiation sources available for general use until the discovery of nuclear fission in 1939 by German chemists Otto Hahn (1879-1968) and Fritz Strassman (1902-1980), and the development of the first nuclear reactor prototype in 1942 under the leadership of Italian physicist Enrico Fermi (1905-1954) in a squash court under the west stand of Stagg Field at the University of Chicago

19

1

. Subsequently the first harnessing of the atom for practical purposes culminated in the first nuclear weapon, which was exploded in 1945.

These developments and their subsequent large-scale use for both war and peace usheredin an exciting nuclear age. They have also produced extensive sources of radiation, primarily from the accompanying large scale production of radioisotopes, both incidentally and by design. These include neutrons as well as alpha, beta and gamma radiations from a bewildering variety of materials made artificially radioactive.

Radioactivity and Tracer Techniques The first phenomenon of radioactivity observed was the blackening of photographic plates by uranium minerals. Although this effect is still used to some extent in research on radioactivity, the property of radioactive substances that is of greatest scientific value is their ability to ionize gases. Under normal conditions, air and other gases do not conduct electricity. If they did, power lines and electrical machines could not operate in the open, as they do. But under some circumstances, air molecules are broken apart into positively and negatively charged fragments called ions. Air thus ionized does conduct electricity. Within a few months after the first discovery of radioactivity, Becquerel found that uranium had the power to ionize air. Specifically, he found that the charge on an electroscope leaked away rapidly through the air if some uranium salts were placed near it. (The same thing happens to a storage battery if sufficient radioactive material is placed nearby.) Ever since that time, the rate of discharge of an electroscope has served as a measure of intensity of radioactivity and nearly all present-day instruments for studying radioactive phenomena still depend on this ionization effect, directly or indirectly. In 1908, the physicist Hans Wilhelm Geiger produced the first cathode ray tube with a centrally wired anode and 5 years later reported counting beta particle emissions with his charged tube. This was to become the now commonly used Geiger-Mueller (G-M) tube, which was used to ‘trace’ radioactivity throughout the body in the ensuing decades2. Wilhelm Mueller, co-inventor and associate of Geiger, is noted by Millard N Croll, a nuclear medicine historian, as “unfortunately, Wilhelm Mueller...immigrated to Australia, and his further activities are entirely lost to history”8.

Curie and Joliot’s findings stimulated similar experiments all over the world. In particular, Fermi reasoned that neutrons, because of their lack of charge, should be effective in penetrating nuclei, especially those of high atomic number which repel protons and alpha particles strongly. He then verified this prediction almost immediately; finding that the nucleus of a bombarded atom captured the neutron to initially produce an unstable nucleus and then achieved stability by emitting an electron. The resultant stable nucleus was one unit higher in mass number and one unit higher in atomic number than the initial target nucleus.

As a result of innumerable experiments carried out since 1934, radioactive isotopes of nearly every element in the periodic table can now be produced. Some regain stability by the emission of positrons, some by the emission of electrons, some by a process known as electron-capture, and a small number (probably three) by alpha-particle emission.

1

The University of Chicago was to become a key training site for Australian nuclear medicine physicians in the 1970s and 80s (see chapter 2).

2 For example, Hermann Blumgart & Otto Yens from Boston used radium to measure arm-to-arm circulation times using such a detector in 1927.

20

Altogether, some five hundred unstable nuclear species have been observed and, in most cases, their atomic numbers and mass numbers have been identified.

These artificially-radioactive elements play an important role in medicine, in ‘tracer’ chemistry and in many other fields of research which can hardly be overestimated.

Artificial Production of Radioisotopes During 1931-1932, a team led by Professor Ernest Lawrence at the University of California, in Berkley, built a particle accelerator which they named cyclotron. Eventually the cyclotron produced a range of radioactive nuclides by suitable nuclear reactions between accelerated ions and elements in the target. The team’s major interests lie in those radionuclides which could be used for medical purposes. On Christmas Eve in 1937, Lawrence’s brother John gave the first dose of the radioisotope phosphorous-32 to a patient with chronic lymphatic leukaemia.5 The nuclear reactors established in Hanford, USA, could be used to produce relatively large quantities of radioisotopes likely to have valuable applications in medicine. Of these, phosphorus-32 and iodine-131 were of particular medical interest. It may seem ironic to some that the reactors built to produce material required for the manufacture of the earliest 'atomic' bombs should also have made possible the development of completely new clinical methods of diagnosis and treatment which have been of great benefit to patients in hospitals and clinics throughout the world.

The Manhattan Project The Manhattan Project was a secret military project established in 1942 to produce the first US nuclear weapon. Fears that Nazi Germany would build and use a nuclear weapon during World War II triggered the start of the Manhattan Project, which was originally based in Manhattan, New York.

US physicist Robert Oppenheimer and General Leslie R. Groves served as directors of this project, which recruited some of the best US scientists, engineers and mathematicians; and a number of European scientists, including Albert Einstein, Enrico Fermi and Leo Szilard.

Under the auspices of the Manhattan Project, three main research and production facilities were established at Oak Ridge, Hanford, and Los Alamos. The Oak Ridge Laboratories in Tennessee provided uranium-235; while weapons-grade plutonium was produced at Hanford, Washington; and nuclear weapons were assembled at Los Alamos in New Mexico.

Los Alamos produced four weapons, two of which (‘Little Boy’ and ‘Fat Man’) were used against Japan in August 1945.

The building of nuclear reactors at Oak Ridge, Tennessee, eventually led to a new, cheaper source of medical radioisotopes after the war ended in 1945. The Atomic Energy Act, passed by Congress on 1 August 1946, created the Atomic Energy Commission; and the Manhattan Project officially ended in 1946, when it became part of the AEC. The Act enabled the peaceful production of medical isotopes in an Oak Ridge reactor; and the modern era of nuclear medicine had begun. Oak Ridge, Tennessee was to figure again much later in nuclear medicine as one of the main sites in the development of positron 21

emission tomography (PET), due to the abundance of nuclear technology infrastructure and human resources which was a legacy of the original Manhattan Project.

In 1986, Josephine Wiseman was accepted into a course run by the Radiation Emergency Assistance Centre Training Site in Oak Ridge, Tennessee; and had this to say about the sleepy town: Oak Ridge was a small rural settlement before the war and was chosen as a nuclear research site, as it was relatively hidden in a valley. During the war, it became a secret city not recorded on any map, although its population swelled to 90,000 with scientific and military personnel. This was considered unfortunate by the population at the time, although one nurse on the REACTS staff, who would have been 20 at the time, relished fond memories of the invasion. This influx of people was housed in pre-fabricated huts which still stand, mostly untouched, giving one the impression of stepping back in time to a southern movie set of the 1940's. The famed bluegrass seemed as green as any I had ever seen, but all the locals complained of the terrible drought which had turned the grass as brown as they had ever seen it. I stayed in the old Guesthouse, renamed the Alexander Motor Inn, where Einstein, 6 Fermi and Oppenheimer had stayed when they visited to work on the Manhattan Project.

It was from here that P-32 was first procured arriving in Brisbane, Australia in 1944.7

References 1. Gardiner, J. H., ‘The Origin, History and Development of the X-Ray Tube’, Journal of the Roentgen Society, May 1909.

2. Brucer, Marshall MD, Vignettes in Nuclear Medicine (No.93), Mallinckrodt, St Louis, 1979.

3. Biro, George. ‘Marie Curie lit up the world with her study’, Australian Doctor, 30 June 1995.

(Further reading: Pflaum, Rosalynd, Grand Obsession: Madame Curie and Her World, Doubleday, 1989.)

4. Tousey, Sinclair, Medical Electricity & Roentgen Rays, W. B. Saunders, 1910.

5. Brucer, M., ‘Nuclear medicine begins with a boa constrictor’, Journal of Nuclear Medicine, 19, 1978.

6. Wiseman, J., ‘Medical Planning and Care in Radiation Accidents’, ANZ Nuclear Medicine, Vol. 17, No. 4, 1986.

7. http://www.atomicmuseum.com/tour/nuclearmedicine.cfm 8. Croll, M.N. Nuclear medicine instrumentation. Historic perspective. Semin Nucl Med. 1994;24(1):310

22

Chapter 2

ADVANCES IN AUSTRALIA Early Use of Radium in Australia According to Sydney Hospital’s Radium Registrar, Sylvia D. Bray, who on 18 May 1939 wrote to the Medical Journal of Australia, the first reported medical use of radium in Australia was on 5 May 1911.

I would like to state that on 17 February 1911, twenty one pieces of radium, consisting of twenty plates of various strengths and one fifty milligram tube, were purchased by Dr Langloh Johnston for the Sydney Hospital, in all a total of 252.5 milligrams.

This radium was first used on 5 May 1911, and from this date onwards was used continuously in the treatment of all grades of skin carcinomata, and the tube was used for carcinoma of the female genital tract, breast cases and glands, as well as many other types of lesions, superficial and deep.

In the eight months of 1911, 163 new cases alone were treated at the clinic, and between 1 1912 and 1922 the annual total of new cases treated varied between 180 and 250.

Radium was first purchased by the Commonwealth Government in 1928 and the department of health established the Commonwealth Radium Laboratory to act as both custodian of the radium and as the centre from which it could be distributed on loan to approved hospitals as required.

However, in a clinical context, the value of radium treatment for cancerous conditions was first demonstrated in France in 1901 and the first radium treatments in Australia were reportedly performed by a Melbourne dermatologist in 1903.

At the Royal Hobart Hospital, radium needles were used for the first time to treat patients suffering from tumours and ulcers in 1912, just eleven years after the action of radium on human tissues first became known. But the initial results were far from encouraging.

In 1913, encouraging results were obtained from radium treatment of certain cancer cases at the London Radium Institute, which issued its first report covering 539 cases treated from the opening of the institute on 14 August 1911 to 31 December 1912.

In the same year, Senior Resident Surgeon and Radiologist of the General Hospital Hobart, E. J. Roberts M.D., presented a paper to the Tasmanian Branch of the British Medical Association entitled ‘The therapeutic value of secondary rays produced from metal by the action of the Rontgen rays.’ Roberts’ paper was then published in the Australasian Medical Gazette on 13 September 1913.

I have not had an opportunity of practically comparing the therapeutic action of the secondary rays with that of the radium emanations, but a careful study of the radium literature has led me to think that for definite prognosis, convenience of manipulation and expense of instalment, the secondary rays are decidedly superior, while the therapeutic effects seem to 2 be more reliable and satisfactory.

23

However, it was not until 1924 that a radioisotope was employed as a diagnostic aid in blood circulation studies in the United States of America.

In 1928, the Commonwealth Government purchased 10 grams of radium, which, in 1929, was distributed to public hospitals in capital cities throughout Australia. It was at this time that the Commonwealth Radium Laboratory was established and its services were made available to radiotherapists who required advice on the physical aspects of gamma-ray therapy.

The use of radium applicators and needles were introduced by Dr W. P. Holman (Launceston Public Hospital) soon after his appointment as a Radiologist in 1925. Radium needles had been used in combination with radical surgery sporadically since 1926 and rather consistently from 1929 until the radium needles were replaced by radon needles in mid-1934. It was at this time that Holman felt strongly about the procedure and a review on its effectiveness was undertaken, culminating in a radical decision to develop a new and more appropriate method of placement of the needles allowing irradiation of the intercostal spaces and axilla as the previous method was completely ineffective in irradiating these critical zones.

In a small proportion of cases from 1926, and in all those regarded as operable from 1929, radium needles were implanted prior to closure of incisions in radical surgery for carcinoma of the breast. However, at the July 1934 Northern Division meeting of the Tasmanian Branch of the British Medical Association, the proportion of patients surviving for five years was reported to be much lower than expected (unpublished).

Holman concluded that a more conservative definition of operability was required and secondly, that the manner in which radium was being used in such breast cases was illogical and inefficient, it prolonged the operation, raised the risk of sepsis, and in certain areas caused radio-necrotic reactions in the traumatised tissues.

Holman's decision was augmented by the increased knowledge of physical measurements hitherto empirical knowledge of the fields around the needles, the availability of the newly developed radon needles and, finally, the stimulus and personal encouragement given by the work of R. Kaye Scott of Melbourne.

Holman carried out a number of experiments towards developing a new technique for the treatment of breast carcinomas in which he implanted the affected breast and adjacent axilla with planes of needles. This was achieved by using wooden swab sticks soaked in sodium iodide and implanted into the breast of a female cadaver. The area was x-rayed to check the accuracy of the implant, then the breast was removed surgically, as from a living patient, and the specimen examined to see whether all the tissue removed would have been irradiated adequately.

In the latter half of the 1930s, Holman submitted a peer-reviewed thesis to the Faculty of Radiologists in London entitled ‘Irradiation in the Treatment of Carcinoma of the Breast’; and for this work was awarded a Fellowship of the Faculty. Although the Faculty advised him to publish the paper, it was never submitted for publication.

24

However, in 1944, the only paper attributed to Holman was in conjunction with Clifford Craig.

In phasing the history of surgical treatment of carcinoma of the breast, Holman and Craig considered that it was as yet too early to report on treatment including radiotherapy, both alone and in conjunction with surgery as, at that time, no universally-acceptable technique had yet been developed.

Early Interest in Radioactive Isotopes Until Curie and Joliot’s ground-breaking research in the 1930s, the only known radioactive substances were those that occurred naturally. However, a new era in the potential of artificially-produced materials was soon recognised.

In ‘The Australian Radiation Laboratory: A Concise History 1929-1979’, J. F. Richardson tells us of the advent of radioisotopes in Australia: In Australia, in the mid-1930s, the possibility of using radioisotopes as tracers in medical research was well recognised, but this application required specialised electronic equipment not then readily obtainable. On the other hand, the effective treatment of malignancies by any safe and effective means available was regarded as being of paramount importance, and the 3 therapeutic use of radioisotopes required only standard hospital equipment.

In 1934, Professor F. P. Sandes, Director of Cancer Treatment, University of Sydney, reported his overseas observations (during an official visit) to the Commonwealth Government, including the following: Induced Radio-Activity Recent research work has focussed a good deal of attention upon this subject in the scientific world and some clinicians hope that in a few years the artificial production of radio-active substances may displace radium from its present premier position. Also, when research has proceeded further, the possibility must be envisaged that certain parts of the body may be rendered temporarily radio-active, with the object of destroying or preventing the advance of a 4 malignant growth.

In his report to the Seventh Australian Cancer Conference (May 1936) on recent developments in radiological physics, Dr C. E. Eddy referred to the possible future use of man-made radioactive materials. In particular, he referred to radioactive sodium, pointing out that the gamma rays from this substance were of somewhat greater penetrating power than those from radium. And in his report to the Ninth Australian Cancer Conference (April 1938), Dr Eddy considered the first application of these new radioactive elements would be to the study of physiological processes; and he referred to suggestions that radioactive iodine might be of value in the diagnosis and treatment of malignancies in general.5 A demand arose in Australia for radioisotopes to be used in medicine, industry and research.

Some cyclotron-produced radioisotopes were available in small amounts from institutions in the USA, but the only source of radioisotopes in the quantities likely to be required was the United States Atomic Energy Commission (USAEC) and the US Government had refused to release these for export until appropriate arrangements had been made for their safe transport and use. It appeared, however, that release would only be a matter of time.

25

Most of the radioisotopes produced in small quantities had short half-lives, which limited the range and quantity of those available to find practical application in medical research. In the mid-1940s, the development of atomic energy programs overseas changed all that.

Commonwealth X-Ray and Radium Laboratory After the purchase of ten grams of radium by the Commonwealth Government in 1928, the Department of Health established the Commonwealth Radium Laboratory to act both as the custodian of the radium and as the centre from which it could be distributed on loan to approved hospitals as needed. The services of the Laboratory were made available to radiotherapists who required advice on the physical aspects of gamma-ray therapy and related problems, and to all concerned with the protection of staff exposed to the hazards associated with the use of radium and its decay products.6 Private sources of radium were known and dispersed amongst the medical fraternity throughout Australia. A private source owned by Dr Ireland was recorded as a loss to the Royal Hobart Hospital when he accepted the position as house surgeon at the Launceston General hospital in 1918 and then surgeon superintendent in December 1919.

Some years later, in 1927, a former surgeon superintendent Dr John Ramsay, acquired 5mg of radium in the form of needles. These were made in Brussels from Dr William Holman's prescription. Holman was soon to turn his attention to radiotherapy and is well known today as a former director of Peter MacCallum Clinic, Melbourne and the Holman Radiotherapy Clinics in Hobart and Launceston. In 1929, the Commonwealth Government distributed 10mg of radium to public hospitals in capital cities and to Launceston. In the mid 1930's Holman submitted a paper to the Faculty of Radiologists in London on the treatment of carcinoma of the breast with radon needles. For this work he was awarded a Fellowship of the Faculty; and although the Faculty advised him to publish the paper, it was never submitted for publication.

In 1935, the Department of Health extended the functions of the Laboratory to include the physical aspects of the use of X-rays in treatment. The name ‘Commonwealth Radium Laboratory’ was also changed that year to ‘Commonwealth X-Ray and Radium Laboratory’.

The Australian free-air standard of X-ray dosage was set up and portable sub-standards (regularly calibrated against the Australian standard) were used to measure the outputs of Xray therapy units in hospitals and in private practices. At this same time, the protection service was extended.

In the mid-1940s, the activities of the Laboratory were extended to the field of physical research with artificially radioactive elements. By arrangement between the Commonwealth Scientific and Industrial Research Organisation and the Department of Health, CSIRO officers were appointed to work in the Laboratory on problems associated with use of radioisotopes in scientific research. A special ‘Tracer Elements Unit’ (comprising both CSIRO and Commonwealth Radium Laboratory officers) was appointed to advise and supervise the physical and protection aspects of the use of radio-isotopes.

When radioactive isotopes became available, specialised knowledge of the Laboratory was used to establish a system for distributing them. At the same time, an advisory service in methods of detecting and measuring radio-isotopes and of safeguarding the health of people working with them was also instituted.

26

The first radio-isotopes were imported into Australia in 1946 and regular deliveries of radiophosphorus began in September 1947. Limited amounts of radio-iodine were received early in 1948 and regular deliveries began later that year.

However, Dr Arthur Cooper from the Queensland Radium Institute (QRI) procured P-32 as early as 1944. The QRI was formed following the visit to Australia of Dr Ralston Paterson and Dr Edith Paterson who came at the invitation of the Commonwealth Government in 1943 to advise the various states on treatment of cancers. The QRI was given responsibility for treatment of cancer patients in Queensland hospitals and was overseen by a council, chaired by the Director-General of Health and Medical Services. Day-to-day management was the responsibility of a director. The first director to be appointed was Dr Arthur Cooper who was later awarded a CBE. The main medical and administrative centre was located at Royal Brisbane Hospital. It was here that through Major Paul McDaniel, who was stationed in Brisbane with General McCarthy’s American forces,that shipments of P-32 were procured through McDaniel’s good friend E. O. Lawrence. Although the shipments originated at Oakridge they were routed through Berkley via Lawrence to Brisbane.

The Queensland Radium Institute ceased to exist on 30 June 1991 following the reorganisation of health services under the Health Services Act 1991.

The QRI 1946 Annual Report stated that: The first use in Australia, for medical purposes, of artificial radioisotopes had already occurred in Brisbane early in 1944 when medical officers of the United States Forces unofficially imported small supplies of phosphorus-32. These were used to treat blood disorders in 7 nineteen patients.

J. F. Richardson further advises that: The Council for Scientific and Industrial Research (CSIR)* was particularly interested in obtaining radioisotopes for research in animal physiology, entomology and metallurgy. The Council was aware the Laboratory had operated a radium and radon service for many years and so had gained considerable experience in the safe handling of radioactive materials.

Believing that the Commonwealth Department of Health, through the Laboratory, would wish to extend these services to include the procurement and distribution of radioisotopes for medical purposes, the Council, in a letter dated 7 January 1946, wrote to the Director-General of Health suggesting the establishment of a joint venture to procure and distribute radioisotopes "for use in Australia and the establishment of a central advisory service for all 3 users”. * The Council was re-constituted as the Commonwealth Scientific and Industrial Research Organization (CSIRO) on 19 May 1949.

The basic proposal was that the CSIR would appoint to its staff a physicist who would work at the Laboratory under the direction of Dr Eddy. Purchase of radioisotopes from the USA would be made by CSIR through its Scientific Liaison Office in Washington. The proposal was accepted and, during 1946 and 1947, arrangements were made to establish an organisation for the regular procurement and distribution in Australia of radioisotopes when they became available in quantity. A physicist was appointed in June 1946, but was unable 27

to take up duty. Subsequently, Dr T. H. Oddie was appointed and took up duty on 19 May 1947. His appointment activated the Tracer Element Section of CSIR. In September 1946, the Tracer Elements Research Committee was formed. The members were Dr F. W. G. White and Mr F. G. Nicholls of the CSIR and Dr C. E. Eddy of the Laboratory. The Committee dealt with matters relating to the procurement, distribution and safe use of radioisotopes. It also provided advice to the Department of Trade and Customs and to scientific organisations.

In addition to the need to ensure that radioisotopes were used safely and for useful purposes, there was also a need to ensure that their use on patients for medical diagnosis or therapy was properly controlled and co-ordinated. To achieve this, the National Health and Medical Research Council (NHMRC) established, at its 23rd Session in June 1947, a ‘Standing Committee on Radio-active Isotopes' with Dr Eddy as chairman. The Committee's duties were to co-ordinate research in Australia in the therapeutic use of radioisotopes and in their use for tracer studies, and to circulate material and literature to the states. Initially, the Committee acted as a therapeutic trials committee. But, as the use of radioisotopes in medicine increased, therapeutic trials committees were established in each state and the original Committee acted in this role in Victoria.

In December 1946, a trial shipment of phosphorus-32 (between 10 and 20 millicuries) was able to be obtained from the USA. Trial shipments of iodine-131 and of sulphur-35 had been requested but the response was that supplies were not yet available for export.

During 1947, supplies of some cyclotron-produced radioisotopes were obtained, but it was still not possible to arrange the regular supply necessary to maintain a service to the medical profession in Australia. Then, on 3 September 1947, President Truman announced that the USAEC was now able to accept requests for radioisotopes from foreign countries prepared to set up the necessary organisation for procurement and distribution. Certain conditions designed to ensure safe, efficient and effective use of exported radioisotopes were imposed.

One of these conditions was that the USAEC would deal only with a central agency designated by the recipient country.

Due to its preparations of 1946 and 1947, Australia was able to meet these conditions immediately and, in anticipation of the presidential statement, had already placed an order for a fortnightly supply of 20 millicuries of phosphorus-32. As a result, Australia received the first exported shipment of a radioisotope from the USAEC’s Oak Ridge Laboratories. It left San Francisco on 5 September and arrived in Melbourne on 11 September. The total cost of this shipment was approximately $US34, including $22 for the phosphorus-32 and $12 for freight. Of the first shipment of 20 millicuries, only 11 millicuries were ultimately available for use, due to loss by radioactive decay. Of the remaining 11 millicuries, 7 were used to treat two patients in Launceston and the rest to treat a patient in Perth.

The Commonwealth X-Ray and Radium Laboratory also wished to obtain a regular supply of iodine-131 for medical purposes. However, delays occurred because of the weight of the container deemed necessary by the USAEC for its safe transport. Air transport appeared too expensive, but the relatively-short half-life of eight days seemed to leave sea transport impractical. Nevertheless, the first of what were intended to be regular orders of iodine-131 was placed in October 1947. The initial order was for 20 millicuries of iodine-131, to be sent 28

by air. The iodine was to cost $US34, but the freight charge would have been at least $US200. So, the order was amended to 40 millicuries, to be sent by sea; and this was duly despatched. But, at the time of arrival in Melbourne, due to radioactive decay, less than 0.3 millicuries was available for use. These difficulties were overcome by the Laboratory supplying lighter transport containers of its own design, which were accepted by the USAEC. Regular monthly air deliveries of iodine-131 began in June 1948.

By the end of February 1948, the Tracer Elements Section had placed 21 orders with the USAEC and had imported seven different radioisotopes. Of these orders, 15 were for radioisotopes required for medical use, including 12 for phosphorus-32 (270 millicuries), two for iodine-131 (60 millicuries) and one for strontium-89 (10 millicuries).

Supplies of artificially-produced radio-active elements required in Australia were obtained from the United States Atomic Energy Commission through the Tracer Element Committee of the Council for Scientific and Industrial Research and the Commonwealth Department of Health and were distributed through the Commonwealth X-Ray and Radium Laboratory. The allocation of radio-elements required for research and treatment of humans was made by the Standing Committee on Radio-isotopes of the National Health and Medical Research Council, while the policy of this Committee was implemented in each State by a Therapeutic Trials Committee, which approved local issues.

The Commonwealth X-ray and Radium Laboratory had been established in 1935, after taking over from the Commonwealth Radium Laboratory. In 1972 the Laboratory became known as the Commonwealth Radiation Laboratory, which was itself renamed the Australian Radiation Laboratory the following year.

Over the years, the Commonwealth X-Ray and Radium Laboratory provided invaluable services, including control and supply of radioisotopes, and latterly radiopharmaceuticals for invitro, invivo and imaging studies.

A number of changes were made to these services following a 1977 review of its functions.

New and revised activities had placed more emphasis on research and development in the public and occupational health fields of ionising radiation, radioactive substances, microwaves and lasers. With the implementation of these revised functions the Laboratory wound down some of its traditional service activities, including procurement and distribution of radiopharmaceuticals, which were transferred to the Australian Atomic Energy Commission (AAEC) and to private industry from January 1978.

The Government decision to cease the free issue of radiopharmaceuticals, a service which the Laboratory had provided to Australian users since 1946, also came into operation in the same year. The main reasons for ending the free supply policy were that the aim of fostering the development of the use of radiopharmaceuticals for medical diagnosis and treatment had been achieved, other equally life-saving and diagnostic materials are not supplied free, and free issue prevents effective control, discourages commercial competition and limits freedom of choice.

In other changes, the Laboratory was no longer responsible for the care and maintenance of Commonwealth radium containers not retained within the Laboratory, or for the operation of a radon service. Users of these radioactive substances were advised of the change. Also in 29

1978, the AAEC arranged for radon to be replaced by gold-198 mounted in similar form to radon containers and issued these containers.

Australia’s first use of I-131 for Thyroid Function Tests Measuring levels of radio-iodine present in the thyroid gland over time following administration, and its rate of excretion in the urine, was suggested as a suitable indication of thyroid function. To determine the most satisfactory criterion, a number of studies relating to a series of patients were investigated and correlated with evidence of clinical examinations and estimations of protein-bound iodine. Analysis of results indicated that the initial portion of the iodine-uptake curve was of most significance in distinguishing between the various functioning states of the thyroid. The value of an index deduced from this part of the curve was found to give a satisfactory indication of the condition of the thyroid.

In May 1948, a small amount of radioactive iodine (I-131) was received in Melbourne.

Arriving at short notice, a Geiger-Muller tube was hurriedly set up and calibrated by Commonwealth X-Ray & Radium Laboratory staff for the first quantitative estimations of the amount of radioactive iodine in a patient under conditions of a tracer test study. Dr Kaye Scott, Honorary Radiotherapist at Royal Melbourne Hospital, in the company of Dr Hal Oddie of the Council for Scientific and Industrial Research were then the first to use radioiodine to measure thyroid function in patients within Australia.

A Thyroid probe installed at the Peter MacCallum Cancer Centre Perhaps this work by Kaye Scott and Hal Oddie could have been much earlier as the initial shipments of two samples of I-131 wandered about the Pacific on cargo steamers for such a length of time that almost complete decay of activity had occurred before the samples were delivered to Australia. However, what did arrive in these misplaced shipments was put to good use on arrival by Hal Oddie for calibration purposes, making the first tracer tests in humans so successful.

During the three year period that followed, 208 such ‘tracer’ studies of thyroid functions were carried out on patients at the Royal Melbourne Hospital. In addition, data for 132 tracer 30

studies were also carried out at the Launceston General Hospital by Dr John Grove who was working closely with the Melbourne group of Scott, Oddie and Eddy.

Neck and thigh Geiger-counter for iodine-131 thyroid uptake measurements

During those investigations, the advantages of various types of physical measuring equipment were examined. A new apparatus was designed and constructed in the laboratory, which enabled the measurement of thyroid retention and renal excretion of radioiodine to be made more quickly and accurately.

From 1950, Kenneth H. Clarke worked on a combined research project carried out by the Commonwealth X-Ray and Radium Laboratory (CXRL), the Royal Melbourne Hospital (RMH) and the Department of Biochemistry, University of Melbourne, into the use of radioactive iodine (I-131) in the study and treatment of disorders of the thyroid gland.

Ken Clarke recently advised that he had joined the Australian Radiation Laboratory ARL (or CXRL as it was known then) in January 1950. Having moved from London, he was put in charge of the radioisotope laboratory and worked with Dr Hal Oddie (officer in charge of the Tracer Elements Section of the CSIR) who was also partly seconded to CXRL. Clarke also worked with Jean Milne and Dr Kaye Scott at Royal Melbourne Hospital on thyroid studies.

As the tracer and therapy I-131 work developed at RMH, physicians Dr Keith Fairly and Dr Bill King became involved in patient management.

From this association, Ken Clark presented his Master of Science thesis, ‘The physical problems involved in the use of radioactive iodine I-131 in the study and treatment of thyroid disorders’, to the University of Melbourne. His work was the basis for the development and introduction of new thyroid counting equipment, which was installed in the Royal Melbourne Hospital in July 1952 and in the Launceston General Hospital in late December 1952.

The majority of research on the development of instrumentation, measuring techniques, radiation dosimetry and clinical evaluation of thyroid disease processes was coming from Melbourne; and particularly through combined research teams from the major hospitals and institutions.

31

On 5 March 1952, a symposium was held by the Victorian Branch of the British Medical Association at the medical hall in Albert St, East Melbourne, on the subject: ‘Radioactive Iodine and Thyroid Disease’. From this symposium, there would appear to be no doubt that both the introduction of new counting equipment and autoradiographic studies of the concentration of radioactive iodine I-131 in thyroid tissue in histological sections removed at surgery were stimulated by the report published in The Medical Journal of Australia on 19 July 1952.

Dr Basil Beirman was the first radiology registrar to be appointed. He was a very bright student from Sydney and is reputed to have had a great sense of humour. In 1979, Dr Beirman wrote of his involvement with radiotherapy and associated functions in 1952: Certainly I played with thyroid tissues as I mentioned to you, utilising material removed at surgery following immediately previous tracer doses of radio-active iodine. These autoradiographs were carried out in the clinical photography department which was virtually an appendage of the X-ray Department. We stained the tissues and tried to correlate blackening of the emulsion, due to the isotope, with acinar morphology. This passing interest was never carried out very seriously, nobody else was really interested in it and it just died-off 8 for lack of time and interest.

Ken Clark further recalled early days in the evolution of radioisotopes in both Melbourne and Launceston: I left CXRL in May 1964, to join the physics department at Peter MacCallum Clinic under Dr John Martin and my first task was to establish a Radioisotope Unit (the term used then – not Nuclear Medicine) at PMC. I believe Jean Milne had moved down to PMC from the RMH when the RMH Radiotherapy Department effectively transferred to PMC and she became involved in the establishment of the Radioisotope Unit as well.

Dr John Grove had been pursuing I-131 diagnostic tests in Launceston and, in 1956, he invited me to advise on the establishment of a more detailed Radioisotope Unit at the Launceston General Hospital.

In 1958, Jean Milne and I were involved in the establishment of Nuclear Medicine departments at Prince Henry Hospital and with Ray de Groot at St Vincent’s Hospital and later, in 1962, at the Royal Children’s Hospital. The doctors involved were Dr Bryan Hudson at PHH, [and a doctor] at St Vincent’s and, a little later, Dr Les Dugdale at the Alfred Hospital and Dr Leon Taft, a haematologist, at the Royal Children’s Hospital.

Diana Harrison (Sheldon) was the first radiographer at PHH and Wendy North (Kelsall) at St Vincent’s Hospital. Both were diagnostic radiographers who were recruited for the specific positions and went through a training period at Peter MacCallum Clinic provided by Ken Clark 9 and Jean Milne.

Australian Atomic Energy Commission Set against the early 1950s backdrop of cold war paranoia and fear of Asian aggression, and under the leadership of Sir Robert Gordon Menzies, the Australian Government established the Australian Atomic Energy Commission. This was a by-product of the strong liaison between Menzies (a great Anglophile) and the British Government and a strong belief of Prime Minister Menzies that the defence forces of Australia would inevitably be armed with nuclear weapons. Recent releases of defence-related documents have revealed 32

extraordinary insights into the mistrust held by Australia, not only of its potential enemies, but also of its allies. They reveal both a country fearful of its future and a belief that battlefield nuclear weapons were the answer to Australia's defence needs.

The harnessing of nuclear energy in Australia for peaceful purposes began in 1953; and the purposeful ‘growth’ phase lasted for about 30 years. But, from the mid-1980s onwards, community perceptions of the technology have been shaped by ‘green’ activism, poor education and a largely media-generated preoccupation with societal risks.

The Australian Atomic Energy Commission, established under the Atomic Energy Act 1953, was responsible to a minister of the Crown (although which minister was not specified in the Act and it changed periodically, being the minister for supply in 1953). The AAEC was assigned three main areas of responsibility: • • •

Uranium exploration, mining and treatment, Construction and operation of plant and equipment for the liberation of atomic energy and its conversion into other useful forms of energy, and Research and training of researchers, including publishing reports and provision of information on uranium and atomic energy.

The commission was required to co-operate with states that had exploration and development programs for uranium. The second and third areas led to the AAEC establishing a major research laboratory and bringing together a nucleus of expertise in nuclear physics, chemistry, engineering and administration. An important part of this research laboratory, the ‘High Flux Australian Reactor’ (HIFAR), achieved criticality on Australia Day 1958. Then Prime Minister Robert Menzies officially opened the AAEC's research establishment at Lucas Heights on 18 April 1958, attended by about 900 staff and guests.

In his opening speech, Menzies said: One of our great tasks is that we should keep ourselves abreast of developments in the world.

We should keep ourselves abreast of scientific research and scientific discovery, and develop in Australia not only great plants, not only great buildings, machinery and technical equipment, but at all times produce more and more people highly trained scientifically for this purpose. This is first and foremost a research establishment and one of its results will be that we in Australia will be scientifically and technically equipped to take advantage of the best that there is in the world, whether that best comes from older and larger and richer countries 1 or from our own.

Introduction of Hospital Nuclear Medicine Departments The first radioisotopes were imported into Australia in 1946; and regular deliveries of radiophosphorus began in September 1947. The first of these shipments, 20 mCi of P-32, went to the Commonwealth X-Ray and Radium Laboratory (CXRL) headquarters in Melbourne, where it was divided into three therapy doses, two for Launceston and one for Perth.

In 1947, Hal Oddie from CXRL and Dr Kaye Scott initiated radioactive iodine-131 uptakes at the Royal Melbourne Hospital. The following year, the NSW Bureau of Physical Science seconded physicist Bernard Scott to support the thyroid investigation unit at Royal Prince Alfred Hospital. Tasmania, Queensland and South Australia soon followed. However, it was a close liaison between the Royal Melbourne and Launceston General Hospitals that saw a 33

heavy preponderance in both I-131 therapy and diagnostic I-131 studies. It was not until 1952 that I-131 therapy was given in NSW and South Australia.11 Royal Prince Alfred Hospital lays claim to being the first in Australia to establish a fullyfunctional and independent Department of Nuclear Medicine. Prior to its establishment, a radioisotope laboratory which had been established within the school of medicine at Sydney University by Professor CRB (Ruthven) Blackburn, was transferred to RPAH in 1964. At this time, Dr Jim McRae was its first director.

Royal Prince Alfred Hospital (RPAH) had been named after Queen Victoria's second son, His Royal Highness Prince Alfred, later Duke of Edinburgh. During a visit to Australia in 1868 Prince Alfred was the victim of an assassination attempt while on a picnic in the now northern Sydney suburb of Clontarf. Australians opened a public subscription fund to build a hospital as a memorial to his safe recovery. The prince authorised his coat of arms to be used as the new hospital's crest. King Edward VII granted the hospital its Royal prefix in 1902.

RPAH Registrars & Overseas Posts (not in strict chronological order) Millicent Marian Tony Walker (Johns Hopkins University) Andrew McLaughlin (University of Chicago) Fred Lomas (Johns Hopkins University) Peter Valk (Donner Laboratory, Berkeley) Ernest Crocker (University of Pennsylvania) Michael Yeates (Upstate University, New York) John Booker Tony Booth (University of Chicago) George Bautovich (University of Chicago) Peter Graham Ian Brittain Len Allen Phil Tan Judy Freund Sharyn Purssell (Royal Marsden Hospital, London) Monica Rossleigh (Memorial Sloan Kettering Cancer Center, NY) Barry Flynn (Harvard Joint Programme in Nuclear Medicine) Patrick Butler (Columbia–Presbyterian NYC) Richard Quinn (Columbia–Presbyterian NYC) Robert Dickenson Rahul Patel Paul Roach (Harvard Joint Programme in Nuclear Medicine) Socrates Angeledes Michael Magee Roger Uren (Harvard Joint Programme in Nuclear Medicine & Beth Israel Hosp).

Robert Howman-Giles (Hospital for Sick Children, Toronto) Reginald Hutcherson Andrew Southee (Harvard Joint Programme in Nuclear Medicine) Fred Khafagi John Chu (Royal Marsden Hospital, London) Vivian Fernandez

34

Kevin Allman (University of Michigan Ann Arbor) Stuart Ramsey (Hammersmith Hospital, London) Rob Greenough (University of Michigan Ann Arbor) Ken Lee (Washington University, St Louis) Kien Lee (University of Michigan Ann Arbor)

Since the 1950s, RPAH has developed training and research collaborations with leading centres of nuclear medicine abroad. In 1983, these collaborations were extended to include those departments with cyclotrons and PET facilities. From 1983 -1992, RPAH staff studied PET organisational and management systems of leading overseas PET centres and established collaborations with the following institutions: MRC Cyclotron Unit, Hammersmith, London, UK Division of Nuclear Medicine, University of Michigan, Ann Arbor, USA Division of Nuclear Medicine, University of California, Los Angeles, USA National Institutes for Health, Bethesda, MD, USA Brookhaven National Laboratory, Upton, NY, USA Mallinckrodt Institute, Washington University, St Louis, MO, USA Washington University, St Louis, MO, USA The Johns Hopkins Medical Institutions, Baltimore, USA Duke University Medical Centre, North Carolina, USA Sloan Kettering Memorial Hospital, New York, USA Karolinska Institute, Stockholm, Sweden Uppsala University PET Centre, Uppsala, Sweden Service Hospital Frederic Joliot, Orsay, France Division of Nuclear Medicine, KFA, Juelich, Germany University of Akita, Akita, Japan.

The RPAH technologists, scientists and physicians who trained in PET at many of these centres facilitated further collaborations and exchanges with these institutions which continue to take place. Over $600,000 worth of scholarships and fellowships were awarded by leading overseas centres to RPAH nuclear medicine staff. Locally, most grants made for overseas study were provided by the NSW State Cancer Council. Two Churchill Fellowships and two Queen Elizabeth II Trust awards were granted to technologists to train overseas.

Professor Terry Jones, Co-Director of the MRC Cyclotron Unit at Hammersmith Hospital, London, commented at the time that “surely, this must be the best prepared and trained PET centre to date ever to be established�. At one stage in 1992 there were around eight expatriot Australians connected with RPAH spending time visiting or working at the MRC Cyclotron Unit and this prompted a visit from the Australian High Commissioner to the UK of the time, the Hon. Doug McClelland AC, to pay a special visit to understand what all the excitement was about.

The period 1975 to 1985 at RPAH was characterised by a very rapid innovative expansion of nuclear cardiology in which the principal people in nuclear medicine were George Bautovich and his physician colleagues; in physics, Brian Hutton and his colleagues, and in cardiology David Kelly, Scandrett Professor of Cardiology.

They developed innovative physical methods including sophisticated and original computer based analyses which were not only published and adopted by overseas nuclear medicine 35

units but also adopted by manufacturers of gamma cameras. Later, when adequate computer facilities became available, the clinically-orientated physicist, Brian Hutton, formulated unique algorithms which allowed bedside studies to be carried out.

The first mobile gamma camera, an Ohio Nuclear Mobile was purchased at Royal Prince Alfred Hospital, Sydney Ken Lee FRACP FCSANZ, of Melbourne, recently wrote: In the 1980s, RPA stood alone as the best nuclear medicine facility in the country and, I believe, one of the best in the world. It had both the equipment and the people. A camera [gamma] in the coronary care unit was unprecedented, allowed clinical and research studies early in acute myocardial infarction, and created a unique relationship between cardiology and nuclear medicine. A mobile scanner opened up a new range of clinical opportunities especially in intensive care patients.

Cardiology replaced liver and lung scanning as the dominant theme of the nuclear medicine department.

Earlier, mention was made of clinical studies carried out in the 1960s of pulmonary blood flow changes in patients with asthma and other studies demonstrating pulmonary embolism.

In the present period major contributions were made into the relationship between the size of aerosol particles and their distribution in the airways – there were important clinical 36

applications. A collaborative group was formed consisting of physiologist Sandra Anderson DSc of the thoracic medical unit at RPAH, respiratory physician Dr Peter Bye, pharmacologists and George Bautovich and Dale Bailey from nuclear medicine. A technetium colloid was used to determine the initial distribution and subsequent movement of inhaled particles by cilia within the bronchial tree. Dr Anderson subsequently patented methodology using mannitol in similar studies for routine clinical use (Bronchitol®, Pharmaxis). A number of important publications resulted from this work.

A most important development in the 1970’s, which became even more important in the 1980s and 1990s, was the expanding involvement of physicists, at first, chiefly at AAEC and then at RPAH, in all of the activities of the nuclear medicine department: instrumentation, computation, methodology, education and, especially, originating practical ideas and problem solving. The physicists became fully-integrated members of the nuclear medicine team and, as a result, they had a clinical orientation and a special interest in patient studies.

The physicists at RPA in 1990 from left to right: Roger Fulton, Dale Bailey, Brett Jackson, Helena Surova (visitor from Czechoslovakia) and Steve Meikle There was fluent communication between clinical and physics groups, which facilitated major cutting-edge developments. The physicists not only assisted in the development of clinical investigations, but were also responsible for many important advances which led to major innovations exemplified by the studies in cardiology and respiratory medicine. They played a pioneering role in identifying and producing algorithms which could be applied immediately in clinical situations. Nuclear medicine as a clinical discipline changed as diagnostic opportunities increased and emerging uses of isotopes could now be identified (eg. Tc in gated heart pool studies, rather than ultrasound or CT).

J. Cormack MSc was the first physicist formally to be part of the nuclear medicine team. He took over from Bernard Scott, whose formal appointment was in radiotherapy. Cormack was joined, and then succeeded, by Brian Hutton PhD, who remarked, “He threw me into the deep-end right from the start. Two weeks after I arrived, in 1975, he sent me to Paris to decide which computers were to be used by RPAH nuclear medicine”. The presence of joint appointments (with ANSTO, CSIRO and the strong group in Wollongong University) continued to attract other high-quality physicists to RPAH. 37

The group was disbanded in 1992-1993 when the ‘hub’ moved briefly to Westmead Hospital.

But the quality of the physicists in this group was attested to by the many letters sent to them from world authorities after their dispersal and by their careers after disbandment. Brian Hutton is now professor of medical physics and molecular imaging science at the University College London Hospital. Dale Bailey PhD (RPAH 1983-1993) is now head physicist at Royal North Shore Hospital and professor in medical radiation sciences at the Faculty of Health Sciences, University of Sydney. Steven Meikle PhD (RPAH 1988-1994) is now codirector of the Brain and Mind Research Institute and associate professor of medical radiation sciences (head of imaging physics and bio-modelling research group) at the University of Sydney. Roger R. Fulton PhD is Associate Professor in medical radiation Sciences at the University of Sydney and working at Westmead Hospital, after spending time at KFA, Juelich, Germany, where he has been invited back on numerous occasions since; and Stefan Eberl BE MSc is now principal scientific officer RPAH. This group also produced a most stimulating environment for nuclear medicine registrars in training, as well as for nuclear medicine physicians, so that excellent research was done and published. It became recognised that opportunities to do good work were available at RPAH and these opportunities were taken. Roger Uren once commented, “I remember the first time I met Jim Adelstein, at Harvard in 1975. He complimented me on an abstract I had presented at the ANZSNM meeting on the use of Bayes’ theorem to analyse the results of liver scans to diagnose cirrhosis. This was suggested to me by John Cormack, one of the physicists at RPAH nuclear medicine at the time.”

The concept of a central cancer institute was the brain-child of Roy Douglas (Pansy) Wright, Peter McCallum and Dr Kay Scott who became the first director of Peter MacCallum Clinic in 1949. In an interview broadcast on Radio National in 2000, Sharon Carleton profiled one of Australia's most influential men of medicine, Pansy Wright. In this interview, Dr Tom Sanderman, a former Director of Radiation Oncology at the Peter McCallum Cancer Institute in Melbourne, said: The first idea was presented to the government in the 1930s. By 1943, New South Wales had brought out two very eminent radiation oncologists, Ralston Patterson and his wife Edith to advise them on the setting up of a cancer institute. Kay Scott and Pansy got them to come down to Victoria and have a look at the situation in Victoria. NSW never went ahead with the idea of a central cancer institute, but Victoria – God bless them – did have that report in front of them.

Round about 1949 or ’50, the country was alive with people who claimed to cure cancer. One of them was an engineer in NSW. It was shown to be a complete and utter fraud. It was the injection of alum into the cancer, which was appearing on the surface and, of course, the alum made the thing slough off and it made it look very much better. But it didn’t cure the thing. Pansy had written to the papers saying that this was so much nonsense, because the Minister of Health at the time had said this sounds like a very good cure, we’ll get him to come down to Victoria.

Pansy wrote and said you already have a report saying that we should have a cancer institute, why don’t you get on and do something about it; and, within 24 hours, the Minister 12 had in fact replied to that to The Age.

38

When radiotherapy services transferred from the Royal Melbourne Hospital to Peter MacCallum Clinic, so did the staff and expertise of Dr Kay Scott and Miss Jean Milne (a trained radiotherapy radiographer). Jean was instrumental in the day to day activities in the progress being made in the development of radioactive iodine and the diagnosis of thyroid disease processes, along with what had, by then, been established for the treatment of blood disorders with radioactive phosphorus. She was, perhaps, one of the first radioisotope technicians in Australia. At the Royal Melbourne Hospital, as there was no fixed laboratory associated with the radioisotope studies, she found herself collecting radioactive urine samples on one floor then transporting them to another floor to the laboratory for measurement and, finally, to a third level for storage. She was affectionately known amongst the hospital staff as ‘The Red Hot Momma’.

The first administrations of radioactive phosphorous were recorded by the Launceston General Hospital on 15 September 1947, by Dr W. P. Holman, assisted by Miss S. Welch.

Limited amounts of radio-iodine (I-131) were received into Australia in early 1948 and regular deliveries began later that year. During this time, a resolution was passed by the Tasmanian Cancer Committee (November 1948) to purchase equipment to study radioisotopes in the diagnosis of thyroid disease.

In 1942, at the instigation of Dr Clifford Craig, Surgeon Superintendent, an inpatient goitre clinic was started. Dr Alan Pryde was surgeon for the first fifty operations and Dr J. A. Newell was the physician in charge of the clinic. In June 1944, Dr Pryde published in the Medical Journal of Australia a short summary and commentary on the work during the period covering the fifty operations from January 1942 to August 1943. The clinic was formally adopted by Dr J. L. Grove on an out-patient basis in 1943. Grove’s association, initially with Dr Pryde and then Dr P. (Pip) Booth, continued for many years, heralding the development of radioisotope investigations and treatment of thyroid disease in Northern Tasmania.

Dr John L. Grove, in association with Dr Pryde, sat with Drs Holman, Curruthers, Muir and Mr George Record on the State Committee (as had been established throughout the Australian States) to deal with the introduction, use and monitoring of radioisotopes for medical diagnosis and treatment. On that day, diagnostic radioisotope facilities were initiated, that would emerge in 1950 with the installation in Tasmania of the first Geiger Counter System, in a small cottage located where the present boiler house stands today on the site of the old Launceston General Hospital.

Miss Welch became the first technician to conduct radioisotope investigations in the diagnostic evaluation of radio-iodine (I-131) uptake in the thyroid gland. For two years, she attended patients referred by Dr Grove (Thyroid Clinic), performing thyroid uptakes in that same cottage that was affectionately known as ‘Geiger Cottage’. Selections of case histories during the early 1950s note the administration of diagnostic and therapeutic doses of radioactive iodine at ‘Geiger Cottage’.

In 1952, by arrangement between the states of Victoria and Tasmania, all radiotherapy was controlled by a Cancer Institute Board established by a Victorian Act. Miss Welch (later Mrs Kennedy) transferred automatically to this organisation with the status of Senior Radiotherapy Technician in Tasmania. Methods of work in some respects were altered and new personalities became her associates.

39

In March 1954, after an extensive career in the field of diagnostic radiography, a Tasmanian pioneer in technical aspects of radiotherapy and radioisotopes, Mrs Kennedy resigned to become a housewife and mother residing in Launceston.

On 13 March 1954, ‘The Examiner’ reported: ‘Radiotherapist Is Farewelled’. “The doyenne of radiotherapy technicians in the state", is how Dr W. P. Holman yesterday described Mrs Geoff Kennedy who has retired from the staff of the Peter MacCallum Clinic at the Launceston General Hospital after service since 1939’.13 An interview with Mrs Kennedy by the Queen Victoria Museum and Art Gallery ‘Launceston Talks - Oral Histories of the Launceston Community’ was published in 1990 by Regal Publications, Launceston.

Miss Sue Welch and Dr Basil Beirman at Geiger Cottage, Launceston General Hospital (mid 1950s)

Tracer techniques were not started in WA until 1956, when the purchase of NaI(Tl) PM probes and well-counters in Royal Perth Hospital allowed I131 uptakes to be performed in the department of biochemistry under Professor Curnow. This was soon followed by Cr51, Fe59 and Co57/58 tests done in Haematology by Dr Pitney. In 1960, the department of medical physics was formed under Bob Stanford to perform all diagnostic and therapy radioisotope tests.

Dr Michael Quinlan was researching for the department of medicine using Selenomethionine Se75 to image the pancreas (in both animals and patients). The initial installation of the Picker scanner was not an unqualified success. Dr Quinlan recalls: "The resolution was not as good as I'd hoped. Then I realised that there was no shielding around the crystal!"

The Picker scanner, once properly shielded and in working order, opened up a whole new world of organ imaging, including I131 albumen lung scanning, Au198 liver scanning, Strontium85 bone scans where patients had to have enemas (to reduce the radiation burden and clear bowel activity), and Hg197 chlormerodrin brain and renal scans, all of which were performed during 1965.

40

Dr Quinlan then went overseas to work in John Hopkins with Dr Henry Wagner for two years.

At that stage, nuclear medicine was still in its infancy and the applications of imaging Technetium99m were not apparent. However, Hal Anger persuaded Henry Wagner to trial his gamma camera (first described in 1958) and the advantages of gamma cameras over scanners were demonstrated; and a new era of nuclear medicine began.

Searle Large-field-of-view (LFoV) gamma camera (c.1980) Much of the early research into radiopharmaceuticals was done at Brookhaven National Laboratory in New York. Bob Fleay who was then the head therapy radiographer at RPH, won a Churchill scholarship to work at Brookhaven for two years and was involved at the cutting-edge of radiopharmaceutical development. On return in 1967, his paper on the applications of Technetium99m was the winning paper out of the 100 fellowships. By 1968, Technetium generators were available all over Australia and in Perth. Bob continued to develop Tc99m radiopharmaceuticals on his return including the first in-house Tc99m MAFH. Nuclear Medicine in WA had initially been run along the UK model, under physicist Bob Stanford, but Michael Quinlan felt the time had come for more clinical interpretation of the scans. Reports stating that there were four dots in the left lobe and one in the right were not very helpful without the clinical interpretation (many have said that the scans were not very helpful).

41

Pertechnetate brain scan and lung perfusion scan using rectilinear scanner In 1969, Quinlan set up a separate nuclear medicine department with Perth's first Anger camera, a Nuclear Chicago Pho II as well as the Picker rectilinear scanner. He also started the department at Sir Charles Gairdner Hospital, in 1970, with a dual-head Ohio rectilinear scanner and four staff. Running two nuclear medicine departments was too demanding even for the most dedicated workaholic.

In 1972, Dr Ivor Surveyor was appointed assistant physician at RPH and head of nuclear medicine in 1973. He worked with technicians Robin Jolly (WA's first nucleographer, who started in 1967), Cheryl Robb, Helen Stretch, Carol Blackwell and Jean Grieve. Dr Surveyor had extensive experience in the UK, having done his MD thesis on whole body counters and training in nuclear medicine in Leeds with the late Dr Clive Hayter, one of the pioneers of nuclear medicine in the UK. In those days, the nuclear medicine department was situated in the basement of the oldest part of RPH. ‘State-of-the-art' technology was performed in Dickensian surroundings. This ambience, combined with the rattling pace of the dual-head Magna Scanner whizzing across the patients a whisker from their nose, must have reduced them to an extremely docile state.

Much later, in 1987, when the floor had to be reinforced for the new Siemens cameras, newspapers were found under the wooden floorboards dating back to 1896 – coincidently, the year Henri Bequerel discovered natural radioactivity of uranium. The newspapers are now in the RPH museum.

Dr Quinlan, known as the ‘father of nuclear medicine' in WA, was the state's first nuclear medicine physician in 1965, and was instrumental in the training of and obtaining positions for new registrars in nuclear medicine. Drs Fred Lovegrove, Agatha van der Schaaf and Harvey Turner began their training at RPH, eventually moving on to become departmental heads at Sir Charles Gairdner and Fremantle Hospitals. Throughout the 1970s and ‘80s nuclear medicine expanded rapidly in WA. Nuclear Medicine in the ACT began in the 1970's at The Royal Canberra Hospital (RCH) and evolved from simple thyroid uptakes into thyroid scans with a rectilinear scanner and radioimmunoassay as a part of the commonwealth health laboratory where T3, T4 and I131 therapy doses were undertaken. Donna Crellin with a qualification in radiotherapy was 42

running the laboratory and after raising her children returned in 1986 to what was now "scanning". In 1972 Dr Fred Lomas was appointed as Director of Nuclear Medicine RCH, after having additional training at John Hopkins Hospital in the US. By 1979 the department held one of the first Digital computers, the DEC-11/34 computer which was initially hardwired to one and eventually 2 Gamma Cameras. Pam Craig was chief technologist at the time having originally worked with Fred at the Prince of Wales Hospital, Randwick, Sydney in 1974.

Woden Valley public hospital started a nuclear medicine service in 1974 with Dr Tony Booth as director and Chris Kelly, Vera Bloxham and Zora Kaspar technologists in training. In 1987, Dr Booth commenced the first private practice in Canberra operating out of John James Memorial Hospital. Bruce Quick ran this very busy private department, running the dual cameras mostly single-handedly. Bruce was also a commonwealth gold-medallist in pistol shooting. There was always a close association with the Australian Institute of Sport and elite athletes were often disappointed with the bone scan findings of stress fractures or shin splints.

In 1973, Physicist Dr Bill Burch was brought to RCH from the UK with a radiotherapy background. He noticed an interesting physics article on a new imaging technique called Ultrasound. He encouraged Dr Lomas to pursue this novel technique and purchased possibly the first 8 transducer unit (Octoson) in Australia. The Nuclear Medicine department then commenced cross-training into this non-ionising modality which took off with great interest. Real-time ultrasound enhanced this modality and then interventional ultrasound made the department the hub for medical staff seeking advice on appropriate imaging and even treatment options for many clinical conditions. The RCH proudly had the "lowest-inAustralia" costs for imaging in both modalities using only 35mm black and white film and its processor with a high daily consumption.

In 1977, three technologists in training (Leonie Ashley, Karen Lindsay and Elizabeth Croft) commenced work at RCH having studied through the Royal Melbourne Institute of Technology. Chris McLaren (now Chief Technologist) arrived in 1980 and his job was to look after the computer acquired studies. "Borrowing" the latest renal and cardiac software from the extensive team of physicists at Royal Prince Alfred Hospital he brought these back to Canberra. Using a cardboard box off the computer screen and a Nikon camera colour slide film, he was able to capture all the analysis and nuclear medicine images. Chris still works at RCH having been there for over 30 years and produced a prospective longitudinal study on infants with vesico-ureteric reflux with comparison to the X-ray equivalent micturating CystoUrethrogram.

The Australian National University had a research cyclotron in the 1970's, reported to be the first cyclotron in Australia which was eventually sold to the Japanese who produced commercial thallium for export back to Australia.

Bill Burch went on to discover Technegas in around 1983-84 and its earlier brother Pseudogas. Finally technetium could be produced into gas-like properties with a particle size many magnitudes smaller than an aerosol. Pseudogas crossed the alveolar membrane and washed-out whereas Technegas was trapped in the fine airways. The lung scan images were outstanding and V/Q's became a more definitive test. The idea that inspired Bill was a true light-globe inspiration with a filament in an inert gas and a high temperature lift-off of a 43

carbon cluster trapped technetium atom. In the first clinical trial of Technegas (1985) inhalation dynamic imaging, planar and dual SPECT were acquired with Xenon comparison images. Colour images including parametric images subtracting perfusion from ventilation were generated.

At the same time RCH was performing a second clinical trial with a new technique of autologous labelled leucocytes with technetium. Ross Hanna had returned from his sponsored training in New Mexico with a Radiopharmacy qualification. The test proved useful especially in detecting active infection and inflammatory bowel disease even with asymptomatic patients. Ross later went on to develop "in-house" a variety of radiopharmaceuticals including DMSA, MDP and Colloid. In the late 1980's Ross established his own private company, RADPHARM Scientific in Belconnen, ACT producing radiopharmaceuticals for Australia and beyond. Ross was awarded life membership of the ANZSNM in 2010 for his service to the nuclear medicine profession.

Dr Lomas commenced his ultrasound private practice in the mid-80's and later added nuclear medicine. He shared this with Dr Paul Sullivan who replaced Dr Booth at Woden Valley who was now full-time in private practice.

With an ACT government decision the abrupt closure of RCH was announced with an amalgamated Woden and Royal hospitals in 1990. The resulting merged hospital was quite amusing with an identity crisis, letterheads changing almost monthly. Finally, "The Canberra Hospital" was the final nomenclature for the campus at Woden Valley which was now undergoing rapid building extensions. This made it the one stop-hospital with "the-lot", from paediatrics, major trauma, surgery to geriatric and oncology. In the amalgamated hospital, Nuclear Medicine was engulfed into an "integrated" Medical Imaging department with a common reception and limited rostered ancillary support from nursing. This made the nuclear medicine section a relatively small part of medical imaging and the radiopharmacy section closed in 2008 making way for the installation of a dedicated PET unit in 2010.

Private practice was flourishing in the 1990's with 5 departments established under 2 groups. Guy Fairbairn (Chief Technologist, Canberra Imaging Group) ably managed his troops in 3 practices. The National Capital Diagnostic Group absorbed the Dr Lomas practice.

The Australian Atomic Energy Commission (AAEC) Originally, Australians requiring radiation therapy, if they could afford to, needed to seek such treatments overseas. In 1928, the Australian Government considered that life-saving treatment being available only to the wealthy was intolerable; and, consequently, decided to purchase 10 grams of radium-226 (around $4M in current day values) for clinical purposes.

A national radon-222 bank was established on 1 June 1929 in the campus of Melbourne University. This facility, the Commonwealth Radium Laboratory, was later to evolve into the Commonwealth X-ray and Radium Laboratory (CXRL) and then finally into the Australian Radiation Laboratory (ARL). Operation of the radon bank was subsequently expanded into a more general service to provide and distribute a range of therapeutic radiation devices.

The first medical use of a man-made radioisotope (as opposed to the natural radioelements that could be separated from radium) occurred in 1944. US Services medical officers, stationed in Brisbane, imported quantities of phosphorus-32 from the USA to treat blood 44

disorders in 19 servicemen patients. After the war (1946), trial shipments of phosphorus-32 were acquired by CXRL from the USA, but attempts to extend the service beyond these, and to include iodine-131 and sulphur-35 shipments, failed because there were no official mechanisms through which the US authorities could export these substances to Australia.

In 1947, the National Health and Medical Research Council (NHMRC) established a Standing Committee on Radioactive Isotopes to coordinate research in the therapeutic use of radioisotopes and their application in tracer studies. In September of that year, President Truman announced that the US Atomic Energy Commission (USAEC) would entertain requests for radioisotopes from other countries, providing they were capable of handling them safely and effectively. However, it was specified that all such requests had to be channelled through a central procurement agency in each requesting country.

With the necessary infrastructure already in place, Australia then took the opportunity to obtain regular consignments of phosphorus-32 and iodine-131. Delivered to CXRL in Melbourne these products were then distributed to each of the Australian states. However, shorter delivery times added to a relative scarcity of US dollars, eventually persuaded CXRL to switch their supply source to the United Kingdom Atomic Energy Authority (UKAEA).

CXRL became consolidated as the sole national authority for the importation of medical radioisotopes into Australia.

The Australian Government decreed that no patient would be charged for radioisotopes used in ‘well-established clinical procedures of diagnosis and therapy’. Such costs were borne, firstly, by the Australian Department of Health and, subsequently, by the National Welfare Fund. In 1953, the Australian Atomic Energy Commission (AAEC) was created with an interest, inter alia, in researching the potential benefits of domestic radioisotope production.

CXRL and the AAEC cooperated to formulate a new policy for the procurement and distribution of radioisotopes. It was agreed that CXRL would maintain its authority to regulate and supply radioisotopes to all medical applications and the AAEC would focus its attention on servicing the industrial and non-medical markets.

With the logistics of supply apparently settled, the medical use of radioisotopes increased rapidly in Australia, particularly in diagnostic areas and, as a result, CXRL encouraged the AAEC to employ its developing technological competence in areas where an outcome could be the replacement of imported medical radioisotopes by domestic equivalents.

In 1961, CXRL gave the AAEC the right of first refusal on the supply of all radioisotope products needed in medicine. This produced a burst of research at Lucas Heights, which resulted in a much wider inventory of products. By 1977, the AAEC was supplying 95% of the 25,000 consignments distributed annually to Australian medical institutions.

During this development period, the AAEC supplied radioisotopes to the medical market only on the authority and explicit direction of CXRL. With the medical demand progressively moving into shorter half-life radioisotopes, more and more consignments were made directly from Lucas Heights to the medical user, largely eliminating CXRL’s role as a distributor.

Consistent with this change in supply policy, the AAEC had to assume certain regulatory responsibilities to ensure that recipients were appropriately licensed to hold and use the products it had supplied.

45

For those radioisotopes not produced at Lucas Heights, the responsibility for import remained, as before, divided between CXRL and the AAEC. However, on 1 January 1978, two Australian Government Acts of deregulation came into force. Firstly, it was decided to discontinue CXRL’s radioisotope supply role. This was to be left to the AAEC and local agents of foreign radioisotope suppliers to compete openly for the Australian market.

Secondly it was decided to discontinue the free issue of medical radioisotopes.

Despite this apparent commercialisation of radioisotope supply, there were many regulatory matters left in place to control usage. For example, radioisotope products intended for medical use had to be approved and licensed by the Australian Department of Health before they could be offered for sale. Where clinical trials were involved, they could only be performed according to the standards of the National Health and Medical Research Council; and they had to follow the protocols of the Therapeutic Goods Administration.

AAEC/ANSTO’s Role in the Development of Nuclear Medicine The Australian nuclear reactor, HIFAR, commenced making medical radioisotopes in 1960.

Initially, these activities were confined to the production of cobalt-60 for teletherapy sources.

The first contained 2,600 curies cobalt-60 and was delivered to St. Vincent’s Hospital, Sydney, in November 1961. Then, solutions of sodium-24 (half-life 15 hours) were supplied for medical research.

In 1962, a four-fold increase in demand for short-lived radioisotopes occurred. But, after substantially expanding its production capacity, in 1964, a restriction on the supply of these preparations was forced upon the AAEC, due to the Therapeutic Substances Regulations requiring all parenteral injections to be sterility-tested before release. The time taken to complete a standard sterility test often exceeded the useful life of the short-lived radioisotope; hence the regulation effectively precluded their manufacture. As a result, the AAEC discontinued supply of short-lived radioactive injections in January 1964, until the problem of sterility-testing could be overcome.

The AAEC then set about establishing comprehensive testing programs for the shorter-lived products in anticipation of the trends that were already happening in Europe and North America. By July 1965, the AAEC was able to recommence the preparation of intravenous radioisotope injections in full conformity with Pharmaceutical Substances Regulations. A five-year plan (1965-1970) was developed to include several new products of phosphorus32, iodine-131, mercury-197 and fluorine-18. In 1967, new radiochemical production laboratories were commissioned.

The completion of the new facilities coincided with the world-wide excitement that was occurring about the diagnostic images being produced by the gamma camera and the immediate need for yet another short-lived radioisotope, technetium-99m (half-life 6 hours).

Research conducted at Lucas Heights uncovered a novel large-scale method for producing technetium-99m from its relatively cheap parent radioisotope, low specific activity molybdenum-99. This provided the AAEC with the ideal opportunity to mount a daily ‘milk run’ of ready-to-use pharmaceutical preparations of technetium-99m to an expanding number of nuclear medicine centres in Sydney.

46

An alternative source of technetium-99m, commonly used in other parts of the world, was the Technetium Generator. This was a device containing expensive high specific activity molybdenum-99 (half-life 66 hours) that was delivered weekly to each nuclear medicine department and required a technician to chemically separate the technetium-99m and then convert it into the appropriate pharmaceutical formula(e); and this to be done under aseptic handling conditions.

While the Sydney centres were served with ready to inject technetium-99m preparations, the nuclear medicine centres in the other Australian cities initially relied upon imported Technetium Generators. In 1968, the AAEC produced its own prototype generator.

In 1969, the AAEC completed the development of iodine-131 production and then began regular deliveries of clinically-useful amounts of fluorine-18 (half-life <2 hours) to Sydney, Melbourne and Adelaide. By 1970, sufficient research had been completed at Lucas Heights to increase the range of technetium-99m products regularly available to all Australian nuclear medicine centres.

Short-lived medical products (mainly based on technetium-99m) constituted 85% of all shipments from Lucas Heights. These products were delivered daily by 9:00 am to hospitals in Sydney, Melbourne, Brisbane, Adelaide, Perth, Hobart and Launceston. To sustain this service, production activities were maintained around-the-clock. The delivery system worked to very tight schedules and enjoyed a high success rate. It was undoubtedly unique at the time and did much to assist Australia achieve a prominent position in the international nuclear medicine community.

The radioisotope production techniques developed at Lucas Heights attracted the attention of the International Atomic Energy Agency (IAEA), which recognised their potential for bringing the health services of other countries more rapidly into the nuclear age.

The 1970â&#x20AC;&#x2122;s were a period of consolidation. Revenue from the sale of radioisotopes grew steadily as the scope of the service expanded. However, by the end of this decade, Australia was lagging behind the rest of the developed world in one respect. By not having a cyclotron, Australia was prevented from exploring the possibilities of positron emission tomography (PET) and had little opportunity to assess the value of a range of new radioisotopes that could only be produced by proton-bombardment. Indeed, the use of these cyclotron products in other countries had shown that the horizons of nuclear medicine could be further extended to provide an even better understanding of the biochemical basis of disease.

During the period 1979-1985, there was much debate and detailed examination on the need for a national cyclotron in Australia. These efforts culminated in August 1986, with the announcement by the Minister for Resources and Energy that the Australian Government would fund the development of a National Medical Cyclotron, to be owned and operated by the AAEC (subsequently renamed the Australian Nuclear Science and Technology Organisation â&#x20AC;&#x201C; ANSTO), but located on the campus of the Royal Prince Alfred Hospital (RPAH), Sydney.

The development was described as having two principal goals. The first goal was the production of radioisotopes, on a commercial basis, for distribution to nuclear medicine 47

departments in hospitals throughout Australia, for use in the clinical diagnosis of a wide variety of health conditions. The second principal goal was the production of very short-lived radioisotopes for use in a national PET research centre associated with the cyclotron.

First PET scanner installed in NSW at the Royal Prince Alfred Hospital (RPAH) Sydney in 1992. IN those days, an FDG brain scan being performed by Stefan Eberl would take about 20 to 25 minutes to acquire. On a modern PET/CT scanner, it can be done in 5 minutes.

Altogether, construction of facilities to house the cyclotron and laboratories (in which to process radioisotopes) took approximately five years to complete. It was finally commissioned in 1991; and, by 1995, the value of its output to be distributed throughout Australia annually exceeded $3 million.

Unfortunately, the drive to accomplish the second goal for the National Medical Cyclotron was influenced by technical changes that dramatically eased the in-hospital installation and operation of small cyclotrons. In these new circumstances, RPAH expressed its preference for a dedicated small cyclotron to be installed and operated as an integral part of the hospital’s PET diagnostic suite. Consequently, the second role for the National Medical Cyclotron was abandoned.

However, despite this minor setback, it is fair to say that, over the past almost 50 years, the AAEC/ANSTO has given outstanding support to Australian nuclear medicine through the provision of a wide service of reactor- and cyclotron-produced radioisotopes. Commitments in research, facilities and specialist manpower have indeed given Australia the opportunity to stay in the vanguard of nuclear medicine to the benefit of the whole Australian community.

The National Medical Cyclotron The decision to establish an Australian medical cyclotron was the result of many years of discussion and ‘lobbying’ by Dr John Morris AO with ANSTO and the relevant government departments.

During the 1980s, the board of ANSTO encouraged by Dr Morris, a member of the AAEC board and head of nuclear medicine at RPAH, began to place greater emphasis on the medical applications of the isotopes it produced, which resulted in two important initiatives.

The first was the creation of a medical research advisory committee, in 1986, chaired by Professor A. (Tony) Basten and composed of experts (including Dr Morris) in a range of 48

relevant fields of medicine. The committee produced a very positive report that highlighted ways in which the organisation’s unique skill-base could be utilised through interactions with hospital and university departments. The second initiative, again led by Morris, related to recognition of the need for Australia to have its own cyclotron so that the community could have access to the full repertoire of medically-important isotopes.

A working-party was established, under Basten’s chairmanship and including Morris at RPAH, to develop a brief on a national medical cyclotron for the Hawke Federal Government. This was presented to Treasurer Paul Keating and Finance Minister Peter Walsh and funding was provided in the federal budget. The cyclotron, with an adjacent PET unit, was to be located at RPAH and managed by ANSTO as a national facility. A baby cyclotron and associated PET was also funded in Melbourne.

In 1985, the establishment of the cyclotron on the RPAH campus was made possible by the very active interest of CEO Dr D. S. Child. The board of directors quickly found a site for it and Dr Morris arranged for technical, scientific and medical staff to have specialised training at overseas centres.

References 1. Bray, S. D., ‘The first use of radium needles in Australia’, Medical Journal Australia, Vol 1, p.849, 3 June, 1939.

2. Roberts, E. J. MD, ‘The therapeutic value of secondary rays produced from metal by the action of the Rontgen rays’, Australasian Medical Gazette, 13 September 1913.

3. Richardson, J. F., The Australian Radiation Laboratory: A concise history 1929-1979.

4. Sandes, F. P., ‘Report to the Federal Government of Australia’, Report of the sixth Australian Cancer Conference, 34, 1935.

5. Eddy, C. E., ‘Some recent developments in radiological physics’, Report of the seventh Australian Cancer Conference, 58, 1936.

6. Extracts from CXRL Annual Report, July 1953.

7. Queensland Radium Institute, Annual Report for the Year Ended 30th June 1946.

8. Bierman, Dr Basil, pers. corresp., 6 November 1979.

9. Clarke, Kenneth H., pers. corresp., (undated).

10. ‘Power to the People’, The Australian Financial Review, 15 April 2005.

11. Broderick, Frank L., The History of the Australian and New Zealand Association of Physicians in Nuclear Medicine.

12. ‘Portrait of a Scientist’, Transcript of interview by Sharon Carleton, Radio National broadcast, 14 October 2000.

13. ‘Radiotherapist Is Farewelled’, The Examiner, 13 March 1954.

49

Chapter 3

ADVANCES IN NEW ZEALAND The following social history of Nuclear Medicine in New Zealand is based on that penned by Dr Allan W. McArthur and first published by the ANZSNM in December 1989.1 Allan was domiciled in Dunedin and was a qualified radiologist. He became a radiotherapy registrar and from there became involved in nuclear medicine. He was perhaps the most active member of the ANZSNM in New Zealand.

Allan died several years ago; however, his legacy to the history of nuclear medicine in New Zealand is reproduced in full as a reminder of the evolution of nuclear medicine in New Zealand. From correspondence with several nuclear medicine pioneers in New Zealand, further anecdotal notes are added to Allanâ&#x20AC;&#x2122;s original work.

The following presentation endeavoured to establish the origins and subsequent growth of the regional radioisotope clinics in New Zealand, thereby complementing Dr Harry Landerâ&#x20AC;&#x2122;s publication in November 1971. The period covered is from 1950 to 1970, an era never previously recorded and one regarded as the great pioneering epoch of nuclear medicine in New Zealand, and not dissimilar to that which also occurred in Australia. In New Zealand, although medical physics services created these isotope clinics, each unit chartered its own course into the turbulent milieu of disease metabolism and structure.

Christchurch was nominated by the National Radiation Laboratory to take command of this new discipline and, in doing so, accumulated many firsts: first prescription, first laboratory and several others. Meanwhile, Dunedin was earning its share of early triumphs and the other regional isotope clinics at Auckland, Palmerston North and Wellington were quietly utilising the available isotopes compatible with their locally available equipment. Unit personnel were formed into teams to bring a safe, reliable diagnostic branch of internal medicine to patients, thus fusing numerous diverse skills with scientific knowledge.

Nuclear medicine in New Zealand began in 1948, at Christchurch Hospital, when the late Jim Campbell, a radiotherapist, prescribed oral I-131, in the same year that artificial isotopes became available in the United Kingdom.

Hosted initially by Medical Physics Services, the radioisotope clinic in each hospital has charted its own course through disease metabolism and structure, resulting in the development of a wide spectrum of clinical interest in New Zealand. Nine clinics have been established, some being more robust than others. Geographically, these clinics are widely dispersed from Auckland in North Island to Invercargill in the far south.

The period under review refers mainly to the decades from 1950 to 1970 (although some comments refer to more recent times), an era of great pioneering effort not previously recorded. The review is intended to complement Harry Lander's excellent publication of November 1971.2 It is a revised version of a paper presented to the society's Annual Scientific Meeting at Christchurch in August 1989.

50

Auckland Hospital Initial interest in nuclear medicine at Auckland Hospital was experienced in three different areas. Kaye Ibbertson of the endocrinology unit had been using radioisotopes in the radioisotope clinic at Auckland Hospital since 1954; and was the dominant actor on the Auckland scene. At about the same time, G. R. Nolan, a senior radiotherapist, had obtained an Ecko scaler, a timer and a Geiger-Mueller tube for the radioisotope clinic and was conducting a half-day clinical course in one room of the former Ward 8. Also in that year, the biochemistry laboratory acquired a sample counter and undertook labelled red cell studies vitamin B12 absorption tests. The radioisotope clinic continued to operate under Nolan's successor, Ross Burton. The work then concentrated on thyroid neck counting and thyroid uptake tests.

In 1963, Bruce White, a scientific officer who had worked first in the pathology laboratory and then in the medical unit with Royce Farrelly and John Scott on endocrine and protein research, joined the medical physics service, then led by Owen Hames. He subsequently transferred to the radioisotope clinic, now under the chairmanship of Kaye Ibbertson, who had returned from the United Kingdom at the end of 1962 and was determined to build up a prestigious radioisotope clinic. The enthusiasm of these two pioneers made the study of thyroid disease a subject of paramount interest.

Kaye Ibbertson & Staff at Auckland 1969 BACK ROW: Marjorie McDonald, Maurice Young, Gerhard Denissen, Murray John, Peter Gluckmand, Andrew Barry, Josephine Sultan. MIDDLE ROW: Gonia McDowell, Noreen ?, Tina ?, Pamela Brown, Raewyn Foster, Margaret Evans, Angela ?, Shirley Durney. FRONT ROW: Bruce White, David Scolt, Carol Horton, Kaye Ibbertson, Dr Sridhar, Ian Holdaway.

Bruce White, in recent correspondence, tells a little more about his early experiences at Auckland: I started nuclear medicine in Auckland about 1963, under the auspices of Kaye Ibbertson, Professor of Endocrinology. I had been doing haematological radioisotope tests in the main pathology lab since 1961 and the radiotherapy department was doing thyroid uptakes for endocrinology. I then joined Professor Ibbertson and, before long, had established a large

51

radioactive diagnostic lab for various pathology tests concentrating on thyroid hormones and other hormones.

We also started to perform scans and it is interesting that it was in 1965 that Jim McRae and I first performed a brain scan in NZ using Tc99m, when Jim was in Auckland at a course on radioisotopes in medicine put on by Auckland University. I think Christchurch might have been performing them before then, using other compounds and a scanner built by Jack Tait, the Christchurch senior physicist.

A hand-held counter connected to a pin-hole collimator positioned over the patient's neck, with the physicist reciting and recording the ratemeter counts, was then the method by which thyroid glands were scanned. The purchase in 1965 of an IDL dual probe scanner, complete with a colour printer and a moving bed for the positioning of patients, revolutionised thyroid scanning at Auckland.

In 1966, liver and bone scans using 198Au, 85Sr and 87mSr produced results of indifferent quality. But, in 1967, technetium -99m became available and the first brain scan was performed in the presence of Jim McRae from Royal Prince Alfred Hospital, Sydney. Now there was another revolution, this time in sensitivity. Bruce White's comment on this event was that â&#x20AC;&#x153;the advent of technetium turned unclear medicine into nuclear medicineâ&#x20AC;?.

During 1967 and 1968, reports on research studies ranging from therapy mechanisms in thyrotoxicosis, thyroid carcinoma function studies and serum calcium controlling mechanisms to radiation synovectomy, were being published by radioisotope clinic staff.

In 1968, a Picker Magnascanner with photodot output improved the quality of bone and brain scans and, because examination times were shortened, the number of patients increased from 700 in 1967 to 980 in 1968.

Between 1966 and 1970, Kaye Ibbertson and his team investigated an epidemic of thyroid disease (goitre) among the Sherpas of Nepal. Assays of blood and urine levels were done by the radioisotope laboratory at Auckland, while his expedition in the field backpacked all of the equipment needed for neck counting up the Himalayas to an altitude of 14,000 feet.

On or about 22 September 1970, Auckland Hospital Board agreed to commission an independent nuclear medicine department because the endocrinology clinic unit had by now grown into a major service employing a staff of 26, all with expanding interests in other aspects of clinical medicine.

Peter Hurley was appointed as nuclear physician in charge of the new department, pending his return from Baltimore in 1972. In the interim, the department was commanded by David Scoff, an endocrinologist recently-returned from the United Kingdom via Yalow's laboratory in the United States; during which time he pioneered growth hormone assay at Auckland Hospital.

The arrival of Peter Hurley as the nuclear medicine department's director saw the installation of a new Nuclear-Chicago gamma camera in the new hospital building. His tragic death, in 1983, robbed New Zealand of a high-calibre nuclear physician; a loss this nation could ill afford.

52

Radioisotope Clinic Staff, Auckland, 1972 BACK ROW: Maurice Young, Jim Featherston, Christine Baker, Raewyn Foster, Lynnanne

Burton, John Carruthers, Paul Orr. MIDDLE ROW: Sylvia Ackroyd, Shirley Durney, Josephine Sultan, Marilyn Beltany, unknown (Carol. . .), unknown, Jennie McGehan. FRONT ROW: Judy Hodgson, Murray John, Bruce White, Peter Hurley, Dorothy Warr, Michael Wilson, Rhona McKenzie

Bruce White recalls: When Peter Hurley returned from his period with Henry Wagner, he came back to a busy department of nuclear medicine that had been functioning for nine to ten years. I was his senior physicist and was with him right through his illness. I would communicate with him a lot while he was at Johns Hopkins.

I canâ&#x20AC;&#x2122;t recall the exact year, but I organised a meeting of the whole of the ANZSNM in Auckland. Unfortunately, at the time, Peter had become quite unwell and was not able to take a very active part in that meeting. During my career, I spent some time with Jim McRae, at Prince Alfred in Sydney and at the Donner Lab, where I also became friendly with Hal Anger. I also did a course in nuclear medicine at the Mass Inst of Tech. I know Jim & family well, having been to the USA for weddings of his & Elizabethâ&#x20AC;&#x2122;s children.

And in personal correspondence to Bruce, in September 1988, Allan McArthur remembers Peter Hurley so fondly: What a great fellow Peter Hurley was; and what a disaster it was for nuclear medicine in this country that we had to lose him out of this life. He had a very broad view of things and obviously had many friends. He and Jim McRae must have been pretty close when Jim was in Sydney.

Waikato Hospital, Hamilton When it opened, in November 1966, the nuclear medicine department of Waikato Hospital was located on the top floor of the new radiotherapy building, as a part of radiotherapy services. Sadly, this department was understaffed and under-equipped.

Howard Tripp was appointed senior physicist of the Department in 1964, and was heavily involved in planning throughout 1964 and early 1965. Within a few days of his arrival, in May 53

1965, he was accidentally killed in the hospital grounds, when run down by a taxi. Gordon Monks arrived from overseas in October 1965 as his replacement.

The nuclear medicine department became operative at the end of 1966, with the installation of a Picker Magnascanner Ill. This instrument was claimed to be the most advanced technology available; it had a hybrid circuitry, being part valve, part transistor. The heat generated by the valves deformed the circuit boards, causing the instrument to fail persistently.

Waikato Magnascanner hybrid circuitry

During 1967, the laboratory acquired uptake and other measuring equipment from Baird Atomic in the United States. The workload rose from 323 patients in 1967-1968 to 507 in 1968-69. By 1974-75, it had soared to 4,187 patients.

In 1969, Alan Lomas, a radiotherapist, spent a six-month attachment at the nuclear medicine department of Royal Prince Alfred Hospital, Sydney. There he gained immense experience in nuclear medicine techniques. On his return to Waikato, Lomas built up a loyal team with Gordon Monks, Elaine Kerr, Berry Alien, Sue Pracy and others, who had to battle valiantly with indifferent equipment to keep the service operational.

In 1970, the acquisition of an automatic gamma-counter markedly improved laboratory efficiency and new imaging techniques for renal and thyroid investigations were introduced.

However, the introduction of these new studies not only increased the workload, but also aggravated defects in the equipment. The purchase of an Elscint whole-body scanner, in 1975, did not alleviate the problem, as it too had several reliability problems.

In July 1981, the nuclear medicine department at Waikato was fragmented; its imaging function going to diagnostic radiology and radio immunoassay going to the Waikato Hospital pathology laboratory.

Napier Hospital In 1957, radiotherapist Dean Harvey pioneered the use of isotope techniques at Napier Hospital. At that time, 150-200 thyroid investigations were performed each year. In 1960, Peter Fleischl inherited the Isotope clinic from Dean Harvey and was aided by ex54

radiographer Anne Wilkinson, who acted as technician for the 4-hour and 48-hour uptake counts of I-131. Don Urquhart, from Palmerston North, assessed the patients and the required doses during his routine visits. The oral doses were given to admitted patients only and they remained in hospital for 24 hours.

In 1966, the protocol was revised and the patients were treated as outpatients. In this same year 48-hour plasma counts were discontinued on the grounds that they were noncontributory. Schilling's tests, radioactive phosphorus assay and therapy doses of I-131 were routine tasks during this time. The isotope clinic was relocated on the ground floor of the Chest Block where it remained until 1970, when it was housed in the new block.

Peter Fleischl was appointed physician-in-charge, in 1970, and John Brooks built up a team to operate the recently-acquired Picker Magnascanner. The first generators used by the clinic were open-ended indium-113 generators from Amersham. Because of the short halflife of this radioisotope, spontaneous preparation was required for each patient prior to use.

Two years later, in 1972, lan McPherson was appointed visiting physician to the clinic. The first technetium-99m generators arrived in June, followed by cold kits for liver and bone scanning.

Palmerston North Hospital Don Urquhart, Athol Rafter (of nuclear sciences) and Ron Walton (who later became a television personality) believe that they gave the first intravenous dose of P-32 to a polycythaemic patient in July 1952. The physicist Campbell Begg started using I-131 and, by December 1954, had sufficient equipment to set up a radioisotope laboratory. In April 1954, Begg returned from sick leave and, as chief physicist, restarted his 24-hour thyroid uptake tests using I-131. By 1962 he had red cell studies using 51Cr well in hand and had introduced Schilling's tests using radiolabelled Vitamin B12.

There are many amusing anecdotes about the lack of accommodation for equipment during Begg's period. Radiation counters were located adjacent to the thin walls of the physicist's office, beyond which were the chest stands holding cassettes and films for the chest clinic Xray unit, simply because there was no other accommodation.

There were also problems with ageing equipment. In 1966, an obsolete 100-sample autowell bought two years earlier would break all of the 100 sample tubes overnight and pile the glass on the floor. In a more subtle way, a teletype machine linked to the Picker Liquimat would often be triggered by the selector button on a nearby lift, with the result that overnight the floor would be carpeted with teletype paper.

The staff had to resort to many subterfuges to accommodate the investigative needs of the veterinary science department of Massey University; but, perhaps these are better left unrecorded.

In 1961, physicist Ray Trott transferred from New Plymouth to Palmerston North to help meet the enormous demand for Trisorb function tests from Don Urquhart's many clinics installed throughout central North Island. This was further helped by the installation of a 2inch well crystal early in 1962. The department's first scan was undertaken in November 1962, by Ray Trott aided by Ron Chisnall of Watson Victor Limited, Auckland. By 1965, 55

Anne Wilkinson, the charge radiographer, was producing scans on a regular basis using a Picker Magnascanner with a single three-inch crystal.

In 1964, the International Atomic Energy Association in Vienna sent a prominent Spanish scientist on a world-wide inspection of thyroid scanning systems. While in New Zealand, he suffered from severe toothache. To add to his discomfort, he was particularly frustrated at Palmerston North, which had the worst thyroid probe he had ever seen, but which gave the best results. By good fortune, the counts lost because of the inadequate field of view were balanced by increased counts resulting from inadequate shielding behind the crystal. A new probe shield arrived a year later.

Between 1964 and 1966, rheumatologist Dick Wigley established a normal range for Schilling's tests among the Manawatu population, based on one of the largest groups of normals in the world. His research group used the Schilling test to stratify the Vitamin B12 deficiencies in rheumatoid patients, some of whom displayed haematological and neuropsychiatric changes.3 He also noted the bizarre effects produced upon vitamin B12 uptake by the ingestion of indomethacin, but did not publish his observation because of the difficulty of producing experimental proof. The possibility of a link between ingestion and suppression is said to have been first suggested by Sister M. Fowles.

Between 1972 and 1976, because there were no full-time clinical staff in radiotherapy, the use of radioactive injections became as much of a problem as was the inadequacy of space to house equipment. Anne Wilkinson is said to have been responsible for the dramatic improvement in radioactive venous technique for all medical staff ranging from house surgeons to senior consultants.

In May 1976, the nuclear medicine department transferred to a new site, with Kevin Smidt being appointed to develop this as an autonomous unit.

New Plymouth Hospital There had been a long established level of co-operation between New Plymouth and Palmerston North Hospitals. Most of the specialised investigations were carried out at Palmerston North, but from 1968, thyroid function tests, serum PBI tests and triomet tests were carried out at New Plymouth. Schilling's tests were commenced at New Plymouth in 1970.

Wellington Hospital As at other centres, early endeavours in nuclear medicine at Wellington Hospital focussed on thyroid function and disease. In January 1952, Eugene Lynch, a radiotherapist in private practice, prescribed I-131 for a patient. On 28 April 1953, at Wellington Hospital, physician Verney Cable treated two patients suffering from polycythaemia with P-32. Many prominent personalities gathered in a lean-to room in the old radiotherapy department to see this procedure carried out; including George Roth, Athol Rafter, Bill McCabe, Eugene Lynch and John Logan.

On the same day, George Roth also discovered a small amount of unsealed radium that had been overlooked during the transfer of the radon plant to Christchurch. The source was sealed and quietly transported to Christchurch for safe disposal. Thirty-six years later, there 56

is still detectable radioactivity in this area; but, since the area is not occupied, it represents no staff hazard.

In 1955, Ross Garrett was appointed full-time physicist and the hospital obtained an Ekco ratemeter and scintillation counter. Of the thyroid tests then available, PBI was the test .most favoured for hyperthyroidism.

From thyroid uptake studies, Ken North from haematology, John Logan, Ross Garrett, and later Wallace Armstrong, went on to research into the skin tumour xeroderma pigmentosa and found high uptakes and low metabolic rates, which proved to be an iodination defect associated with non-endemic cretinism. These researchers also found that high doses of vitamin A reduced the uptakes to normal and prevented further skin tumours. This group also discovered depressed uptakes and salivary iodine elevation in lymphoma patients following irradiation of enlarged glands outside the neck.

Wallace Armstrong was appointed as physicist early in 1956. As architect of the radioisotope unit, he obtained space to accommodate laboratories, scanning rooms to house rectilinear scanners and automatic radiation counters for use in the laboratories.

In the early 1960s, organ imaging of all types was introduced using two rectilinear scanners located in the old X-ray department. In 1969-â&#x20AC;&#x2DC;70, these scanners were replaced by two new gamma cameras, but they remained in the old building until the end of 1970. In that year, radiotherapist Joe Wallace was appointed to develop the nuclear medicine department, which was relocated in a new hospital block close to the clinical school.

It is of paramount importance to acknowledge the contribution of Wallace Armstrong to nuclear medicine research at Wellington Hospital. He had a consuming interest in tritium, so he and Paul Manson, a Canadian interested in Iymphocytes, encouraged Mary Glasgow (a student from Canterbury) to investigate, during the 1968-â&#x20AC;&#x2DC;69 vacation, the destructive forces in the various fractions of vitamin E upon Iymphocytes. Her work confirmed that some of these fractions were immunosuppressive.4 Much of this original research at Wellington received little recognition at the time. It now seems that after three decades of neglect, the roles of vitamin E in immunosuppression and vitamin A in xeroderma pigmentosa tumours are at long last becoming acknowledged.

Christchurch Hospital In 1948, radiotherapist Jim Campbell prescribed the first doses of I-131 for medical use in New Zealand. Three shipments were imported direct from Oak Ridge, Tennessee. These were calibrated and dispensed by Dominion X-ray and Radium Laboratory (DXRL) staff, including George Roth, Bert Yeabsley and Jim McCahon.

In July 1954, Bob Borthwick was appointed full-time physicist to the North Canterbury Hospital Board, after previous service with Wellington Hospital and DXRL. He quickly set up a 'hot lab' in the basement of Ward 13 and soon infiltrated the basement of Ward 12. Jack Tait joined the North Canterbury Board when Bob Borthwick departed on study leave in May 1954.

57

Dr B. E. W. Brownlie was appointed as the first nuclear medicine physician to Christchurch Hospital in 1971. He had been involved in thyroid research in Glasgow and had worked in the nuclear medicine department at Stanford University, California. The radioisotope laboratory was renamed the ‘Department of Nuclear Medicine’ in 1972.

Bevan Brownlie recalls: The basement of Ward 13 was, however, far from an optimal site for clinical studies. Patients were wheeled out into the cold air and down into a tunnel under Ward 13 before reaching the department. Some clinicians referred to the area as the ‘dungeons’. Lights in the corridor had to be left on permanently to allay patients’ anxiety before arriving in the department having already survived the ‘cold air treatment’.

The basement facility had no waiting area and patients requiring scans or laboratory tests waited in the narrow corridor. The doctor’s office was situated under the Ward 13 sanitiser unit and, at times, it became necessary for belongings to be removed from cupboards as ‘brown solution’ was found to be seeping down the wall. Despite these poor working conditions, a very good service was developed using a team approach involving technicians.

5 physicists, doctors and nurses.

In October 1957, DXRL issued a memorandum stating that radioisotope requisition and distribution should be centralised at the Christchurch Hospital isotope laboratory; at least initially. At the time, there were two radiotherapists with interests in radioisotopes; in the same year George Gates joined the unit as a physics technician. In 1962, the pioneering team of Jack Tait, George Gates, Tony Goldstein and Jim Campbell was joined by physicist Tom Rogers; and the unit moved into top gear. In the hospital's engineering facility, isodose plotters, a cobalt field scanner and a background radiation monitor were designed and built.

Probe renography with I-131 hippuran and flat field collimators had already been launched by these innovators in 1962. In 1963, Jack Tait and George Gates, encouraged and aided by the rest of the team, built a radioisotope scanner for whole body imaging.

After several modifications and improvements to ancillary equipment, it went into continuous service in 1966. This scanner was powered by 'cake mixer' motors, these being the only variable speed electric motors available at the time. The scanner utilised ‘Sunbeam’ cake mixer motors to move the radiation detector across the patient who was positioned on an old X-Ray examination table. The distribution of the tracer isotope was printed on a modulated line using an ink pen. This home-made machine gave valuable service for almost ten years.

Ian Ross recalls: I didn't build a scanner, but did build a whole body counter for animal work. I used a turntable to spin the animal in front of dual detectors. It worked brilliantly with dead rats, but an unanticipated complication with live rats was that the rats persisted in running in the opposite direction to the turntable at exactly the right speed to remain facing the same way. Varying the speed of the turntable made no difference; they just ran faster until, eventually, centripetal force was exceeded, whence the rat flew across the lab. … Also, the tale of having to 6 decontaminate the cremation-oven with the skeleton inside! … Ah, the good old days!

58

Home-Made Whole-Body Scanner at Christchurch (improved model)

In 1966, when technetium became available in Christchurch, Tom Rogers and George Gates designed and manufactured a focussing collimator with thin septae to combine successfully high sensitivity with fine resolution. Until 1968, Tom Rogers also acted as radiopharmacist until the appointment of a radiochemist.

In 1966, the laboratory appointed Jennifer Gorman as the first full-time technician. In 1967, the first automatic sample-changing beta and gamma counters were installed to cope with the surge of interest in diagnostic radioisotope studies.

In October 1970, Christchurch Hospital acquired and installed New Zealand's first gamma camera - a Nuclear Enterprises Scinticamera III. As Christchurch was not satisfied with the multi-channel analyser's ability to handle the numerical data from the camera during dynamic studies, a modified version of a DEC PDP8/1 mini-computer was bought for on-line acquisition. Installed in December 1970, this was the first on-line data acquisition system acquired by a hospital in Australasia. Within a month, it was being used in shunt detection studies for the Cardiology Department.

Jack Tait and Tom Rogers were engaged productively in other activities at this time. They lectured in physics to radiographers and medical registrars, they trained physicists from other centres and, under the Colombo plan, taught students from Thailand. Both made exchange visits to the All India Institute of Medical Sciences in New Delhi and to Bangkok. In 1966, Jack Tait spent six weeks with Kaye Ibbertson's team investigating the goitre epidemic among Sherpas.

Until 1971, the radioisotope laboratory remained a section of the radiotherapy department under the initial chairmanship of Jim Campbell, then Tony Goldstein and finally Harry Fox. In 1972, it became an autonomous nuclear medicine department headed by Bevan Brownlie, a recently appointed nuclear physician.

59

Nuclear Enterprises Scintiscanner at Christchurch The scanner had on-line acquisition from a POP8 mini-computer. On left is Bevan Brownlie, nuclear physician at the hospital in 1970.

Christchurch Isotope Laboratory Staff 1969 BACK ROW: Robyn McGill, George Gates, Tom Rogers, Alun Beddoe, Hugh Webb, Eddie Fuller, Diane Dodd. MIDDLE ROW: Ngaire Cattermole, Mary Glasgow, Sue Caldwell, Jack Tait, Betty Sparks, Sue Bligh, Ruth Hunt. FRONT ROW: Dr Wanida Guratani, Miss Mauli (students from Thailand).

Dunedin Hospital In 1950, the dean of the Otago Medical School, Sir Charles Hercus, had two very able researchers, Dick Purves and Duncan Adams, on the staff of the Thyroid Research Unit. At that time they were using homemade counting equipment to carry out thyroid tracer tests 60

using I-131. Dick Purves had had broad physics experience before entering medicine. On 13 August 1950, they investigated a large skull tumour in an elderly lady and proved that it was of thyroid origin by surface counting techniques. In September 1955, Hugh Jamieson took on responsibility for routine thyroid tests to allow Purves and Adams to undertake further work in thyroid disease.

In 1958, the radioisotope clinic was relocated along with the radiotherapy department to Wakari Hospital where the range of investigations was expanded to include haematological problems.

In December 1961, the Otago Hospital Board purchased a Picker Cliniscanner with a 2â&#x20AC;? x 1â&#x20AC;? sodium iodide crystal. Recordings of emergent radiation from the patient were produced by a vibrating stylus moving over heat-sensitive Teledeltos paper. Trials and checks were completed on 18 January 1962, and the scanner put into service. Interpretation of the black images was difficult, particularly the isolation of small lesions, with the result that there was little clinical interest in the method.

In 1965-66, physicist Fergus Thomson and physics engineer Colin Medcalf designed and fitted a colour print-out system using a multi-coloured typewriter ribbon. Their first colour scan was produced on 22 February 1966. In the following year, this unit produced a colour scan of a skull secondary deposit, using I-131 as the tracer, the diagnosis being confirmed by biopsy. Clinical colleagues accepted the colour scanner with increasing confidence and soon the demand outpaced the ability of this first-generation machine to cope. Throughout 1967 it became increasingly unreliable and, by early 1968, had to be withdrawn from service.

Picker Cllniscanner at Dunedin Modified type with colour printer (L) and stylus recording on Teledeltos paper (R). At this stage the machine was still pedestal-mounted.

For ease of handling and positioning of patients under the recording head, engineering staff of the radiotherapy department converted the whole unit to a ceiling mounted device, getting rid of the pedestal; thereby increasing available room space and patient accessibility. It was an impressive feat of engineering, having 600 lbs of equipment running freely and safely from a ceiling-mounting; a fact much appreciated by the technicians (then all young females) who had to position the patients on a trolley.

61

Ceiling-Mounted Cliniscanner Photo shows the hydraulic elevation. The total weight of the machine was 600 Ibs.

In June 1968, the Southland Hospital Board, at Invercargill, loaned its Picker Magnascanner V to Wakari Hospital, while its technical and medical staff were trained in the new discipline of nuclear medicine. This scanner had a single 5” diameter sodium iodide crystal, which produced good quality colour prints on ordinary paper. It performed magnificently for threeand-a-half years before being returned to South land for further service.

The relocation and re-equipping of a new nuclear medicine department at Dunedin Hospital continued from March 1969 through most of 1971. This was completed on 10 November 1971, when the new department opened in the old X-ray Block.

Equipment for the new laboratory was upgraded, counting equipment automated, and a new Pho-Gamma III gamma camera installed. The relatively-new Radiax rectilinear scanner from Wakari Hospital became a stand-by unit for special investigations only. Professor David Stewart directed the Department's activities.

A large number of dedicated staff members contributed to the success of this department and it is fitting to mention some of them; although, unfortunately, space does not permit a full roll of honour.

In 1969, the old Amersham molybdenum technetium generator was a monster. It was unsterile and difficult to elute. Everybody avoided it except Colin Medcalf. He eluted it and autoclaved the elute before 9:00 am on each working day. Nobody could have done this onerous task more faithfully and, fortunately for all staff, he foresaw the need for adequate protective screening while handling the radioisotope. This was soon in place after local manufacture.

Lynne Forster (1971), Jill Cornish (1973-‘74) and Jeanette Wood (1974-‘76) were members of a group of graduate chemists and pharmacists who built up the fully-equipped radiochemical laboratory and developed a wide range of reliable radiopharmaceuticals. In 1977, Dr Graeme Boniface (worked at ANSTO, now in Canada) refined the freeze-dried cold 62

kit procedures pioneered by his predecessors. lan Ross, physicist with the group in 1970â&#x20AC;&#x2DC;72, supervised the selection and installation of the automated counting equipment in the laboratories, thereby increasing their efficiency.

As senior physicist, Hugh Jamieson led this enthusiastic, loyal and dedicated team with diverse training and interests and served Dunedin Hospital with distinction for more than 38 years.

Nuclear Medicine Staff at Dunedin 1970 BACK ROW: M. Looser, G. Waite, E. Merton, M. Best, C. Medcalf, H. D. Jamieson, A. Baxter.

MIDDLE ROW: S. Douglas, Y. Fraser, E. Thomson, S. Donner, S. Clearwater, P. Raffills, N. Moore. FRONT ROW: M. Illingworth, A. W. McArthur, J. Walker, R. Saunders.

Southland Hospital, Invercargill Located at latitude 46°24' S, this is believed to be the most southerly nuclear medicine department in the world. It is no surprise that thyroid disease should be of interest to this area of New Zealand, because there is such an abnormally-high incidence of goitre in the human and animal population.

Thyroid tests using I-131 capsules commenced in mid-1968. T3 and T4 function tests were done in a private pathology laboratory which used the hospital well-counter by arrangement.

In September 1971, accommodation was allocated for the nuclear medicine department in the old X-ray department at Kew Hospital.

The untimely death of Graham Tait, physician designate for the nuclear medicine department in Invercargill, in October 1971, prevented the department from starting up in January 1972.

Don Yeaman, the charge nucleographer, returned from Dunedin in December 1971 and set about building up the new department with almost no aid. It is a great tribute to his tenacity that the Department eventually became functional in late October 1972. The Picker Magnascanner V, having been returned from Wakari, produced its first scan in November.

63

Hot laboratory equipment was acquired with the help of the local Lions Club and, by early 1974, fortnightly and then weekly generators were arriving from Amersham. In May 1974, Hugh Jamieson and a team from physics services at Dunedin visited Kew Hospital and gave helpful advice on the safe handling of unsealed sources, generator management, waste disposal and the screening of accommodation. Freeze-dried kits became available from Dunedin Hospital stocks and the range of examinations expanded.

In theory, the department was a fully-fledged unit, but it was equipped only with a secondgeneration scanner. Departmental staff had no ancillary services help, so they did their own elution, calibration, dispensing, autoclaving and then the scanning. It took 45 minutes for radiopharmaceutical preparation. Scanning times per patient were: brain, 60 minutes; lung, 90 minutes; liver and spleen, 40-60 minutes; placenta, 30-40 minutes; and bone took an entire afternoon.

It soon became obvious that this system could not cope with the rapidly increasing work load. Planning for a new department on another site could not be postponed. This new department opened in 1982 with a new Sigma 438 gamma camera and modified automatic counting equipment. Many dedicated staff members have served in the department, including Don Yeaman from December 1971 until 1973, Bernice Moir 1974-â&#x20AC;&#x2DC;79, Pam Spence 1976-â&#x20AC;&#x2DC;88 and Geoff Roff 1988.

Isotope Distribution Because of New Zealand's isolation in the South Pacific, all nuclear medicine departments have had recurring difficulties in securing regular deliveries of short-lived radioisotopes from point of manufacture; predominantly in the northern hemisphere. Australia had problems of a similar nature, but with its larger population and wider-based economy, it was able to create its own radiopharmaceutical manufacturing facility as part of the Australian Atomic Energy Commission (now ANSTO).

New Zealand could not do this, so it had to remain a purchaser, not only from Australia, but also from the United Kingdom, the Netherlands, France and the United States. This involved long-distance carriage by airlines, which did not necessarily understand the intricacies of handling short-lived radioactive materials. Despite the fact that radioisotopes have been carried around the world for more than 35 years, the problems persist even on short hauls across the Tasman Sea. There is no foreseeable answer for the improvement of such deliveries.

Technologist Training Technician training has not been a success in New Zealand until recent times, when the Auckland Hospital group has been able to run a series of successful courses. Christchurch supported the Melbourne Institute of Technology training courses in earlier times and most of its technicians secured qualifications at that institute. Other units adopted a more haphazard method with the result that qualified technicians were very rare persons. When the New Zealand Branch of the ANZSNM was formed in 1971, a serious attempt was made to set up a common core in first year medical science at the Central Institute of Technology at Heretaunga, but as this was not strongly supported by students, it had to be phased-out.

64

References 1. Nuclear Medicine News, December 1989.

2. Lander, H., ‘Nuclear Medicine in New Zealand’, Nuclear Medicine News, November 1971.

3. Bieder and Wigley, R. D., ‘Vitamin B2 deficiency in rheumatoid arthritis’, New Zealand Medical Journal, 63, pp.375-378, 1964.

4. Mann, P. and Logan, J. W., ‘Suppression of the mixed lymphocyte reaction by alpha-tocopherol’, New Zealand Medical Journal, 72, pp.31-33, 1970.

5. Brownlie, B. E. W., ‘The Department of Nuclear Medicine’, in The History of the Canterbury Area Health Board, ed. Silverson, A., 1993.

6. Ross, I., pers. comm,, 14 March 2007.

65

Chapter 4

The ANZSNM A Nuclear Medicine Society During the late 1960s, interest in nuclear medicine and a nationwide society of nuclear medicine had been growing strongly throughout the larger states of Australia. A Victorian group was established and a New South Wales group was just commencing.

In November 1968, a meeting of users of radioisotopes in medicine and biology was convened jointly by Dr Provan Murray (physician, Prince of Wales Hospital), Mr Alan Downes (chemist, CSIRO) and Mr B. W. Scott (physicist, State Bureau of Physical Services) to discuss the desirability of the formation of a society embracing personnel involved in the use of radioisotopes. It was resolved, after considerable discussion, that a society be formed to bring together all those people interested in the use of radioisotopes in medicine and biology. Forty-eight people agreed to join such a society.

A steering committee, chaired by B. W. Scott, was appointed to investigate the name, objects and membership. Members of this committee included Drs J. N. Gregory, I. S. Jenkinson, J. G. Morris, C. Hambly, G. Lowenthal, Mr A. M. Downes and Associate Professor J. M. McRae. This committee produced a draft resolution, in due course, in which it was proposed that the society be called the Society of Nuclear Medicine (NSW). Great care was taken to define nuclear medicine in the widest possible terms and to ensure that the membership qualifications were free from discrimination between university graduates and non-graduates, or between medical and scientific or technical personnel, and that the society should remain a purely-scientific society.

The Royal Australian College of Radiologists was keen to promote nuclear medicine and the Royal Australian College of Physicians was interested in progressing plans to develop a course of training leading to a joint diploma. However, although in general agreement on this way forward, at a meeting in Sydney, both bodies decided to refer the matter to the forthcoming meeting in Adelaide so that the nuclear medicine specialists could take the matter over together. This decision was made through reservations expressed at that meeting by Dr John Morris and Dr Jim McRae.

The meeting in Sydney was a very valuable one in the development and establishment of the impending society. It at least made it more obvious that workers in nuclear medicine were interested in their own affairs and that Adelaide would be a landmark meeting of specialists in the field from all over Australia.

In April 1969, Dr Harry Lander wrote to Professor W. S. C. Hare, expressing his desire to establish a college of nuclear medicine. He strongly felt that the interests of those working in the field of nuclear medicine could not be adequately represented by physicians, radiologists or pathologists, as the discipline was an entity in its own right. He realised that there would be difficulties in establishing such a college, but felt that they were surmountable. He sent 66

copies of this correspondence to colleagues: Dr John Andrews and Dr Les Dugdale in Melbourne and Dr John Morris in Sydney.1 Professor Hareâ&#x20AC;&#x2122;s response expressed his views on the subject of a national body of nuclear medicine:

Such a society will prove an excellent forum for all those, both medical and non-medical, who are interested in the speciality. Secondly, as you have pointed out, there is a need for a course of training for medical graduates leading to a certificate. In addition I think there is a third need, which you imply, but which has not been discussed in detail yet, and that is for some sort of association of medical nuclear medicine specialists, through which they can promote their professional status etc. and which can act as a second forum for scientific discussion.

We have thought about the possibility of a college of nuclear medicine being set up from the outset. However, the number of medical graduates involved at this stage, and for a good number of years to come, is so small that it would be out of context with other established colleges. The College of Radiologists would be disappointed if such a move was made at this stage, as there is a strong feeling, along American lines, that the radiological sciences should stick together. To this end, I am sure every effort would be made to promote and accommodate the speciality within the structure of the college. As time goes by, if my predictions are correct, we would look to nuclear medicine as playing a major part in college affairs. In a relatively short time, the number of nuclear medicine specialists should exceed 2 the number of radiotherapists.

Hare concludes his letter by emphasising the success of the impending Adelaide meeting, but adding:

However, as Professor of Radiology, I hope the decisions which are made are such that those working in the radiological sciences will group together and not develop in isolation one from 2 another.

There was very strong support from all recipients of Landers letter, but all had reservations with regard to the establishment of a college of nuclear medicine. Dugdale replied:

I am in sympathy with the idea of formation of a college of nuclear medicine, but I am rather 3 afraid that the practical difficulties involved may render it impossible at this stage.

Dugdale elaborated on what he felt would be some of the difficulties associated with the proposal. He considered that foundation members should be medically-qualified and involved in large-scale clinical applications of radioisotopes. He felt that with this vocation limitation, there would be probably only 15 to 20 people in Australasia suitable for full 67

membership. He also felt that it would be difficult for non-medically-qualified persons within such a college and that they, regardless of qualification or seniority, would never obtain full membership. This, he believed, would lead to bitterness within the departments of nuclear medicine. To satisfy all workers he said:

I would think it desirable that an Australasian society of nuclear medicine be inaugurated, 3 rather along the lines of the Society of Nuclear Medicine in the USA.

Dugdale concluded in saying that he was looking forward with great interest to the meeting in Adelaide. However, John Andrews was a little more diplomatic in his reply:

As you know, there has been discussions going on for at least about two years regarding the future of nuclear medicine and its associations, and I have been in a somewhat unique position, being in both the Royal College of Physicians and the College of Radiologists. It is, however, the latter college that has asked me to help in the preparation of part 1 of a diploma.

I felt, from the outset, it would be better if we were not irrevocably tied to any one college and, for this reason, it was my suggestion that the diploma should be a conjoint effort, involving 4 both colleges; and this eventually became accepted by them.

Previously, Andrews had thought of the possibility of an independent body of nuclear medicine, but rejected it because there were so few people actively working and interested in the field. Now, he felt that things may have changed. He concluded with what we would regard today as a very sound prediction:

I would be interested to hear other people’s opinions when we meet in Adelaide, which for 4 nuclear medicine will be a very important meeting, I feel.

Foundation Meeting The Society was inaugurated in Adelaide, in May 1969, when the majority of specialists in nuclear medicine in Australia were gathered for the ‘Seminar in Nuclear Medicine’, conducted by the South Australian Branch of the (now Royal) College of Pathologists of Australia. At this historic meeting, at the Royal Adelaide Hospital on 21 May 1969, the following office Bearers were elected:

President:

Dr H. Lander

Secretary:

Mr P. Simmons

Treasurer:

Dr P. M. Ronai

Committee:

Mr B. W. Scott (NSW) 68

Dr I. P. C. Murray (NSW) Dr L. Dugdale (Vic) Dr J. Andrews (Vic) Dr M. Quinlan (WA) Dr R. Stanford (WA) Dr R. J. Connolly (Tas) Dr R. Baker (SA) Dr I. Buttfield (Qld) Mr R. Boyd (ACT)

The meeting lasted two days; and with its initial 23 members, ‘The Australian Society of Nuclear Medicine’ was born.

By November that year, the ASNM membership, including both full Members and Associate (non-graduate) Members, totalled seventy-nine. State representation included:

New South Wales – 24 Members & 6 Associates, Western Australia – 13 Members & 3 Associates, Victoria – 10 Members & 1 Associate, Tasmania – 7 Members & 1 Associate, South Australia – 6 Members, and Queensland – 4 Members.

In addition to the above, three medical or science graduates from New Zealand also joined the Society within its first six months. Foreseeing likely membership from New Zealand, the possibility of calling the Society ‘The Australian and New Zealand (or Australasian) Society of Nuclear Medicine’ had been raised at the inaugural meeting in Adelaide. But, unfortunately, as no New Zealanders were present at the foundation meeting, it was considered perhaps presumptuous to include any reference to New Zealand in the title of the Society at that time.

69

However, in view of the interest being shown in the Society by New Zealanders in the field of nuclear medicine, the name of the Society was to be reconsidered at the first Annual General Meeting to be held in Sydney on 11 February 1970. By that meeting, the membership had grown to over one hundred. This rapid growth was attributed to the encouragement of membership from as wide a group and variety of interests as possible.

The only requirement being, that a member or potential member should have an interest in nuclear medicine in one or other of its many facets, which included graduates in medicine, physics, chemistry and pharmacy. Membership was also open to technologists and representation from commercial interests, particularly in the fields of nuclear instrumentation and radiopharmaceuticals. Even at this early stage of development, many companies had taken out sustaining membership in the society. But, more importantly, their representatives had joined as individuals, many of whom took an extremely active role in affairs of the society.

The following year, in his presidential address at the Annual Scientific Meeting, in Melbourne in 1971, Dr Harry Lander was to say:

Not only have many companies taken out sustaining membership in our society but more important, their representatives have joined our ranks as individuals and in many instances have been extremely active in the affairs of the society. This has undoubtedly been to our mutual benefit and certainly, in at least one respect, we must be rather unique and perhaps hold some sort of record. For I know of no other scientific society – at least in this dextrorotatory part of the world – in which successive secretaries have been drawn from the allegedly-tainted ranks of the world of commerce. I assure you that the society has gained much from this particularly close association and I would like to take this opportunity to thank our present Secretary, Mr R. J. L. Alsop of Consolidated Nucleonics Pty Ltd for the very valuable work he has performed on behalf of the society over the last twelve months.

The first Scientific Meeting of the Australian Society of Nuclear Medicine was held in conjunction with the Endocrine Society of Australia (joint sessions), over 11–13 February 1970, at the Prince of Wales Hospital, Randwick, NSW. The theme, over the three days, was focused on radioimmunoassy, thyroid disorders and invivo and invitro studies. Speakers included Professor Basil Hetzel, Drs Creswell Eastman, Proven Murray, Les Dugdale, Harry Lander, John Morris, David Cook, Fred Lomas and Ian Hales, and Mr Laurie W. Steven and B. W. Scott. Full registration was $5.00 and for Associates it was $2.00. Return air-travel to this meeting, from Melbourne through Ansett Airlines of Australia, would have cost: firstclass - $56.80, economy - $47.00 and group-travel - $42.00.

The Society saw an unprecedented growth. The constitution was ratified at that first and very successful Annual Scientific Meeting in Sydney. Following representation from New Zealand, the name was changed to the Australian and New Zealand Society of Nuclear Medicine (ANZSNM) and by the second Annual Scientific Meeting, held in Melbourne, the membership numbered almost two-hundred. One of the major reasons for this rapid growth was the selflessness of the Victorian Radioisotope Study Group, which had been formed several years earlier. This group, with its already strong and active membership and regular, 70

well-attended meetings, after negotiation with ANZSNM and of its own initiative, became the Victorian Branch of the ANZSNM. This meeting of minds and achievement of unity should be credited to Messrs R. J. de Groot, E. H. Clarke, R. J. L. Alsop and Drs B. Rush, J. T. Andrews and L. M. Dugdale.

The following letter was received from Mr R. de Groot, Honorary Secretary/Treasurer of the Radioisotope Study Group of Victoria.

A special general meeting of the Radioisotopes Study Group was held on 15 April 1970 at the Cancer Institute, Melbourne. The Chairman, Dr B. Rush, presided and approximately 20 members attended. Dr Rush outlined, briefly, the history of the group which came into being in 1966, following the successful completion of an eight week course on ‘Radioactive Isotopes in Diagnosis and Investigation’. Since then, a fairly vigorous programme of scientific meetings involving lectures, demonstrations and instructional evenings has been followed. Dr Rush paid tribute to Mr K. H. Clarke in the organization and running of this course and in the early work of the group.

With a financial membership of 56 in 1969 and with regard to our previous years’ scientific programmes, the group may be regarded as a successful enterprise.

Dr Rush then referred to the Australian and New Zealand Society of Nuclear Medicine. This society was formed last year to cater for the interests of all people involved in the practice of nuclear medicine throughout Australia and New Zealand. A scientific meeting was held in Adelaide last year and another in Sydney in February this year.

In view of the formation of this society to cover interests similar to our own, but on a much wider regional scale, the committee of the Radioisotope Study Group has considered the future of the group and has held discussions with executive members of the society to explore the possibility of our group becoming the Victorian branch of the society.

It would appear that there is no good reason for the group to continue to exist as a separate entity and that we should all join the society instead. However, as the society can hold only periodic or Annual Scientific Meetings on a wide regional scale, our local needs can be covered if we form a state branch and preserve our scientific programme and machinery for running it. This costs a small amount of money – mainly for postage etc. – and, as we do not want to pay two subscriptions, an agreement has been reached with the executive of the society to rebate a portion of each member’s subscription to the state branch for running expenses, so that we can continue to function as before.

After brief discussion, it was resolved unanimously that the Radioisotope Group be disbanded and that all interested parties should apply for membership in the Australian and New Zealand

71

Society of Nuclear Medicine and that the members of the society resident in Victoria form the Victorian branch of the society.

Members of that committee forming the Victorian Branch were: Chairman, Dr B. Rush; Honorary Secretary/Treasurer, Mr R. de Groot; Mr R. Alsop; Miss J. Milne and Drs J. Andrews, J. Coghlan, L. Dugdale, E. Gilford and M. Pain.

These first two years of the Society were pivotal in the awakening of interest in nuclear medicine and its new techniques in Australia and New Zealand, not only for routine diagnosis and management but also for research.

Lander went on to say:

Public interest has been aroused and become manifest by the considerable space and time which has been devoted to nuclear medicine and its various techniques by all forms of the mass media, both nationally and regionally, in the last year or two. There must be few branches of medicine, for example, which have gained as much attention as nuclear medicine did recently in the pages of that august publication: ‘The Australian Financial Review’. This publicity has been educational, not only to hospital administrators and to the holders of governmental purse strings, but has also been reflected in the generosity of certain public and private sectors of the community.

An example of this was evident in Adelaide, where a complete gamma camera was generously made available by Searle Nucleonics, solely for clinical research purposes.

Outstanding contributions were provided by charitable foundations, community organisations and several altruistic individuals in support of the development and establishment of new departments of nuclear medicine in every state of Australia and both islands of New Zealand. Of note, in 1969, there were only two gamma cameras in Australia; two years later fifteen were in routine use with three in one laboratory and four departments having Dual 5” rectilinear scanners. Prior to this, the majority of expanding departments had a single head 3” or 5” rectilinear scanner for diagnostic imaging.

Lander also showed concern for inadequately trained physicians and the need for adequate standards of service in this expanding and new arena of medicine:

It is possible that this expansion has occurred, and is occurring, too quickly. I’m sure that it will be obvious to all of you that too great a demand could lead all too easily to a rather large ‘credibility gap’ in the science. If poorly-trained physicians are placed in charge of departments in which the work is carried out by inadequately-trained technicians, only chaos can result and there will be a ‘backlash’ against the techniques we have to offer.

72

Historically, in the first two decades of the use of radioisotopes in Australia, the majority of laboratories in Australia and New Zealand were run either by trained therapy radiographers, physicists or technologists under somewhat minimal or even no supervision by medical officers. This had occurred as the radioisotope laboratories were regarded merely the ‘Cinderella’ offshoots of existing departments of radiology, radiotherapy, endocrinology or even pathology. Where then did this field of medicine belong and to whom should the discipline be entrusted?

Although there was interest from the above mentioned departments, it soon became obvious that nuclear medicine facilities must be autonomous and self contained.

Lander concluded on this note:

Otherwise, they are forever likely to be understaffed or administered by persons who have little interest in, or cognisance of their full clinical potential. If a good service is provided, nuclear medicine ‘sells’ itself and there is generally little difficulty in obtaining adequate equipment and staff, for such is demanded by clinicians as a diagnostic service. If, however, inaccurate diagnoses are made, or misleading or erroneous results given at frequent intervals, then a service will inevitably fall into disrepute or, at best, not be used to its full advantage.

There was concern within the society that the greatest danger lay in persons without medical training, irrespective of their qualifications, pontificating upon medical matters about which they were inadequately informed; and clinicians ignorant of the art and science of nuclear medicine accepting these views without qualification. This very situation was largely responsible for the rather sorry plight of nuclear medicine in the United Kingdom and several European countries in the 1960s.

The society’s view was expressed by Harry Lander:

… ultimate responsibility for, and control of the application of these techniques to clinical problems, must reside with the physician adequately trained in nuclear medicine techniques.

The physician, physicist, chemist and technologist must all work together in harmony, each appreciating the value and limitations of him/herself as well as the other, if the best interests of the patient and the discipline are to be served.

It behoves us all – and I believe it is an important function of the society to ensure that adequate standards and safeguards with respect to both equipment and personnel are not

73

only established but maintained in all units. Every endeavour must be made to upgrade those units which do not provide a satisfactory service; and there are still several in this country.

Medical Nucleography Society At the same time, the Australian Society of Medical Nucleography was inaugurated in Victoria. The objects of this new Society were to bring together the technical fraternity engaged in the practice of this new and expanding profession of nuclear medicine.

Membership was inclusive of the Royal Melbourne Institute of Technology Radioisotope Technician Certificate, holders of the conjoint-board certificate of competence as a radiographer or therapy radiographer with two years experience in an approved radioisotope department, and trainees who were currently undertaking a course in the Associate Diploma in Medical Nucleography of the Royal Melbourne Institute of Technology. This course was offered by external tuition in stages from 1970 and was fully available by 1972. It was then universally available to everyone within Australia who met the entrance qualification* and employment requirement#.

* Syllabus differences between states made it difficult to equate subjects. However, in NSW, passes in the appropriate subjects at Levels 1 & 2 of the Higher Schools Certificate were required. The equivalent of four D-L level passes at Matriculation applied for South Australia. # Candidates must be in full employment in the field of nuclear medicine under the supervision of an appropriately-qualified medical practitioner.

It interesting to note that, following the above announcement, a consensus of members of the New South Wales Association of Physicians in Nuclear Medicine had met and decided that there was no need for a course of this type.5 However, the number of applications and support for the course received by RMIT from other states and New Zealand suggested that this view was not shared by members of the society elsewhere.

A moratorium for membership to this society, with a closing date of December 1972, was also offered to any applicant who held a certificate or diploma in: radiography, therapy radiography, medical laboratory technology, or a similar standard embracing the study of anatomy and physiology, physics, a medical subject or a paramedical technique subject.

However, the applicant was also to fulfil the criteria of having worked full time in a radioisotope department for a minimum of two years and having practical experience in scanning, in vivo and invitro metabolic studies, haematological investigations and handling millicurie quantities of liquid sources.

74

The majority of technicians were recruited from radiotherapy, as they were already experienced in the use of unsealed sources of radioactivity. This grandfather clause allowed a diverse and experienced workforce to develop all round Australia.

Annual Scientific Meetings Following a most successful first meeting in May 1969, the second annual general meeting and first annual scientific meeting were duly scheduled for Sydney in 1970. This event was held at the Prince of Wales Hospital, Randwick, from 11-13 February 1969, where several landmark decisions were made.

Combined seminars with the Endocrine Society of Australia were held on radioimmunoassy and recent advances in thyroid physiology. Nineteen scientific papers, outlining original contributions, were presented at three sessions.

A constitution was formulated and adopted; and, following representation from members in New Zealand, the society was renamed: ‘The Australian and New Zealand Society of Nuclear Medicine’ (ANZSNM).

The first official organ of the society: ‘Nuclear Medicine News’, edited by Dr Harry Lander, was endorsed. However, perhaps the most important decision made at this meeting was that the society should concern itself predominantly with scientific business. Matters such as training, examination and accreditation of nuclear physicians, and fees to be charged for nuclear medicine procedures, were to lie more properly within the province of the recentlyformed ‘Australian Association of Physicians in Nuclear Medicine’.

As a consequence of these decisions, several interstate specialists in nuclear medicine approached the NSW Association of Physicians in Nuclear Medicine to form an expanded Australian and New Zealand Association. This was done against all omens on Friday 13 February 1970. The membership was small and, as the executive committee lived in Sydney, meetings were held at city restaurants. Frank Broderick recalls: … these early meetings were boisterous and memorable, especially those held at the Hungry Horse restaurants in Paddington. The menu and the agenda would appear interchangeably.

Sometimes one was unsure as to whether one was voting for duck a l’ orange, a bottle of Grange Hermitage or a meeting with the AAEC.

The New Zealand contingent of the ANZSNM was discrete yet important to the overall scheme of things. Manpower was always at a premium and yet the hospitals were extraordinarily lucky in the calibre of the people they attracted into nuclear medicine. Peter Hurley, one of the ‘Johns Hopkins’ team that first described gated-heart scanning, and Brian White, staffed Auckland. Bevan Brownlie, at Christchurch, was early in the use of computer techniques with his Nuclear Enterprises gamma camera and PDP8. David Stewart, returned from Prince of Wales to Dunedin where he became professor of Medicine.

It was also agreed at this meeting that senior technicians with suitable qualifications could be admitted to full membership of the Society. The full membership fee at this time was $4.00.

75

Formation of the First Branch The November 1968 draft constitution was presented to a second meeting of the NSW society, in August 1969, at which it was approved and accepted. However, it was unanimously agreed that the formation of the society, as originally planned, could not go ahead without detriment to the Australian society and that those who were interested and eligible should take up appropriate membership of the Australian society of nuclear medicine. The NSW committee members of the Australian society were directed to use the draft constitution as a guide when rules and a constitution for the Australian society were being discussed at the forthcoming committee meeting of the society. It was resolved that the NSW members form a NSW branch of the ASNM, and a branch committee was elected.

This committee consisted of the original steering committee comprising Messrs A. Downes and B. W. Scott, Drs J. N. Gregory, C. Hambly, I. S. Jenkinson, G. Lowenthal, J. G. Morris, I. P. C. Murray and ACT representative Mr R. Boyd. Mr B. W. Scott was elected chairman and Dr G. Lowenthal as secretary.

A provisional constitution for the branch was accepted at a general meeting of members held on 9 February 1970; and, in form, this was adopted at the second annual general meeting of the ANZSNM held in Sydney on 17 February 1970.

The first annual general meeting of the branch was held on 28 July 1971, at the Royal Prince Alfred Hospital, at which a report from the retiring president Mr B. W. Scott was delivered.

The meeting was followed by the first scientific meeting where Mr A. M. Downes (senior principal research scientist at the CSIRO division of animal physiology) spoke on the subject: â&#x20AC;&#x2DC;Applications of beta-emitters with low end-point energies to biomedical researchâ&#x20AC;&#x2122;. In his talk, he discussed the principle uses of beta-emitting radionuclides 3H, 14C and 35S in relation to applications in nuclear medicine. Examples of their use were drawn from research conducted within his CSIRO division.

National Nuclear Medicine Day

Professor Provan Murray with jockey Shane Dye at the launch of National Nuclear Medicine Day

The following account of the first Nuclear Medicine Day in Australia was reported by Dick McLean in the December 1993 edition of the ANZSNM Newsletter:

76

The concept of the day was conceived over several glasses of wine at the Annual Scientific Meeting in Canberra, but the gestation period was slow. A steering committee, comprising representatives of all groups and from most states, had an initial teleconference at which the concept was supported. However, the first step of securing a high-profile person to launch the day was not without difficulty. The Health Minister, Senator Graham Richardson, was suggested. But, despite one letter, three faxes and eight telephone calls over a four-week period, it was not possible to even talk to his appointment secretary! After a rapid change of plan, Robyn Williams, presenter of the ABC Radio Science Show was approached and he agreed to perform. Anne McCaig, media liaison officer for David Hill, General Manager of the ABC, gave valuable input at various stages, suggesting strategies and supplying lists of contact people for the television, radio and print media.

The launch was planned for Thursday 16 September at the Prince of Wales Hospital and members of the Hospital's public relations department, particularly Ken Simmons, were of invaluable assistance.

In the month leading up to the open day, the assistance of the public relations department of Ansto was sought and Chris Tweedie in particular was most helpful. For example, he was able to use his contact with the AAP media group to fax news releases to all the appropriate media outlets and personally contacted a number of media representatives to gain coverage.

The idea for a bumper sticker took shape in the last few weeks and it was through the assistance of Chris that these were printed and distributed at short notice. A number of commercial companies were approached and all were happy to contribute. These included Radpharm, ADAC, Du Pont, Medical Applications, GE Medical, Mallinckrodt and Amersham.

The launch at the Prince of Wales Hospital was moderately successful since, thanks to Ken Simmons, there was coverage by Channel 9. Professor Provan Murray, in his capacity as president of the world federation, introduced the concept of the day and outlined the status of Australian nuclear medicine in the world. Professor John Dwyer spoke on the value of nuclear medicine in treating patients with AIDS and Professor Bill Bates emphasised its effective use in the treatment of children. The theme of the value of nuclear medicine in the management of sporting injuries was highlighted by the presence of a number of sports personalities, including Shane Dye (champion jockey), Aaron Raper (Cronulla-Sutherland rugby league player) and Warwick Waugh (Wallaby forward). There was 90 seconds of coverage via the Channel 9 news network to the other States.

Individual State committees organised their own publicity. In Queensland, Fred Khafagi and Emlyn Jones were interviewed on ABC Radio. There was good coverage on Prime Television and ABC Radio in Canberra. In Melbourne, Rod Hicks had a 15-20 minute interview on ABC Radio. In Western Australia, there were radio and television interviews involving Geoff Bower.

In South Australia, Wendy Barber had several radio interviews. Most states were also able to generate some newspaper coverage; this seemed to be more successful in the country areas.

Unfortunately, Sydney was unable to attract any mainstream media attention although Professor Dwyer devoted his weekly page in the widely-distributed suburban papers to 'Nuclear Medicine Magicians'.

Western Australia lived up to its name as the â&#x20AC;&#x2DC;state of excitementâ&#x20AC;&#x2122; by producing some exciting discussion in relation to the potential for National Nuclear Medicine Day to be seen as illegal advertising! The issue was resolved in favour of the Day. The Day itself, when departments were opened to the public, tended to be a flop. One exception was Royal Brisbane Hospital, which opened the week before and had approximately 150 people through the department. Once again, regional centres generally fared better, including Wollongong Hospital and Woden Valley Hospital (relatively provincial).

77

In major centres, between 20 and 50 people went through public hospitals with the numbers attending private practices ranged between zero and ten. Rather than opening their department, however, the Royal North Shore Hospital achieved considerable public attention at a weekday exhibition in the lobby with equipment, a video and staff on hand for discussion.

For those who are unconvinced that we need to promote our specialty to the general public, I would suggest that you read the editorial in the European Journal of Nuclear Medicine (1992, 19, 835) and the reprint of the presentation by Henry Wagner at the June SNM meeting (Journal of Nuclear Medicine, 1993, 34, 27N-33N). Those of you who were present at the Canberra meeting and heard Paul Lynham talk should be in no doubt.

With the insights gained and the contacts made from this year's effort, next year's open day will probably be held close to the time of the world federation meeting and should be much 6 more successful.

ANZSNM Newsletter and Journal The establishment of ‘Nuclear Medicine News’, the first official organ of the Australian Society of Nuclear Medicine, by Dr Harry Lander in November 1969, allowed the immediate dissemination of nuclear medicine throughout Australia. However, within a matter of months, and after just two issues (November 1969 and January 1970), at the second annual meeting in Sydney in February 1970, the society was renamed: the Australian & New Zealand Society of Nuclear Medicine.

The purpose of the newsletter was to keep members of the society informed about matters of mutual interest relating to the field of nuclear medicine in Australia and New Zealand.

Accordingly, it was proposed that the newsletter be prepared and distributed bimonthly, subject to the receipt of information and financial assistance for such preparation and distribution.

Following inaugural editor, Dr Harry Lander (November 1969 - April 1974), subsequent editors have included Dr G. C. Lowenthal (1974), Mr P. J. F. Newton (1990), Ms Rachel Bullard (2001), Dr Barry Chatterton (2006) and Dr Alex Pitman (2007). Book reviewers have included Dr Hoeschl (1970s) and Dr Patrick Butler (1991).

In the September 1990 issue, Dr G. C. Lowenthal paid tribute to Dr Hoeschl for his major contribution to the society in reviewing books on a regular basis for the newsletter: It is now well over 15 years since the society struggled to put its Roneod journal, then known as ‘Nuclear Medicine News’, firmly on its feet. Right from the beginning, there was the intention to include a book review section. It was Dr Hoeschl who was a strong advocate for such a move. What was not much forthcoming at the time were books to be reviewed. This was not surprising, because publishing houses were blissfully unaware of the existence of ‘Nuclear Medicine News’ or, if aware of it, were all too well aware of its small circulation.

In the end, persistence paid off. A book review section began to appear even before ‘Nuclear Medicine News’ underwent its metamorphosis to become the professionally printed newsletter with Dr Hoeschl as the book review editor. He has been known in this capacity by every member of the society from that time to today.

In recent months, Dr Hoeschl has been looking around to find a successor. He felt that he had done his share on behalf of all of us. A successor has now been found in Dr Patrick Butler,

78

director of nuclear medicine at the St George Hospital, Kogarah, NSW, who kindly agreed to undertake this important honorary task. Dr Hoeschl felt free to retire from an office he had held for about 15 years with great credit to everyone concerned and for the benefit of all readers of the newsletter.

Dr Hoeschl had not only been book review editor, he played a very important part in the aforementioned metamorphosis. He did this in at least three respects. He was an outspoken advocate of the need for upgrading the appearance of ‘Nuclear Medicine News’. He made a strong case showing that a properly-printed issue would be financially viable, and it was he who found the printing firm. That he made a good choice is evident from the fact that that firm has continued to be our typesetter and printers nearly 12 years later. Also, when I, as the editor at that time, had to be overseas for long periods, Dr Hoeschl was repeatedly willing to stand in as acting editor.

It was quite a job to persuade book publishers that the new newsletter was a sufficiently widely-read publication to make it worth their while to send us expensive textbooks for review.

Early on, we kept bemoaning the fact that there were not more books sent to us for review, because we knew that the book review section was as much and perhaps more appreciated by readers as any other section. Still, things improved and Dr Hoeschl managed to get enough books for reviews to fill upwards to 10 per cent of the text - though mostly it was rather less than that.

There was not only the publishing houses to be persuaded. People who were willing and able to write reviews were not always as forthcoming as the book review editor and readers might have wished. Book reviewers were often rather less perturbed about failure to meet deadlines than the review editor. Still, on the whole, Dr Hoeschl received excellent cooperation from other society members with a few of the reviewers carrying rather more than their fair share of the workload. But then, good deeds carry their own reward!

Our society was well-served by its book review editor and it is my privilege to state this fact.

He is certain to remain an active member of the society and I hope he will remain so for many years to come. I take the opportunity to welcome Dr Butler to what is an onerous task. The present honorary editor, Mr Newton, has expanded the volume of the newsletter and there has been a growing number of advertisements and other help from supporting members and friends of the society. At this stage, it may even be possible to achieve the desirable goal of book reviews making up 10 per cent of the text more often than not! Dr Hoeschl has certainly earned himself an honourable release from his duties. Once again, we all thank him and wish 7 him well for the future.

References 1. Lander, H., pers. corresp. to Hare, W. S. C., 22 April 1969.

2. Hare, W. S. C., pers. corresp. to Lander, H., April 1969.

3. Dugdale, L. M., pers. corresp. to Lander, H., 29 April 1969.

4. Andrews, J. T., pers. corresp. to Lander, H., 1 May 1969.

5. Nuclear Medicine News, 1, 1, January 1970.

6. Nuclear Medicine News, ‘Nuclear medicine makes much more than an atom of difference’, 24, 4, December 1993.

7. Nuclear Medicine News, ‘One more review’, 21, September 1990.

79

Chapter 5

TRAINING AND ACCREDITATION Training, Examination and Certification of Nuclear Physicians At the inaugural ANZSNM meeting in Adelaide in May 1969, considerable discussion had taken place with regard to the most appropriate specialist qualification for medical graduates working in the field of nuclear medicine. Four possibilities were considered:

(1) Membership of a New College â&#x20AC;&#x201C; The Australian College of Nuclear Medicine This had been rejected as it was considered impracticable due to the small number of people working in nuclear medicine at the time.

(2) Membership of the College of Radiologists of Australasia This had been generally considered undesirable as, even at that time, developments in nuclear medicine were moving more into the area of physiological studies, rather than radiological techniques.

(3) Conjoint Diploma of the College of Radiologists of Australasia and Royal Australasian College of Physicians This was also thought to be undesirable.

(4) Membership of the Royal Australasian College of Physicians Of all the options, this was the most favoured and a committee was formed to commence negotiations with the Royal Australasian College of Physicians on future training, examination and certification of medical specialists in nuclear medicine in Australasia.

Representatives of both societies met in Sydney on 27 September 1969. The ASNM was represented by Drs H. Lander, J. Morris, L. Dugdale, M. Quinlan and Associate Professor J. McRae. The RACP was represented by Drs H. Maynard Rennie, J. L. Frew and G. L. McDonald. At the conclusion of this meeting Dr Lander, with the full support of his colleagues, recommended:

That the College of Physicians be asked to set up an educational advisory committee in nuclear medicine.

80

That the committee comprise eight members, made up from two member nominations each from the Australian College of Physicians, College of Radiologists of Australasia, College of Pathologists of Australia and the Australian Society of Nuclear Medicine (medical members only).

That the committee consider the following terms of reference: 1. Accreditation of posts 3. Vocational training programme 3. Certification in the speciality

The recommendation was brought before the council of the college and, on 22 October, the ASNM was informed that the council of the RACP had accepted the recommendations of the combined committee on nuclear medicine and that an educational advisory committee in nuclear medicine to the RACP was to be established. They further informed the society that they were in the process of establishing a permanent accreditation and credentials board under the chairmanship of Professor Bryan Hudson. This board would have the task of accrediting hospital posts for physician training, and examining the training credentials of candidates for membership of the college.

A major role of the RPAH department has been the facilitation of all aspects of nuclear medicine education, locally and internationally. It became a regional training centre for nuclear medicine â&#x20AC;&#x201C; IAEA (Vienna), ANSTO. The physician training program at RPAH was based on the general sequence of a term as rotating SMO, then registrar followed by overseas training, return as staff specialist at RPAH or to some other hospital nuclear medicine department. Overseas postings were usually arranged by Morris and were facilitated by the goodwill engendered by successive trainees passing through these overseas establishments. On the broader scene, RPAH has assisted the establishment of nuclear medicine services in other hospitals by providing trained nuclear medicine physicians, by consulting (J. G. Morris had twelve consultant positions) and by providing a service. For example, Dr Robert Howman Giles carried out studies at RPAH on children from RAHC, whilst they were setting up their department.

There were many hospitals in NSW that had associations with RPAH and their facilities were amplified by the assistance given by the rotation to them of registrars in training at RPAH. The department at Lidcombe Hospital was developed under the supervision of John Booker, after he completed his training at RPAH; and he was assisted by their registrars on rotation.

Somewhat similar arrangements were made with Lewisham Hospital and Auburn Hospital.

Michael Yeates from RPAH set up the department at Liverpool Hospital, after he came back from Syracuse in upstate New York; and also set up a laboratory for in-vitro work. Later, he went to Sydney Hospital where he was director before entering private practice. A number of RPAH-trained nuclear medicine physicians set up departments in other NSW cities. Fred Lomas, after training at RPAH, spent 1972 in the USA and returned to take charge of nuclear medicine at the Canberra Hospital. Tony Booth (RPAH registrar 1974) went from 81

RPAH to Chicago to train with Paul Harper and Gottschalk and, on his return, established the department at Woden Valley Hospital, Canberra. Sharon Pussell initially trained at RPAH, then in the UK and USA, and then returned to RPAH before establishing a department of nuclear medicine in Orange Base Hospital. She was joined there by Greenough who had been to Michigan to train in PET oncology with Wahl.

Other physicians who trained at RPAH and later established themselves elsewhere included the late Paul Farrer, who trained with McRae and then worked in the USA, Peter Ronai who went to Adelaide and then to the USA, and Peter Valk (deceased) who was responsible, along with ex-RPAH physicist Dale Bailey PhD, for producing one of the first comprehensive textbooks on clinical PET whilst he was in California. This PET text book, Positron Emission Tomography: Basic Science and Clinical Practice, a 900 page tome published by SpringerVerlag UK, contains many sections written by scientists from RPAH. It was usual for trainees to have obtained their MRACP prior to undertaking nuclear medicine training. This additional clinical experience made them sought-after by overseas groups; and they established many long lasting collaborative relationships. Roger Uren, for example, who went to Harvard in 1976 and was immediately involved in their gated heat pool studies, has been invited back twice and has arranged visits to RPAH by Harvard staff.

The nuclear medicine scientific core group became the source of advice to NSW, Australian and international agencies, and supported ANSTO with training programs. Brian Hutton, leader of the physicist group, always played an active role in education. For example, until 1992, he taught computer courses related to nuclear medicine at ANSTO, which were funded by IAEA. Similarly, with ANSTO, he visited Thailand and other countries on a number of occasions training technicians, as there was a short-fall of teachers and training. He met Heather Patterson and they discussed how to solve the problem and, after some meetings in 1992, the idea of distance assisted training (DAT) was developed. Programs have been developed to allow distance assisted learning to take place for nuclear medicine technicians who are not directly in association with a major centre; as is the case in much of Southeast Asia and China, which have been funded by IAEA in 1997-1999 and 1999-2002. The current programs are being hosted by the University of Sydney. The programs have been adopted by the EU, have recently been translated into Chinese, and the whole program has been adopted and supported by IAEA. The programs are widely applicable and their range of use could be global.

Mike Rutland sums up the situation in New Zealand as follows:

â&#x20AC;Ś departments may be run either by a nuclear medicine qualified physician or by a consultant radiologist. In theory, the radiologists require two years work in nuclear medicine to get a radioisotope licence from the National Radiation Laboratory (NRL). In practice, this has usually been less than six months. The physicians are registered with the Medical Council of New Zealand as internal medicine specialists. There is no sub-speciality of nuclear medicine in New Zealand. If they have three years or more nuclear medicine training they are entitled to a radioisotope licence. Other radioisotope licences are held by endocrinologists, cardiologists and oncologists, all of whom have quite variable training in the use of unsealed radioisotopes. There are no training posts for nuclear medicine specialists in New Zealand.

82

In the past three years, the NRL has changed from issuing one licence to the head of a department to issuing a licence to everyone who works with radioisotopes. The licence fee income went up from $60 per year to in excess of $1,000 per year. In addition, although the NRL ‘appoints’ a principal licensee, all the other doctors hold their own licences, and are to some extent independent practitioners, with the potential for some confusion.

There is no doubt that Harry Lander was the driving force behind the establishment of the ANZSNM. However, he was a typical Scot: ambitious, and had a great deal of trouble relinquishing his self- imposed directorship of the Royal Adelaide Hospital’s Department of Nuclear Medicine, as will be seen in the first official director’s comments that follow:

Before I got the Adelaide job, Harry Lander was given the task of planning the nuclear medicine department at the Institute of Medical and Veterinary Science (IMVS). The IMVS is an independent entity sited on the grounds of the Royal Adelaide Hospital (RAH) and providing laboratory services for the hospital and for other medical and veterinary facilities in South Australia.

Harry was not trained in nuclear medicine, but had some familiarity with Cr-51 and P-32 labelling of RBCs and platelets by virtue of his haematology subspecialty. At the time (and for many years afterwards), he was Reader in the Department of Medicine at the University of Adelaide, based at the RAH. I am not sure where Harry got the information to help him decide what equipment to order. I vaguely remember his writing to me to ask my opinion and I'm sure he wrote to others in Australia, and probably overseas.

My recommendation was to go for the Nuclear Chicago scintillation camera, with which I was most impressed from the work in Hal Anger's lab that I had witnessed during my postgraduate fellowship at Donner Lab in 1964. (I was about to leave for the USA at that point January, 1968 - to pursue my Churchill Fellowship, the major thrust of which was to spend time with Hal Anger and his gamma and positron cameras, as well as to visit the other major nuclear medicine labs in North America.) I don't know what input Harry had from others.

The end result was that Harry ordered two Nuclear Chicago scintillation cameras, one equipped for single photon imaging and the other for both single photon and positron imaging.

(At this time there were no other scintillation cameras in Australia or, as far as I was aware, in the Southern Hemisphere, and I believe ours was one of the first, if not the first positron camera Nuclear Chicago had sold.

At that time, all the nuclear medicine physicians in Australia were committed to the rectilinear scanner and the commonly-held view was that the scintillation camera would never displace the rectilinear scanner. Even Henry Wagner at Johns Hopkins was fully committed to rectilinear scanners at the time and did not get his first Anger camera until several years later.

However, Alex Gottschalk, who did a fellowship with Hal Anger, had gone back to Chicago and was publishing imaging studies with the Anger camera, including the early Tc-99m images, using the Tc-99m that Paul Harper produced at the University of Chicago. (I visited Alex and Paul on my Churchill Fellowship.)

83

In addition to the two scintillation cameras, Harry ordered a Picker rectilinear scanner (I'm pretty sure it had a 3" crystal), as I-131 was still the tracer used in most labs for thyroid scanning and the efficiency of the 3/4" crystal of the Nuclear Chicago scintillation camera was insufficient for the 364 keV photons of I-131. Nuclear Chicago later came out with the 1/2" crystal camera for improved resolution of Tc-99m imaging. But, by then, the tracers used for thyroid imaging were Tc-99m and I-123, both of which could be imaged efficiently with a 1/2" detector. We upgraded one of the two cameras to the 1/2" crystal, retaining the 3/4" crystal on the camera equipped with the positron detector for imaging the 511keV photos of positron decay.

Harry also ordered the usual in vitro equipment (Packard Liquid scintillation counter and gamma counter, and a planchette counter for P-32), as well as a G-M counter for area monitoring.

When I applied for and was appointed to the Adelaide job, it was advertised as ‘Director of Nuclear Medicine’. However, when I arrived in Adelaide after my Churchill Fellowship, I found that Harry Lander had assumed the title of Director of Nuclear Medicine in addition to his position as Reader in Medicine and was occupying the Director of Nuclear Medicine's office in the new department, in addition to his office in the Department of Medicine. This led to a particularly awkward period during which Jim Bonnin, the head of the IMVS, pointed out to Harry, in no uncertain terms, that his role in the planning phases was not meant to transition into a permanent appointment as Director of Nuclear Medicine. Harry moved out of the Director's office, but continued to act as Director of Nuclear Medicine for several months, until he finally accepted defeat and withdrew into a secondary role. However, my relations with 1 Harry thereafter, while superficially pleasant, were always a bit awkward.

Technologist Training It was soon recognised by the ANZSNM that adequate training of technologists in nuclear medicine was of considerable importance to the future development of nuclear medicine services throughout Australasia. The society’s official organ, Nuclear Medicine News, devoted an entire issue to presenting news and views on this subject in 1971.2

The first officially-recognised course of training in radioisotopes was established by the Royal Melbourne Institute of Technology (RMIT) in Victoria, in 1964. It is believed that the ‘Radioisotope Technician Certificate’ was the first three-year course of study in nuclear medicine technology in the world.3 Canada introduced a similar course in 1965, which was run by the Canadian Society of Radiological Technicians in co-operation with the Canadian Medical Association.4 This was a basic two-year course, followed by the availability of advanced certificates.5

At the 1970 Annual General Meeting in Sydney, it became obvious from discussion that widely divergent views existed among members with regard to the type of training that technologists in the field of nuclear medicine should undergo. Miss Jean Milne was present 84

at this meeting and presented the view for the Associate Diploma in Medical Nucleography of the Royal Melbourne Institute of Technology. Many members seemed to consider the entrance standard to the RMIT course was set too high; and that relatively few people interested in becoming technologists in medical nucleography possessed sufficient qualifications to even begin the course.6 The ANZAPNM had the view that a course wasn’t needed at all:

… two correspondents felt that it was wrong for ‘Nuclear Medicine News’ to support the Associate Diploma in Medical Nucleography of the Royal Melbourne Institute of Technology, because a consensus of members of the New South Wales Association of Physicians in Nuclear Medicine had met and decided that there was no need for a course of this type. The number of applicants and support for the course, which has been received by the Royal Melbourne Institute of Technology from the other states of Australia and from New Zealand, would suggest that this view is not shared by members of the society in other states.

It was from contentious issues such as this that ‘Nuclear Medicine News’ introduced a correspondence column. The editor stated that:

Argument and constructive criticism is to be welcomed if it benefits the development of nuclear medicine as a whole in this country. For this reason, it is proposed to incorporate a correspondence column in the next issue of ‘Nuclear Medicine News’ and it is hoped that members will take an opportunity to express their views in it. However, it is hoped that the views expressed by members will have national, rather than parochial, interests at heart and 7 will do nothing to create enmity between different sections of our membership.

Victoria was the first Australian state to recognise that a separate training and accreditation scheme was necessary for technologists in the field of nuclear medicine.

A precursor radioisotope certificate course was first established with Peter MacCallum Clinic around 1963. At that time, several radioisotope departments were being set up in major Melbourne hospitals: Prince Henry's, St Vincent’s, Royal Children's, and Royal Melbourne Hospitals as well as at the Mercy Hospital. In support of these new departments Peter MacCallum Clinic provided staff, mainly therapy radiographers, to start these ventures and decided that there needed to be a formal course.

It was then realised that this course of study would require a more formal approach, so the Peter MacCallum Clinic joined forces with the Royal Melbourne Institute of Technology (RMIT) and the three-year course commenced in 1964. The object of the course was to produce well-trained technical personnel for hospital radioisotope units, having a sound knowledge of physics, clinical principles and practice and instrumentation. Those who were instrumental in the development and delivery of the course were Miss J. Milne, Dr J. 85

Andrews and Mr K. Clarke (Cancer Institute) and Messrs D. Bendel, W. Chappell and E. Heywood (RMIT).

The origins of Peter MacCallum Clinic grew out of the Royal Melbourne Hospital and the radioisotope department at RMH was taken to Peter MacCallum when it was established in 1950. Jean Milne was in charge of the isotope department at Royal Melbourne and was instrumental in the establishment of the radioisotope department at Peter MacCallum Clinic. From the very onset, Peter MacCallum made sure that radioisotope education was part of the therapy radiographer course at RMIT at that time.8

The sequence of events that had led to this started in 1930, following a national cancer conference called by the Commonwealth Minister of Health. Cancer organisations met annually to discuss how best to tackle the disease. At the first conference, it was noted that Victoria did not have its own cancer organisation, but New South Wales, Queensland, South Australia and Tasmania did.

However it was not until 1936, that the Anti-Cancer Council of Victoria was constituted. The volunteer-based charity raised the equivalent of $6 million in today's money in its first appeal in 1936–‘37.

In 1937, two members of the Cancer Council’s Executive Committee, Professor Peter MacCallum and Dr Rutherford Kaye Scott, developed a plan to tackle the installation and maintenance of treatment and follow up records, liaison with medical officers, development of a hospice and almoner service, and development of research and expansion of facilities and treatment.

In line with the plan, the Medical and Scientific Committee recommended that £6,500 be made available to the University of Melbourne for an X-ray and radium laboratory. Professor MacCallum and Dr Kaye Scott recommended research funding should be allocated to studies likely to improve existing treatments, especially radiotherapy and surgery. Patient support services began almost immediately after the Cancer Council's 1937 plan was developed.

A key feature of the MacCallum/Kaye Scott plan was the establishment of a central cancer institute for the radiation treatment of cancer. During the 1940s, the Cancer Council's Executive Committee and Medical and Scientific Committee worked in conjunction to establish the Central Cancer Institute.

Two world authorities on the radiation treatment of cancer visited Australia in 1943 and, at the Cancer Council's invitation, came to Melbourne to work in collaboration with the Cancer Council to advise the Government on the establishment of an institute. Their report to the Premier supported the creation of a central institute in which all radiation treatment would be carried out. It would be open to public and private patients, and be staffed by full-time radiotherapists.

86

After years of work, a Bill incorporating the Cancer Institute was passed in December 1948.

The Institute was renamed the Peter MacCallum Cancer Clinic in 1950. In 1951, the Executive Committee set about fulfilling another of its key objectives - the funding of cancer research.

The coordination of all activities in relation to cancer research began with the Medical and Scientific Committee approving several requests for experimental research funding. Dr R. Motteram, a pathologist at the Austin Hospital, was sent overseas at the expense of the Cancer Council to study experimental work in transmissible tumours in animals. A grant was also given to Professor Trikojus to carry out research into radioactive iodine, with particular reference to thyroid carcinoma. Dr Kaye Scott also received funding to study the therapeutic efficacy of radioactive iodine, radioactive phosphorus and nitrogen mustard at the Royal Melbourne and Austin Hospitals.9 In her paper published in 1965, Jean Milne gives a brief history of the expansion of medical radioisotope work in Melbourne from the 1950s. Prior to this, she was the only full-time radiographer performing radioisotope work in Melbourne at the Royal Melbourne Hospital.

These ‘pioneering’ days were fraught with such inconveniences as having three locations for the various aspects of the work situated on the ground, fourth and seventh floors. Equipment was minimal but most up-to-date for that era. Ten Geiger-counters were used for thyroid uptake studies and valuable basic investigations of technique were performed. By 1955, three-and-one-half radiographers were occupied full-time in two hospitals. By this time, iodine and phosphorus were part of the routine clinical programme and three further radioisotopes were proving their usefulness, iron and chromium in anaemia investigations and colloidal gold 3 in treatment of serous effusions.

The following table shows the expansion of services, radioisotopes and radiographers employed in radioisotope investigations in Victoria.3 Year

Hospitals

Radiographers

1950 1955 1960 1965 1970

1 2 4 6 ~10

1 31/2 6 12 (+4x2nd year trainees) ~20

Radioisotopes available 2 5 9 12 ?

The success of these units was dependent on the provision of adequately-trained staff, experienced in all aspects of radioisotope handling and protection, the use of detectors, basic clinical procedures and a full understanding of patient handling. This led to the Cancer Institute publishing Jean Milne and Ken Clark’s 1962 ‘A Design for a Radioisotope Unit for a Large General Hospital’;10 and soon after, a course of study at Peter MacCallum Clinic, and then at RMIT. Until 1963, all the radioisotope training had, out of necessity, been undertaken in the existing departments with no formal lecture programme. The introduction of one year of radioisotope lectures in the third year of the radiotherapy course at RMIT consolidated the theoretical training of radiographers employed in radioisotopes, but was not considered a complete training program. In 1965, of the twelve radiographers engaged in radioisotope work, eight had therapy backgrounds and four in diagnostics.

First president of the Australian Society of Nucleography, Ron McCartney recalls establishment of that first course:

87

… Ken Clarke was head physicist in 1963, and he and Jean talked to RMIT and got them to start the course in radioisotopes in 1964. Four students were taken on, funded by PMC. The first two years were mainly subjects common with the diagnostic and therapy courses. PMC basically conducted any extra subjects at no cost to RMIT. I was appointed as a temporary lecturer at RMIT in January 1964. Whilst my main duties were in physics, diagnostic radiography, therapy radiography and radioisotopes, I was basically in charge of the therapy and radioisotope streams. Dave Bendel was the senior lecturer in charge of the whole area.

There were a lot of discussions with the Australian Institute of Radiography about radioisotope technicians being accepted as AIR members. This was not agreed to, so the emerging radioisotope people started a new professional body, which was called the Australian Society of Nucleography. When the RMIT started their diploma courses the initial course in radioisotopes was named the Associate Diploma in Nucleography; mainly at my insistence. However, the world has moved on. Nuclear medicine and nuclear medicine technologists had become the norm, the Australian Society of Nuclear Medicine had been formed and they now wanted to control technician training. Consequentially, within a short 11 period of time, the name was changed to ‘nuclear medicine technology’.

Students enrolled in the initial RMIT radioisotope technician course, in 1964, were: Merilyn June Coxhill, Allen William Morley, Diane Christine Stanley, Francis Maree Stewart and Carol Ann Mcintyre.

The three-year course of study was also offered as a correspondence course for external students, leading to the award of Associate Diploma in Nucleography. Interstate candidates were required to be in full-time employment in the field of nuclear medicine, under the supervision of an appropriately-qualified medical practitioner. In 1971, the fee for the five first year subjects was $125. The course later progressed to a full diploma and then to a degree.

Early in 1970, the NSW Branch of the ANZSNM appointed a committee to organize a training scheme for nuclear medicine technologists. A syllabus was prepared and negotiations commenced with the Department of Technical Education. By 1971, an offer was made to provide a course contingent on sufficient students being available, along with some minor modifications to the suggested syllabus. The first obstacle was overcome by the Hospital’s Commission by the provision of a number of additional positions in departments of nuclear medicine in several hospitals.

The course provided by the Sydney Technical College’s School of Biological Sciences was a four year part-time certificate, based on the syllabus provided by the committee. Due to such short notice, in order for this course to commence in February 1971, the Technical College had to make some necessary changes to the originally-suggested course structure.

The Society has always had a major role in the training of nuclear medicine technologists 88

since inception of the accreditation board. This board is composed of technologists and scientific and medical representatives, and has two primary areas of concern: approval of courses and departments suitable for training, and assessment of trained individuals seeking accreditation from the ANZSNM. The Board maintains active communications with all educational institutions proposing new or amended courses, and can and does comment on specific matters related to course content. However, the Board does not dictate to academic institutions how they should run a course. But, where it is felt that certain academic areas have been overlooked, it will strongly recommend review of those subjects before the course is approved.

In December 1987, the Secretary of ANZSNM, Richard Smart PhD, reported on the then state of the art in nuclear medicine training in New South Wales:

The training program for nuclear medicine technologists (NMTs) in NSW is currently undergoing its biggest change since a formal academic course was first established in 1971.

Since that time, the academic training of NMTs has been undertaken by Sydney Technical College, initially as a three-year part-time certificate and, since 1981, as a four-year, parttime, associate diploma (UG3). Clinical experience was gained on-the-job with little direction from the college until 1983, when a clinical log-book was introduced to ensure that the student attained competency in all the essential areas of practice. A student rotation scheme between hospitals was organised by the chief technologists independently of the college, to provide clinical experience in all aspects of nuclear medicine.

In June 1983, the NSW Higher Education Board (HEB) appointed an ad hoc committee to investigate the education of radiographers and other 'imaging technologists' in NSW. The report of the committee, 'Education in Imaging Technology and Therapeutic Radiography' was published in January 1985 and recommended that a single course, leading to a UG2 diploma of applied sciences, be established in which students would gain instruction in three diagnostic modalities (diagnostic radiography, nuclear medicine and ultrasound) or therapeutic radiography and two diagnostic modalities.

Following written submissions from all the professional bodies, including the NSW branch of the society, a second ad hoc committee, under Mr Parry, the Chairman of the HEB, recommended that a UG2 course be provided in medical radiation technology (the preferred generic name for the discipline) at Cumberland College of Health Sciences. The Parry Report (October 1985) responded to the concerns of the professional bodies that a 'jack-of-all-trades and master-of-none' would be unemployable, and recommended that a common core of subjects be studied by all students, but that a student would specialise to the appropriate professional standard in one modality only.

Although Cumberland College accepted the invitation from the HEB to run the course, no funds were forthcoming from the Commonwealth Tertiary Education Commission (CTEC), so nothing further happened until the end of 1986, when funding was finally approved. Ron McCartney was appointed as head of the School of Medical Radiation Technology in May 1987 and took up his duties in July. Ron was formerly a senior lecturer at RMIT and has

89

experience in physics, therapeutic radiography and nuclear medicine. Recently, lecturers in each of the clinical modalities and in physics/instrumentation have been appointed, and the course will commence in February 1988. Ron McCartney is to be congratulated on the speed and thoroughness with which he has been able to design the curricula for the course, assisted by the External Advisory Committee.

The Diploma in Applied Science course will be full-time for three years, including 24, 21 and 21 weeks of academic study per year for the three years and 9, 15 and 15 weeks of hospital clinical practice. The clinical practice will be in blocks of between three and five weeks and the students will gain experience at a different hospital for each block. The academic subjects in the first year are common to all students and include all the basic sciences: general physics and maths, radiation physics, anatomy and physiology, behavioural science and computing.

In addition, two subjects: medical radiation principles and medical radiation applications, introduce the students to the physical principles and the clinical applications of all four modalities, so that the students have a basic understanding of the other disciplines.

The subjects specific to nuclear medicine are developed in depth in the second and third years with a much smaller proportion of the syllabus directed to common subjects (e.g. pathology, behavioural science and administration). One innovative concept is to have one image-processing subject for all the modalities, as increasingly digitally-acquired and manipulated images are being used in each of the four areas. The clinical applications of the image-processing will be different in each area, but the concepts are the same. An introduction to ultrasonography is included for both the diagnostic radiographers and the nuclear medicine technologists, but the graduates of the course would need additional training in ultrasound before they could practise independently.

The new syllabus should give the students a much better theoretical knowledge of nuclear medicine than students currently achieve through the associate diploma course.

Radiopharmacy will be taught as an integrated subject, rather than as part of the clinical procedures, so sterile production and quality control, for example, will be covered in considerably more depth. Similarly, the instrumentation courses have been substantially updated and give considerable emphasis in the third year to such topics as SPECT, PET, NMR and bone densitometry in addition to studies of the gamma camera and its associated computers.

Many members of the NSW nuclear medicine community have reluctantly accepted the move from part-time training to a full-time course. Obviously, the number of hours of clinical experience achieved by the students at the end of their three-year course (1,365 hours to be precise) will be much less than was achieved by students undertaking the UG3 course. To ensure that the hours spent in the hospitals are as productive as can be achieved, the clinical experience will be coordinated, as much as possible, so that it ties in with the academic subjects. Simon Cowell, who has recently been appointed as Lecturer in Nuclear Medicine, will have the task of ensuring that this happens.

The course proposal has been accepted by the External Advisory Committee, subject to several minor conditions, but at the time of writing (November 1987) it has not been assessed

90

by the HEB. However, this will be completed before the commencement of the course in February. The course proposal will also be assessed by the society's Accreditation Board at its next meeting to ensure that graduates of the course meet the society's conditions for accreditation. It will be necessary, as with the other full-time courses in Victoria and SA, for the graduates to gain one year of additional clinical experience before being eligible for accreditation.

The remaining problem in NSW relates not to the content of the course, but to the number of students that Cumberland College can take into the nuclear medicine stream. The proposed intake was recently cut from 20 to 15 as a consequence of the decision by the NSW Minister of Education to allow diagnostic radiography courses to continue at Newcastle College of Advanced Education and at Riverina-Murray Institute of Higher Education. He proposed that students at Newcastle or Riverina-Murray, who wished to study nuclear medicine or therapeutic radiography, could transfer to Cumberland for their second and third years. It is unrealistic to expect five students each year to transfer and, in view of the chronic shortage of NMTs in NSW, the NSW branch of the society has lobbied for an increase in the student intake to 30.

Whether we are successful remains to be seen. You will just have to wait for the next issue's 12 exciting instalment!

The â&#x20AC;&#x2DC;Diploma of Medical Radiation Technology (Nuclear Medicine)â&#x20AC;&#x2122; commenced at Cumberland College of Health Sciences in 1988. Simon Cowell was appointed in an ongoing role as lecturer and both Professor Proven Murray and Dr Richard Smart were instrumental in development of the course. This development was not without incident when it was announced that student places had been reduced from 25 to 15. However, funding for 20 places was restored. A further announcement was also made in that there was a plan to introduce an external conversion course from associate diploma to diploma level, to allow an upgrading of qualification. The majority of this course was prepared by Richard Smart and the first intake was scheduled for 1989. It was to run for three years and then be reviewed.

Linda McCarthy reported on this course:

The course combined 162 hours of college attendance with 228 hours of independent study, totalling 390 hours. College attendance involved five blocks of three days (Monday, Friday and Saturday) in the first year.13

Gary Minch reviewed the status of education in medical radiation science, which was greatly influenced by the AIR and those courses associated with diagnostic and therapy radiography. However there were parallels with nuclear medicine as will be seen in the following excerpts from his research.14 Prior to the move to Cumberland College of Health Sciences, the students undertaking the part time course at Sydney Technical College (STC) were people who had been chosen to undertake a traineeship. Traineeships were won through job interviews with one of the departments with available trainee positions. Within Sydney, these positions were mainly located within teaching hospitals. Prior to 1978, regionally based radiography and nuclear medicine trainees undertook the Royal Melbourne Institute of Technology external diploma of

91

applied science course. In 1976, RMIT reduced enrolments from outside the state because of altered funding arrangements. In 1978, NSW upgraded to an associate diploma and courses in radiography were commenced at Riverina-Murray Institute of Higher Education (RMIHE) and Newcastle College of Advanced Education (NCAE). The associate diploma commenced at Sydney Technical College in the same year (Pearson, 1984, p. 10-11). This was five years after the Australian Institute of Radiography had approached the New South Wales Higher Education Board (NSW HEB), to express concern that, at that time (1973): New South Wales was the only mainland state which still trained radiographers at TAFE certificate standard (Pearson, 1984, p. 10).

This was also the case with nuclear medicine training. It is speculation only as to the comparative rigour of the two courses.

It became apparent that changes to tertiary education at a commonwealth level had a significant influence on the potential for radiography/nuclear medicine to upgrade out of the TAFE system in NSW and from the CAE system in Victoria.

The following excerpts, although not having direct relevance to nuclear medicine, clearly relate to why and how education went from hospital-based training to a full-time degree in under 20 years.

According to Harman and Meek (1988), higher education was expanding more rapidly than universities could handle. In August 1961, Sir Leslie Martin set up the ‘Committee on the Future of Tertiary Education’. The report which came from this committee was known as the ‘Martin Report’ (1964). Significantly, radiography was studied by the committee in 1962. The report on radiography showed certificate as the standard Australia wide. The report stated: These courses barely reached tertiary standard. The committee believes that they should be strengthened and that training should continue to be done at tertiary institutions (Martin, 1964, p. 130, in Cottrell, 1996, p. 5).

According to Rodgers, (1985, p. 14) the Martin Committee suggested that in the NSW case: Advantages may well accrue in combining the basic facilities for such specialist courses such as physiotherapy, occupational therapy and speech pathology in a technical college, or in adopting the Victorian plan of providing accommodation for them in a paramedical college.

Also, the Committee suggested that: "much of the content of paramedical courses is inappropriate for universities" (Rodgers, 1985, p. 14).

The Martin committee (1964) indicated five areas (or fields) in which technical colleges acted. Two of these ‘fields’ which directly related to radiography were: (1) Trade courses, of sub-matriculation standard, to equip workers with various industrial skills, and (2) Certificate courses for technicians, embracing both theoretical and practical components (Maclaine, p. 206 cited in Cottrell, 1986, p. 10).

With this reorganisation and commencement of CAEs in 1965, certificate courses would have to transfer away from institutes of technology. Courses in South Australia and Victoria 92

were faced with this prospect. Fortunately, it was within the internal structures of these colleges that decisions on the level of courses were made. South Australian courses went to advanced certificate and Victorian radiography courses within RMIT, which only had three ‘associateship’ diploma and diploma level courses, were upgraded to an ‘associateship diploma’ (McCartney pers. comm. 1998; and Baird 1992).

An ‘associateship diploma’ is a credential which was offered by RMIT; it is not to be confused with the ‘associate diploma’ courses.

RMIT was able to make independent decisions on the level of awards and it was decided that the associateship diploma was the suitable qualification. This preceded the introduction of the nationwide ‘Australian Council on Awards in Advanced Education, Nomenclenture of Awards’ (ACAAE, 1972), which resulted from the Wiltshire Committee, which was set up "in order to gain a consistency of awards in Advanced Education" (Cottrell, 1986, p. 6).

According to McCartney (interview 1998) the level of the ‘associateship diploma’ was higher than the associate diploma (called a UG3 under the ACAAE convention), which was recognised in the standardised nomenclature. It was equivalent to diploma level.

According to Professor McCartney (pers. comm. 1998), the associateship diploma was equivalent to the diploma courses that existed in other institutions and states. The ACAAE standardisation led to associateship diploma courses being renamed ‘diploma’ and RMIT appropriately reaccredited its course. The diploma commenced in 1975, as a three-year part-time course. According to Cottrell (1986, p. 10):

As a direct result of the nomenclature and guidelines of the Australian council’s nomenclature and guidelines for awards in advanced education, the radiography profession decided that the UG2 guidelines best suited the type of education it considered suitable for radiographers.

Ron McCartney suggested that it was the decision of RMIT to make the course a diploma (called a UG2 under the ACAAE convention) that prompted the AIR through the conjoint board to recommend UG2 to be established nationwide at the earliest date. This is the time at which all States and educational institutions were notified by the conjoint board that UG2 was to be the minimum qualification by 1980. Also, in 1978, the RMIT course became threeyears full-time. This heralded the move from hospital-based training to full-time academic preparation with clinical blocks.

There is no doubt that NSW had been slow in the upgrading process. Later critical analysis would suggest that they faced tougher opposition from their medically-trained colleagues.

93

As stated earlier, there was opposition only from one quarter, when the Royal Melbourne Institute of Technology introduced their Associate Diploma in Medical Nucleography, and this had come from a consensus of members of the New South Wales Association of Physicians in Nuclear Medicine, who had met and decided that there was no need for a course of this type. This view was not shared by the rest of the nuclear medicine community throughout Australia and New Zealand, as reported in Nuclear Medicine News.12 According to the AIR, by the early 1970s, all states were at the minimum level of UG3. This is not consistent with the actual date that the UG3 courses appeared in NSW at Sydney Technical College, and Riverina and Newcastle Colleges of Advanced Education, according to the Pearson Report 1978 (NSW HEB 1984, p. 11). NSW courses, still within the TAFE system, were already falling well behind. In NSW, the basic qualification for radiography had been a TAFE certificate since 1971. For NSW, the first step in radiography's upgrading from certificate to degree was this upgrading from technical certificate to associate diploma.

Up until the 1978 introduction of Riverina College's external studies associate diploma course in radiography, regionally based trainee radiographers in NSW qualified for professional recognition through RMIT's external diploma of applied science course. In Australia, until 1978, only Sydney and Newcastle-based radiographers still studied for a TAFE certificate (NSW HEB, 1984, p. 10). This prompted the AIR to approach the NSW HEB in 1973. The NSW TAFE indicated that it was willing to upgrade the course to associate diploma level.

At this time, Cumberland College of Health Sciences was approached by the AIR; and the college declined to accept. Amongst reasons given was the fact that radiography required ‘technical’ training and also that Cumberland College's priority was for the academic development of the ‘therapies’. From subsequent interviews (McCartney, pers. comm., 1998; Miller, pers. comm., 1997; and Ryan, pers. comm., 1996), it would appear that the underlying cause was the issue of funding rather than suitability. The fact that these points were used at this time is, however, interesting and will contribute to the critical analysis in later chapters. The associate diploma was finally started at Sydney Technical College in 1978.

The Australian Institute of Radiography sent out a statement on 22 April 1985 that, as from 1986, no course will be recognised at less than UG2 level. This was ratified by the NSW branch of the AIR on 6 July 1985. A motion was passed stating; That chief radiographers support the New South Wales state committee in their endeavours to introduce a UG2 course in radiography education in this state in 1986. (NSW AIR, 11 July 1985).

After a significant amount of activity between all parties concerned, the 1986 UG3 students were finally recognised by the conjoint board for accreditation, but only if they completed a conversion course.

The diploma course in NSW’s commenced in 1988 at Cumberland College of Health Sciences (Robinson, 1998). Within NSW itself, once the radiography course was established at Cumberland College, the credentials rose at the quickest allowable rate. A conversion course was run at Charles Sturt University for the 1987 intake, to take them from UG3 to UG2. Conversion courses at Cumberland College of Health Sciences were for nuclear 94

medicine and radiotherapy only, and continued from 1989 to 1992. The bachelor of applied science was introduced in 1992 at Cumberland College of Health Sciences (since 1990 the University of Sydney Health Sciences Faculty) and an honours degree in 1993. Conversion courses to degree commenced in 1993. The first PhD course was established in 1994.

From Diploma to Degree A condition of the approval of the diploma course was that a review be undertaken in the third year from the course’s commencement. The review was set down for 1990. The advisory committee was advised at a meeting in April 1989 that, as well as the review taking place: At the same time a separate proposal will be developed for the introduction in 1991 of a degree course in medical radiation technology. (Cumberland College of Health Sciences Medical Radiation Technology Ext. Adv. Comm., Minutes, 7 April 1989)

At this meeting, according to the minutes: The Committee generally indicated that they did not see a justification for a degree level course at this stage (point #4, p.2). The nuclear medicine technologist representative expressed concern that those with a certificate were "finding it hard to keep up with the rapid changes in training” (point#9, p. 2).

The diploma review was postponed until 1991. The bachelor’s degree commenced at Cumberland College in 1992. At this time bachelor’s degrees in nuclear medicine technology were evident in seven universities. In 1993, the first honours degree commenced at Sydney University and, in 1995, the first master’s course commenced, also at The Cumberland College of Health Sciences, The University of Sydney.

Courses offered by Cumberland College of Health Sciences: 1. Diploma of Applied Science 1988-1993 2. Conversion course to Diploma 1989-1992 3. Bachelor of Applied Science 1992 to present 4. Bachelor of Applied Science Honours 1993 to present 5. Conversion course to degree 1993 to present 6. PhD 1994 7. Preparation for conversion to degree 1994 8. Master of Applied Science 1995 With the move to the CAE system at Cumberland College, the representation from the practitioners was increased to give them a majority. With the merging with the Sydney University, the committee membership was once again modified. Smart (interview, 1997) had been a physicist member of a number of committees advising on nuclear medicine education at Sydney Technical College and then medical radiation technology at Cumberland College of Health Sciences. Although he worked diligently to improve nuclear medicine technologist education, he strongly believed that they only required technical education. He believed that scientists should be employed for the more complex work, which requires a degree education. He, along with medical members of the committees, argued against upgrading the education and the move from TAFE. Part of the professionalisation 95

process for technologists was to ‘gain control over their own education’. This was partly achieved by ensuring that they made up the majority on education advisory panels. Smart's (interview, 1997) experience was probably typical of that experienced by other medical and scientific advisors. He states: I basically was moved out of that committee when it went from Cumberland as a stand-alone college to Cumberland being part of Sydney Uni, which coincided with the change to a degree. They used that change as a way of rationalising the composition of the committee.

Everyone that was appointed previously was thanked for their time and advised that the committee was no longer in existence; and a new committee was formed. Basically, I think that the people they wanted were on that committee and people like myself, that they did not agree with, were not wanted on that committee (Smart, pers. comm., 1997).

Other professions, such as physicists, engineers, biochemists and others had valid concerns that their occupational territory might also be taken over by highly-credentialed medical radiation technologists. The nuclear medicine modality had already debated a name change to ‘nuclear medicine scientist’, amongst others.

External Training for Nuclear Medicine Technologists In 1971, in states where the number of new technologists training each year was small, the situation was considered most unsatisfactory, as only rudimentary in-service training was provided. All of these states had trained therapy and diagnostic radiographers and medical laboratory technologists, as well as those taking advantage of the correspondence course offered by RMIT, employed in the various nuclear medicine units. Generally, but not always, they received gratuities in accord with their previous qualifications. Tasmania took advantage of the availability of therapy radiographers from the satellite clinics of the Victorian Cancer Institute (Peter MacCallum Clinics) in both Hobart and Launceston. These Clinics had supported radioisotope studies prior to hospital departments of nuclear medicine being established in the 1960s. The only exception to this rule was the employment and inhouse training of nurses by Roger Connolly in Hobart in the 1970s, when he found it extremely difficult to recruit staff to the Royal Hobart Hospital. The Launceston General, on the other hand, established a strong liaison with RMIT and set about training nuclear medicine technologists from the inception of the correspondence course established in the late 1960s.

Editor of Nuclear Medicine News (September 1971), Harry Lander, stated:

The need for the separate training and qualification of technicians in nuclear medicine in each state is essential if satisfactory people are to be attracted to and maintained in this field. A shortage of adequately qualified persons can only lead to the provision of unsatisfactory nuclear medicine services within these states, particularly in the smaller and peripheral centres.

By 1987, nuclear medicine, although well established as a medical community, was still a comparatively small discipline compared to radiography and, consequently, there has still 96

been insufficient numbers of student technologists to warrant an undergraduate course, except in Victoria, New South Wales and South Australia.

Previously, the Royal Melbourne Institute of Technology (RMIT) was the only institution to ever offer their nuclear medicine course by the external mode, which enabled students in WA, Tasmania, the ACT, Queensland and New Zealand to obtain a tertiary qualification in nuclear medicine. The external course became outdated and ceased operation in 1985, owing to financial constraints on RMIT. Since that time, the courses in Victoria, NSW and SA have all been revised, but nothing has been available for the smaller states.

The society quite rightly was concerned for many years about the lack of training facilities outside of south-eastern Australia, and actively lobbied the various academic bodies to provide a new external-studies course.

The ANZSNM Newsletter reported the following responses from various institutions.

(a) In 1985, RMIT indicated that it would not be offering its degree program by external studies for at least three years, until the graduates had successfully completed the course by the internal mode.

(b) The South Australian Institute of Technology (SAlT) indicated that it would consider offering its UG2 Diploma in Applied Science (Nuclear Medicine) by the external mode, if: an approved principal provider would not offer the course; student enrolment would be sufficient to be cost-effective; and nuclear medicine technology could be taught feasibly through external studies.

(c) CTEC stated that SAlT could develop an external course using the infrastructure of a principal provider (e.g., the South Australian College of Advanced Education). It is, therefore, possible that either RMIT or SAlT could offer an undergraduate course in nuclear medicine technology given sufficient evidence that a course would be feasible and cost-effective.

It is important to be aware of the regulations governing external studies, as recommended by the Commonwealth Tertiary Education Commission (CTEC). CTEC designated institutions as principal providers or specialist providers. Principal providers had the facilities for providing external studies on a large scale; and specialist providers had expertise in a specialised area and would enter into an arrangement with a principal provider for the production and distribution of the course material.

The situation in both New Zealand and Western Australia changed. Due to the lack of an external course, a 'conversion course' for radiographers was instigated in New Zealand in 1985, jointly administered by the New Zealand branch of the society and the New Zealand Society of Radiographers and Medical Radiation Technologists. This was commenced to 97

satisfy the requirements for registration by the New Zealand Medical Radiation Technologists' Board, and was not intended to qualify the technologist for accreditation by the society's accreditation board.

In 1988, a postgraduate diploma course (two years part-time) was made available in WA for qualified radiographers, who were employed in a nuclear medicine department, to gain the necessary theoretical knowledge of nuclear medicine. The course was offered by Curtin University. The syllabus was assessed and, after revision, approved by the Accreditation Board.

In a further article, Richard Smart posed the following questions:

Would a postgraduate diploma, similar to that offered by Curtin University, if available externally, be more appropriate than an undergraduate course for the smaller states?

Although the Committee of the Society was strongly of the opinion that an undergraduate course to a UG2 Diploma or higher qualification is the ideal method of training nuclear medicine technologists, is this a practical approach for the smaller states?

In particular, for the smaller states: is there provision in the industrial awards for student technologists? if the answer to (a) is yes, is funding available for student positions? do those employed as nuclear medicine technologists have radiography (diagnostic or therapeutic) as their primary qualification? if the answer to (c) is yes, would funding be available for an external postgraduate diploma?

Finally, given the current complexity of nuclear medicine instrumentation and procedures, can nuclear medicine technology be feasibly taught by the external mode?

Before the society could recommend negotiations with the academic institutions, the committee sought the views of the membership on the above issues.

In the societyâ&#x20AC;&#x2122;s 1988 Annual Report, President Rick Baker reported:

98

There is a definite need for an external course to satisfy the training requirements of Queensland, Tasmania, New Zealand and some country centres. At this stage, no definite proposal has been received. It is likely that the difficulties involved in presenting an undergraduate course will be too great, so an external postgraduate course may be more 15 effective.

In September that year, it became obvious that any glimmer of an external course in nuclear medicine technology was still a long way off, and perhaps never to see the light of day.

However, the society, through its accreditation board, continued its quest. It was recorded that Ms Wendy Hooper of the accreditation board would conduct a survey to assess the likely support for such a course. At the same time, a letter was written to Curtin University of Technology in Perth, enquiring about the possibility of its postgraduate course being made available externally. A reply had been received and the university was quite optimistic that this option would be available in 1990-91.16

By June 1989, it was reported that Curtin University in Western Australia would have its postgraduate Diploma course available to external students in 1990. There was no progress on an external under-graduate course.17

New Zealand As late as 1989, it was reported in the ANZSNM Newsletter that training of nuclear medicine technologists in New Zealand had not been very successful, and that only very recently had the Auckland Hospital group run a series of successful courses. Christchurch supported the RMIT training course in earlier times and most of its technicians secured qualifications from that institute. Other units had adopted a more haphazard method, with result that qualified technicians were very rare persons. When the New Zealand branch of the ANZSNM was formed in 1971, a serious attempt was made to set up a common core in first year medical science at the Central Institute of Technology at Heretaunga.

Despite the fact that were only a small number of trained nuclear medicine physicians in New Zealand, remarkable progress had been made in the provision of nuclear medicine facilities in both the North and South Islands.

In order to consider the various problems associated with adequate technician training, a special meeting of experts was called by the Central Institute of Technology at Petone, near Wellington. This meeting was held on Friday 13 August 1971, at which there was a diversity of views expressed from both the physicians and physicists present. Dr Harry Lander was present at the meeting, by invitation, and reported quite extensively on the needs within nuclear medicine covering organ imaging (rectilinear scanner & gamma camera), haematology (invivo and invitro studies) and chemical (radioimmunoassay & radiopharmacy). Discussion of a Health Department bursary, for one year was also discussed, prior to entering hospital training got a further two years. Such training could be 99

monitored by CIT, through scrutiny of student log-books and the final examination controlled

by CIT. This received general support from the meeting and mention was made that this would be a distinct improvement on the present Melbourne correspondence course which was studied by students training outside the six major centres in New Zealand.

It was finally resolved, after several submitted ideas, that a sub-committee be formed to investigate the feasibility of a course in medical science which would include common core subjects suitable for radiodiagnosis, radiotherapy and nuclear medicine. There were several views expressed on this subject at that meeting.

Bruce White, who, at that time, was senior physicist in the radioisotope unit at Auckland Hospital, said that his unit had their own training scheme for technicians. He was most emphatic that the field of nuclear medicine was divided into two categories. The first was ‘scanning techniques’, involving patients; and the second was ‘laboratory techniques’ involving in vitro procedures on patient specimens. This division allowed him to explore the notion that training offered by RMIT was not a satisfactory option for Auckland, as it combined both scanning and laboratory techniques into the one course and he regarded this as undesirable. His reasoning was that, in his experience, people oriented towards radiography have no desire and are, in fact, incapable of precise laboratory work; and the converse applies to laboratory technicians. I am of the opinion that he had no concept that this was an emerging new profession unrelated to radiography and laboratory technology.

We employ full-time trained radiographers to perform the workload in category one. With a three-month period of extra training on physics of scanning, radiographers make superb scanning technicians. We take on people with a scientific laboratory interest straight from school with university entrance and train them to perform the work in category two.

He concluded by saying:

The medical, scientific and technical staff involved are satisfied with our present training scheme. However, I readily admit that it is the workload in Auckland which makes it possible to make the division in training. In the smaller centres this may not be possible, but I see the answer in staff from these centres undergoing a post-qualification training course in a larger centre for perhaps six months to a year; that is, if the Centre or Laboratory intends to concentrate on the medical laboratory application, then this extra training should be given to a qualified medical laboratory technologist or science graduate. If the Centre wishes to concentrate on scanning techniques, the extra training should be undertaken by a qualified radiographer. If the Centre wishes to undertake both these applications, then the extra training should be given to two people, one with a laboratory background and one with a radiology background.

His final statement is left for you to consider: 100

It would be a very rare person indeed who could reach the required standard of expertise in both.

There were several other views expressed, which included those of Dr David Stewart and Mr R. J. Trott.18

In 1988, Dr Allan McArthur was compiling a history of the evolution of nuclear medicine in New Zealand. He had asked Bruce White to provide him with some historical facts. It is interesting to note Bruce’s reply:

My own feelings about the nuclear medicine society are rather negative, particularly in view of the fact that they did not regard any of my technical staff as being suitable for accreditation. I do not know if you recall any of this correspondence, but it was predominately due to the fact that nuclear medicine at Auckland Hospital was so large that radioassay and scanning were split; the radioassay being performed by laboratory technologists and the scanning work by radiographers. The nuclear medicine society insisted that accreditation could only be awarded to technical staff who were familiar with both areas of nuclear medicine. My staff were therefore precluded. I felt quite bitter about this. … I subsequently resigned from the 19 Society.

Today, Bruce White is retired and reminisces about technician training at the Auckland Hospital giving us a more comprehensive insight and understanding of the situation:

I came to this job in the radioassay department from a hospital laboratory background, where I was a scientific officer, whereas other physicists’ primary responsibilities were in radiotherapy. This influenced the training and qualifications of my radioassay laboratory staff.

In 1988, our laboratory was performing over 4,800 patient samples per month that came from everywhere over the North Island. They ranged through growth hormone, cortisol, and all the thyroid tests. We also did the blood volumes, red cell survival and B12 absorption tests.

With the assays, we made up most of the reagents ourselves, including raising antibodies, charging resins etc. We never went to kits – where, as you know, all reagents are already made up – initially because they were not available and later because we were happy with our in-house methods and knew how to change reagents if standard curves were not optimum, etc. We employed one graduate radiochemist, who also made the scanning compounds, and a graduate steroid chemist (who looked after quality control & new assays) but the real work was done by ten technicians. The size of our operation could not be compared with other smaller departments in New Zealand, where a few thyroxine kits, etc. may be imported. And yet, irrespective of the size and nature of the operation, it was all covered by the blanket statement in vitro tests.

101

The NZ Institute of Medical Laboratory Technology did introduce a nuclear medicine option into their five-year course. This was the same general qualification that haematology and clinical chemistry technologists studied for before specialising. I would give the lectures in the nuclear medicine option. (I did hold the NZIMLT qualification as well as my science degree.)

So their career opportunities, salary scales, etc. flowed through to our senior staff in the Lab as well. Most of the lab technicians were on a two-year training scheme in radioassay techniques, also run by the NZIMLT. They became qualified as laboratory assistants and were on par with lab assistants in the main pathology labs.

All our scans were done by qualified radiographers. They were performing 500 scans per month. I found radiographers excellent for this work as they already had the anatomy knowledge, knew all about things like contrast controls and positioning, and were comfortable handling big equipment, etc. We had 3 radiographers and never had trouble filling vacancies from people who wanted a change from routine diagnostic radiology.

The other thing was that I wanted all the staff to have a universally-recognised qualification so that they could just notch into a recognised career structure if they ever wanted to leave our specialist area and no career path was closed to them. For example, two of our lab staff finished up in university research labs and the qualification they had was applicable and recognised there as well.

So, you can imagine my dilemma in trying to accommodate yet another training scheme in both aspects of nuclear medicine when this was all functioning so well in Auckland. I could see that other parts of the country might want this, but I don’t think they were ever sure how such graduates would be paid, as the health department in Wellington decided all salaries.

You can also see why none of my staff could get ANZSNM qualification. They were highlyqualified specialists and fully-employed in only one aspect of ‘nuclear medicine’. But, looking into the future, I thought more powerful forces could cause these two aspects to split wide 20 apart; and so it transpired.

Unfortunately the proposed course at CIT was not strongly supported by students and was phased out.

Dr Mike D. Rutland, from the Department of Nuclear Medicine at Auckland City Hospital, sums up the New Zealand situation:

…this has been precarious. In 1984, the NZ Government required NMTs to be registered; and set up a registration board, but there were no courses in NZ, nor even a list of registrable qualifications. The late Paul Orr and his colleagues (with some minor assistance from myself) set up and ran a course for qualified radiographers to get trained and certified in nuclear medicine. Unfortunately, the numbers were small, there was no help from government, and after ten years, or so, the employers of the NMTs who were running the course started to become intolerant of the time their employees were putting into the training and examining of

102

the trainees! Since that time, NZ has used some of the distance-learning courses provided from Australia. The universities are not interested unless we can guarantee them 15 new trainees per year, which is still double the current turnover in NZ. There have never been any 21 NMT training positions in New Zealand.

Accreditation of Nuclear Medicine Technologists As part of society business, this issue was discussed by the 1973-74 committee. Dr H. Lander, then a member of the committee, agreed to explore the possibility of establishing an Australian school, which would offer a centralised training scheme for nuclear medicine technologists from all parts of Australia. Dr Lander wrote to the Chairman of the Australian Committee on Technical and Further Education in Canberra.22

Considerable discussion ensued on this matter. Under the federal system of government within Australia, together with the clearly-differing voice of New Zealand, it was virtually impossible to establish nuclear medicine technologist training at the same level in every region. It was decided under these circumstances that, in order for technologists to proceed overseas, they required some form of adequate certification.22 A subcommittee was formed, which led to the Accreditation Subcommittee of the ANZSNM. The recently-formed Australian and New Zealand Society of Nuclear Medicine Technologists was represented on this subcommittee by Mrs R. Jamieson and Mr P. Richards.

At the 1974 Annual General Meeting of the ANZSNM, the concept of accreditation for nuclear medicine technologists was proposed. A motion was passed stating: That the incoming committee give first priority to settling the issue of technical training.

Finally, at the societyâ&#x20AC;&#x2122;s 1975 AGM, an accreditation subcommittee was formed. This committee consisted of the president or vice-president of the society, a physician, a nongraduate and two technologists. The committee was to ensure candidatesâ&#x20AC;&#x2122; competence in either in vivo or in vitro procedures using unsealed radioactive sources.

The preceding years had seen unprecedented growth in nuclear medicine technology and the availability of radiopharmaceuticals; but, in particular, the growth of technologists in training and working throughout Australia and New Zealand. In Australia, courses were now available in Victoria (Royal Melbourne Institute of Technology), New South Wales (Sydney Technical College), and South Australia (South Australian Institute of Technology). Each of these courses varied from state to state and, likewise, the same situation occurred in New Zealand. Because of these wide and sometimes diverse variations in training schemes, it was realised that there was a need for a series of standards to be established for the formulation of uniform accreditation criteria. The rules were published in the ANZSNM's August 1979 newsletter24 and came into effect on 1 January 1980.

103

There were two ways a technologist could receive accreditation. The first was the successful completion of a recognised course in nuclear medicine technology as provided by the previously-named three institutes. Alternatively, provision was made for a suitably-qualified applicant to work for two years continuously in a recognised nuclear medicine department, displaying expertise in all standard fields of nuclear medicine technology, as outlined by the accreditation rules. Initially, there was provision, in exceptional cases, for technologists without any allied formal qualification, but with long and wide experience to also be accredited.

In 1991, the inaugural chairman, Dr John Andrews, prepared an overview of the history of the societyâ&#x20AC;&#x2122;s accreditation board for qualified nuclear medicine technologists, which was subsequently published in the ANZSNM newsletter. The following is part of his report:

Over the last few years, there have been several articles in the newsletter detailing different aspects of technologist accreditation and the accreditation board. This is an attempt to indicate briefly an overall view of the history of the board and where we are at.

When nuclear medicine procedures first evolved in Australia, they were performed by allied health professionals who adopted the newly required skills from an in-house training program.

By 1964, the first full course in nuclear medicine technology was established at the Royal Melbourne Institute of Technology (RMIT), as a three-year certificate course aimed at achieving a standard of expertise in nuclear medicine technology, at least equivalent to that required in the related fields of diagnostic and therapeutic radiography. This preceded the formation of the Australian and New Zealand Society of Nuclear Medicine (ANZSNM), which was founded in 1969.

Subsequently, similar courses were set up in New South Wales and South Australia, but not in the other states, although an external studies course was available to them from RMIT. A course was also developed in New Zealand, but this was subsequently abandoned.

Because of these wide variations in training schemes, a national standard was required, and thus the idea was put forward of technologists' accreditation by the ANZSNM. This was first raised in 1974 and was instigated in 1975. The Accreditation Subcommittee, as it was then known, was to consist of the president or vice-president of the society, a nuclear medicine physician, a science graduate and two nuclear medicine technologists.

Its aim was to define a standard of excellence for nuclear medicine technologists that would ensure their competence in both in vivo and in vitro procedures, using unsealed radioactive sources. The society therefore developed a major role in the training of nuclear medicine technologists, by virtue of its accreditation board. To date, more than 400 technologists have been accredited by the board. The majority of these are in Australia, although there are a number also in New Zealand, and most have completed a recognised course in nuclear medicine.

104

Since those early days, some courses have upgraded their qualification to a degree level.

Others have commenced at the technological level (e.g. at Cumberland College of Health Sciences and, more recently, Newcastle University), whereas a different approach has been used by Curtin University to introduce a postgraduate diploma in the subject.

In recent times, there has also been a tendency for nuclear medicine technologists from other countries to apply to work in Australia and to seek accreditation. This has led to the reciprocal arrangement with the Canadian Association of Medical Radiation Technologists (CAMRT), but has not involved any other countries.

The current arrangements in place for such technologists, other than Canadian, is that provided they have undertaken a course in nuclear medicine technology, and have worked for a considerable time in the area, they may apply for interim accreditation for a period of up to three years.

During this time, they would have to work in an approved department and would sit for an examination set by the accreditation board. On successful completion of this examination and a log book, the candidate would then be eligible for full accreditation. This method has already been successfully used.

The accreditation board also has the responsibility to approve hospital departments for the purpose of the training of technologists; a role similar to that of the Australian and New Zealand Association of Physicians in Nuclear Medicine (ANZAPNM) for the training of physicians in nuclear medicine.

An approved department is one in which the time spent by the student technologists working there counts towards the clinical experience components of their course, or for an intern year after completion of their course.

Therefore, departments that wish to participate in the training program need to meet certain requirements for technologist training. These include having accredited personnel in charge of the staff, providing a wide exposure to studies and clinical conditions, having documented protocols for all routine procedures, radiation protection and quality assurance, having welldeveloped philosophies regarding patient care and treatment, and keeping a well-maintained resource library with relevant current journals and other topical literature.

In the past year, the board has set up a specific course leading to an examination for accreditation for those technologists working in nuclear medicine in areas where they are unable to undertake a standard course leading to a qualification in nuclear medicine technology. The course is being coordinated by Ms Heather Patterson at the Royal Prince Alfred Hospital, Camperdown, NSW, which is strongly supporting the project. But this would not be possible, also, without the active support of the nuclear medicine community which is supplying the course material and assessment of assignments.

This then is a brief overview of the training of nuclear medicine technologists for the purposes of accreditation, the background to it, the process of accreditation and the approval of departments for training. It has obviously taken a long time to develop the various facets of accreditation and the special training schemes, but they are reasonably well established. The

105

aim is to achieve and sustain an overall high standard of nuclear medicine technology in 25 Australia and New Zealand.

In 1992, the accreditation board, under the dedicated and able chairmanship of Dr John Andrews, conducted a 'one-off' course of study. This provided an avenue for accreditation for practically-experienced technologists who otherwise lacked recognised qualifications.

The course, followed by a multicentre examination in March of that year, was co-ordinated

by Ms Heather Patterson and supported by the resources of the Royal Prince Alfred Hospital. Twenty-seven technologists successfully completed the course. .

That year, the society appointed a working party to assess the possibility of the accreditation board becoming self-funding. This might involve the recouping of expenditure for such functions as accreditation of departments and possibly periodic re-accreditation of individual technologists. It also marked a decision by technologists to form a special Interest group within the society

In another educational initiative, Mr Simon Cowell of Cumberland College, succeeded in obtaining funding from the national office of Overseas Skills Recognition for a one-year project to establish competency-based standards in nuclear medicine technology. And a steering committee, including representatives of professional bodies, educational institutions, industrial relations groups and state-based working parties, was established to develop the societyâ&#x20AC;&#x2122;s growing interaction with various government bodies.

Professional Development Continued professional development has been linked to accreditation and augmented by a database designed and launched as an interactive programme in January 2007.

The database was designed by Paul Richards, a former chief nuclear medicine technologist at the Launceston General Hospital and a former senior lecturer at Charles Sturt University.

Paul was responsible for establishing an undergraduate degree at Charles Sturt University in the late 1990s. Peter Foster a computer programmer converted the program for the web.

Both Paul and Peter have maintained and further developed this database ever since.

The concept of continued professional development was first raised by Chris McLaren, chief nuclear medicine technologist at the Canberra Hospital, at the ANZSNMT committee meeting of 28 April 1995. This was during the Annual Scientific Meeting in Brisbane.

Continued professional development was an item of new business in which general discussion ensued where those present felt the need to promote a further ongoing commitment to education for qualified technologists. The formation of a committee was agreed with Chris as chair and members Maree Keating (NZ), Vivienne Bush (NSW) and Jodi Fam. By August that year, the subcommittee had prepared a report with several recommendations which included a survey of technologists throughout Australia and New 106

Zealand to identify current needs and what technologists required to sustain an ongoing program.

Inspiration from Henry Wagnerâ&#x20AC;&#x2122;s foreword in the December 1995 Journal of Nuclear Medicine Technology supplement was perhaps a precursor to the enthusiasm unleashed by the subcommittee. However it took another ten years before it was fully accepted.

Nuclear Medicine technology demands more skills from its practitioners than any other allied health profession. The modem technologist is not only responsible for the technical excellence of the studies, but also serves as the staff manager, is involved in the funding, budget, billing and cash flow; and establishes and maintains good working relationships with nuclear medicine physicians and, equally important, with the physicians who refer patients for nuclear medicine studies.

The technologist must constantly educate the referring physicians and patients about the nature of the study, its purpose and the amount of radiation to which the patient will be exposed. Staff education, safety programmes and compliance with regulatory agencies all fall within the 26 technologistâ&#x20AC;&#x2122;s responsibilities.

This statement recognised the increasing responsibilities evident in the role of the nuclear medicine technologist at that time and the growing reliance on professionalism. It also emphasised the necessity of continuous advancement in standards of practice. It was argued that a continuing education program, effectively organised and reaching the defined needs of nuclear medicine technologists, could become a powerful instrument in encouraging high standards. However, the impact of a system with potential to regulate standards of the profession should be scrutinised thoroughly.

107

References 1. Ronai, P., pers. comm., March 2007.

2. Nuclear Medicine News, 2, 5, September 1971.

3. Milne, J., ‘The Establishment of A Radioisotope Course’, The Radiographer, 12, 3, p.8, 1965.

4. Clarke, K., pers. comm. to Broderick, F., 23 March 1987.

5. Jamieson, R., ‘Nuclear Medicine Technology Training’, The Australian Society of Nuclear Medicine Technologists Newsletter, 5, October 1975.

6. Nuclear Medicine News, 1, 3, March 1970.

7. Nuclear Medicine News, 1, 2, January 1970.

8. McCartney, R., pers. comm., 31 January 2007.

9. Cancer Council of Victoria, 70 Years of Fighting Cancer 1936-2006, http://www.cancervic.org.au 10. Clark, K. H. & Milne, J., ‘A Design for a Radioisotope Unit for a Large General Hospital’, American Journal of Roentgenology, Radiotherapy and Nuclear Medicine, LXV111, 2, August 1962.

11. McCartney, R., pers. comm., February 2007.

12. Nuclear Medicine News, 1987.

13. ‘NSW Branch of the Society of Nuclear Medicine Technologists’, Nuclear Medicine News, 20, 1, p.5, March 1989.

14. Minch, G., A histography of the upgrading of radiography education in New South Wales, Thesis, University of Sydney, 1999.

15. Nuclear Medicine News, 19, 2, June 1988.

16. ‘Secretary’s Report on the 19th Annual General Meeting and Committee Meeting of the Society’, ANZSNM Newsletter, 19, 3, p.4, September 1988.

17. Nuclear Medicine News, 20, 2, June 1989.

18. Nuclear Medicine News, 2, 5, September 1971.

19. White, B., pers. corresp. to A. McArthur, 13 July 1988.

20. White, B., pers. comm., February 2007.

21. Rutland, M.D. (nuclear medicine specialist, Auckland City Hospital), pers. comm. February 2007.

22. Nuclear Medicine News, 6, 1, February 1975.

23. Nuclear Medicine News, 6, 3, August 1975.

24. Nuclear Medicine News, 10, 3, August 1979.

25. Nuclear Medicine News, 22, 3, September 1991.

26. Journal of Nuclear Medicine Technology, 23, 4, December 1995.

108

Chapter 6

SPECIALISATIONS AND INTEREST GROUPS Association of Physicians in Nuclear Medicine The use of radioisotopes in the diagnosis and treatment of human disease processes began in Australia with the administration of radioactive phosphorous in Launceston, Tasmania, and Perth, Western Australia, in 1947. Following this, radioactive iodine was also made available for treatment and diagnosis of thyroid conditions. The majority of these activities took place in association with radiotherapy, radiology of pathology departments in hospitals around Australia. The 1950s were associated mainly with therapeutic treatments, using P-32 and I-131 thyroid and haematological I-131, Cr-51 and Fe-59 studies, as well as some early investigations of renal status using I-131 Hippuran. The 1960s brought a flourish of newly available radionuclides and organ imaging using 3” and 5” Picker magna scanners with 97Hg-Chlormeridrin for liver scanning, F-18 for bone scanning, Se-75-methionine for pancreatic scanning, I-131 Magro Aggregated Albumin (MAA) for lung scanning, and I-131 Rose Bengal for gall-bladder scanning. Later that year, a 99mTc-generator became available and a new world of imaging began.

In 1968, Henry Wagner Jr of Johns Hopkins and David Kuhl from the University of Pennsylvania visited Australia; an inspired suggestion of the AAEC. This visit was jointly funded by USAEC & AAEC. They gave a series of lectures in each state and visited many of the hospitals.

Frank Broderick recalls: Both were pioneers in nuclear medicine and as a team they were hard to beat, motivators, instructors, entertainers – all of these and more. Each hospital that they visited profited from a stream of seemingly effortless information; answers to problems, pithy summaries of unsolved problems and great experience in a wide range of techniques. All this was done with good humour and an understanding but dramatic flair. Many association members date their initial 1 interest in nuclear medicine to that tour.

I am sure that most will agree with Frank Broderick that they were truly inspirational and certainly had a major influence on the development of not only nuclear medicine, but with the formation of the ANZSNM in 1969.

Nearly forty years later, Jim McRae made this comment: There is no doubt that Henry Wagner and Kuhl gave credence to nuclear medicine and Hopkins certainly was a Mecca. Henry Wagner was a towering figure in the field and his ability to recognise important new developments was extraordinary. His summary at the end of the annual meeting of SNM was the most watched show and hit on all the high points. His 2 presentations were unmatched for clarity and fervour in the future of nuclear medicine.

With an increasing interest in nuclear medicine in all states of Australia, but particularly NSW, physicians were becoming more preoccupied with nuclear medicine studies. Although their numbers were small, an enthusiastic group banded together in NSW and formed an Association of Physicians in Nuclear Medicine. Interest was mounting throughout Australia and following the establishment of the Australian Society of Nuclear Medicine in May 1969, 109

the group was approached by other interstate physicians to consider an expanded Australian and New Zealand Association of Physicians in Nuclear Medicine.

Frank Broderick further recalls: This was done against all omens on Friday 13 February 1970. The membership was small and the executive lived in Sydney, so our early meetings were held at city restaurants. These early meetings were boisterous and memorable, especially those held at the Hungry Horse restaurant in Paddington. The menu and the agenda would appear interchangeably.

Sometimes one was unsure as to whether one was voting for duck a l’orange, a bottle of Grange Hermitage or a meeting with the AAEC.

Forty years later, following the earliest of meetings at the Hungry Horse in late 1968, a NSW pioneers’ dinner was held at Lucio’s Italian Restaurant in Windsor Street, Paddington (formerly The Hungry Horse) on 16 February 2008. Several pioneers of nuclear medicine were present and Frank Broderick described the past meeting as noisy and rumbumptious in contrast to the sophistication of the present company.

With discussion on where this association was to fit in the greater scheme of things, with regard to training and accreditation in the medical fraternity, led to some thoughts of establishing a college of nuclear medicine physicians. This was predominantly mooted by Harry Lander following the Adelaide meeting in 1969. The association numbers were relatively small, but there was an overwhelming desire by all members to maintain this new speciality clinically-orientated. This primarily led to favouring affiliation with the Royal Australian College of Physicians (RACP) rather than the Royal Australian College of Radiology.

In Frank Broderick’s 1988 ‘History of the Australian and New Zealand Association of Physicians in Nuclear Medicine’, he said: In 1970, a combined committee (chaired initially by Dr H. M. Rennie and later by Dr J. Frew), with representatives of the RACP, RACR and RCPA, and the Association unanimously agreed that nuclear medicine be accepted as a sub-specialty of internal medicine. An RACP educational sub-committee was formed to produce a training programme parallel with those in other medical specialities. Training after the first part of the RACP examination became the responsibility of a supervisor for each of the approved posts in nuclear medicine.

The association was formally-established for two major reasons: firstly, that it would establish political credibility for physicians in the field of nuclear medicine; and secondly, that it would establish a bona fide training program for physicians. In 1972, the training syllabus was published in Nuclear Medicine News.

Special Interest Groups & Sub Committees One of the major aspects in the development of the society was the establishment of special interest groups (SIGs). These groups represent the special interests of members of the society and today include: • • •

Technologists (Australian & New Zealand Society of Nuclear Medicine Technologists), Radiopharmacy, Physics/Computer Science, 110

• • •

Nurses, Accreditation Board, Technical Standards Committee.

In 1995, special funding was put aside to support the activities of these groups and guidelines for funding special interest groups were published.3 Radiopharmacy Group At the ANZSNM 1984 Annual Scientific Meeting in Adelaide, discussions were held with regard to the formation of a radiopharmacy group within the Society. This was formalised at the May 1985 Annual Scientific Meeting at Manly, Sydney, when the inaugural general meeting was held. Office bearers elected at that meeting were: Chairman: Mr Ross Hanna (Royal Canberra Hospital), Secretary (& SA representative): Dr Rick Baker (Royal Adelaide Hospital), New South Wales Representative: Mr Peter Yates (St Vincent’s Hospital), Victorian Representative: Mr Gordon Chan (Austin Hospital), New Zealand Representative: Mr Mark Best (Dunedin Hospital), and Western Australia Representative: Mr Andrew Martindale (Fremantle Hospital).

It was announced that nominations would be received from Queensland and Tasmania by interested parties.

Membership of the group was open to all persons qualified, or engaged, in the profession of radiopharmacy; and included anyone involved with the dispensing, development, research, supply, marketing or regulation of radionuclides and radioactive products intended for diagnostic purposes. The aims of the radiopharmacy group were to foster the profession of radiopharmacy in Australia by dissemination of information on new products and applications, adverse reactions, malfunctions, professional opportunities; and to provide members of the profession with a united voice on matters of concern.

By September that year, the group had conducted a seminar on regulatory requirements for the introduction of new radiopharmaceuticals into Australia, and had formulated guidelines for the practice of radiopharmacy in Australian hospitals.4 A regular column ‘Radiopharmacy News’ has been a major contribution to ANZ Nuclear Medicine from the group’s inception.

Nurses’ Group There has always been a presence of nurses in the history of nuclear medicine and the society in Australia and New Zealand. Early pioneers were no doubt assisted by nurses; and we have testament that they were active in providing not only patient care, but technical assistance in several institutions around Australia and New Zealand.

The nursing special interest group evolved from biannual informal meetings with nurses from nuclear medicine departments in Sydney and Canberra. The purpose of these meetings was to provide a forum for nurses practicing in the field of nuclear medicine to meet and exchange information and experience about their work.

In 1992, a meeting of nuclear medicine nurses from NSW and ACT expressed enthusiasm in forming a special interest group of the Society. On Saturday 25 July, 17 nurses from the 111

ACT and NSW attended an inaugural meeting of nuclear medicine nurses. Those attending were from St George, Royal Prince Alfred, Wollongong, Prince of Wales, Liverpool, Westmead, St Vincent's and Woden Valley (Canberra) hospitals. The ensuing general discussion was on an informal basis, covering role, work practices and functions within the institutions in which participants were employed. Those attending found this a valuable experience. There was enthusiastic agreement to meet again in November to discuss involvement in the 1993 ANZSNM Annual Scientific Meeting in Canberra.

In 1993, at the Annual Scientific Meeting held in Canberra, the inaugural nurses’ workshop was held and a steering Committee formed. The Workshop was well attended by nurses from Queensland, South Australia, ACT and New South Wales. The nurses present adopted a constitution, elected a president/chairperson, elected a secretary/treasurer and discussed the objectives of the society. The secretary of the SIG wrote to the president and committee of the ANZSNM to inform them of the inaugural formation of the Nurses Special Interest Group.

The SIG meets annually at the society conference and is used as a forum to discuss professional issues, policies, protocols and research topics. It is also a great opportunity to network with other nuclear medicine nurses, as it is a specialised field with a small nursing community.

Although membership of the Society is limited by the numbers of nurses employed in nuclear medicine, they have been a major influence on patient care and, at times, a welcomed addition to technical services offered in departments that were either short-staffed or unable to attract technical staff.

Cathy Boyd, president of the ANZSNM nurses’ group reported: There were two presentations during the workshop; ‘An Overview of Nuclear Medicine at Woden Valley Hospital’ by Cathie Boyd (Woden Valley Hospital, Canberra) and ‘Show and Tell’ by Olive Tierney (Royal Brisbane Hospital). The workshop also included enthusiastic general discussion on such topics as paediatric sedation and day case procedures, Ceretec scanning, thallium imaging, Sestamibi stress testing, and planning for the next nurses workshop in 1996.

Gail Creighton reported on the cystogram experiences of nursing staff at the Prince of Wales Hospital. Gail had also visited both Camperdown Children's Hospital, at Camperdown, NSW, and Woden Valley Hospital to observe procedure. The Taranaki experience was reviewed during the ‘A Time to Play: DRCs’ workshop by Marie Keating, who had similarly spent time with nursing staff and technicians at Woden Valley Hospital.

The group was off to a splendid start.

In 1995, the group saw its first change in office-bearers at the annual meeting held in Bowral, NSW. Nurses attended from Woden Valley Hospital (Canberra), Wollongong Hospital, Prince of Wales Hospital (Sydney), Southern Nuclear Medicine Private Group (NSW) and St Vincent's Hospital (Sydney). Nominations were called for a new president and secretary/treasurer. Caroline Cargill (St Vincent's Hospital, Sydney) and Gail Creighton (Prince of Wales Hospital, Sydney) were then elected to these positions.

112

Technologists’ Group Prior to the establishment of this special interest group, The Australian Society of Nuclear Medicine Technologists came into existence in 1974, following the establishment of a steering committee at the Annual Scientific Meeting of ANZSNM in Sydney. The steering committee comprised: Miss V. Reid (St George’s Hospital, Kogarah), Miss C. Wood (St George’s Hospital, Kogarah), Miss N. Nelson (Royal North Shore Hospital, Sydney), Mrs J. Robilliard (Alfred Hospital, Melbourne), Mrs R. Jamieson (Peter MacCallum Clinic, Melbourne), and Mr R. Booth (St Vincent’s Hospital, Melbourne).

In May 1975, the first annual general meeting was held in Sydney. At this meeting, the constitution of the society was ratified and the following office bearers elected: President: Mrs Rae Jamieson (VIC) Vice President: Mr Paul Richards (TAS) Secretary: Mr Russell Booth (VIC) Treasurer: Valerie Reid (NSW) The first Newsletter of the ANZSNMT was circulated in January 1975, and the second followed the AGM that year. This newsletter also reported that a modest journal was to be established with support from several companies in the field of nuclear medicine. The first of several of these official organs was printed and distributed widely to the nuclear medicine technologist community throughout Australia and New Zealand. They contained valuable insights to the development and history of technology of the mid 1970s. The newsletter was discontinued, due to financial restraints, but returned in a flourish of editions in the mid to late 1990s.

Physics Group Technical Standards Subcommittee At the March 1986 annual general meeting, in Hobart, the federal executive and members accepted a proposal to form a subcommittee of the society to consider technical issues, related particularly to standardisation of instrumentation and computing. It was agreed that this subcommittee would report on a regular basis to the federal committee of the society and use the ANZSNM newsletter to provide the members with information on its progress and to report on issues that may be of interest to the membership.

The subcommittee was duly formed and, by the June 1986 issue of the newsletter, had under the chairmanship of Brian Hutton of Royal Prince Alfred Hospital, discussed its general objectives and initiated several tasks under coordination of members of the subcommittee. The initial objectives recorded at that time were: 1. To investigate the possibility of establishing a national calibration service for dose calibrators, 2. To review and develop national standards for the transfer of digital images, 3. To survey the use of computers for nuclear medicine administration, 113

4. To develop the exchange of data for inter-comparison, quality-control and teaching purposes (software phantoms), 5. To encourage the adoption of standard quality-control procedures, so that instruments can be inter-compared, acceptance tests considered and minimum standards defined, and 6. To investigate the possibility of manufacturing standard phantoms for national use.

Society members were encouraged to support this new committee and communicate any technical matters considered of national interest. In particular, the subcommittee welcomed short reports on any problems or incidents involving instrumentation and computing (eg, design problems and limitations or incidents where patient safety may be at risk). To support this, the subcommittee prepared and circulated an incident form.5 Computer-User Group The eighth Annual Scientific Meeting of the ANZSNM was held in Hobart from 6 to 8 June 1977. This event is well remembered because of an unexpected air strike, which meant a reorganisation of what had been originally scheduled; and because of this, the intended guest speaker, Dr D. Croft, was unable to attend.

It was at this meeting that Mr Brian Hutton, a medical physicist from the Department of Nuclear Medicine at Royal Prince Alfred Hospital, presented a very interesting paper in which he discussed his experience in using a small dedicated computer for nuclear medicine data processing. It was suggested at that meeting that a computer user's group should be formed and Brian was asked to do this and act as its initial chairman.

It was understandable that the formation of such a group would be a formidable task in view of the large distance between user and the diversity of computer systems and applications.

However, there was sufficient overlap, particularly in the use of high-level languages, such as Fortran and Basic, to warrant the formation of a usersâ&#x20AC;&#x2122; group; and this was keenly supported by those present at the conference.

The following were the initial suggestions for the activities of such a group: 1. Exchange of Fortran and Basic programs, 2. Report of work in progress in each department to avoid unnecessary overlap of programs, 3. Discussion of problems relevant to any particular system, 4. Provisions of a means of meeting (other user's to discuss common interests possibly through the inclusion of a computer workshop and discussion group as part of the annual meeting), and 5. Provision of teaching sessions and advice to new users.

By December that year, eight centres had expressed interest in the group and, with support of the society, the group was formed. The formation of the group obviously required full cooperation of computer users throughout Australia and New Zealand and would undoubtedly involve extra work in providing adequate documentation of written programs. It was felt, however, that this effort would be offset by the benefits to be gained by participants in exchanging ideas.6 114

In January 2008, Professor Brian Hutton, who is now based in London at the Institute of Nuclear Medicine, provided this summary of the group’s activities over the past three decades: This was the first predominantly physics-based group that was formally supported by the ANZSNM (although participation was not restricted to physicists). It formed an important landmark in the technological development in Australia and NZ, as it paved the way for longstanding cooperation between physicists across the region.

The formation of the Computer Users’ Group recognised the importance of cooperation in a region where technical resources were limited compared to many other countries. The policy of sharing software was important in establishing computer applications in the region, but also formed the basis for an international recognition of ANZ achievements. There are several notable software packages that were widely used; some internationally. Examples are the Westmead renal package and the RPAH cardiac analysis software (ultimately distributed by Philips).

The establishment of the group, to some extent, crossed boundaries that tend to arise due to differences between manufacturers’ systems. In fact, in parallel with the society group, a Gamma-11 users’ group was also established under the auspices of Digital Equipment; and this group, along with similar groups in Finland, the Netherlands and Canada, tended to lead the way in computer software development and exchange.

An important project established by the Computer Users Group was the intercomparison of data analysis using software phantoms; a project that predated the European COST B2 project and the more recent UK ACPSEM work in this area. The project had to tackle exchange of clinical data between different suppliers well before DICOM was even thought 3 of ! In fact, the approach followed directly influenced the adoption of Interfile as an international standard for nuclear medicine data exchange (which is still in use today).

The Computer Users Group continued to have meetings in conjunction with annual conferences, although the name was to some extent misleading as these meetings provided a forum for more technically-detailed exchange than normally occurred in the ANZSNM conference sessions, providing an avenue to present works in progress. (I remember, for example, that the first presentation on OSEM was at one of these meetings and the visiting scientist from the US, at that time, implemented this immediately on his return, well before this was formally published). The interest in promoting standards and developing the use of computers to quantify QC parameters led to the establishment of the Technical Standards Group, an important sub-committee of the ANZSNM. In time, the Computer Users Group effectively evolved into the Physics Special Interest Group, which provided a more comprehensive forum for physics exchange and contribution to the NM profession (now operating jointly with the ACPSEM). But the willingness to cooperate and encourage exchange of software still continues, most recently with the IDL Users Group (established by Leighton Barnden under the Physics SIG), which again tends to cross boundaries between the main manufactures based on the development software IDL which is widely used in NM. The willingness to cooperate rather than compete has always been foremost in the NM physics community and, I believe, continues to provide the region with a unique regional 7 strength.

3

The group developed a standardised file format for exchanging nuclear medicine data between different computer systems which became known as Interfile. This standard was adopted by all nuclear medicine vendors and remains in use on a variety of forms to this day.

115

At the time of writing, Brian was the Chair of Medical Physics in Nuclear Medicine and Molecular Imaging Science, at the Institute of Nuclear Medicine, UCL in London, UK.

116

References 1. Broderick, F., ‘To Follow Knowledge’, History of the Australian and New Zealand Association of Physicians in Nuclear Medicine, 1988.

2. McRae, J., pers. comm., April 2007.

3. Journal of Nuclear Medicine, 26, 2, June 1995.

4. Journal of Nuclear Medicine, 16, 3, September 1985.

5. Journal of Nuclear Medicine, 17, 2, June 1986.

6. Journal of Nuclear Medicine, 8, 4, December 1977.

7. Hutton, B., pers. comm., 19 January 2008.

117

Chapter 7

KEY MILESTONES IN AUSTRALIA Key milestones in the evolution and development of nuclear medicine in Australia specifically include: recognition of the medical diagnostic and therapeutic roles of radionuclides, development of short-lived radionuclides, introduction of the gamma camera, and the distribution of radiopharmaceuticals in Australia.

Recognition of Diagnostic and Therapeutic Roles of Radionuclides Australia was at the forefront of the therapeutic revolution of artificially-produced radionuclides. In the early to late 1940s, this specifically included radioactive iodine for the treatment of thyroid disease processes, and radioactive phosphorus used exclusively for blood disorders such as polycythaemia rubra vera and leukaemia. The Commonwealth XRay and Radium Laboratory in Melbourne was the centre and focus of its importation, calibration and distribution of these two radionuclides. With the clinical interest of Dr Kaye Scott (oncologist consultant at the Royal Melbourne Hospital) and CXRL physicists Hal Oddie and Cecil Eddy, it was not long before diagnostic evaluation of the thyroid disease processes and development of instrumentation were being undertaken by this group. In 1947, Hal Oddie and Kaye Scott were instrumental in the introduction of radioiodine (I131) uptakes at the Royal Melbourne Hospital.

In the following year, the New South Wales Bureau of Physical Sciences seconded physicist Bernard Scott to support a thyroid investigation unit at the Royal Prince Alfred Hospital in Sydney. Also from Sydney, Dr C. R. B. Blackburn, a young and enthusiastic graduate and hockey blue from Sydney University, had recognised the potential of radionuclides. In 1948, whilst at Columbia Presbyterian Hospital in New York, he developed an interest in the tracer technique using radioisotopes where studies of sickle cell anaemia and intramedullary haemolysis in pernicious anaemia were in progress. His interest continued and, when he was appointed professor of medicine at Sydney University, he organised and established a radiobiology department and made arrangements for Dr Jim McRae to be trained at the University of California’s Donner Laboratory at Berkley.1 The powerhouse of Sydney University and the Royal Prince Alfred, under the directorship of McRae, drove nuclear medicine.

Development of Short-Lived Radionuclides The isotope of technetium had been discovered as early as 1937, by E. Segre and C. Perrier in Enrico Fermi’s laboratory in Rome, Italy. Their discovery had emanated from a small sample of molybdenum target, which had been sent from Berkley to their cyclotron laboratory to be bombarded with 8Mev deuterons.2 Later, Segre and Glen Seaborg, in Berkley, California, repeated the experiment, nominating the 6.6 hour half-life radionuclide as Tc99m. The technetium Tc99m generator was developed by Stang and Powell Richards in 1960. Henry Wagner, in his book: ‘A Personal History of Nuclear Medicine’, reports that, in 1961, it was commercially-available. However, no one had recognised its important characteristics for organ imaging until 1963, when Paul Harper, Catherine Lathrop and Alex Gottschalk administered Tc99m Pertechnetate for scanning of the thyroid, as well as Tc99m sulphur colloid for study of the reticuloendothelial system in the liver, spleen and bone marrow; and, later, Pertechnetate for the detection of brain tumours.3 118

The two most popular radionuclides developed for commercial use in Australia, in the 1960s, were Technetium (Tc99m) and Indium (In113). Great credit must be given to Rex Boyd and his team at the AAEC, who, from 1968, provided a highly-efficient production and reliable distribution of Tc99m radiopharmaceuticals. They developed a perfusion lung imaging agent Tc99m macro aggregated ferrous hydroxide and a renal agent Tc99m gluconate. In 1971, a bone scanning agent called SKELTEC Tc99m polyphosphate underwent extensive trials and, in 1975, was replaced by Tc99m pyrophosphate.

Paediatric renal perfusion scan taken in 1968 As well as these two exceptional radionuclides, the cyclotron produced fluorine (F18), which, with its short half-life of only 110 minutes and favourable 511keV positron emissions for thick crystal scintillation scanners (3” and 5”), was shipped all over Australia and used as a superior bone imaging agent over the longer-lived (T1/2 = 2.8 hours) Strontium (Sr87m). The strontium-yttrium generators were a common sight in the mid 1960s.

In a landmark communication of 8 December 1972, CXRL released Tc99m stannouspolyphosphate for routine diagnostic use around Australia. This had followed several months of intensive work by the isotope production group to standardise production techniques and establish safety and effectiveness in animals; and clinical trials by Dr I. P. C. Murray and others, at Prince of Wales Hospital, to confirm safety in humans.4 Generator production at AAEC became a reality in 1967, and this made the distribution of inhouse Tc99m available to departments throughout Australia and New Zealand. This, of course, allowed the daily milking of Tc99m from its mother product – Mo99 – and revolutionised organ imaging, not only in the capital city hospitals, but in rural Australia where private practices were being established at an alarming rate.

In 1969, it was reported that radioactive Indium (In113m) was a promising, inexpensive, new broad-spectrum organ imaging agent, some years after it had been introduced to the nuclear medicine imaging programs by several specialists. With simplified methods using prepared vials, In113m labelled compounds were being developed for brain, kidney, lung, liver, spleen, bone marrow and blood-pool scanning agents.

119

These new radiopharmaceuticals allowed much greater doses of radionuclide to be administered with very significantly reduced radiation hazard to the patient. The clarity of scan was greatly improved and the time taken to perform the study was markedly reduced.

Clinicians were quick to appreciate the value of these new radiopharmaceuticals and the demand for organ imaging grew at an alarming rate.

Introduction of the Gamma Camera The first conventional gamma camera in Australia was purchased and installed by Dr Harry Lander in Adelaide. Harry was larger than life and described by Frank Broderick as ebullient, outrageous before decorum and deanships descended. The advantages of thinner crystals and larger fields of view, along with the short-lived Tc99m labelled pharmaceuticals, saw a revolution in organ imaging throughout Australia. Although the rectilinear scanner had served us well, it was slowly replaced and, by the early 1970s, almost all departments throughout Australia and New Zealand had gamma camera installations.

The introduction of the gamma camera added a new dimension to nuclear medicine.

Increased sensitivity of this instrumentation, and the ability to view a whole organ simultaneously, allowed â&#x20AC;&#x2DC;scintiphotosâ&#x20AC;&#x2122; to be obtained within a few minutes. In addition to this, the acquisition of images every few seconds allowed for visualising the dynamic flow of blood through organs. The addition of accessories, such as the multi-parameter analyser, fast digital magnetic or video tape-recording units, and the use of a computer, allowed quantification of events in selected regions of interest and the introduction of subtraction techniques to improve visualisation of such organs as the pancreas.5

The first Large Field of View (LFOV) gamma cameras were single detector analog systems Distribution of Radiopharmaceuticals With the advent of organ imaging in the 1960s, the importation and distribution of radionuclides saw the development of departments of nuclear medicine in major hospitals throughout the country. As a consequence of the flourishing nuclear medicine speciality, two centres: The Australian Radiation Laboratory (formerly Commonwealth X-Ray and Radium Laboratory, Melbourne) and the Atomic Energy Commission (at Lucas Heights, Sydney) took responsibility for the production, distribution and importation of radionuclides.

During 1974 and 1975, two government committees of enquiry were established, which were of major interest to the ANZSNM. The first of these committees to come to the notice of the society was a government committee of enquiry into the distribution of radiopharmaceuticals in Australia. The Association of Physicians in Nuclear Medicine was asked to appoint a representative to this body; and they appointed Dr Frank Broderick. The purpose of this 120

committee was to look into the manufacture and distribution of radiopharmaceuticals in Australia to achieve maximum efficiency and, at the same time, keep costs within reasonable limits.6 The first meeting was held on 5 February 1975. At this meeting, the committee considered the difficulties of radiopharmaceutical distribution experienced at that time by users throughout Australia. Radiopharmaceuticals produced by the Australian Atomic Energy Commission (AAEC) were distributed through a dual system. The Australian Radiation Laboratory (ARL) received bulk supplies of some radiopharmaceuticals from the AAEC for distribution to Melbourne users only, as well as bulk supplies of iodine-131 and phosphorus32, which were repacked and distributed to users all over Australia, including Sydney. All other users were supplied direct from AAEC.7 The committee questioned the validity of the dual system of distribution and sought the views of the AAEC as well as those of Professor P. M. Ronai and Dr J. McRae on the roles of ARL and AAEC in the procurement and distribution of radiopharmaceuticals in Australia. Both Ronai and McRae were noted and respected specialists in nuclear medicine and, at the time, were working in senior positions in the USA, respectively at the University of Colorado Medical Centre and Donner Laboratories at the University of California.

There had been growing concern from several hospitals in Sydney of deficiencies that existed in the procurement of radiopharmaceuticals and services from ARL. These complaints ranged from careless documentation (invoices & despatch), incorrect packaging (erroneous labelling and breakages) and numerous occasions where patient studies were unduly delayed and patient care was impaired, either because radionuclides were not available or, when promised, were not delivered. On 23 December 1974, the Minister of Health, Dr D. Everingham, received a letter of complaint from the Australian & New Zealand Association of Physicians in Nuclear Medicine outlining complaints from four Sydney hospitals, under the signatures of Drs A. McLaughlin, I. B. Hales, J. J. Burke and Associate Professor I. P. C. Murray.8 The matter had been raised at one of the regular inter-hospital meetings between departments of nuclear medicine in September that year. In past years, similar complaints had been raised but not followed-through. At the May 1975 annual general meeting of ANZAPNM, where members from all states were present, unanimous dissatisfaction was expressed with regard to the availability and distribution of radiopharmaceuticals in Australia. Dr John Morris then wrote to the Deputy Director General of Health, Dr C. Evans.9 This correspondence contained recommendations for upgrading the production, distribution and development of radiopharmaceuticals in Australia as a measure to remedy the deficiencies and duplication of the system that existed at this time.

The government committee met again in September 1975 and reviewed replies of the AAEC and those sought from Professor Ronai and Dr McRae. Supported by Professor Blackburn, Dr Broderick and Dr B. Arkles, who were also members of the committee, recommended that: All radiopharmaceuticals produced by the Australian Atomic Energy Commission for in vivo medical uses in Australia should be distributed directly by the commission against authority from the Australian Radiation Laboratory.

On the matter of procurement and distribution of imported radiopharmaceuticals, the committee recommended that: 121

All imported radiopharmaceuticals for in vivo medical uses should be procured and distributed by the Australian Radiation Laboratory.

At the committeeâ&#x20AC;&#x2122;s first meeting, a submission on the establishment of an Australian radiopharmaceutical laboratory and a day-centre hospital at Lucas Heights, from Dr J. Morris of Royal Prince Alfred Hospital, Sydney, was tabled. Dr Morris suggested that: The laboratory was to be autonomous, affiliated with a university department of medicine and its teaching hospitals, and headed by a suitably qualified medical person.

The submission was considered and a request, that Morris submit a detailed proposal following comments, sought from the AAEC, Professor Ronai and Dr McRae. In the revised proposal, it was suggested that the national centre for procurement, production, development and distribution of the in vivo and in vitro radiopharmaceuticals should be part of the AAEC. He also suggested that a dedicated medical cyclotron be provided and that a feasibility study for the day-centre for diagnostic, therapeutic or research projects be considered.

The AAEC, in reply, stated that it was not in favour of a separate autonomous Australian radiopharmaceutical laboratory associated with a university, as the Australian Radiation Laboratory and the Commission were already established and experienced. However, the proposed hospital day-centre, they agreed, would be desirably associated with a university and its teaching hospitals. The AAEC was also happy to provide a site for this centre with a cyclotron facility close by, which might have applications for neutron therapy and the production of ultra-short-lived radioisotopes and, where possible, convert them to an appropriate form for medical use.7 In reply, Dr J. McRae stated that the functions proposed by Morris were too all-embracing and he felt that it would be a mistake to develop major medical facilities away from a hospital medical school, quoting the Donner Laboratory and Brookhaven National Laboratory, in the USA, which had seen a reduction in patient activities as nuclear medicine facilities developed in major medical schools and hospitals. Professor P. Ronai did not make any comments relevant to Dr Morrisâ&#x20AC;&#x2122;s proposal.7 Committee members Professor Blackburn, Dr B. Arkles and Dr F. Broderick supported the proposal that an Australian radiopharmaceutical laboratory should be established at Lucas Heights with cyclotron facilities. It was also recommended and supported that such a facility should only concern itself with in vivo radiopharmaceuticals and training of personnel.

For those radioisotopes not produced at Lucas Heights, the responsibility for import remained, as before, divided between ARL and the AAEC. However, on 1 January 1978, two Australian Government Acts of deregulation came into force. Firstly, it was decided to discontinue ARLâ&#x20AC;&#x2122;s radioisotope supply role, with the AAEC and local agents of foreign radioisotope suppliers then left to compete openly for the Australian market. Secondly, it was decided to discontinue the free issue of medical radioisotopes.

Despite this apparent commercialisation of radioisotope supply, there were many regulatory matters left in place to control usage. For example, radioisotope products had to be 122

approved and licensed by the Australian Department of Health before they could be offered for sale. Where clinical trials were involved, they could only be performed according to the standards of the National Health and Medical Research Council and they had to follow the protocols of the Therapeutic Goods Administration.

In his introductory address at a Canberra symposium on radiopharmaceuticals, 11-12 November 1977, Dr Roger Connolly perhaps sheds some light on the mood of the day and what is recognised as a turning-point in the evolution of nuclear medicine in Australia. This, in part, is what he said: In your letter to me, Mr President, you thanked me for agreeing to give a short opening address. You did not underline ‘short’, but I have the message! You also gave me a more difficult task when you wrote "of-course, if you find any good things to say about ARL and the AAEC, then you should do so".

For all of us whose faces, from time to time, have gone from pink to red to black to ashen in dealing with what we thought was the abysmal ineptitude displayed by these two bodies, there may be a time of reckoning. In the months ahead, we too may find that it is difficult to fulfil today's requests yesterday; and that commonwealth bureaucracy has to be fought by us individually and not left to Don Keam, John Bonnyman, Rex Boyd, Bill Wiblin and the teams who have served us well in the past - the people who inexplicably remain our friends in spite of the torrents of abuse we have poured over them. You see that I am ‘making friends with the mammon of iniquity’ and I suggest you may care to follow my example.

One may have thought that these two bodies would serve a much less useful purpose in the future, but I think we shall realise at the end of these sessions that this is far from the truth. I believe that the opposite will occur in a healthy competitive atmosphere.

It may be that some of us think that the Government decision on radiopharmaceutical charging is not entirely a correct one; and some compromise in the future may be required. It is neither my right nor my intention to argue this here today, but in my travels around most of the nuclear medicine departments in Australia, plus recent investigation into my own affairs, there is one matter where we must stand up with few exceptions and say "mea culpa".

Because it was all ‘free’, paid for by the shadowy nebulous other guy - the taxpayer, how strict has been our audit in the past? How many expensive radionuclides have been poured down the sinks and onto the tips in our several cities? How much over-ordering have we done?

How much over-supply have we allowed when original requirements were superseded by other materials? How often have we favoured ‘kits’, because they were easier to use, even though more expensive? You will agree that it is time for us to look deeply at this matter.

The human nature, being what it is, the decision forcing us to account to our local bodies for what we spend must be a good thing in the wider interest of the community. Further, the abdication of many nuclear medicine physicians from the clinical arena, resulting in huge numbers of unnecessary investigations, must stop. Let us not criticise before we put our own houses in order.

I hope we will be discussing a subject which I have mentioned many times to the point of boredom for some of you. Our good friends from the commercial firms may not like what I have to say, but it does seem to me that centres throughout Australia could provide supplies of labelled antigens and antibodies as well as other radiopharmaceuticals. In Hobart, friends from USA, UK, Adelaide, Perth and Sydney have supplied us with antibodies to digoxin, thyroxine, triiodothyronine, TSH, FSH, and LH, to mention a few.

123

If anyone here wishes to have a digoxin antibody of high titre, which we have raised, it will be a pleasure to send it to you. I believe we should think seriously about establishing centres where labelling can be done and antibodies produced and distributed. There are enough places in Australia where this could be done and the fees charged directed to research, further development and other department needs. I am sure that the Endocrine Society and similar bodies would cooperate.

We all have our own thoughts about how we are going to cope with the problems. It will include, among many others things, the bulk supply of our radionuclides, customs and import formalities, the labelling of our compounds, the many recipes for ‘in-house’ preparation and the necessity for strict radiation, chemical purity, sterility and all the other controls.

I hope that uniform standards throughout Australia and New Zealand can be applied and enforced. It will be far better for us to keep our own houses in order with our own quality controls than have these imposed on us from outside. Proper standards and a code of conduct drawn up by our society for our society are long overdue. We require these as a protection not only against radiation hazards, but also to counter many of the stupidities inflicted on us by some non-clinicians.

We can, and shall, cope with the situation, aided by the many experts gathered here to help us, not only in the next two days, but in the months ahead. Let none of us lay down laws 10 without considering all aspects of our situation.

A second turning-point was a request from the Director General of Health to the Society, to supply a representative to a sub-committee to enquire into the testing and releasing of radiopharmaceuticals in Australia. This was an independent committee, concerned mainly with standards for the release of new radiopharmaceuticals together with the setting up of acceptable clinical trials to ensure that the established standards were met. Dr Ian Hales was appointed the society’s representative.

Positron Emission Tomography in Australia The story of Positron Emission Tomography (PET) in Australia can be traced back to the late 1960s when Henry Wagener and David Kuhl were asked to comment on the potential for cyclotrons in medicine and the new uses emerging for positron emitting tracers. Their recommendations took some 20 years to be realised, resulting in the National Medical Cyclotron project in the late 1980s. Australia was effectively trapped in a “chicken & egg” situation as there was no cyclotron in the country to provide the radionuclides needed for PET (principally 18F, 11C, 13N, and 15O all with shore half-lives) and hence there was no case to install a PET scanner.

PET is one of the most advanced and sophisticated techniques for imaging the human body.

It has uses in both basic medical research and in detecting disease. It employs radioactive compounds made in a cyclotron to study cellular processes throughout the body. It does this with extremely high sensitivity, that is, only tiny amounts of the radioactive "tracer" are required, and these are typically administered in homeopathic doses. For this reason, they did not affect the body while it is being studied. Through the 1990s and 2000s PET was the most rapidly expanding area in medical imaging in the USA and Europe.

124

The Hawke Federal government approved the construction of a cyclotron dedicated to medical usage and a co-existing PET camera in 1986 and it was decided to site this at Sydney's Royal Prince Alfred Hospital (RPAH), due to its advanced medical referral pattern, expertise, proximity to the University of Sydney, and access to transport routes including Sydney airport. ANSTO were to be the owners and operators of the cyclotron and the hospital furnished the PET scanner suite and raised the funds to buy the first PET camera.

The total cost of the project was in excess of $25m. This development required extensive planning and project management and was admired by many in the international community for the thorough training and knowledge-gathering by the staff as they travelled to PET centres of excellence in the USA and Europe for extended periods. The “team” reassembled in late 1991 for the official opening of the National Medical cyclotron by the GovernorGeneral, Bill Hayden.

The National Medical Cyclotron (NMC) project had dual roles: it was to produce certain single photon radioisotopes used in routine nuclear medicine which, at that stage, needed to be imported from overseas at great expense, and secondly, to produce the short-lived positron emitting radioisotopes required for the PET scanner. The project had a ‘national’ vision and was recognised as an unique scientific tool. At the time of the launch, PET scanning had recognised clinical roles in management of epilepsy and cardiovascular disease, and an emerging role in cancer detection. It had been used in basic medical and physiological research due to its unique abilities to make radio labelled pharmaceuticals and study basic processes such as brain blood flow when performing different mental activities.

Consequently, it was envisioned that the National Medical Cyclotron PET scanner would split its workload roughly 50/50 between clinical studies and research studies. A national scientific committee was established to review potential projects from applicants anywhere in Australia. A number of researchers were successful at this time in garnering NH&MRC funding for research studies on the RPAH PET scanner using radioisotopes made by the cyclotron.

It was also recognised that the role of PET was still emerging he clinical medicine and that it needed to be assessed alongside pre-existing techniques. To this end, an evaluation programme was set up to study PET’s impact, including cost-benefit studies, in epilepsy and detection of damaged, but still viable, heart muscle. These studies were to be jointly funded by the Federal and New South Wales state governments.

In November 1990, a report was prepared by the National Health Technology Advisory Panel (NHTAP) and finalised by the interim Australian Health Technology Advisory Committee. Comments were called following the following executive summary, which was published in the March 1991 edition of the ANZSNM Newsletter.

It is not considered that a sufficient case has yet been established for the routine use of PET as a clinical service in Australia. Further evaluation is needed of PET as a clinical tool, but it is suggested that there could be some value in using the technology as a primary reference method in developing applications of lower cost techniques.

Although Commonwealth funding has been sought for the operating costs of the two proposed PET units, the approaches from hospitals were made prior to the establishment of the nationally-funded centres program by the Australian Health Minister's advisory council, and the proposals were not assessed on that basis.

125

It is considered that, if one or both PET units are established, the technology should be subject to a co-ordinated evaluation of clinical and cost benefits, all patients scanned should be suitable for inclusion in evaluation protocols and criteria for the selection of patients for PET scans should be developed. Evaluations undertaken should include assessment of patient benefit from the use of PET in cardiac and neurological applications in comparison with alternatives, particularly SPECT in cardiac and glioma studies, and SPECT and magnetic resonance imaging (MRI) in epilepsy studies. Studies should be prospective and closely involve referring clinicians. An independent organisation with expertise in evaluation should also be involved. Regular reports on the evaluations should be sent to appropriate commonwealth and state authorities and professional bodies; and no further units should be considered until evaluations, including cost-benefit analysis, are completed.

At the time PET was seen as a high-cost diagnostic imaging technology. It had been used in research for a number of years. In the USA, there was an increasing trend toward its use as a routine clinical tool.

126

Two Australian hospitals established PET units during 1991. The Royal Prince Alfred Hospital installed a PET unit in association with the National Medical Cyclotron facility that was constructed at the hospital. The PET unit had a capital cost of $5m. The Austin Hospital

Present at the opening of the RPAH PET facility and the National Medical Cyclotron project in 1991 (left to right): Dale Bailey (RPAH physicist), â&#x20AC;&#x2DC;patientâ&#x20AC;&#x2122; Kim Silva (RPAH technologist), Dallas Hayden (wife of Bill Hayden, far right), Professor John Morris (RPAH Head of Department of Nuclear Medicine), Dr Doug Baird (RPAH cardiothoracic surgeon and chairman of the RPAH Board) and the Governor-General of Australia, the Hon. Bill Hayden AC. also established a PET unit incorporating a small dedicated cyclotron (see below). The capital cost was about $9m.

In December 1991, G. F. Egan and W. J McKay reported on the status of the positron emission tomography centre at the Austin Hospital in Heidelberg, Victoria, which they discussed at length. In conclusion they said: Positron emission tomography is an exciting imaging modality having the ability to image functional processes in vivo. Due to the short half-lives of the radioisotopes used in PET studies, it is necessary to produce the radioisotopes at their point of use with a cyclotron.

Images of the in-vivo radiopharmaceutical distribution, having 6 mm spatial resolution, are collected with the PET scanner.

The Austin Hospital PET centre, consisting of a 10 MeV cyclotron, radiochemistry laboratories, a full-body PET scanner and image analysis laboratories, is expected to be operational by June 1992, when routine clinical scanning will commence. The initial clinical 11 studies will concentrate on refractory epilepsy and myocardial perfusion and viability.

127

Commonwealth PET Project The National PET Data Collection project was set up in response to a Commonwealth review of PET which recommended inter alia that there be such a data collection undertaken and that the ANZAPNM coordinate such a project. The Commonwealth funded the ANZAPNM for the coordination and also provided funding to the participating sites for data collection management as well as providing access to Medicare items for PET for those sites.

The structure of the project included a coordinating organisation, the Australian and New Zealand Association of Physicians in Nuclear Medicine (ANZAPNM) with the role of establishing protocols and forming a publications committee. The participating sites were determined via a competitive tendering process with eight sites across Australia being successful: 1.

2.

3.

4.

5.

6.

7.

8.

Austin Hospital, Melbourne Royal Prince Alfred Hospital, Sydney Liverpool Hospital, Sydney Peter MacCallum Cancer Centre, Melbourne Royal Adelaide Hospital, Adelaide Sir Charles Gardiner Hospital, Perth The Wesley Hospital, Brisbane Royal Brisbane and Women’s Hospital, Brisbane

A separate data organisation was engaged to receive the data, undertake analysis and provide reports to the project. Demographic data were collected for all scans. The project generated a range of reports, with some indications the subject of prospective clinical protocols and full reports.

As a result of the National PET Data Collection project, PET Medicare item numbers were established and made available to all accredited PET centres within Australia.

References 1. Broderick, F., ‘To Follow Knowledge’, in Wiseman J. (Ed), The History of the Australian and New Zealand Association of Physicians in Nuclear Medicine, 1988.

2. Brucer, M., A Chronology of Nuclear Medicine, 1990.

3. Wagner, H. N., A Personal History of Nuclear Medicine, Springer, 2006.

4. Nuclear Medicine News, 4, 1, January 1973.

5. Nuclear Medicine News, 1, 6, July 1970.

6. Nuclear Medicine News, 6, 3, August 1975.

7. Australian Department of Health, Committee to Review Radiopharmaceuticals, Radiochemicals, and Radiobiologicals, Minutes, 30 September 1975.

8. ANZAPNM, corresp. to Minister for Health, 13 December 1974.

9. Morris, J.G., pers. corresp. to Deputy Director-General of Health, 17 June 1975.

10. Nuclear Medicine News, 8, 4, December 1977.

11. Nuclear Medicine News, 22, 4, 1991.

128

Chapter 8

PERSONAL TRIBUTES Roger Connolly MB BS FRCPE FRACP (1924 - 1994) Roger Connolly was a prominent member of the Association of Physicians in Nuclear Medicine, since its formation in 1969. He was a pioneer in the introduction of endocrinology and nuclear medicine services in Hobart, Tasmania, and much of the developed nature of the specialties in Hobart was due to his influence.

Apart from his residency at Sydney Hospital and three years in the Oxford hospitals, his entire medical life was spent working in Tasmania, largely in the fields of endocrinology and nuclear medicine.

In the early 1960s, he was an honorary physician to the Royal Hobart Hospital and established diabetic, thyroid and endocrine clinics there. He spent about half his working week in unpaid hospital activities. This became so apparent to the hospital administration that they invited him to become a full-time staff specialist in 1967. In the following years, he established a high-quality laboratory focussed on the newly-emerging technique of radio-immunoassay.

In the 1960s, an unexpected tenfold increase in the incidence of hyper-thyroidism occurred throughout Tasmania. Roger played a leading part in the subsequent investigation, which showed it to be due to iodination of bread in a community where many people had iodinedeficient nodular goitres. This increase in hyperthyroidism (the Jod-Basedow phenomenon) had occurred many years before in Europe; and proved to be a temporary wave. The counter-balancing advantage was, of course, correction for subsequent generations of the iodine deficiency that had led to the development of nodular goitre in the first place.

In 1971, Roger became the director of the newly-founded department of nuclear medicine.

His early training at Oxford included experience in radiotracer techniques; and this was buttressed by his great experience in thyroid disease during the1960s.

He was an enthusiastic exponent and innovator, in terms of introducing computer analysis into organ scanning, and rapidly established a first-class diagnostic service. He retired as director of nuclear medicine at Royal Hobart Hospital in 1991 and continued part-time in the new department established at Calvary Hospital, Hobart.

He was an exceptional individual in terms of personal attributes: selfless and yet practical.

He had a wonderfully quirky sense of humour. We spent an hour or so together, a few days before his death, and he gave me a highly-entertaining (and salacious) account of recent medical events in Hobart. It did us both good.

He lived his life to the full and was richly endowed in his family life with his wife, Pat, six children and their families. He even acquired two new grandchildren in the fortnight before 129

his death.

Every group needs a Roger Connolly to lighten the day and help keep balance in their lives.

- Frank Broderick Born in Sydney on 5 October 1924, to Anne, wife of Kevin Connolly, bank manger, and daughter of Francis Ross, public servant, Roger John, youngest of four, was reared mainly by his mother. He attended the Marist Brothers College at Darlinghurst and graduated from the University of Sydney with second class honours in 1947.

Residency at Sydney Hospital was followed by transfer to the Royal Hobart Hospital in 1949 as a resident and later, medical registrar. There, like many another young physician, he fell under the inspiring spell of Ralph Whishaw. Travelling to Britain he worked in Oxford as a registrar under Professor L. J. Witts and Dr Richie Russell. His interest in the use of radioactive substances began here, fostered by Dr Paul Fourman.

Entering private practice in Hobart in 1954, Roger was appointed to the Royal Hobart Hospital as an honorary physician. A change to full-time staff specialist occurred in 1967. He founded the department of endocrinology and later, the department of nuclear medicine. For many years he was the only specialist in both fields in southern Tasmania. With others, he played an important part in elucidating the causes of the fifteen-fold upsurge of thyrotoxicosis, which followed the addition of iodine to Tasmanian bread; a supplement unknowingly reinforced by the use of iodine solutions in dairying (â&#x20AC;&#x2DC;Increase in thyrotoxicosis in an endemic goitre area after iodation of breadâ&#x20AC;&#x2122; 1970, Lancet 1: 500). A thesis based on this work earned a doctorate from the University of Tasmania. In time, others took over the endocrinology unit while Roger remained in charge of the nuclear field. He became a life member of both the Australian and New Zealand Society of Nuclear Medicine and the Association of Physicians in Nuclear Medicine. Formally, he retired from RHH in 1988, after service over forty years, but continued to fill an administrative role until 1991.

Outside the hospital, he was involved in the Citizen Military Forces, saw brief service in Malaya and Vietnam, and became CO of 10th Field Ambulance and ADMS Tasmania command. He retired in 1971 with the rank of Lieutenant-Colonel and award of the Efficiency Decoration. He became a senior consultant at the Repatriation General Hospital, Hobart and a consultant to both the Repatriation Department and the Department of the Army. A university lecturer and tutor, he took part in a wide range .of undergraduate and postgraduate teaching until retirement.

A devout and lifelong Catholic, Roger was involved in many church activities. Perhaps closest to his heart was the foundation of the St John Fisher College at the University of Tasmania, of which he remained a council member for over two decades. In Hobart, Roger met radiographer Patricia Lynch. An unexpectedly-early offer of a ship's doctor position led to the 1952 celebration of their marriage taking place in London, rather than in her home city of Sydney. The bride was given away by long-term friend Joe Corey, later professor of obstetrics and gynaecology. Best man Bob Pitney was to become a distinguished haematologist. Patricia and the six children of their happy union: Helen (programme officer, Australia volunteers), Peter (personnel officer), Margaret (violinist), Catherine (nurse), Elizabeth (nurse) and James (lawyer), all survived Roger.

130

Short and freckled with curly red hair surrounding early baldness, Roger was quick-moving and quick-witted; the latter talent serving to entertain his friends and to confound his opponents. By his own admission, he was not a good committee man; he was not always tolerant or patient. Family life was important to him and it was warm. Music was an enduring interest and a source of great pleasure. He enjoyed woodwork and took to bowls, with enthusiasm, in latter days. His life, professional and otherwise, was one of well-focused intelligence and vigour. He died from colon cancer, at home in the presence of his family.

- T. Kirkland Harry Lander MB BS FRACP FAFPHM (1928 – 1998) Harry Lander was born on 8 September 1928 in Edinburgh, Scotland, and died on 30 December 1998 of cardiac failure in Adelaide. He had a prolonged history of ischaemic heart disease, which first presented as angina when Harry was in his late twenties. He had his first myocardial infarction in his early thirties and a more severe episode in 1983. He had three separate coronary by-pass operations and several angioplasties, and spent much of his last year of life in hospital. Nonetheless, he was a pioneering academic almost to the end.

His father, also named Harry Lander, was a health inspector. His mother’s maiden name was Jean Ramsay Crichton. He had no brothers or sisters. After an early childhood in Malaya, Singapore and Sumatra, the family settled in Perth WA, in 1941, where Harry’s senior schooling was at Guildford Grammar School.

In 1946, he commenced medicine at the University of Western Australia, obtaining distinctions in biology, physics and chemistry in his first year. The remainder of his undergraduate training was at the University of Adelaide, where he graduated with distinction in 1951. He obtained his MRACP in 1956 and FRACP in 1965. He was elected a Foundation Fellow of the Australian Faculty of Public Health Medicine in 1991.

After an intern year at the Royal Adelaide Hospital (RAH) in 1952, he was a medical registrar at the Fremantle Hospital in 1953. He was then appointed lecturer in pathology at the University of Adelaide (with Professor J. S. Robertson) in 1954; and, in 1955, was assistant to the Mortlock Professor of Medicine (H. N. Robson). He was a research fellow in Adelaide for a further two years before spending 13 months in Oxford, UK, at the Radcliffe Infirmary, as tutor in medicine and assistant to the Nuffield Professor of Medicine (L. J. Witts).

Harry was appointed senior lecturer in medicine at the University of Adelaide (RAH) in 1959, associate-professor in 1965 and full professor in 1984. During these years in Adelaide, he demonstrated his original mind, his ability to think laterally and to be an excellent teacher and examiner in medicine. While always intellectually scrupulously honest, he stirred his colleagues at every grand round meeting by stimulating observations and questions. He was a real ‘devil’s advocate’, but underlying his somewhat provocative and mischievous exterior lay a kind heart. He was a great conversationalist and his friendship was treasured.

Harry made a number of original contributions to medicine. An initial interest lay in arsenical and heavy-metal poisoning, an area in which his forensic advice was sought. He played a significant role with Donald Simpson and Norrie Robson in New Guinea by discovering the origins of the fatal nervous system disease Kuru, which turned out to be a prion disease transmitted by tribal cannibalism (Simpson D. A., Lander H., Robson H. N., ‘Observations on 131

Kuru: II Clinical Features’, Ann Med. 1959, 8, 8-15). He studied haematology with a special interest in platelet function as the Harkness Fellow, Commonwealth Fund of New York, and senior Fulbright Fellow in St Louis USA in 1965-‘66. On return to the RAH he was given the task by Dr R. Kimber of managing Adelaide’s first bone marrow transplant. He was the father of nuclear medicine in Adelaide and was the foundation head of the division of nuclear medicine from 1967-‘69.

A major achievement was Harry’s success when he was seconded by the University of Adelaide to become dean of the faculty of medicine, Fiji School of Medicine, University of the South Pacific in Suva, 1984 -1988. After much tribulation in the process, he set this medical school on a much-higher plane. In 1988, he also had consultancies with AIDAB, the World Bank and WHO to review Fiji’s health services as well as medical education in the South Pacific. In 1989, he was appointed professor of international health at the University of Hawaii’s school of public health in Honolulu.

Harry was awarded a number of visiting lectureships in Australia and abroad, including several in New Zealand cities, Los Angeles, Singapore and Malaysia. He fulfilled many other roles in medical administration in Australia and in Fiji. He was foundation president of the Australian and New Zealand Society of Nuclear Medicine, editor of ‘Nuclear Medicine Australia’, and was later elected honorary life member of the society He was a member of the standing committee of the senate of the University of Adelaide for a number of years from 1970. As well as being a meticulous planner of final MB BS examinations in Adelaide, he was a visiting examiner in medicine for two years in Kuala Lumpur.

One of his final commitments was as consultant auditor to the Australian Hospital Care Study of 15,000 admissions in NSW and SA in 1994, looking at adverse events and their preventability.

Harry’s list of publications and abstracts exceeds 200 items, including several books and chapters of books. He had a remarkably productive life despite his lifetime medical problem.

He was married twice; first to Constance Margaret Price, a registered nurse and midwife, in 1953. They had three children: Andrew, Elizabeth and David. His second marriage, in 1984, was to Pamela Ann Nicholson, a senior dietitian at the Flinders Medical Centre. They had no children. Both wives and his three children survive him.

Harry’s principal hobbies were flying and hang-gliding; and he achieved a private pilot’s license with night flying rating.

- R. Hecker No history of early nuclear medicine in Australia would be complete without reference to the place of Harry Lander, who was instrumental in establishing the speciality in Adelaide and was a prime mover in organising the society (ANZSNM) and the association (ANZAPNM).

Harry was Reader in the Department of Medicine, University of Adelaide in the mid-1960s.

He was a haematologist and a general physician, based at the Royal Adelaide Hospital. His interest in haematology led him into the use of radioisotopes for cell labelling and survival studies; and there was a laboratory devoted to these investigations in the university department. The comprehensive rebuilding of the RAH (I believe the structural phase was 132

completed around 1964) provided an opportunity to establish a department of nuclear medicine by bringing together all radioisotope-based testing in a single location. At the time, only haematological investigations and limited thyroid imaging (by interested radiotherapists) were available at RCH, and the hospital owned a ‘state-of-the-art’ whole body counter.

All of the RAH’s pathology testing was the responsibility of the Institute of Medical & Veterinary Science (IMVS), with which the RAH shared a large campus on the corner of North Terrace and Frome Road, Adelaide. With Harry’s persuasive lobbying, the IMVS enthusiastically embraced the establishment of what was to be a new specialist unit; and they took a large space on the seventh floor of the new hospital, adjacent to the blood bank, which they also operated.

The new department of nuclear medicine was lavish by the standards of the day. It was designed to house purpose-specific laboratory spaces, a hot-lab, a basic radiopharmacy, gamma and liquid scintillation counting facilities, and a large open laboratory to be used for imaging that could house up to four separate imaging systems. Harry, who was personally responsible for the design of the original nuclear medicine department, was the first director of nuclear medicine, while continuing in his main role as reader in the university.

With charm, determination, ‘chutzpah’ and some sleight of hand, he set about satisfying his ‘shopping list’ of people and equipment. He attracted Dr Peter Ronai, a young Australian medical graduate fresh from post-graduate studies in nuclear medicine at the Donner Labs in the US, and Dr Rick Baker, a chemist who would soon make a major contribution to clinical radiochemistry in Australia.

His equipment list included the usual chairs, tables, desks, and other mundane items, a rectilinear scanner, then the standard imaging workhorse in nuclear medicine, and a ‘camera (gamma)’. In this way, the first Anger Scintillation camera to be delivered to an Australian nuclear medicine department: a Nuclear Chicago Pho Gamm III with a coincidence positron imaging attachment literally crept in under the cost accountant’s radar.

Radiopharmaceuticals were provided by the Lucas Heights ANSTO facility, through daily flights from Sydney; ‘cold’ kits were not yet available. These shipments included twice weekly deliveries of Na18F, which was used for bone imaging with the Anger positron system. Association with the IMVS made a supply of small animals available for radiopharmaceutical development, and pinhole images of mice and rats were revealing a steady stream of new data.

Harry was a persistent lobbyist for nuclear medicine in South Australia and he was instrumental in establishing an active research programme in nuclear medicine. In 1968, David Cook joined the department of medicine as an NHMRC research scholar. Over the next three years, he and Harry, working primarily in the new department of nuclear medicine, investigated the potential for improving the diagnosis of pulmonary embolism. Along the way, they devised a cheap and effective system for inhalation lung imaging, which significantly improved the accuracy of lung scanning techniques for PE. In 1969 Harry hosted a meeting of Australian physicians, radiologists and radiotherapists at the Royal Adelaide Hospital, with the aim of organising a roof-body that would represent nuclear medicine specialists and a society to foster the development of nuclear medicine in 133

general. At that meeting, it was decided to seek affiliation with the college of physicians, which led to the eventual establishment of the ANZAPNM. Subsequently, Harry relinquished his role as director of nuclear medicine to Peter Ronai, while retaining an interest in nuclear medicine, but never at the intensity of his initial association.

- David J. Cook MD FRACP Vincent Francis Antico MB BS FRACP DDU (1950-1995) The medical community was stunned and saddened by the untimely death of Dr Vince Antico on 19 October 1995, at the age of 44 years.

Vince was the youngest of three brothers and proud of his Italian ancestry. He went to school at Waverley College in Sydney, graduated in medicine from the University of NSW, in 1974, and trained in internal medicine at the Prince of Wales Hospital from 1974 to 1978. He passed the FRACP (Part 1) in 1978, and undertook two years of training in nuclear medicine at Prince of Wales Hospital, during 1979 and 1980. Vince married Lucinda Caleo in 1980. They moved to Toronto, Canada in 1981, where Vince completed his training in nuclear medicine at the Hospital for Sick Children. They returned to Sydney in 1982, where Vince worked as the senior medical registrar and specialty nuclear medicine registrar at the Prince of Wales Hospital, until he accepted his first consultant post. In June 1982, he commenced work as a physician in nuclear medicine at Sir Charles Gairdner Hospital in Perth. Vince and Lucinda enjoyed three happy and successful years in Perth where their daughter, Jacqueline, was born. However, they decided to come home to their families in Sydney and Vince commenced work at the Westmead Hospital in October 1985 as physician in nuclear medicine and diagnostic ultrasound. Their son, Daniel, was born in 1987 and the youngest, Benjamin, was born in 1989.

In 1988, Vince became the deputy director of the department. His special interest was nuclear cardiology, at which he excelled and which led to a parallel interest in echocardiography. He grasped new developments very quickly and was responsible for expanding and implementing new services. Due to his personality and great charm, he forged both professional and personal links with medical and paramedical staff. When working at Westmead was no longer a challenge, he looked for new horizons and opportunities and, at the end of 1993, entered full-time private practice on the central coast, working in both Gosford and Wyong, until the time of his death.

Vince was very popular amongst his peers, because he was always helpful, hardworking and able to achieve things with a minimum of fuss. He played an active part in the Australian and New Zealand Society of Nuclear Medicine and Association of Physicians in Nuclear Medicine. He was also a keen member of the Australian Society of Paediatric Imaging, the Cardiac Society of Australia and New Zealand, the American Society of Echocardiography 134

and the Australasian Society for Ultrasound in Medicine (of which he was secretary of the NSW branch between 1990 and 1992). Vince was a regular attendee at nuclear medicine, ultrasound and cardiology conferences in Australia and overseas, regularly contributing papers of high standard. His most recent contribution was as chairman of the sponsorship committee for the World Federation of Nuclear Medicine and Biology in Sydney, 1994.

Vince was also active in teaching and research. He had an analytical mind and was able to explain concepts clearly. A whole generation of nuclear medicine, radiology and cardiology registrars can thank Vince for the time he spent enthusiastically teaching them and advancing their knowledge and expertise.

Vince will always be fondly remembered for his outgoing nature, boundless energy and vigour, and natural gift to put people at ease in his company and make new friends quickly.

He was the confidante of many and had a genuine love and concern for others. He had many interests in addition to medicine; most notable was his love of sport, especially golf. He was a devoted family man with great love for his wife Lucinda and their three children, Jacqueline, Daniel and Benjamin.

Vince is remembered and sadly missed by all who knew him as a good friend, teacher and dedicated professional.

- Simon Gruenewald and Monica Rossleigh Robert George Sephton BSc PhD MACPSEM (1936 - 2000) Bob Sephton died in April 2000 after a brief fight with cancer; the disease he spent most of his working life investigating. After completing his schooling in Mackay, Queensland, where he achieved dux of school, Bob went to the University of Queensland, completing his BSc (Hon) in 1958.

Bob's first position was with the weapons research establishment at Woomera, where he was employed as an experimental officer. In 1960, Bob took up a position of research assistant at the physics department of Imperial College, University of London, where he investigated the performance of image-amplifying tubes and their application to satellitetracking.

Bob returned to Australia in 1964 to join the CSIRO physics division in Sydney, where he took up a 12-month appointment as experimental officer. In 1965, Bob joined the Peter MacCallum Cancer Institute (or Cancer Institute Board, as it was then known), beginning a 35-year association with cancer research and treatment.

Bob's main fields of interest were nuclear medicine imaging, together with radiation and tumour biology. He continually sought ways to improve the information content of images and sought an in-depth understanding of the mechanism of tumour-chemical interaction.

Bob investigated extensively the radio tracer gallium 67, used as a tumour-seeking agent in clinical imaging. He studied the mechanism by which gallium becomes concentrated in tumour cells and the kinetics of its uptake. Pioneering research on cultured cells was carried out by Bob in collaboration with Alan Harrison of the Walter and Eliza Hall Institute.

135

Much of the experimental work was carried out on mice. On more than one occasion, all members of the department would be seen on all fours, looking under the furniture for one of the experimental subjects which had escaped.

Work progressed to clinical trials where patients were injected with iron after the administration of gallium. The iron improved the imaging by promoting clearance of the gallium from the circulation and enhancing accumulation in the tumour. In 1990, Bob Sephton was appointed director of the department of physical sciences at Peter Mac. Consequently, his field of interest broadened to include therapeutic radiology.

Bob designed the compact linear accelerator bunkers for the relocated Peter Mac at East Melbourne and developed an innovative local-shielding method for high dose-rate brachytherapy. Mobile lead shields, close to the patient, enabled an existing operating theatre to be used for treatment without the expense of constructing a new shielded treatment room.

Some of Bob's other projects involved imaging of tumour blood-flow, high resolution imaging of lung tumours and their responses to therapy, studies of radiation damage to lung, and a diagnostic-quality ‘on-line’ portal imaging system. He developed a film cassette with a new film-screen combination, which produced portal check-films for radiotherapy of vastly improved quality.

Extensive collaboration with the research division and with clinicians was fundamental to Bob's way of working. He published dozens of papers in international journals.

One referee quoted: "Dr Sephton has a sharp analytical mind and is well-versed in the application of the mathematical-physical approach to biological problems of clinical significance”.

For many years, Bob was a respected reviewer for research-grant applications for the National Health and Medical Research Council and the Anti-Cancer Council of Victoria.

Bob was a member of the Australasian College of Physical Scientists in Medicine since its formation. He served on the Victorian branch committee for many years and was a member of the scientific program committee for EPSM conferences when they were held in Melbourne.

A large number of people will count it a privilege to have known Bob Sephton and to have had their lives influenced by his. He will be remembered with deep appreciation.

Joseph Patrick Savage MB MS FRACS (1929 - 2005) Born in Adelaide, the sixth and youngest son of Bert and Helen Savage, he was educated at Loreto Convent and Rostrevor College. Initially, he began training for the priesthood; but, after two years, left the seminary and, in 1948, began his medical course at the University of Adelaide, graduating in 1953.

136

He did resident years in Adelaide and Perth and then began general surgical training at the Royal Adelaide Hospital. Also in 1955, he married Pamela Darian Smith and they had three children: Peter, Sally and Anna.

On completion of surgical training, Joe spent a year conducting research at the Queen Elizabeth Hospital and gained the degree of Master of Surgery.

In 1961, having decided to specialise in paediatric surgery, he went to England and worked at the Great Ormond Street Hospital for Sick Children. In 1965, he returned to Adelaide becoming the first full-time surgeon at the Adelaide Children’s Hospital, where he established the department of surgery.

He was a gifted surgeon and inspiring teacher, leading by example the establishment of paediatric surgery as a separate discipline. Joe was not a ‘political’ person and never sought high office or recognition. He practised with dedication for the best care of his patients and the pursuit of the science of surgery.

In 1972, a chronic lung disease, which was to eventually claim his life, began to hamper his ability to maintain the physical and emotional demands of operating on small children.

Clear-headed as ever, he elected to leave surgery and began retraining in the relatively-new field of nuclear medicine. This was firstly at the Royal Adelaide Hospital department, established about three years earlier, and with which he maintained considerable contact, and subsequently, at the Toronto Hospital for Sick Children. It became a demonstration of his considerable intellect when, in 1975, he returned to the Children’s and established its first department of nuclear medicine.

The department was the third in Adelaide and was the first with an in-house computer and SPECT. Joe’s reputation as a surgeon and his understanding of paediatric pathology led to early adoption in the hospital of nuclear techniques in paediatric urology, bone scanning (with early research on electrical stimulation of fracture healing) cardiology and the central nervous system, particularly CSF shunts. Over half of his considerable publications are nuclear medicine related.

As he approached retirement age, he sought another challenge and, in 1985, opened the first private nuclear medicine practice in Adelaide with Drs Perrett and partners.

This was not to be the end of Joe’s endeavours in different areas. In 1994, due to further deterioration of his health, Joe retired from medicine and set about creating a new venture in horticulture. On a small property in the Adelaide Hills, he and Pam grew and marketed gerberas with considerable success. At the same time, he assisted his daughter Anna in her pursuit of equestrian glory. Joe became very involved in the sport and supported it in many ways. Tragically, Anna was killed in a freak riding accident in 1997.

Joe had a great love of music and was a keen cricket fan. He was almost always a sensitive, modest man, but, particularly in his earlier surgical career, was prone to outbursts of emotion when things were not quite going his way. The contrast of these from Joe’s usual controlled demeanour shocked many when first seen. (The following poem was written by a trainee who took over Joe’s position as head of surgery). Joe was loved by his friends, who readily 137

forgave his occasional irascible outbursts. He was greatly admired by his patients and their parents and colleagues, especially by those with whom he worked closely.

A SAVAGE MAN When I first came to Adelaide I knew no one at all But Joe had had our fridge filled up And he and Pam did call.

The nextest day, Joe showed me round A quiet thoughtful bloke And not a hint of hidden fire No placid waters broke.

That evening to my Moo I said Just aren’t I fortunate To have me such a nice kind man With whom to operate.

But came the nextest day, my friends He called me up to see Him operate by methods new Up there in theatre three.

I tiptoed into hush and asked Is’t going as it should?

But that roused up the hidden beast Who said, “no fucking good!”

The nurses were shocked, my friends They’d heard it all before So I smiled very sweetly And tiptoed out the door.

(Shakingspeare; AKA Brian Douglas)

- Bill McCoy and Barry Chatterton

138

Ian Provan Cathcart Murray AM MB ChB MD FRCPE FRACP FRCP Hon FACR (1929 - 2000) Provan Murray was born in Glasgow, the son of Ian Murray, a noted diabetic-specialist and his wife Annabel (nee Tully), a physiologist. After an initial desire for a career in journalism, he decided to study medicine and graduated from the University of Glasgow in 1952. He was a fierce Scottish nationalist and was proud of his active involvement, when a student, in the retrieval of the Stone of Scone from Westminster Abbey and its return to its rightful place in Scotland. Although the stone was subsequently sent back to England, he was pleased that, a few years ago, it did return to Scotland where it belonged. After completing his training as an endocrinologist with a special interest in thyroid endocrinology at the Glasgow Royal Infirmary, he was awarded a Rockefeller Foundation Fellowship and took up the position of clinical and research fellow at the Massachusetts General Hospital in Boston, as well as research fellow in medicine at Harvard University. In 1963, he accepted a position at the Prince of Wales Hospital in Sydney, where he founded the first Australian department of nuclear medicine. At the time of his retirement from this hospital in June 1994, he was still director of the department and associate professor of medicine at the University of New South Wales. He continued working in private practice until 1999.

Provan was a foundation committee member of the Australian and New Zealand Society of Nuclear Medicine (ANZSNM) and the foundation president of the Australian and New Zealand Association of Physicians in Nuclear Medicine (ANZAPNM) in 1970-â&#x20AC;&#x2DC;72. Initially, his main research interest was in thyroid endocrinology; but, in 1970, he became involved in developing the first technetium-based bone-scanning agents with colleagues from the Australian Atomic Energy Commission (AAEC), now known as the Australian Nuclear Science and Technology Organization (ANSTO). Bone scanning became his main research interest and he developed an international reputation in this field of nuclear medicine. This was recognised by his election to the International Skeletal Society and the granting of honorary fellowship by the American College of Radiologists. He was author of over 150 scientific papers, 11 invited chapters and 2 textbooks.

The establishment of the first training course for nuclear medicine technologists at Sydney Technical College was one of his many achievements. He continued to maintain an active interest in technologist training, having been on the Cumberland College External Advisory Committee for the School of Medical Radiation Technology. He was also responsible for the initiation of the ANZSNMâ&#x20AC;&#x2122;s Mallinckrodt award for technologists. He was actively involved for many years in the NSW Radiation Advisory Council and made a major contribution in this area. He also served on the ANSTO Biomedicine and Health Program Review and Nuclear Medicine Liaison Committees.

Provan had many international interests. He was a foundation member of the Paediatric Imaging Council of the Society of Nuclear Medicine and made a significant contribution to paediatric nuclear medicine knowledge. He was president of the Asia and Oceania Federation of Nuclear Medicine (1976-1978) and was secretary-general of the first congress of the federation in Sydney, in 1976. He represented the ANZSNM as the Australian delegate for the World Federation of Nuclear Medicine and Biology from 1975. He was president of the World Federation and hosted the very successful World Congress in Sydney 139

in 1994. He was also the head and principal investigator of the WHO Collaborating Centre for Nuclear Medicine in the Western Pacific region. He had a great interest in China and was a guest speaker there on several occasions. One of his awards was an honorary professorship at the Military Post-graduate Medical School and Chinese People’s Liberation Army General Hospital in Beijing. He was made a member of the Order of Australia for his services to nuclear medicine in 1994 and was granted honorary life-membership of the ANZSNM in 1993 and of the ANZAPNM in 1994.

The quest for new and bigger challenges resulted in his co-editorship, along with Professor Peter Ell, University College, London, of a major international textbook of nuclear medicine: ‘Nuclear medicine in clinical diagnosis and treatment’, which was first published by Churchill Livingstone in 1994, with a second edition released in 1998.

Outside his medical specialty, Provan had a great love and knowledge of opera, enjoyed pastel painting and was also a keen follower of cricket and rugby. While academic pursuit was of importance to him, of equal importance was the enjoyment of life. He loved a good party and organized some great ones. The highlight of the world congress dinner that he hosted as president was Provan’s dramatic entrance, dressed as the Roman emperor in his chariot. At that dinner, he addressed the audience by the salutation, “Friends, Englishmen and physicists, lend me your ears”. This is an example of his great sense of humour and capacity for fun.

Provan had a deep love for his adopted country and a great capacity for friendship. He was proud of his early involvement with the Don Talbot Swimming School and his chairmanship of the council of the Uniting Church in Double Bay and Woollahra. His circle of friends was wide and international. He was singularly fortunate in his wife Margaret (nee Crosher), whom he married in 1956, and his children: Gail, Colin and Kim; and later his grandchildren: Jordan, Rachel, Adam and James. They, together with his sister, Elizabeth, in Scotland, were a very close family unit and his loss to them is profound.

The grandfather of Australian nuclear medicine and the mentor of numerous physicians and technologists, died at the age of 71, after a long battle with chronic lung disease.

- F. Broderick, B. Walker and M. Rossleigh Peter Valk MB BS FRACP (1940 – 2003) Peter was born in Estonia in 1940. He immigrated to Australia at the age of nine and grew up in Wollongong. He studied medicine at the University of Sydney, graduating in 1965. He served his intern and residency years at Prince Henry Hospital, Sydney and the Royal Adelaide Hospital, before taking a registrar position in nuclear medicine at Royal Prince Alfred Hospital, Sydney (1970-‘72).

While at RPA, he met Professor Jim McRae, who was to have a lasting impact on his future career. Peter spent part of his physician training overseas, at the Lawrence Livermore Laboratories in Berkeley, California, following McRae and working with outstanding basic researchers and SPECT and PET developers, such as Tom Budinger, Hal Anger (of 'Anger Camera' fame), Steve Derenzo and McRae. He spent a year in Lyon, France, as medecin étranger at the Centre 140

de Medicine Nucléaire; and as assistant etranger, Universite Claude Bernard, where he met his future wife, Carol. He obtained his FRACP in 1974. Peter and Carol returned to Sydney in 1976, with Peter as director of nuclear medicine and diagnostic ultrasound at Sydney Hospital.

After Sydney Hospital was decommissioned as an inpatient facility in the late 1970s, Peter relocated to St Vincent's Hospital in Darlinghurst, Sydney. It was during this time that I first encountered Peter; as a physician lecturer in the nuclear medicine technicians' certificate for the Sydney Technical College. From recollection, he taught endocrinology, and dominated the lecture room with his personality and intellect.

Peter returned to the USA and the Bay Area in 1986, after a decade in Sydney. He became chief of medical imaging and, in 1989, an adjunct associate professor in radiology at the University of California at San Francisco. In 1992, he established the world's first private clinical PET facility at the Northern California PET Imaging Centre in Sacramento. In 1998, he became president of the newly-formed Institute for Clinical PET (recently incorporated into the Academy of Molecular Imaging) and worked closely with medical insurers and legislators to provide reimbursement in the USA for PET studies. Peter's contribution and skills in convincing the bean-counters of the value of PET was crucial. If only we had Peter's abilities in Australia for this cause!

In 1997, Peter was invited to visit and lecture on PET in Argentina by the IAEA, accompanied by his wife, Carol. During this time, he met David Townsend and his wife, Carol. A close friendship developed. Around this time, Peter was invited to join the board of directors of CTI PET Systems, Knoxville, Tennessee. CTI was the world's leading developer of PET scanners, and Peter's appointment came as a surprise to many who assumed that they would be chosen as the initial clinical appointee to the board. Peter was a doer, and backed up his convictions with straight-forward opinions.

In 1998, I approached the publisher Springer–Verlag, in the UK, to fund a project to produce a comprehensive textbook on PET. They responded enthusiastically. I asked a couple of colleagues and good friends to join me on the project as co-editors: David Townsend and Michael Maisey were obvious choices. The US arm of Springer suggested adding an 'American' editor who was a well-known name. The three existing editors had long-since decided that working with colleagues and friends that we could count on was paramount in the selection process, and the obvious choice was Peter. We approached Peter with this proposal in early 2000 and his response was, "How could I not accept an invitation to work with such a great bunch of guys?" This was a typical example of Peter's humour. It was only some time later that we learnt that Peter had been courted by numerous publishers to write a text on PET, but that he had always refused. When Springer's New York office learnt that Peter had agreed to work on this book they wrote to their UK counterparts demanding to know how they had enticed him and what the inducements were. They saw it as a major coup.

Peter devoted enormous energy to this project, which became ‘Positron Emission Tomography: Basic Science & Clinical Practice’, throughout 2001-‘02. His sections, the clinical aspects of PET, became dominant as he and I shared the majority of the editorial responsibilities. I would often receive phone calls in my London office from Peter who would be struggling with one contribution or another, along with complaints about, "... why I ever took this project on ..."

But we would end up agreeing that it was worth continuing with, as there was such a vacuum in this area. We delivered the final manuscript, which turned out to be almost 900 printed pages, to the publisher in May 2002. Peter received the first printed copy in March of 2003, some weeks after he had taken himself to see a neurologist friend with some confusion and motor coordination problems. He had a CT scan, which revealed cerebral 141

lesions from an unknown primary. A further CT scan and, ironically a PET scan, revealed a primary lung carcinoma.

Peter was initially given 3-6 weeks to live. He had steroids to shrink the inflammation in his head, along with radiation and chemotherapy to address the cancer, and responded well.

Peter was well-enough by March 2003, to travel to France, a great love of his, on vacation with Carol. In June, he joined us and Springer representatives in New Orleans at the Society of Nuclear Medicine's annual scientific meeting where we had a great time signing copies at the launch of the new textbook and catching up with friends. Peter and Carol were at all of the social functions.

I recall speaking with Peter in the first days after he had received what was, clearly, a fairly dismal prognosis. I phoned him with some trepidation, not knowing what one should really say. The conversation was one of the most uplifting moments in my life - he spoke about the clarity and lack of clutter that the diagnosis and prognosis had given him. He was focused on enjoying life and his friends and family as he had not been able to do before. He even joked about being able to drink all the superb Californian red wines he had been laying down in his cellar! I was left astonished and humbled by Peter's courageous approach to his perilous situation.

He travelled extensively throughout 2003, between treatments, including a number of trips to Europe. News of his demise reached me just before Christmas.

It was a privilege to be taught by Peter, participate in the emergence of PET as a clinical diagnostic tool with him, and work with him on a textbook which stands as a tribute to his clinical skills and energy in promoting clinical PET. His Australian training in internal medicine obviously stood him in great stead in a US nuclear medicine environment dominated by radiology. It was clear to me that his success was firmly based on two factors: his sharp clinical acumen combined with an obvious talent at interpreting functional image data, and his straight-forward, no-nonsense, balanced Australian attitude.2 - Dale Bailey

References 1. Nuclear Medicine News, p.18, March 2004.

2. Nuclear Medicine News, pp.19-20, March 2004.

3. Nuclear Medicine News, 26, 1, p.6, September, 1995.

142

Chapter 9

PERSONAL REFLECTIONS AND CONTRIBUTIONS In 1988, Peter Ronai was living in the USA and wrote to Josephine Wiseman, giving a very interesting account of the early days of nuclear medicine in Australia.

Your request for information on the early days of nuclear medicine in Australia has not been forgotten – just delayed by the need for the concurrence of several conditions: (a) vacation, (b) no conference to attend, (c) no administrative work facing a deadline, and (d) no pressing jobs around the house.

Unfortunately, like a conjunction of Jupiter, Venus and Mars, this doesn’t happen very often!

I’m sure you know that nuclear medicine in Australia began with Jim McRae – or perhaps more accurately with Ruthven Blackburn. Blackie recruited Jim to go to Berkley and train in what was then known as ‘radioisotopes’. Jim spent three years at Donner Lab, on the Berkley campus, receiving a PhD from the University of California. Interestingly, his PhD thesis concerned graft-versus host disease in mice receiving allotransplants – not a very ‘nuclear’ topic, though his PhD was in medical physics.

In late January 2007, shortly after Professor Emeritus Ruthven Blackburn received a most deserved AC on Australia Day, he had the following to say on nuclear medicine at RPAH, the University of Sydney and the founding work of Jim McRae. In 1947-1948, I was at Columbia-Presbyterian Medical School on a Rockefeller Foundation Fellowship when Irving London et al were using radioisotopes to study sickle cell haemoglobin in patients and Randolph West et al were using 60Co to study Vitamin B12, also a clinical study. I was impressed with the value of this type of methodology and when I returned to be Director of the clinical research unit (CRU) at RPAH in 1949, I decided to use radioactive isotopes in appropriate studies.

In 1952-1953, we obtained I-131 from the Commonwealth X-Ray and Radium Laboratory through Dr E. P. George PhD, physicist at St Vincent’s Hospital, and with W. J. Hensley, labelled human serum albumin to estimate its t1/2 in patients with ascites due to cirrhosis of the liver. But these studies were not pursued in-depth. The first labelling was carried out in a beaker in the CRU laboratory and it seemed to us that the only way to test our preparation was to give each other an IV dose which we did without incident. In 1957-1959, at St Vincent’s Hospital, Dr J. B. Hickie of the department of medicine, University of Sydney, and his associates, with Dr E. P. George, were using I-131 labelled human serum albumin to measure cardiac output and I-131 labelled triolein to study fat metabolism.

In the CRU, both before and after it was incorporated into the department of medicine (DoM) in 1957, we used a number of isotopes to investigate patients. For those with liver disease, we studied blood flow and anatomical changes with colloidal Au-198 and chromic P-32 phosphate; I-131 IC green, I131 rose Bengal and colloidal P-32 phosphate were used to study liver function. I-131 labelled triolein helped elucidate patients with fat malabsorption, Hg-203 chlormeridrin for the diagnosis of renal tumours (1966), I-125 labelled dyes to study liver function (1970), Fe-59 in haematological studies and others.

I was confident that there was going to be a big expansion in the use of the current and future isotopes in medicine and the high level of physics involved made the development of such a field in the department logical.

143

I was appointed professor of medicine in the University of Sydney in 1956 and soon afterwards went overseas to visit medical schools in the USA, UK and Europe as professor of medicine elect, not as the director of the clinical research unit. I was again supported by the Rockefeller Foundation. At that time, it seemed reasonable for me to visit the leading centres making, using and developing radioisotopes in San Francisco and New York to further my interests and intentions in the use of radioisotopes, since I was visiting these cities to see their medical schools.

The Donner Laboratories at the Lawrence Berkeley National Laboratory at the University of California at Berkeley was a fairly obvious choice, since I knew about the use of P-32 in polycythemia. I had been elected a member of the International Society of Haematology in the late 1950s, at the same time as Carl de Gruchy and Fred Gunz. There I met with Jim Born the chief administrator, George Warner and Mrs Adamson (who were determining liver blood flow) and Donald Rosenthal (who was using I-131 and with whom I spoke about long term risks). I also met Will Siri PhD physicist (who emphasised the importance of physics know-how), R. McCombs (a young worker at Lawrence working on the pituitary) and I spent some time with Myron Pollycove (who was using Fe-59). I was able to arrange for an appropriately qualified, but as yet unnamed, member of my staff to be trained there.

At Brookhaven, my visit was facilitated by Robert F. Loeb (in whose department I had trained and who mentored me). He was the key medical figure in Columbia-P&S Medical School. Columbia University was one of the universities that got together and established the unit at Brookhaven. I met with Lee Farr (Cosmotron), Dahl, Robertson, Van Slyke and Patterson (physics). At lunch with Farr et al we talked about the hazards of Ca-45. I did not visit any other similar units in the USA, UK, Scandinavia or Europe on that trip.

Neither the Donner Laboratory nor Brookhaven had integrated clinical facilities and so did not provide the model I had in mind (ie. one in which integrated clinical and research facilities were essential).

The hospital with its patients was an essential element in the equation as will be referred to later in this account.

James McRae, MB BS (Hons I) had first used radioactive tracers in 1951, when he spent a year doing his BSc (Med) with Professor de Burgh using P32. He worked in the clinical research unit (RPAH), where radioactive isotopes were in use. He was medical registrar in 1956 and 1957, then became acting-director of research while I was overseas. He was interested to take the opportunity to be trained in the use of isotopes in medicine; and he obtained his PhD in medical physics at the Donner Laboratories. He said he soon “learnt that the program for this PhD was a very rigorous course in math, physics, nuclear physics and nuclear chemistry with a usual time course of four years”. There was no recognition of nuclear medicine as a field of medicine at Donner and which was not affiliated with a hospital. McRae was assigned to work with Lola Kelly, whose field was radiation biology (graft versus host reactions). This became the subject of his thesis, which involved using the appropriate radioactive tracers for iron kinetic studies, red cell and plasma volumes, blood loss and plasma loss.

He “met with John Lawrence the MD brother of Ernest Lawrence (the inventor of the cyclotron and the reason Donner Lab had the earliest access to new radioactive isotopes)”. He visited some other medical centres in the USA, such as the Massachusetts General, where there was a nuclear medicine department. He returned to the department of medicine at Sydney in 1960.

I had thought for some time that medical research was a long way behind physics, especially theoretical physics, and I had developed an imaginary department with a physicist familiar with biology in medicine and a medical-mathematician: these two imaginary people, in whatever particular field they researched, would influence the attitudes of other departmental research workers. In 1956, I also discussed with Professor Harry Messel (physics), the idea of a school of medical physics, which appealed to both of us, but we could take no action then.

144

The first appointment I made to the staff of the department was Dr. Kemp T. Fowler (physics PhD), who had designed and helped Metropolitan Vickers build the first respiratory mass spectrometer for clinical use. Financial support for his salary was obtained from a variety of commercial organisations and, on 17 October 1957, he arrived in the department and made many contributions, publishing alone or with Professor J. R. Read, based on the mass spectrometer. His PhD (medical physics) students went on to senior academic posts. One became deputy vice-chancellor of Monash University. Another physicist, Leopold Dintenfass PhD (1921-1990), a physical chemist previously in the paint industry, was director of haemorheology and biorheology and a senior research fellow in the DoM from 1962 to 1975. He published widely on haemorheology and biorheology, alone and with cardiologists and haematologists, in both purely scientific and clinical journals, such as the ‘American Heart Journal’. He developed the first Australian experiment conducted on the NASA space shuttle.

So McRae, with a PhD in medical physics and a strong background in tracer technology, fitted admirably into my overall plan.

In August 1958, I wrote to the vice-chancellor, as chairman of the NSW/University of Sydney Cancer Council, requesting funds to buy a scanner for the management of cancer patients when McRae returned. Further, in January 1960, I wrote to Dr W. D. Refshauge, Director General of Health for the Commonwealth, informing him that I had established a ‘radiobiological section’ in the department of 1 medicine. This was an early warning notice that we would be applying for NHMRC support in the near future.

In October 1960, McRae was recommended for appointment as senior lecturer in medicine (radiobiology) in the DoM and this was confirmed in December 1960. His stated goal was to establish 2 nuclear medicine in the department in the university and at Royal Prince Alfred Hospital. The laboratory he requested was set up for in vitro work directed to tracer investigations, where the installation of the state of the art benches, lipped to prevent radiation spillage, proved less desirable when imaging overtook the earlier initiatives.

In January 1961, I informed the vice-chancellor that a section of radiation medicine had been 3 established in the department. I used the term ’radiobiology’ at that time as the term ‘nuclear medicine’ was not then in use.

As director of the CRU, and then as professor of medicine, I had close associations with the administration of RPAH (in 1961, I was elected to the board of directors) and particularly with general superintendent Dr E. F. Thomson, who had previously been in charge of laboratory services. It was planned that there would be a close association between the university group and their activities and those of the clinical services in the hospital. This resulted in the appointment of McRae to the position of director of diagnostic isotope services at RPAH in 1964.

It was fortunate that Dr Rex Money, head of the department of neurosurgery at RPAH, had seen the use of As74, a positron emitter, for the diagnosis of brain tumours when visiting the Massachusetts General Hospital in Boston. As a result, it was arranged, in July 1958, that a hospital-owned Baird4 Atomic radio-isotope scanner (one of the first ever made) would be installed in the DoM. It arrived in mid-1961 and was set up by McRae who recalls that the first case sent by Dr Money was a meningioma and, as is typical, it gave an impressive scan. Studies were performed using it for a number of years until Tc scans and camera studies replaced it with better results, but this was the start of isotopic imaging proper in the department.

The investigation of patients with thyroid disease and the I-131 therapy for thyrotoxicosis and thyroid cancer at RPAH were under the control of Dr J. K. Donovan (radiation oncologist) and Mr Brian Scott (physicist) of the State Bureau of Physical Services from 1959 until 1972. Bernard Scott had done early thyroid count profiles using a perforated lead plate and counting over each hole and plotting the count rates.

145

Soon after returning to the department of medicine, McRae joined the Royal Australian Army Medical Corps Reserve (at my suggestion) and for a number of years gave lectures on nuclear warfare, fallout patterns and radiation syndromes and their treatment. He also became a member of the Australian Safety group, which met regularly to review radiation standards. He was promoted to associate professor of medicine in 1962, and assigned to St George Hospital in 1963 to teach medicine to the fifth-year students and run the classes on history taking. His students did well in their exams and their successes were a source of pleasure and pride to him; some later became nuclear medicine specialists. Dr John G. Morris MRACP was also appointed to this hospital in 1963, as lecturer to assist him, and became student supervisor there.

The clinical activities of the department quickly expanded to include a full range of radioisotope activities for the elucidation of problems in patients in RPAH with a variety of disorders. McRae quickly established collaborative relationships with a number of special groups which resulted in many collaborative studies, for example with Firkin’s haematology and Skyring’s gastroenterological groups, using Fe-59, the anaemia of chronic ulcerative colitis was elucidated for the first time. Woolcock and Read, in respiratory medicine, with McRae and Morris, using I-131 labelled macro-aggregated human serum albumen, published the first paper on abnormal blood flow distribution in patients with asthma.

Fe-59 iron oxide (I use ‘iron’ because I do not know whether they were using ferrous or ferric, or if indeed it matters in this account) was subsequently used for pulmonary vascular studies and Morris reported on their value in demonstrating pulmonary embolism at an IAEA meeting in Vienna. Further liver scans were carried out with the CRU, including determining liver/sacrum ratios as an indication of liver function - a decreased liver with concomitant bone marrow uptake. Renal scans with Hg-203 chlormeridin, to show renal tumours, were carried with the surgeons.

In 1963, McRae published a landmark article in ‘Atomic Energy in Australia’, setting out the medical uses of radioisotopes. Under the heading Diagnostic Services, he wrote: An isotope diagnostic service capable of performing the majority of the investigations outlined must have certain key people. There must be a physicist and an electronic expert to deal with physical aspects and instrument maintenance and development respectively. The initial cost of many devices is several thousand pounds and their life span is limited without technical improvements and constant maintenance. There should be one person who bridges the gap between physicist and clinician – a medical physicist whose original training may have been in medicine or in physics. ... Working with the essential key personnel there must be medical registrars or permanent staff doctors whose interests and activities include supervising and performing the isotope investigations of their specialty – haematologists, gastroenterologists, etc. In such a way, the most economical and best use can be 5 made of an isotope facility.

This certainly echoed my thoughts.

At this time, all the nuclear medicine specialists were, like McRae, qualified physicians and members of the RACP. It was hardly surprising that the RACP council became actively interested in nuclear medicine when so many RPAH physicians, with experience of it, were intimately concerned with its policy-making and management.

Between 1966 and 1976, A. W. Morrow, H. M. Rennie and S. J. M. Goulston were presidents, G. L. McDonald and R. J. Mulhearn were honorary secretaries, J. R. Sands and A. P. Skyring were honorary treasurers; and I was on the council for much of this time. The RACP established an educational advisory committee on nuclear medicine (with representatives of the RACP, the RACR and the ANZAPNM), convened by John Morris.

The committee recommended that nuclear medicine should be a specialty of internal medicine in Australia and that appropriate training and accreditation programs should be developed. This was the

146

first time in the world that nuclear medicine was introduced as an independent specialty. The RACP followed these recommendations and introduced the new specialty in 1970 and, initially, the majority of physicians in nuclear medicine were trained at RPAH. At this time, the close association of RPAH and the Australian School of Nuclear Technology at Lucas Heights began and they have been actively involved in vocational training in nuclear medicine locally and in SEA ever since.

Morris trained with McRae in the DoM during 1963-1964, became a physician in nuclear medicine at RPAH in 1965, was head of the department of nuclear medicine there from 1971 until 1995 and was made clinical professor of medicine at the University of Sydney in 1992. Starting in 1968, he supervised courses in nuclear medicine conducted by the PGC in medicine at the University of Sydney and was lecturer in nuclear medicine for the AAEC. In 1968, he received a NSW Cancer Council Scholarship to study nuclear medicine in the USA and Europe.

A Picker Magnascanner was bought and installed in the department of medicine in mid-1963, as a result of the generosity of Mr Stanley Fox. This enabled a much wider range of patient studies to be carried out using I-131 rose Bengal and Au-198 colloid (liver & biliary tract), Hg-203 chlormerodrin (renal tract), Se-75 selenomethionine (pancreas).

This increased the number of patients referred from RPAH for study in the medical school and the service became increasingly difficult for several reasons. The scanner was a long way from most hospital wards and involved considerable ‘wasted’ time for the porters and accompanying nurses.

There were large numbers of undergraduates attending lectures and moving around the building and research activities involving sheep etc. were being carried out. McRae was appointed director of diagnostic isotope services at RPAH in 1964; and, as a result of the planned development of nuclear medicine in RPAH in association with the department of medicine at the university, the clinical service component of McRae’s service and the necessary equipment were transferred to RPAH. The workload at RPAH rapidly increased and extra accommodation for these services was found, in 1967, in a nearby old pie-factory in Salisbury Road, Camperdown. This later became the premises of the RPAH department of nuclear medicine.

McRae’s first formal trainee in the DoM was Paul Farrer (1962-1964), supported by the NSW State Cancer Council, whose PhD thesis concerned positron scanning with As-74. He later worked in the Strong Memorial Hospital, NY, then McGill University in Montreal and finally at the Veterans Administration Hospital in Martinez, California, where he was also an instructor.

In December 1962, Peter Wagner worked briefly as a ‘part-time temporary laboratory assistant’ and, in 1965, as a graduate research fellow before going to San Diego, California, in 1970. He and McRae used macro aggregated human serum albumen to develop, with members of the RPAH isotope diagnostic services, a technique for lung scanning. Wagner became professor of medicine in 1984 and then head of the division of physiology in 1999 at the University of California, San Diego. He has recently been president of the American Thoracic Society. It is of interest that a publication of his, with J. B. West in 1974, was listed by Andras Gideon as one of 99 landmark publications from five centuries.

In 1963, Peter M. Ronai did relevant mathematics and physics courses in the university, while doing clinical studies at RPAH before going to Berkeley, California, in 1964, to enter the PhD program.

Unfortunately, ill-health compelled him to return to Sydney, where he continued his PhD program (1965-1967) studying allograft rejection in mice using radiolabels. He also did clinical service at RPAH. In 1968, after a three-month visit to the USA, he became director of the new nuclear medicine department of the IMVS/Royal Adelaide Hospital in Adelaide, where he was joined by Millicent Marion in 1970. In 1975, he went to Denver for three years, then Kansas as a radiology resident before entering private practice in Salem, Oregon, where he became chairman of the diagnostic imaging department of the Salem Memorial Hospital.

147

In 1964, Nitaya Smitananda, from the Faculty of Tropical Medicine at the University of Medical Sciences in Bangkok, supported by a Colombo Plan Fellowship and the University of Sydney, became a PhD student with McRae. Her thesis: ‘Erythropoesis and graft-versus-host exactions in mice, using Fe59’, earned her the degree in 1967, when she became the first woman to obtain a PhD in the Department of Medicine.

Brian Doust, who had been a student of McRae’s at St George Hospital and trained at RPAH in 1965, later became head of radiology at St Vincent’s Hospital in Sydney. Anthony (Tony) G. Walker also worked with Jim McRae at the University of Sydney from 1967, was registrar at RPAH in 1968 and in diagnostic isotopes at the pie factory. Others, around 1967, included Millicent Marion (who went to Adelaide in 1970), Fred Lomas and Peter Valk.

McRae soon became closely associated with the then Australian Atomic Energy Commission (AAEC), which became the Australian Nuclear Science and Technology Organisation (ANSTO) in 1987. In March 1961, he sent a document on the teaching of radiation medicine to H. L. Bichel for publication in their journal. Largely at McRae’s instigation, AAEC at Lucas Heights became involved in the local production of medical radioisotopes. Rex Boyd led the team that produced a model for Tc-99 production and distribution, which was the first time in the world that a nationally-based daily supply system for short-lived radiopharmaceuticals had been developed. This model far surpassed the USA ‘central’ radiopharmacy endeavours; and hospitals there got most of their supplies from Canada.

In 1969, McRae wrote an important memo to Professor Blackburn stressing the need to engage the AAEC in the production of radiopharmaceuticals and the need for an Australian cyclotron to produce the appropriate ones with short-half lives.

In 1967, Associate Professor Barry Firkin persuaded W. J. (Bill) O’Sullivan PhD to come to the Department of Medicine (as a ‘real’ biochemist), where he initially worked with Jim McRae, John Morris and Peter Valk synthesizing isotopic technetium and chromium compounds for possible use in scanning; but there is no evidence that any were ever used in patients. Bill O’Sullivan left the department in 1974 to become Professor of Medical Biochemistry at the UNSW, at a time when he was also President of the Australian Society for Medical Research.

In 1963, as a Colombo Plan Fellow, McRae established a research facility in isotopes for the Faculty of Tropical Medicine in Bangkok, so that they could study helminth infestations in infants. This important Thailand initiative led to a continuing close association which is dealt with later. There are now two PET facilities in Bangkok. In late 1965, McRae visited Asian centres of nuclear medicine on behalf of WHO to evaluate the activities and needs of Manila, Japan, South Korea, Malaysia, Singapore and India. He also worked in Auckland, New Zealand, for several weeks carrying out scans, including Tc99 brain scans; and he took part in a course of radioisotopes in medicine arranged

by Auckland University.

In 1967, McRae asked John Morris to consider undertaking one of two jobs with the International Atomic Energy Agency (IAEA) and he accepted one, as a technical expert in nuclear medicine charged with the responsibility of organising a nuclear medicine department in the Panduri Hospital in Bucharest, Romania, for four months. This led Morris, together with RPAH, into a close association with IAEA, which has continued ever since and has led to other important associations. When there were IAEA meetings in Vienna or Salzburg in 1969, Morris attended as the medically-qualified person with AAEC. He sat with McRae, Henry Wagner, Hal Anger and others, and so his and the RPAH connections developed further.

There has been a strong association between RPAH nuclear medicine and south-east Asian countries since the visits by James McRae in 1962 and 1965. Thailand, in particular, sent us very good students and the important Thailand initiative was particularly facilitated by Nitaya Smitananda,

148

who has already been mentioned. The strong medical and physics associations with Thailand are dealt with later, when we discuss the international collaborations of RPAH. Two early medical graduates from Papua-New Guinea were Adolph Saweri, who spent a term in nuclear medicine, and Issy Kevau, who trained in cardiology.

McRae returned to the Donner Laboratories in 1969 for a brief sabbatical visit; and several publications with H. O. Anger followed. He finally returned to California, on 31 December 1970, for family reasons and worked with Anger before going to the Oakland Children’s Hospital, Oakland, California.

James McRae’s period in the Department of Medicine (1960 to 1970) was of very great importance to Australian nuclear medicine. His association with AAEC and RPAH strongly reinforced a research and educational outlook in both these institutions. He publicly foresaw the essential lines of future development of nuclear medicine; and, in 1969, wrote a memo to me (Blackburn) on the need to engage AAEC in radiopharmaceuticals and a need for an Australian cyclotron. He appreciated the need for physicists, of the required physics, and the necessity of their close inter-digitation with clinicians. He trained people who adopted and continued his initiatives and established the lasting 6 RPAH-University of Sydney-ANSTO association in all aspects of nuclear medicine.

Jim McRae offered the following reminiscences and thoughts on nuclear medicine.

Readers should be aware that these comments are being written 56 years after their commencement and 18 years after I retired from nuclear medicine.

My first contact with radioactive tracers was in 1951, when I did a BSc(Med) with Professor de Burgh.

We explored the replication of ectromelia virus in the mouse liver using P32 to measure the turnover of phosphorus in mitochondria microsomes. Don Metcalf preceded me and Gus Nossal followed the next year with Professor de Burgh. Barry Firkin worked with Professor Thorpe in 1951. At the time, I did not realise how early in tracer technology this work was. I was one of the professorial residents at RPAH in 1954, and was medical registrar in the clinical research ward in 1956 and 1957, with Professor Blackburn. Again, I had the opportunity to use radioactive tracers, measuring hepatic blood flow.

At the end of 1957, I passed the membership and, at this time, Professor Blackburn asked whether I would be interested in training at Donner Laboratory, which he had visited in 1956 and had arranged for a training position in the future. A fellowship was arranged (Lederle International Fellowship).

In January 1958, we (my wife Elizabeth and three-month-old Amanda) left Sydney on a Qantas Super Constellation, which had four-regular propeller engines and a top speed of 180 mph. On the second day, I awoke to see one propeller idling and fuel being pumped out. Next came the captain’s voice to alert us to a stop on Canton Island; a minute spot, two degrees south of the equator, and a refuelling airfield for fighters flown to Australia during WW2. We spent 24 hours waiting for a replacement engine and the onward flight to San Francisco.

We had left Sydney, not knowing the exact location of Berkeley to San Francisco; something not imaginable in this day of global positioning and maps on the internet. A bus ride (segregated) to downtown San Francisco and cab to the Shattuck Hotel in Berkeley answered the location of UC Berkeley and Donner Laboratory (a distance of 45 miles). The room rate was $9. Accommodation was found in a small apartment about a mile from Donner Lab, through the service to foreign students run by International House. The person was Mrs McGlaughlin and, of interest is the fact that Mrs McGlaughlin is still active in community affairs and now, at over 90, has participated in a protest to stop the University cutting down some oak trees to make way for an addition to the football stadium.

149

This involvement is typical Berkeley. We lived in that apartment for three years, paying first $80 per month and later $90.

I met with John Lawrence (the program director and brother of Ernest Lawrence, inventor of the cyclotron) and the reason Donner Lab had the earliest access to new radioactive isotopes. I learned that the program he offered was a PhD in medical physics, involving courses in math, physics, nuclear physics, nuclear chemistry and radiation biology, with a usual time of four years. Not only was this the only option, but I had already missed the first week of classes. The medical physics program centred at Donner was started in 1944 and drew physicians from the US and all over the world. It provided training in the use of radioactive tracers in medical research and in radiobiology. Candidates were assigned an advisor from the active research staff.

Although Hal Anger was busy upstairs, I did not meet him and was unaware of the major contributions he was about to make. There was no recognition of nuclear medicine as a field of medicine at Donner and it was not affiliated with a hospital. I was assigned to work with Lola Kelly whose field was radiation biology. There was intense interest in radiation damage and in transplantation problems, specifically graft versus host reactions. This became the subject of my thesis and I treated the mouse with graft versus host syndrome as I would a sick patient. The anaemia was fully evaluated with iron kinetic studies, red cell and plasma volumes, blood loss and plasma loss using the appropriate radioactive tracers. The basic course work was a constant background.

In late 1959, we made a 56-day trip of over 12,000 miles, visiting centres active in radiobiology and tracer methodology, including Los Alamos, Brookhaven National Laboratory, Oak Ridge, and Bar Harbor in Maine. We made this trip in a 1952 de Soto, lacking a heater, window-defroster and airconditioner. This was typical for a cheap Californian car with its mild climate, but not ideal in the snow and subfreezing conditions we experienced. We had two children in the back, our daughter, now close to two, and son of six months. My wife has uncovered a diary she kept on this adventure and it makes the experience live again and reinforces the joys and rashness of younger years.

On our travels, we visited Tony Edwards at the Mayo Clinic, Barry Firkin in St Louis and Kaye Ellem at the Wistar Institute in Philadelphia, to mention some Australians in the US in 1959. There was a nuclear medicine department at the Massachusetts General Hospital and the diary mentions lots of equipment (it must have included the positron scanner). We also visited many national parks on our route, including Bryce Canyon, which we saw on a brilliant morning, but cold enough to freeze the dribble on the baby’s bib. I completed the course work and thesis for my PhD at the end of 1960 and was appointed senior lecturer in medicine (radiobiology) in 1961. My father commented that I had been a student for 14 years.

The laboratory design I requested was planned for bench work and tracer investigations, as I did not foresee the major role that organ imaging was about to play. Following my appointment, there was a news release which was headed ‘Radiation Medicine as New University Course’. “The department of medicine in the University of Sydney will soon provide general training in radiation medicine amongst its regular courses. A considerable amount of isotope detection equipment has been provided by the postgraduate medical foundation. These steps have been taken because we have entered the nuclear age in which there is an increasing need for doctors, biologists, physicists and other groups to have special knowledge of different aspects of radiation said Professor Blackburn and Dr McRae.” The major emphasis of the news release was radiobiology with the disclaimer that radiation medicine was chosen in preference to nuclear medicine, because the significance to man of radiations of all types will be a central theme. It was a time of great concern about nuclear weapons. It was noted that particular medical uses of isotopes will be presented and, late in the article, it stated that "other scanning devices capable of precise localisation will be required". In conclusion, it was said that the courses were aimed to "achieve the safe and optimal peaceful use of atomic energy”.

150

Apart from my nuclear medicine activities, I was assigned to St George Hospital to oversee the students and run the classes on history taking. My students did well in their exams and I took pleasure and pride in their success. Frank Broderick and I conducted Saturday morning rounds for interested physicians and these were also well received. A number of these students entered nuclear medicine (i.e., Andrew McLaughlin, Fred Lomas and others).

The clinical activities in the radiation medicine section quickly expanded to include a full range of radioisotope tracer techniques to investigate haematological problems. Other specialists were encouraged to participate and an early project was an evaluation of the anaemia of ulcerative colitis (Beal, Skyring et al, November 1963). Renograms were performed and I can especially remember performing studies with the patient erect (standing) to evaluate the effect of posture on renal blood flow noting that some kidneys drop some distance and the renal artery could kink.

The department was not involved in radioassays, which commonly were major activities in early nuclear medicine departments. With the delivery of the positron scanner in mid-1961 (chosen and finance found by Dr Rex Money, the senior neurosurgeon at RPAH), imaging was started. To provide patient oversight and technical support Sister Meredith McDade joined the group. Nurses were often the first to be nuclear medicine â&#x20AC;&#x2DC;techniciansâ&#x20AC;&#x2122;.

Throughout my career in nuclear medicine, I performed many scans and camera studies. The doctors working with me followed this routine and became proficient in performing all studies. The tracer doses were prepared and administered by the medical staff. Millicent Marion communicated to me that she fell through a balcony at RPAH en route to a ward with a little lead pot of isotope. None spilt!

The fact that the MDs did many of the early studies, adjusting the settings and positioning the patient, greatly speeded the learning process. We (the medical staff) perused the history and examined the patient and, as a result, the accuracy of the final report was enhanced as we became familiar with interpreting the images.

This policy led to John Morris' mantra: "Reports must be in the proper clinical context". I wonder if the reason we took this approach was our clinical medicine background; unlike radiology, where so many reports are read from film alone.

I returned to Donner Laboratory on sabbatical leave in 1968 and worked closely with Hal Anger. The nuclear medicine group was not closely integrated. Hal Anger always worked alone on instrument design, apart from excellent technical support. Notable were Pete Dowling, in the machine shop, who fabricated much of the imaging equipment, including housing, shielding and many collimators. Hal also had an engineering assistant, John Gurule, who worked on maintenance and continuous upgrades to the electronics. Both Pete Dowling and John Gurule have provided input to these musings.

Hal actively participated in the evaluation of new isotopes and tracers to assess the need for instrument modifications. He worked with a series of physicians (Bill Myers and Alex Gottschalk) in the evaluation of his positron camera, whole-body scanner, multiplane tomographic scanner (I was the first to report on this), transmission scintigraphy and rotational sciniscintigraphy. He designed numerous collimators for different sensitivities and energies. His primary camera had three collimators on a clover leaf support, such that a low energy, medium energy or pinhole collimator could be rotated into position over the supine or prone patient. The patient was positioned by moving the bed as needed. The pinhole collimator had inserts of different apertures made of platinum. Most images were recorded on Polaroid film, using a camera with a shutter opened at six different apertures to provide different levels of exposure.

With computer storage and manipulation available today, this seems very simplistic. For dynamic studies, the Polaroid film was manually pulled in a suitable time sequence. It was the first time that I

151

worked with Hal Anger and realized the level of his achievements and his appreciation of what was needed to further imaging.

A brief review of Hal’s huge contributions to Nuclear Medicine seems appropriate: 1950 Designed the well counter, 1952 Pin-hole camera 1, 1953 Early whole-body scanner with 16 detectors, 1956 Anger camera prototype, 1959 Positron camera, 1965 Whole-body scanner with 64 detectors (a real workhorse), 1966-68 Multiplane Tomographic scanner, 1968 Transmission imaging, 1970-72 Major upgrades of the positron camera and whole body scanner, and 1973 Cardiac gated dynamic mobile probe for cardiac ejection.

Professor Blackburn has found a letter I wrote to him in May 1968, which enthusiastically reported on the work at hand. The multiplane tomographic scanner was almost finished, as was a new camera with 16” crystal. There was a new model of the Nuclear Chicago commercial camera on loan for his evaluation. We had just completed a series of transmission images to test their place in imaging. I wrote that continued experience has convinced me that ‘proper camera studies’ take a long time. By the time you have done a dynamic study, early and late scintiphotos, even a brain study takes an hour or more. Bearing in mind the clinical load at RPAH, I recommended funding at least two cameras. I was not as enthusiastic about the immediate need for a positron camera. So happy was I with the rate of change in imaging that I asked, "What would your reaction be to some extension of my stay in Berkeley if developments were booming at Donner and stationary in Sydney?" I do not have an answer to that request; but, as events unfolded, it was not until the spring of 1969 that I returned to Sydney. I was most fortunate to have worked with Hal at the acme of his career.

In 1971, I was appointed research fellow at Donner Laboratory, with the responsibility of conducting the imaging studies using Hal Anger's instruments and new isotopes and compounds prepared by Yukio Yano (radiochemist working with Hal Anger) and myself. Examples included Kr81m and Rb81 generators and T99m diphosphonate. I was particularly interested in determining the optimal amount of stannous chloride to formulate the Tc99m bone scan agent. Rats were injected immediately after preparation, but there may well have been reasons to explore the effects of different amounts of tin on the stability of the bone scan agent over time. I never found that bone scanning agents obtained from radiopharmacies gave the same quality of images as did freshly prepared kits.

Since stannous tin was being used so widely to produce Tc99m tracers, I investigated the toxicity of tin in rats. The lethal dose was determined and the kidneys were the critical organ. As part of this study, I explored the distribution of Tc 99 pertechnetate, at times following the injection of tin (Journal of Nuclear Medicine, Vol.15, pp.151-155, 1974). With smaller challenge, doses of tin red cell uptake was pronounced.

At this time, there were reports of abnormal distribution of Tc99m pertechnetate in patients who had had a bone scan a few days previously. Tony Walker contacted me because he had noted the altered distribution of pertechnetate in such patients. From these observations came the method of in vivo labelling of red cells for blood pool and cardiac studies. Note that some tracer compounds ‘give up their tin to red cells better than others, with pyrophosphate being a good primer’. Handmaker, Hal and I explored rotational sciniscintigraphy. Multiple images of the liver and spleen were taken with the patient on a rotating turntable and recorded as a 16-frame film loop. When played, this loop gave a remarkable three-dimensional feel.

There seems to be an advantage in interpreting serial images focused around an area, as multiple CT images are better interpreted in a moving sequence versus single frame viewing. In 1975, when Joe

152

Kriss was on sabbatical leave, I substituted for him at the Stanford nuclear medicine department two days a week for six months, supervising the nuclear medicine trainees. There I saw a technetium glove resulting from the injection of the bone scan agent into the radial artery. The bones in the wrist and hand â&#x20AC;&#x2DC;light upâ&#x20AC;&#x2122; in a glove pattern.

In 1976, the funding at Donner was redirected and clinical type programs reduced. I joined a private group in San Francisco with its own radiopharmacy (Radpharm), which supplied other hospitals. In 1978, I applied to Children's Hospital in Oakland to commence a nuclear medicine service in-house.

Prior to this time, a few studies had been done at nearby hospitals. From October 1978 until April 1989, I was the only person in the department. I picked the children up from the ward, prepared, calibrated and injected all tracer doses, conducted every study and typed the reports. All the imaging was done on a portable camera and numerous studies were performed in the intensive-care nursery and ward. By studying the critically-ill children and infants this way, nursing assistance was available.

In the department, the mother frequently provided helpful oversight. For infants, a plywood extension was attached to the camera head which faced upwards. Excellent prone and supine images could be obtained.

For several years, I also was the quality assurance director and learnt much about tracking and addressing problems in clinical care. A quality-control check was made on the accuracy of the nuclear medicine reports for random blocks of days against the discharge diagnosis. I provided emergency scans at night and weekends with calls about every two weeks. With only a few odd holidays, it was time to retire in 1969 and have an extended holiday in Scotland. It is now 18 years since I retired and the contacts and memories involved in this project have been special.

One of the last areas that I was exploring at Donner, in 1973, was the use of a cardiac gate to image the heart in diastole and systole. In multiple studies over the chest, I had noted the variation in cardiac size and a gating circuit was built to trigger off the R-wave and accumulate a series of images. This system was shown to visitors. At the same time, I had also had the electronic support group build a respiratory gate to see if image quality could be improved by freezing respiratory movement. Hal Anger was not involved with these gates.

At the same time, as I was experimenting with the EKG gate to measure ejection fraction, Donald van Dyke and Hal Anger were evaluating a detector (cardiac gated dynamic mobile probe) which was centred over the left ventricle as best as could be assessed by X-ray and an external lead marker.

The probe had a central area which recorded activity in the left ventricle and a concentric ring of equal area recording the surrounding activity, which was the subtracted background activity. The ejection fraction could be calculated and the results were judged of value. The parallel development of the probe, and the fact that Hal was not directly involved with the gating approach, was critical to advancing the technique and perfecting the EKG gate. Research proceeds better with a coordinated effort and a narrow focus. The EKG and respiratory gates remained after my departure and were not further developed at Donner. The alternate probe approach was superseded as gated cardiac studies proved so successful.

Tony Walker provided the following reflections and recollections on postgraduate training in the USA. In the latter 1950s and â&#x20AC;&#x2DC;60s, the far-sighted approach to the potential of radionuclide s in medicine taken by Professor Blackburn and the department of medicine at Sydney University, and then at RPAH, resulted in the doors being open to Jim McRae and John Morris to place fellows and registrars into the top postgraduate nuclear medicine programs overseas and, particularly, in the USA.

153

Thus, an opportunity became available to me to work at Johns Hopkins Hospital in Baltimore, Maryland, from mid-1968 in the department of nuclear medicine created and headed by Henry N. Wagner Jr MD. Arriving in Baltimore just after the riots and destruction of the poorer old areas of town (which included the JHH site) following the shooting of Martin Luther King and then Robert F. Kennedy was indeed daunting; and Baltimore was not an altogether happy place. It would be fair to say that moving with my wife and two children to this environment left me well outside my comfort zone. This, however, is much of the point of the whole experience!

Henry’s genius, his passion, his contributions and far-sighted approach to nuclear medicine are very well known to all. Suffice it to say that a Google search of his name will give 3,520,000 entries; and the ‘Henry N. Wagner Jr MD Professorship in Nuclear Medicine’ was recently established at JHH in his honour. In 1968, however, the ‘deep end’ approach for training was more suited to some than others. Nevertheless, Henry and his wife Anne were always warm and outgoing to me ever after that year of fellowship at JHH. At the Istanbul meeting in 2000, he wore a Sydney Olympics tie to his major presentation and duly castigated me when I did not notice it. He also gave me his congratulations on the success of the Sydney Olympics; I had to confess I had not been involved.

This tradition of extending warmth and honour to previous fellows has meant a great deal to me far beyond the benefit of having JHH on the CV. A couple of other examples of his humour: at the Beijing meeting in 1988, an unfortunate interpreter informed a noisy busload of attendees that we were going to a “cock party”. As I stifled my laughter, thinking I was the only one to pick this up, I noticed Henry in the front seat cracking up with mirth, obviously enjoying the moment! In 1968, after Richard Nixon nominated Spiro Agnew (then Governor of Maryland) as his vice-presidential running mate, Henry turned around to us lesser mortals at the morning clinical cases conference and announced the orders of the CIA: “If anything happens to Nixon, the first order is to shoot Agnew”. The memory of this far-sighted comment came back when VP Agnew later resigned after receiving bribes in office.

Despite my initial introduction to the USA, I went on to stay there for 11 years, returning to Sydney to join Ern Crocker at Westmead; first at Westmead Hospital and later in Practice. I enjoyed my time in nuclear medicine in the USA, as I did in Sydney before leaving and after returning. They were, however, all very different. I am most grateful to Jim McRae and John Morris for a unique opportunity at RPAH and JHH. One final thought; age gives insights into things, people and events that would have been very useful to have had when much younger.

Sue Lefmann (née Woolf), one of several nuclear medicine technologists, who helped develop the many departments throughout Australia and New Zealand, shares some of her recollections.

On 6 December 1960, I commenced training as a therapy radiographer at the Royal North Shore Hospital in Sydney. By the third year of my course, I was the only student; and Sydney Technical College refused to run a course for one student. As it so happened, I married that year and re-located to Brisbane, where I re-commenced training through The Queensland Radium Institute.

As a therapy radiographer, we were required to work in ‘radioisotopes’ and those were the days where I-131 doses were assayed and our gloves were ‘washed out’ and left to dry before re-use. At this time, the physicists were producing some type of bone scan using Fluorine.

My more official entry into nuclear medicine came in 1971, when, whilst working at Guys Hospital in London, I was asked by the chief radiographer Margaret Howard, if I would like to spend some time in ‘scanning’. Always being one to try out new challenges, I readily accepted and so began my passion for nuclear medicine.

154

At Guy’s Hospital I spent my time developing films and helping the doctors and physicists perform scans using, I think, a Nuclear Chicago Rectilinear Scanner.

During this time, I fell pregnant with my second child; appropriately named Martin Guy, as I was threading radium into containers at this time. On my return to Sydney, as I was pregnant, it was not acceptable to work in a radiation area. I waited until my son was eight months old and approached Dr Ian Hales, who offered me a position running the scanning department at Hornsby Hospital. At my job interview, Mr Stame George was rather perplexed as to how I was going to manage working as I had two children.

At Hornsby Hospital I had a Picker Rectilinear Scanner and daily delivery of radioisotope from Lucas Heights. I performed perfusion lung scans, brain scans, liver and spleen and thyroid scans. When we took delivery of a Searle Gamma Camera in 1973, we added bone scans to the service. Royal North Shore sent registrars almost on a daily basis to Hornsby and they would return to RNS for reporting; or I would send any urgent scans down either by courier or in a taxi, for reporting. We had great fun with the registrars, most of whom are now specialising. A few that I can remember are Dominic Collis (now a radiologist), Rod Aroney (who I believe is in a political position and drove a very cool sports car), Mark Cohen (another radiologist), Jonathon Ell (a neurologist) and Harry.

Drs Ian Hales, Bob Cooper and Jo Wiseman regularly came to Hornsby to do our reporting. For Bob, it was closer for him to go home, but Jo Wiseman invariably left RNS at lunchtime and arrived at Hornsby (via her hairdresser) for reporting at one minute to 5:00 pm. I was then expected to wait back until she had finished reporting.

Documentation was rather light-on, there were no computer printouts for doses, and no hot lab record sheet. Still, no errors were made.

RNS sent students to me for training for several weeks at a time and most of them are still currently working in nuclear medicine or ultrasound. Some of them are Sarah (Burcham) Lawrence, Janis (Upcroft) Von Tackash, Sharon (Venables) Berchiary and Sue (Beevers) Darnell. There commenced my ‘training’ of nuclear medicine students, which is still continuing to this day.

Patients undergoing a brain scan had a four-view rectilinear scan, with each view taking 15 minutes.

This was the main diagnostic tool in patients who had either a cerebral tumour, infarct or sub-dural haematoma. The Picker scanner was a temperamental piece; it usually required a ‘hit on top and two punches’ at the front, just to get it going. Failing to do this was a ‘no go, no scan’ situation. Many patients went direct to OT to have a craniotomy on the ‘look’ of the brain scan.

The arrival of the Gamma Camera in 1973 meant dynamic studies with two second frames were performed on the brain scans; and I would furiously stand and ‘pull’ Polaroids, changing packs midway, for one minute. If the intensity was incorrect, in the analogue era prior to digital, we lost the study and had hefty explaining to do to our doctors. There, ‘technically unsatisfactory’ was born.

Doses were of course in millicuries and we all had a difficult time converting to Becquerels. Patient doses were much the same as now and, coming from a background in radiation therapy, I was very aware of the dose to the patient and, of course, to us technicians (as we were known at the time).

A constantly changing profession, I have upgraded by doing an undergraduate course (designed by the University of Sydney specifically for me) and the conversion course; graduating in 1999. Since then, I have been successful in completing the CT for nuclear medicine technicians and the bone densitometry course (ANZSBM). I have been employed at Westmead Hospital as a senior nuclear medicine technician since 1995.

155

Peter Ronai was a junior resident at Royal Prince Alfred Hospital and had come to a career crossroad in 1962, as he was unhappy in his situation at RPAH. In 1962, I was a junior RMO at RPAH. After the friendly atmosphere of the ‘country club’ (RNSH), where I had been a medical student, I found the atmosphere at RPAH quite unpleasant - so much so that I was ‘turned-off’ clinical medicine and decided on a career in research. Fortunately, as I was coming to this decision, Jim McCrae gave a lecture to the PA residents on ‘radioisotopes’. Here was a discipline, it seemed to me, that would be useful in any field of research; and I decided (against advice from many people) to not apply for a senior RMO position after my junior RMO year, but to enrol as a PhD candidate with Jim McRae. I started with Jim in the department of medicine in January 1963. Like Paul Farrer, I had also been born in Hungary (my surname means ‘one who comes from the plain’).

In 1948, physicist Bernard Scott established the thyroid investigation unit at Royal Prince Alfred Hospital. Sue Lefmann also remembers Mr Scott giving physics lectures in the dungeons of RPA in 1962 & 1963.

156

I can still see his smiling face and thick mop of grey, white hair. He had a peaceful calmness about him. Another who gave us lectures was Charles Keage. The lectures were at St Anne’s Church Hall in Darlinghurst just along from RPA. ‘Radiography’, as it was called, was either diagnostic or therapy and the first year of the course was common to both. Therapy was not the most popular and most people did diagnostic. There was also Dr Colin Hambly, who smoked his way through our lectures at Sydney Hospital and embarrassed me no end one day when lecturing about 'penile' cancer. I asked a very naïve, dumb question – at 17, I was not quite like the average 17-year-old today – to which Dr Hambly replied, “Miss Woolf, they come in all shapes and sizes you know. Well, I went scarlet; hot and cold all over, and nearly died on the spot with embarrassment.

Millicent Marion-Hughes also remembered Bernard Scott from her registrar days at RPA in 1966.

I remember Bern very well. He was a marvellous man; he was a grandfather figure, I think, in the department. He was always very kind and very gentle and did not put himself forward very much, but he was a very good person to ask about things.

He was very popular with the staff and popular with everybody, because of his kindly attitude and ability to explain things in such a way and it was that which I remember him for. He was heavily involved in the radiotherapy department and was only partly involved in nuclear medicine.

I think that I was very fortunate, as I had just decided that I did not want to be a child-psychiatrist and I spoke to Professor Blackburn and he suggested that I may like to come over and work at Sydney University with Associate Professor Jim McRae. Jim was a mentor to nuclear medicine people like me when I first went to work there in 1966. We worked in the university at the same time that John (Dr John Morris) was getting things going over at the Royal Prince Alfred, in what we used to call the ‘Pie Factory’. Jim was a very capable and industrious man, and he had very strong views on how nuclear medicine should be carried out and what training should be involved for nuclear medicine. He was also very anxious for us to have available the very best sort of equipment; and I remember him writing letters to the United States to the Donner Laboratory discussing gamma camera when most people were not even talking about such things very much. He had the positron scanner, which was the initial instrumentation. It was a coincidence scanner and was very much used as a brain scanner. Jim had PhD students work with him and he was also very friendly with people in the respiratory unit, so his ideas about nuclear medicine involved trying to get as much use as possible. I have to tell you that one of the most delightful things about the seminar is that I actually made contact with him again.

Dr Andrew McLaughlin provided his following memories of ‘The Pie Factory’.7 One day, in late 1968, I had to make a decision about my medical future. I briefly considered anaesthetics but dismissed it: 90% boredom with 10% panic. Having been the Intern on the McRae/Morris Medical Unit at St George Hospital, my close association with Frank Broderick and the establishment of a Radioisotope Department, under the guidance of Jim McRae and John Morris in 1964/65, radioisotopes beckoned.

I was familiar with the basics from my contact with the new department and its founders and staff. I tentatively rang John Morris, who was a fearsome medical history presentations tutor, (his infamous quote being: ‘What do you think this is Alice in Wonderland? ‘). I asked him for a registrar position for the following year. He said to come to RPAH for an interview, which I nervously did. I received a call

157

the next day from John (‘Ding’) Chalmers who offered me the job. I later had contact with Ding in the excellent RACP training programme; he was also universally feared.

I became the third Registrar at RPAH behind Millicent Marion and Tony Walker, along with Fred Lomas (also a St George student). Subsequently, there were many Registrars: over 30, at least 18 of whom, by my reckoning, became heads of departments.

In 1969, there were many striking, and less than ideal, aspects of the ‘Pie Factory' (Scott’s pies, I think): the cramped conditions, the many staff of technologists and registrars, the patients on trolleys in the limited corridor space and sitting in the small waiting room, etc. To make space even tighter, several rooms and a small alcove, were occupied by John Donovan and Sr Hellier, who did his bookings and was to be avoided, and an Alan someone, who occupied a large shielded room and did 131 the I uptakes from the thyroid clinic: JKD operated in our space. Eventually, under pressure, we acquired their space, which was desperately needed but only partly relieved the situation.

There were two rectilinear Picker scanners when I arrived and one in room 326 in the New Medical School where Jim McRae was based. There was also a 3 probe ‘whole body bone scanner, which 18 printed out graphically count rates over the trunk, using F when it became available. These were very embarrassing to produce at Grand Rounds as ‘evidence’ of metastatic bone disease. I’m sure no one believed them and thought them rather farcical.

Nevertheless, a large number of patients per day were scanned: brains, livers, lungs, thyroids, renals (renograms only at room 326). The registrars were responsible for calculating doses, drawing them up (not done now) and injecting the patients in the corridor on trolleys including a small number of babies and children, sitting side by side in the waiting room. Radiation safety rules were almost non-existent.

There was nowhere to interview the patient or examine them except in the scan room, which held everyone up. The techs didn’t like it.

There was no registrar’s office (JM had a small phone booth packed with everything from papers, books, bridles, etc. and was literally a phone booth as he was always on the phone). I think there was only room for two chairs for visitors – others had to stand. JM hosted a continuous stream of visitors to the ‘phone booth’ from old mates and colleagues, ALP luminaries, well known racing identities, not so well known ones, politicians (including Peter Morris, Federal Minister, to the former head of the PM’s office John Menadue). It was here that I met and got to know many of them. Even reporting was done every afternoon in the ‘phone booth’. Things were relieved a bit when we acquired JKD’s office as a registrar and reporting room. Reporting was always interesting with JM. He hadn’t changed much from student tutor – case history days. He still wanted to know all about the patient including the ESR and the FEV1. JM had a property at Cobbitty, near Camden – Cobbitty Lodge Stud and Stables – a sort of R & R for horses! It was here, every December, he hosted a Christmas barbeque for the staff and his friends and acquaintances – ones who may not have visited the ‘phone booth‘. JM’s network of people was vast. I remember Graham Freudenberg (chief speechwriter and press secretary to numerous Labor Prime Ministers and Premiers) was usually present. The Cobbitty barbeques were unforgettable – the heat, dust, the flies and smell of chaff and horses! There were always lots of kids including my own.

It seemed to take a long time before we acquired a gamma camera. An English one was installed, on trial in room 326, and was run by Peter Valk and Jim McRae. Valk abandoned the Pie Factory and the registrar roster after several vigorous ‘debates’ with JM and retreated to the med school for his own advancement and to the annoyance of the rest of us.

Finally, two Nuclear Chicago analogue cameras were acquired and the rectilinear scans were abandoned; thankfully. We could now do brain dynamic studies. Computerization came much, much later.

158

At the eastern end of the Pie Factory was a large room/lab, a small store room, a vault and a largish office for Bern Scott. Bern was a lovely man and the physicist. He began giving registrars lectures in the afternoons. Most of us didn’t understand them and slept. It turned out his son Peter was in my class at med school. We eventually acquired a second young physicist – John Cormack, a Scot, from Barts in London. He added a new and exciting dimension to the Pie Factory. Brian Hutton was recruited (also a Scotsman) a few years later.

An excellent tradition stated in 1969/70 – going overseas to prestigious universities and hospitals for further training. There was no formal training program, like today. However, we all trained in internal medicine – under Ding Chalmers: 8:00 am cases, Saturday am cases and Thursday am ECG’s, tests, a lecture, etc. None of our registrars failed the RACP exams.

Tony Walker was the first to go overseas, to Johns Hopkins University. He ended up staying in the US for many years, working in Milwaukee. Fred Lomas followed after 1½ years, also to Johns Hopkins University. In 1972, I went to the University of Chicago’s Argonne Cancer Research Hospital under Paul V. Harper, a practising surgeon and director of the research cyclotron in the basement. A remarkable man who pioneered the use of technetium for liver scans, etc. with his team of chemists under Katherine Lathrop; both of whom are now sadly deceased. The clinical department was directed by Paul B Hoffer (editor of the year book in Nuclear Medicine for many years). Alex Gottschalk was Chairman of Radiology and Carlos Beckerman was a trainee resident at the time. Bob Beck was the head of physics. It was a powerful team to work with. Harper was full of ideas; we 13 performed the first NH3 myocardial perfusion studies at the time with a modified NC gamma camera (tungsten collimator) and a motorised cart, which transported it to cardiology to do the stress and rest 13 studies. My contribution to this was to prove, in mice, that NH3 was metabolically incorporated into 13 the myocardium to become N-glutamate. We proved this by giving mice a glutamine synthesase 13 inhibitor compared against controls without inhibitor. There was no NH3 in the myocardium of glutamine synthesise inhibited mice. This data was included into the large paper published in 13 Radiology in 1973 - Clinical Myocardial Imaging using NH3. I spent a year in Chicago. George Bautovich also came to Chicago very soon after me. He stayed two years. The only problem with Chicago was the long, very cold winters of snow and ice.

Peter Valk, after 1½ years, went to the University of California, Berekley campus, and worked with Tom Budinger, Hal Anger et al at the Donner Laboratory (Jim McRae’s old haunt); and the site where Hal Anger developed the gamma camera. Many registrars followed overseas – Ern Crocker, University of Pennsylvania (David Kuhl); Mick Yeates, Upstate University, New York (John McAfee); Roger Uren Harvard (Jim Adelstein); Bob Howman – Giles Hospital for Sick Children Toronto (David Gilday); Monica Rossleigh, Memorial-Sloan Kettering NYC (Steve Larson); Barry Flynn, Harvard’s Joint Programme in NM (Bill Kaplan); Patrick Butler and Richard Quinn, Columbia - Presbyterian NYC (Phil Alderson); Kevin Allman University of Michigan (David Kuhl); Kien-Sen Lee also University of Michigan; Andrew Southee and later Paul Roach Harvard’s Joint Programme in NM; Sharyn Pussell, Royal Marsden, London.

Sadly, very few trainees in Nuclear Medicine, these days, do overseas training. This is much to their detriment and the speciality. Jim McRae, unfortunately, left us and returned to the USA to take up Director of NM at Oakland Children’s Hospital; he still lives in California – he was a great loss.

After much pressure on the Administrator of RPAH, an extension was built at the back of the Pie Factory, which linked into the tunnel system to Page, KGV and the main hospital. The patients originally came to the department in wheel chairs and trolleys, across Missenden Road, via the Page tunnel and then into the open street behind Page, rain, hail or shine!

The new extension we planned carefully. I insisted on three patient examination rooms, a largish reporting room and several offices, a much needed conference room/library and an office for clerical staff, a reception desk/switchboard and separate tea room. The space available was not large enough

159

for all this. Having just extended my house at Hurstville with an upstairs addition, I suggested the same for the Pie Factory. The conference room, JM’s office, tea room and toilets were upstairs. When completed, it was relative ‘luxury’ with two staff specialist offices for George and me, a registrar office for several registrars and ample trolley parking and waiting room with a TV. This survived for many years including computerization of the department with DEC computers led by the physicist's head, John Cormack, Brian Hutton, Dale Bailey et al. Many registrars and rotating residents worked there.

However, there was still a major problem. The hospital was elsewhere in Camperdown - over the road. Somehow, we had to move over there. That’s another story.

Only a few early papers emanated from the Pie Factory. It was very hard to do any research, clinical or basic. However, with the ‘luxurious’ experience of the extension, things began to change. George Bautovich, after he finally finished his PhD with John Turtle, was involved in research (he was like a pig in mud, so to speak, in Chicago with Harper). Multiple research projects were started in conjunction with AAEC (Ric Hunt) Cardiology (David Kelly) and other departments, notably Haematology (Doug Joshua).

Research took on a new direction when Reg Hutcherson became a registrar in 1974. He was surgically trained and we were across the road from the animal house and big Bill, who ran it. He would get us greyhounds; anytime and any number. Reg’s surgical skills were utilized frequently. In those days, animal ethics committees were unheard of, so we could almost do anything. We purchased a portable midget Boyles anaesthetic machine, surgical instruments, endotracheal tubes, drugs etc. for canine surgical procedures. This added a new dimension to research; Reg’s surgery with me doing most gassing - biliary surgery (Ric Hunt) and new biliary agents, coronary artery ligations and myocardial agents (also Ric Hunt). Some of our canines became quite ill, but we gently euthanized the sick ones. Many papers and abstracts, in particular for meetings, were produced. This trend (many abstracts for scientific meetings) persisted until I left in 1993. RPA always had the most papers at ANZSNM scientific meetings and a few papers each year at overseas meetings, including the SNM. With the expansion of the physics department and computerization, the department became a centre of excellence and a lot of local and overseas students wanted to work there.

Continuing education was important, long before the current demands. That’s why a conference room was so important. I organised the weekly seminars and interesting case presentations involving physicians, registrars, physicists and technologists. A programme was planned months in advance and people knew when they were presenting a subject they had to research. Visiting speakers were also common from other departments. Attendees at overseas meetings were compulsorily expected to present a summary of the meeting – SNM, ANZSNM, IAEA meetings, World Federation and later EANM meetings. RPAH Nuclear Medicine was the leading department in the country and was widely known and respected internationally. This was aided by the overseas training programme and sites visited meeting our ‘ambassadors‘.

This was particularly so with Harvard, thanks to Roger Uren’s contacts and lasting impression on Tony Parker, Jim Adelstein, Len Holman, Jerry Koloday, Henry Royal and, last but not least, Bill Kaplan. In 1981/82 Roger was asked back to Harvard for 6 months. He organised an exchange with Bill Kaplan and Henry Royal, both for three months each. I just happened to have a small Honda Civic car spare (can’t remember why) and lent it to both of them. They were very grateful and saw a lot of the usual tourist sites in and out of town on weekends. Having them in the department added a further dimension of resident overseas professors. Bill gave the Kaplan lectures for the Post Graduate Committee in Medicine, University of Sydney and introduced us to pelvic lympho-scintigraphy in males with testicular tumours, for radiation planning. The injections were made using long needles deep into each ischo-rectal space. Henry Royal led a research project on radionuclide plethesmography, with Igor Singer, for the diagnosis of DVT’s. It was great having such distinguished visitors from ‘Man’s Best Medical School‘. Henry was recently President of the SNM. That was a great six months and led to strong bonds with Bill and Henry.

160

If the extended Pie Factor was a relative ‘three stars’, the move across Missenden Road in late 1990, to the new department, was ‘six stars’. Finally, Nuclear Medicine joined the main hospital. We had not one, but two floors of the old A Block; the first for offices/library, a lusciously large, dividable conference room, fondly named the McRae Room by JM (appropriately, I thought). The second floor was all the clinical area, cameras, computing, reporting. It was fantastic. Just being on site in the main hospital was exciting. Clinicians used to drop in and see their patient studies – a rarity in the Pie Factory. Scot-Skirving Theatre was right next door for Grand Rounds on Fridays. It was hard to be late but Magee often achieved it!

Well before the move, JM was heavily lobbying his contacts in the Federal Government (two brothers were MHR’s) for a cyclotron and PET scanner, which were both overdue in Australia. This continued successfully after the move. The National Medical Cyclotron facility was located on campus in the 1990s, as was the PET suite. This added the essential last missing link to RPAH Nuclear Medicine.

It’s a great pity it has turned out to be less than ideal with its current structure. This must change urgently!

I spent 25 years at RPAH, the best part of my working life, and enjoyed nearly every minute of it.

Private practice pales by comparison.

Further pie-factory memories.

Despite the Pie Factory’s geographic isolation from the main hospital, clinical interactions were the cornerstone of the department and strengthened the clinical basis of nuclear medicine, which is being diluted today. Specific recollections include: 1. Stan Goulston’s Wednesday afternoon x-ray sessions with Brian Freaker and subsequent A1-ward round are my first recollection of this.

2. Professor Blackburn’s twice weekly ward rounds in BP1 – McLaughlin/Morris. This led to my attachment as a clinician on the Blackburn unit and later, after his retirement, to Harding-Burns/John Hassell’s Unit.

3. Neurology meetings on Thursday afternoons in Scot-Skirving Lecture Theatre – Crocker.

4. Grand rounds Fridays – all staff (or most).

5. In 1978, Ludwig Institute for Cancer Research was established by Professor Martin Tattersall. This became a very strong clinical connection in conjunction with Haematology – Harry Kronenberg, Doug Joshua and John Gibson. Kanamatsu also moved from Sydney Hospital to RPA – Paul Vincent, Graham Young and Harry Iland. Oncology grand rounds were at 8:00 am on Tuesdays – McLaughlin.

The haematology connection led to the strong gallium/lymphoma staging / restarting, prediction of outcome studies that put gallium in lymphoma management on the map. This was taken up worldwide until FDG-PET took over.

6. Strong ties were established with cardiology, when David Kelly was appointed professor. He trained at Johns Hopkins. Thallium scans were pioneered there and were established at RPAH about 78/79, the first in Australia. Ian Bailey also trained at Johns Hopkins with Bill Strauss. Cardiology became a strong ally of NM with Phil Harris and others – Bautovich/Uren & numerous cardiology registrars.

7. Cardiology meetings were Thursdays at lunchtime – attended by most.

161

8. The acquisition of a mobile gamma camera led to cardiac studies in CCU – ‘hot spot’ pyrophosphate for acute MI’s, gated blood pools for EF and wall motion etc. Exercise thallium was performed in the cardiology exercise room for many years until we moved over to A7.

9. A second mobile camera was acquired and this was used in ICU for V/Q studies. The liver transplant unit was established and post-op HIDA studies were performed using the mobile camera also in ICU. A strong interface was established with Mick Stephen and Ross Scheil of the liver transplant team.

10. Numerous research projects were established with multiple clinical departments: cardiology – many; haematology – gallium/lymphoma; melanoma unit – regional perfusion; surgery – skin blood flaw/amputees; respiratory – ventilation – lung mechanics; neurology – complex partial seizures/cerebral perfusion; urology – varicoceles/blood pools, infertility; and neurosurgery – CSF leaks – quantification of CSF shunt function, to name but a few.

Pie-factory anecdotes: 1. At an RMO’s Mess Dinner, one of the Pie Factory’s future registrars, and later a Staff specialist, was involved in an incident with another RMO in the courtyard of the RMO’s quarters. It ended with a full jug of beer being poured over the other RMO who had earlier thrown beer in his face for talking to the same female physio he was.

2. One nameless registrar, from the first day of arrival, was nick-named ‘The disappearing registrar’.

He had an extraordinary ability to be talking to you one minute and disappearing, very fast, the next, for long absences. He would appear late at Grand Rounds, stand at the door and leave first. He would rarely be seated.

3. Another registrar could always be found, very early in the mornings, catching a wave at Bondi beach.

4. Another registrar would leave early on Fridays (and miss Grand Rounds, which were held at the inconvenient time of 5:00 pm in those days until it was changed to 1:00 pm on Fridays, years later after the retirement of CRB2) and ride his motor bike to Canberra, where he really lived.

5. ‘The Three Registrars’, at lunchtimes in the tea room, would try and ace each other with trivia questions and the like, and entertained everyone.

Visitors were a prominent, almost weekly, event at the Pie Factory, especially in the seventies. They came from Sydney, interstate and overseas. They would come for a day, a few days, a week or some longer. I remember a Jamaican radiologist who stayed for a while. He was a cricket tragic and attended every test match at the Kingston Cricket Ground, Sabina Park. He used to delight in telling me he also was commonly sunburnt. I didn’t believe him. They came from far and wide – Bangladesh, just after independence. Pramanek was one I remember; he complained about the Resident’s Quarter’s food (as we all did). He had constant indigestion. “Your food is so bland here”, was his lament.

Fred Lomas shared the following recollections on nuclear medicine training.

While these are some personal recollections, they are probably fairly representative of the experiences of others aiming to capture the spirit of the times.

162

After eighteen months in nuclear medicine at RPA in Sydney, I had my MRACP and Dr John Morris organized my further training with Henry N. Wagner Jr at JHH. This was funded by the postgraduate committee in medicine at the University of Sydney, and I arrived in June 1970. I followed Dr Michael Quinlan from Perth and after me came Dr Josephine Wiseman from Sydney.

The term started with a six-week course in radiation physics by Drs Tom Mitchell and Ed Buddinger, aimed at the theoretical component of the newly-established American Board in Nuclear Medicine.

These were full of homespun wisdom and far from dry.

All trainees and fellows were thrown in at the deep-end: rostered to run the department, give clinical advice, write provisional reports and match wits with the hospital clinical teams who pressed us for results on their evening rounds. This forced us to get off the fence and make decisions, with the moment of truth coming the next morning when we presented the cases to the entire nuclear medicine unit and a consensus report was formulated. If our opinion was wrong, we pleaded mea culpa with the referring doctors. This was a great stimulus to learning.

The Australians were more fortunate than many trainees in having quite sound experience behind us and enjoying English as our first language!

The morning conferences were not to be missed. In the audience of fifty or so was the most eclectic array of talent from almost every medical discipline. The entry path into nuclear medicine was far from clear and many specialists were attracted to this new field. There always seemed to be someone on hand to answer the most abstruse questions. It was an extraordinarily-stimulating environment for learning and research. Many working relationships began at these meetings. Frank Deland, Malcolm Cooper, Richard Holmes, H. William Strauss, Buck Rhodes were some of the luminaries.

At each morning meeting, Henry would come up with at least three great ideas for projects and papers. He taught us healthy scepticism with a notice in bold letters above the viewing boxes: “Help stomp out myths”. In the era before ‘evidence-based medicine’ he was ahead of his time. In those days, I doubt that he actually believed the results of any work not done at JHH. Many fellows were self-funded, but to run the department required grant money; and lots of it. We had a round of NIH grants during my stay and everyone had at least one project. Henry submitted over sixty grant proposals that round; and we did each our presentations. Unfortunately, our proposal on gallium-67 for breast cancer was a dud on our preliminary results. But, without missing a beat, Henry brought them up to date on our data in this ‘fast moving field’ and calmly modified the proposal to melanoma detection. I was impressed; he probably got the money too.

As individuals, we were chronically short of funds for living. My Australian grant was set at the poverty line for Baltimore, which meant wives worked, if possible, and even selling blood for transfusion or research was not to be sneezed at! Many of us spent time in the hospital medical outpatient clinics, which offered further insights into the American health-care system.

The trainees, both American and foreign were a mutually supporting group, giving help and advice to new arrivals and collaborating on projects.

JHH had a gamma camera, out at the Jessup State prison, for establishing normal ranges for scans and other research projects. (The technology was new and I am not sure we had a gamma camera at RPAH at the time). Jail was another side of America one would not normally see. The concept of ‘informed consent’ was only slowly evolving and few questioned the ethics of experiments on prisoners. While our work was comparatively harmless, it rapidly became clear that prisoners (and staff) were so bored that they would volunteer for anything to break the monotony.

163

The hospital itself (JHH) was located in the downtown ghetto, some of which had been burned-out in recent ‘race riots’. Arson was still a popular pastime and we were casual, but interested, observers of three riots in two years. A priority then was to obtain a hospital parking permit. This was particularly important for on-call work at night, but the area was pretty scary even in daylight. With a murder rate of one per day, stopping for red lights at night was something of a luxury. One learned not to take risks and this was one of the most difficult adjustments because, safety, in those days, was not a real consideration in Australia.

Peter Hurley from New Zealand became the senior fellow overseeing the department. He was very approachable and had a solution to every problem; whether a difficult case, an impasse in a project or touring information. He formed a brilliant working relationship with H. William Straus. Bill would come out with a plethora of ideas, Peter would apply the common-sense test and, between them, they produced some great papers, including probably the first gated heart study on a gamma camera.

Peter resolved to visit the capitol of every state capital in the USA during his stay and, being an inveterate traveller, he succeeded.

He returned to New Zealand, but died later of a brain tumour, before he could reach his full potential.

He was a great personality, clinician and researcher.

Wendy North was Henry’s personal assistant (or ‘girl-Friday’) for many years. She was a radiographer from Melbourne who also organized the paperwork for grants and publications. Always a fairly-private person, she left and we all lost touch with her about 1973.

Gallium-67 became available for research and, having a ready supply of patients, I managed spend a productive year and get some good publications on its use in tumours and infections. This was before the big explosion in diagnostic imaging, which came in the mid 1970s with CT, ultrasound and computerised nuclear medicine. Everything was analogue; digital was just a word. I had spent my clinical years from 1966 with only limited imaging techniques for diagnosis (these were still the days of the diagnostic laparotomy) and we felt we were doing ground-breaking work.

Before the American Board in Nuclear Medicine was established, the department had developed its own graduation ceremony. It was a very funny show and culminated in the presentation of the diploma of ‘Dabbler in Nuclear Medicine’. The citation is probably worth recording.

Unlike many of the other international fellows at JHH, I think all the Australians eventually returned home and made their various contributions here. The opportunities and stimulation were major temptations to stay. We had a saying that, “After two years in America, it was difficult to return home; after three years, well nigh impossible”. Our American colleagues could never understand why we wanted to leave.

Being fundamentally a clinician, the challenge of starting up a green-fields nuclear medicine site appealed and, after two years, I accepted the newly-created job in Canberra.

As a medical student at St. George Hospital, Professor Jim McRae and Dr John Morris were strong influences on my career. I obtained a vacation scholarship to do a small project on hippuran renograms in hypertension in late 1965. The RPAH department had not yet been established, so patient studies were done in the adjacent Sydney University Medical school. Dr. Peter Ronai was also there doing a PhD. Another Adelaide Doctor, Millicent Marion, was also there.

I remember the first scanner I ever saw; a coincidence detector, which gave a very crude brain scan using some filthy tracer – very much by guess and by God.

164

When I joined the RPAH Department in 1969, the transition to technetium seemed a giant leap, although fluorine-18 was still the only available bone-scan agent. The Picker rectilinear scanner did life-size colour-dot printouts with recognisable anatomy.

It is difficult to understand now how limited the choice of imaging was in those days. There was no CT or ultrasound and the gold standards were angiography and exploratory laparotomy. Scanning was so primitive that Professor Blackburn cautioned me when I went into nuclear medicine: “Maintain your clinical skills and don’t risk your career on any single technology” – wise words which I took to heart.

We make our best contributions when we have close clinical involvement.

Dr. John Morris headed the department and ensured we did not lose our clinical orientation.

(Professor McRae went to California and initially worked for some time with Hal Anger at Berkley. He remained in the USA.). John spent much energy ensuring that physicians and not radiologists would shape the course of nuclear medicine in Australia.

My contemporaries included Dr Andrew McLaughlin. Dr Ross Jeremy, a rheumatologist, was doing a project with fluorine-18 bone scans. Drs George Bautovitch and Peter Falk were doing PhD work.

At RPAH, the radioiodine therapy doses were initially administered by radiotherapists who started what was to become one of my major clinical interests.

Jim McCrae recalled the following memories of early developments in the evolution of nuclear medicine at Donner Laboratory.

In 1971, I was appointed a research fellow at Donner Laboratory, with the responsibility of conducting the imaging studies using Hal Anger’s instruments and new isotopes and compounds prepared by Yukio Yano and myself. Examples of these radioisotopes included Kr81m and Rb81 generators and Tc99m diphosphonate. I was particularly interested in determining the optimal amount of stannous chloride to formulate this bone scan agent. Rats were injected immediately after preparation, but there may well have been reasons to explore the effects of different amounts of tin and the stability of the bone scan agent over time. I never found prepared bone scan agent obtained from radiopharmacies to give the same quality of scan obtained using freshly prepared kits.

In 1975, when Joe Kriss was on sabbatical leave, I substituted for him at the Stanford nuclear medicine department two days a week for six months, supervising the nuclear medicine trainees.

There I saw the first technetium glove resulting from the injection of the bone scan agent into the radial artery.

In 1976, the funding at Donner was redirected and clinical type programs reduced. I joined a private group in San Francisco with its own radiopharmacy (Radpharm) which supplied other hospitals. In 1978, I applied to the Children’s Hospital in Oakland to commence a nuclear medicine service inhouse. Prior to this time, a few studies had been done at nearby hospitals. From October 1978 until April 1989, I was the only person in the department. I picked the children up from the ward, prepared, calibrated and injected all tracer doses, conducted every study and typed the reports. Imaging was all done on a portable camera; and numerous studies were performed in the intensive-care nursery and ward.

By studying the critically ill children and infants this way, nursing assistance was available. In the department, the mother frequently provided helpful oversight. For infants, a plywood extension was attached to the camera head which faced upwards. Excellent prone and supine images could be obtained.

165

For several years, I also was the quality assurance director and learnt much about tracking and addressing problems in clinical care. I provided emergency scans at night and weekends, with calls about every two weeks. With only a few odd holidays, it was time to retire in 1989 and have an extended holiday in Scotland.

Paul Richards’ reflections include the following.

I had trained as a therapy radiographer with Peter MacCallum Clinic, in 1963, and later in physics and nuclear medicine with RMIT. Following my ‘national service’, I was awarded a Rotary Foundation Scholarship to study for my master’s degree in radiological sciences at Johns Hopkins University.

Arriving in the midst of the summer in 1973, I attended the nuclear medicine summer school run by Wagner’s team of Drs Buck Rhodes, Ed Buddemyer and William (Bill) Mitchell. Over 20 home-grown and international physicians attended that school, of which several have remain in contact with me to this day Shigio Omorie from Japan, another from Sweden and Jim Quinlan from Maryland, USA. Following the summer school, I was joined by a fellow Australian, Dr Fred Lovegrove from Perth, Western Australia. In later years, when travelling to European conferences, I had the pleasure of visiting them in their home countries.

Life at Hopkins was a busy one for me and I spent most of my time researching the properties of stannous gluconate, prepared chemically with stannous chloride and electrolytically with tin electrodes. The failure of either preparation to localise in human gall-bladders, but consistently in several animal species: dog, cat and rabbit, led to my 1974 thesis on the species-dependency of radiopharmaceuticals. Bill Strauss took a keen interest in my preparation and used it on two occasions in patients suffering from myocardial infarcts. I later heard that there was a slight blush of concentration and it was also reported, at the time, that the preparation localised in a brain tumour.

99m

I had the opportunity to trial my Tc stannous gluconate preparations at the Jessup State prison outside of Johns Hopkins and, as Fred Lomas has already mentioned, the concept of ‘informed consent’ was only slowly evolving and few questioned the ethics of experiments on prisoners.

However, most of my work was confined to the laboratory and the animal house, which was lookedafter by Jim, a most gentle soul, who was a great asset to me during my research at Hopkins.

I am sure that most of the Hopkins alumni experienced racial tensions. My experience was close by the Hopkins school of hygiene, similar to that told by Tony Walker of Peter Hurley’s experience. I had a similar experience to Peter Hurley in Baltimore as well, in 1973. Rudi Chamile, a Melbourne-based physician who worked with John Andrews (RMH), was visiting me at Hopkins. It was about 5:30 pm and we had left the hospital and were walking to my car as Rudi was staying with us. He suggested getting a bottle of wine for that night’s meal and, as there was a bar close by, we decided to have a quick drink and purchase the wine. Rudi had no idea of the tensions that still existed in Baltimore as we were there at the time they were bussing black children out beyond the beltway to the county, and white children into the inner-city schools, as this was their great integration plan. It had limited success and things turned back to normal. The city of Baltimore, at that time, had a 60% black population with the majority of Caucasians living either just inside or outside the Baltimore beltway. To cut a long story short, we stood in this black bar – not a white man in sight – for five minutes before realising that we were not going to be served and that, if we did not leave, there may be consequences. We left with Rudi dumbfounded, as this had been the first time he had experienced such intense racial tension. We did buy the wine elsewhere and Rudi enjoyed the rest of his three-day stopover on what was a grand tour of NM. The lab and animal house technician was called Jim; an American Negro who lived in downtown Baltimore. He was well known to most of the early visiting Australians. He was a great help to me in the lab in handling the dogs and cats, which I worked on for my thesis: ‘Species dependency of

166

radiopharmaceuticals’. Jim and I were fairly close. He had a strong grip on the dogs when I was anaesthetising them with pentothal and, as you know, a misdirected or tissued dose would send them insane! I respected Jim for this. He invited me into his family home for one of his extended family gatherings and Sue and Adam (my wife and son) had the greatest of times; and there was not a white face in sight.

On another occasion, I was visiting ‘The Block’ (similar to Sydney’s Kings Cross area) with my next door neighbour. He had insisted that Johnny Pollack’s polish sausages at the block were the best in the world and I was not to return to Australia without trying them. During our visit, we were lured into a topless bar for a drink and, after leaving the premises, three gun-shots rang out behind us. I read in the paper the next day that there had been a fatal shooting at ‘The Block’. Johnny Pollack’s sausage was great, but I preferred the Chesapeake Bay crabs much better.

The laboratory was a thriving community of research. Collaboration was of the highest standard and the facilities available were second to none. My supervisors were Dr Fazell Hosain (recognised for his development of 99mTc pyrophosphate; the first superior technetium labelled phosphate as a bone imaging agent) and Dr Buck Rhodes, who had been instrumental in the development of 3M microspheres for lung imaging. I thoroughly enjoyed my time at Hopkins and the surgical interventions, cannulating canine gall-bladders provided by Fred Lovegrove during my research.

However, as Fred Lomas has pointed out, scholarship money always leaves you on the poverty-line and, with a young family, I did resort to selling my blood infrequently, when not eking out a few more US dollars from my sponsor, Rotary International. Perhaps having the vice-chancellor of Johns Hopkins University, Mr Ross Jones, as my Rotary International counsellor was our path to surviving what was, perhaps, one of my most rewarding nuclear medicine experiences.

Roger Uren also reflects on the 1970s.

I believe that it was at that meeting, in 1974, that JM talked to Jim Conway from Chicago about a good place for me to do a fellowship year in the USA. Andrew McLaughlin and George Bautovich had gone to Chicago and Ernie Crocker to Philadelphia with David Kuhl. Jim Adelstein’s unit in Boston was recommended and I went there in January 1976. On the way, I dropped in on Ernie Crocker and his wife in Philadelphia, where he showed me the Liberty Bell and introduced me to bagels and loks.

I was the recipient of a NSW State Cancer Council fellowship in cancer. The joint program in nuclear medicine under Jim Adelstein’s direction consisted of the Peter Bent Brigham Hospital (now merged with the Women’s Lying-in Hospital to be: The Brigham and Women’s Hospital), The Beth Israel Hospital, The Boston Children’s Hospital and The Farber Research Laboratories where the radiopharmacy was located, as well as the animal labs.

I was at the Peter Bent Brigham Hospital under B. Leonard Holman. Junior staff at the time were Barbara McNeil and Bill Kaplan; and one of the residents was Tony Parker. David Drum and Ted Treves were also on staff; Ted over at the Children’s Hospital. David Drum, an ex-naval officer, had a droll sense of humour and I remember him suggesting that the best use of the radioactive waste from the power reactors in the USA would be to make ceramic tiles from the waste and pave the streets of Boston and New York. The heat generated from the tiles would constantly melt the ice and prevent thousands of hip and leg fractures each year, caused by slipping on the ice during winter.

I remember the first time I met Jim Adelstein. He complimented an abstract I had presented, at the ANZSNM meeting, on the use of Bayes’ theorem to analyse the results of liver scans to diagnose cirrhosis. This was suggested to me by John Cormack, one of the physicists at RPAH nuclear medicine at the time. Barbara McNeil was just getting interested in this approach and went on to make an entire career out of this way of evaluating new technology. She is now a presidential advisor

167

on medical technologies. I worked with Len and Tony Parker on gated heart pool scanning using a 30 degree slant-hole collimator. We would collect three views in each patient on magnetic tape in list mode. I had software to reformat this data into 16 frames for each view. The reformatting of each view took three hours of computing time.

I lived next to the hospital, in an apartment on Tremont Street, on the edge of ‘the combat zone’, as it was known in 1976. (That was the year of the riots at the English High School right next to Harvard Medical School behind the PBBH). I would start the first view reformatting at 5:00 pm, then go home and have an ‘old-fashioned’ or two, then return to start the next view, then return home to watch a Star Trek episode or two and, finally, at 11:00 pm, go back to the hospital to start the last view reformatting. The next morning, I would thus have all three views complete. I did over 100 patients this way. These were among the first GHPSs. Len Holman went on to be chief of radiology at the Brigham and Women’s Hospital.

The first weekend I was in Boston, Bill Kaplan invited me to join a staff party he was having at his home; and we became firm friends from that day. Bill was the first man to show me the value of a man-to-man hug; and in the end he was my best friend. Bill became director of nuclear medicine at the Dana Farber Medical Center that became part of the joint program; he was much loved by his patients. He was always voted the best oncology nuclear medicine physician in the USA by his peers.

He first taught me lymphoscintigraphy, using 99mTc antimony sulphide colloid (a technique he had picked up from Gunes Ege, in Toronto, who used it in breast cancer), which recently has become my main research interest.

After my fellowship in Boston, in 1976, I moved on to Paris. In 1975, at JM’s suggestion, I applied for a French Government Stage (or scholarship) to go the L’Hopital Frederick Joliot in Orsay, outside Paris. This was successful. By the time I had finished my year in Boston, however, I felt that if I was going to France to Paris, I should be in Paris and not 60 km outside the city. I consulted Peter Valk, who had been in France, and he suggested the American Hospital of Paris and one or two other city hospitals. I wrote to them all and they all replied positively, also offering extra funds. I chose the American Hospital in Neuilly sur Seine that was under the directorship of Roger Perez. I worked there with Claude Planchon and Jean-Pierre Massin, the other physicians, and spoke French the whole time, except with Roger Perez who was fluent in English.

There was no ultrasound at all at the hospital in 1977, so that is what I did. We purchased a machine from Scotland and I set it up and taught one of the radiologists how to perform US. I lived in the resident’s quarters, with a bunch of residents who were English-speakers, and manned the casualty and intensive care units. We had a visit during the year from Professor Blackburn and I remember him commenting on how busy the place was.

They were very-hard workers and Roger had rewarded himself with a lovely chateau in Neuilly that had many original Chagall paintings hanging on the wall, as well as maids and his own chef. Roger and I became good friends and he followed me as the visiting professor at the Beth Israel in 1982-‘83.

When my future wife, Maureen, visited me in Paris, in 1977, and Roger and his wife Claude invited us for dinner, I was very impressed when he announced to his children that they would all speak English that night since Maureen’s comprehension of French was not perfect; and they promptly did just that.

Sadly, the year Roger retired, he and Claude were Xmas shopping in Neuilly when they were struck by a motorcyclist. Roger was killed instantly and Claude was severely injured.

I returned to RPAH, in late 1977, and was a staff specialist there in nuclear medicine with George Bautovich (who had returned from Chicago in late 1975) and Andrew McLaughlin until 1984. Soon after I returned, Ernie Crocker left to head the new department of nuclear medicine and ultrasound at Westmead. When I returned, I brought with me software to collect and reformat GHPSs. These studies revolutionised the practice of nuclear medicine at a time when we were starting to lose patients to the new technologies of CT scans and Ultrasound. These latter tests were replacing the

168

anatomical imaging we did in livers and brains looking for tumours; and the advent of GHPSs and thalium myocardial perfusion imaging moved nuclear medicine closer to its functional imaging roots.

We did a lot of collaborative research with David Kelly and his cardiology team. Every patient who was admitted to coronary care had a GHPS, which we would animate on a monitor next to the patients bed, so that, on ward rounds, the cardiologist could see the patients’ heart beating as he examined them. I think that was a world-first that they no longer do. With the introduction of GHPS, nuclear medicine introduced the use of computers in clinical medicine and LVEF became a standard measurement post myocardial infarction. This also gave nuclear medicine new respectability in the eyes of our clinical colleagues, brushing aside the ‘unclear’ medicine jibe. Those cines of beating hearts were very compelling viewing at grand rounds and other clinical meetings. We also featured at the college of physician meetings, and at the cardiac society meetings, where I personally presented several plenary session talks on GHPS and thallium myocardial perfusion imaging.

I was invited back to Harvard as a visiting professor in 1981-‘82 and worked at the Beth Israel Hospital with Tony Parker again, who was on the staff there as well as Henry Royal and Jerry Kolodny. Dove Front, from Haifa in Israel, was a regular visitor. (Dove died of a massive heart attack about five years ago.)

At this time, I was asked to take charge of a new SPECT scanner that had been donated to the BI and, with Len Holman and Tom Hill from the New England Deaconess Hospital, we did the first studies on regional cerebral blood flow in a living human, using I123-iodoamphetamine. Unfortunately, about six years ago, Len was shovelling snow and developed a sharp pain in his back, which was caused by a pathological fracture in his vertebra. Bone scan showed multiple mets from a silent oesophageal Ca and he died soon after, aged 56 years.

I also worked with Bill Kaplan on several projects, but my biggest achievement was convincing Bill to take his family to Australia for three months to do my job at RPAH, in 1981. This he did; and he and Susan, with their children Doug and Anne, had an unforgettable experience that he often talked about on my subsequent visits to Boston. While here, he presented: ‘The Kaplan Lectures’ at RPAH. We caught up regularly as I visited the US at least annually, since my wife, who I met at the Peter Bent Brigham Hospital, is American with relatives remaining in the USA. It was tragic that Bill died, aged 56, of probable bowel cancer that had seeded through his peritoneum. He presented with a bloated abdomen. Henry Royal also came out and did three months in my job at RPAH. He went on to work at the Mallinkrodt Institute in St Louis, where he is now the chief of nuclear medicine and was recently president of the US Society of Nuclear Medicine.

In the early-eighties, we got Jim Adelstein down as the visiting professor to the ANZSNM meeting, I think in 1981, in Christchurch; and, since his son has married an Australian girl specialising in aquaculture in Tasmania, Jim and Mary now spend about half the year here in Australia and have a permanent apartment in Hobart.

In 1984, I resigned from RPAH and started my own nuclear medicine practice with Rob HowmanGiles at the Missenden Medical Centre in Camperdown. It was there, around 1986, that I started 99m doing lymphatic mapping using lymphoscintigraphy for the Sydney Melanoma Unit. We used Tc antimony sulphide colloid in melanoma patients who had a lesion located at a site where the drainage might be ‘ambiguous’ (e.g., near the midline of the trunk or around the level of the umbilicus). Over a five-year period, we did a total of about 200 patients in this way, and the information was used to guide the melanoma surgeons to which node field they needed to dissect.

In 1991, John Thompson (at the time, deputy-director of the melanoma unit) rang to ask me if I could locate not just the node field, but the actual lymph node that received the drainage from the melanoma site. This question was prompted by research done by Don Morton, chief of surgery at the John Wayne Cancer Center in Santa Monica, who described locating the ‘sentinel node’ using blue

169

dye injections at the melanoma skin site. He found that if this node could be removed and carefully examined histologically, it accurately staged that node field. We had been seeing this node on our lymphoscintigraphy studies, but it was standard teaching in cancer surgery that you should not ‘nodepick’; and either remove all the nodes or none. John’s question prompted us to perform the first study that showed lymphoscintigraphy could locate the sentinel lymph node and, with the addition of a gamma detecting probe, greatly simplified the retrieval of the sentinel node at surgery. This approach has now been adopted as the preferred method for SLN biopsy. At this point (in January 2008), we have completed lymphatic mapping of the sentinel nodes in over 7,000 patients with melanoma and, in the process, described several new lymphatic drainage pathways that drain the skin in humans.

I found my time in Boston and Paris to be a highlight of my postgraduate career and, as mentioned, a time when I made friends that I still value today. Last August, I revisited Boston and spent time with Annick Van Den Abbeele, who is now chief of radiology at the Dana Farber Cancer Center (Bill Kaplan’s old home), and she lamented the fact that they were no longer seeing a steady stream of nuclear medicine trainees flowing through from Australia. I will once more be visiting Paris this year and would not think of passing through without once again visiting my friends at The American Hospital, especially Dr Claude Planchon, who has fought and won his own battle with lymphoma and now runs a support program in France for patients who have survived cancer.

I would encourage any trainee to make every effort to include a year at a major nuclear medicine department overseas at the end of their local training. You will be welcomed into the international community of nuclear medicine physicians and it will be a great year of learning and, perhaps most importantly, life experience.

For the 25th anniversary of the establishment of the department of nuclear medicine at the Royal Melbourne Hospital, chief nuclear medicine technologist, Ms Ruth McGennisken, prepared the following potted history.

(1966–1971) In April 1966, Dr J. T. Andrews was appointed the Radioisotope Specialist-In Charge of the Radioisotope (R/I) Unit at the Royal Melbourne Hospital; later to become Director of the Department of Nuclear Medicine. Other members of his staff were Ray Pope PhD (a physicist) and two R/I technicians: Mary Watson and Jenny Vincent. Radioisotopes had been used in this hospital since the late 1940's, by Dr Kaye Scott in association with Hal Oddie, then Ken Clarke and Jean Milne; and thereafter in association with the Endocrine Unit. The work performed was largely Thyroid function tests and Therapy. In vitro counting of samples for other Departments and Hospitals, using a well crystal and a valve type scaler, and occasional renograms were also done.

In November of that year, a 3" Rectilinear Scanner was purchased; and this saw the introduction of Brain (197/203Bg), Liver (198Au), Kidney (197/203Hg) and Thyroid (131) scans. Other studies offered by this time included 51Cr Blood Labelling, PLE, Protein Bound Iodine levels T4 and T3 Resin uptakes. Many renograms were now being performed using 131I Hippuran and a dual probe system.

Due to the lack of a suitable bone scanning agent, bone ‘scans’ were done using a Renal probe and 85Sr (ie. manual counting) at 5 cm intervals along the axial skeleton and the plotting on graph paper of isocount curves. These were done on a daily basis for five days.

During these early years, a physicist and technician joined the department from Malaysia on the then Colombo plan. Both remain in contact. Being the first totally integrated Department of Nuclear Medicine in Victoria, a scintigraphy service was offered to other hospitals; namely Repatriation General Hospital, St Vincent’s Hospital, Queen Victoria Hospital and Royal Children’s Hospital.

170

A second rectilinear scanner (5" crystal and colour printer) was installed in 1967; and a gamma camera ‘on trial’ was later purchased. The gamma counter was heavily utilised by the department and others, counting up to 700 samples per week. Nuclear Medicine was up and running!

The staff numbers increased with a Trainee Nuclear Medicine Physician (NMP) Dr. B. Arkles, to be followed later by Dr. R. Chmiel. A registered nurse and a medical typist were appointed, the typing of results prior to this being done by the R/I technician.

Dr Pope left to work in New York; and Mr Laurie Steven, the second of only four physicists appointed so far to the Department commenced. Mary Watson resigned and Ruth McGennisken was appointed Senior Technician. The technician numbers by this time being three qualified, one third-year trainee and four students (Associate Diploma of Applied Science in Medical Nucleography). Students were employees of the Peter McCallum Clinic and were seconded to other hospitals. Sodium and Potassium studies, along with placenta scintiscans, were now being offered.

Joy! A film processor was installed and the need to run to the second floor of the main building (Radiology) or to Fracture Clinic was eliminated. Brain and Liver scan numbers were increasing daily.

Bone scans on the rectilinear scanner commenced, moving from 85Sr to 87Sr/18F until Technetium in the form of Polyphosphate was available, later to be followed by Pyrophosphate and then MDP (1979). I131 MAA and 113mInFeOH were used for lung scans with 133Xe available for ventilation studies.

Technetium availability and new compounds obviously gave great impetus to Nuclear Medicine imaging, with the arrival of pertechnetate in 1968, via Australian Radiation Laboratory; thus the great surge in brain scans.

The Department gained, at this stage, three extra rooms across the corridor, when Electronic Engineering moved to greener pastures.

(1972–1976) More expansion – technicians, then nucleographers and then nuclear medicine technologists increased to seven; and the first graduate of the new RMIT course – Diploma of Applied Science (Medical Nucleography) – joined the staff. Accreditation (ANZSNM) for NMT's was gained in 1975.

Pancreas scintigraphy with dual isotope subtraction (75Se/198Au) on the scanner was developed by L. Steven. 99mTcDTPA, and Gluconate were introduced and 131I for thyroid scanning was largely replaced by technetium pertechnetate. A second gamma camera, with a whole body bed and imager (no more pulling Polaroids for dynamics), was donated by the Myer Foundation, replacing one scanner.

Dr. J. McKay (NMP) was appointed, P. A. Guignard replaced L. Steven and a Registrar position was acquired. Dr. M. Lichtenstein was appointed as a trainee NMP, and a nursing aide and a part-time clerical assistant completed the staff.

(1977–1981) The installation of a dedicated computer system (MDS) saw a change in cardiac studies and, along with the acquisition of a Cardiac Gate, exercise and rest cardiac gated blood pool studies were introduced. Cerebral studies were starting to be replaced by the new CT scanner; a Toshiba 402 gamma camera arrived, 198Au seed implants continued, and T3 + T4 resin uptakes transferred to Biochemistry.

GFR studies were well established by this time and thallium was being introduced for cardiac studies in addition to the OGBP scans, although it did not come into full time use for several years. Two more

171

rooms were acquired; a ‘cold’ and a ‘warm’ laboratory downstairs in the basement. There were several successive registrars appointed to the department over this period.

Dr Andrews and Miss Jean Milne saw the publication of their book: ‘Nuclear Medicine, Clinical and Technological Bases’, and Wayne Blanchett won the Mallinckrodt Award for NMTs. He was the first computer specialist NMT in Victoria.

(1982–1986) Dr Mack Jost joined the staff as a Trainee NMP and Nouria Salehi PhD was appointed Honorary Scientist, later to replace P. Guignard. Professor Shiquan Jia visited for one year through the Australia/China (Shandong Medical University) Project. The MDS Computer was replaced by a Simis 5 Informatek System. The Gamma IV camera and bed were replaced by a GE400 SPECT system and, eventually, the Gamma III by a GE300 mobile system.

In conjunction with the Research Centre for Cancer and Transplantation of the University of Melbourne (Professor I. F. C. McKenzie) immuno-scinitgraphy was developed initially in the study of colonic tumours and their metastases. Subsequently, a new technique of immunolymphoscintigraphy was developed for the detection of lymph node metastases from breast cancer.

White cell and platelet labelling were well underway and the department joined the clinical trial of Ceretec HMPAO across Australia. Aerosols, which had replaced the early 133Xe system, were extensively used and, at this stage, Technegas was being released.

(1987–1991) Dr Lichtenstien and Salehi, along with David Binns (NMT) converted the replaced Gamma Camera into a Bone Mineral Densitometer (using 153 Gadolinium), on line to the Informatek Computer. A Bone Mineral Density Service was established by the University Department of Medicine (Dr J. Wark) with the involvement of both Departments of Nuclear Medicine and Radiology and, in 1990, a Hologic X-ray Bone densitometer was commissioned.

During this time, there was a significant increase in cardiac stress testing, particularly 201Tl studies.

Technegas ventilation studies were well established by this time.

1989 saw the commencement of the Intern Programme for Nuclear Medicine Technologists, in association with the new Bachelor of Applied Science (Medical Radiations).

1991 saw an extra NMT added to the establishment, making eight in total, and the appointment of a Nuclear Medicine Trainee Specialist, Dr T. Cain.

The department, over the past 25 years, has seen many advances in Nuclear Medicine, a changing face of the profession, and has been instrumental in the training of Nuclear Medicine Physicians and Technologists. It has collaborated with various departments and institutions in research and the clinical applications of radiopharmaceuticals. Approximately 100 publications have emanated both from this department alone and in collaboration with others.

Nuclear Medicine Physicians and Nuclear Medicine Technologists have participated in their own professional development and the development of their professions. The department has seen office bearers in the ANZSNM, ANZSPNM, VSNMT, RACP and the ANZSNM Accreditation Board; and had representation on the Victorian Government Radiation Advisory Committee and the Medical Radiation Technologist Registration Board of Victoria.

The department gained ANZSNM accreditation for the training of NMTs in 1988 and for the training of Physicians in 1989, albeit that by this time the first Directors of Nuclear Medicine at the Austin, Repatriation General and St Vincent’s Hospitals had been members of this department.

172

Mrs Audrey Shoobridge (nee Jacobson) trained at the Launceston General Hospital under Doris Tucker and Sue Kennedy during 1950 to 1953, a period of transition in radiotherapy, radiology and radioisotope services. She reports the following.

In the early days of the X-ray and Radiography Departments – ‘X-ray’ as it was generally called – the unit was situated on the ground floor of the old General Hospital building. It was in the shape of a T with Radiotherapy forming the top of the T and facing onto Charles Street, while the diagnostic section was sited on either side of the stem. The diagnostic rooms were on the south side of the offices etc. to the north.

It was a very friendly and more-or-less one unit. Sister Tucker was in charge of X-ray and Sue Welch was technician in charge of Radiotherapy. Sister Tucker always attended the radium clinics as the out-patient clinic was called. These were held every Thursday afternoon at 4:00 pm for new and follow-up patients of X-ray therapy, radium and what have you.

Supervising the whole was Dr W. P. Holman, who came on an essential basis each morning for diagnostic work; screening on some afternoons and Radium Clinic on Thursdays.

Sue, Tuckie (as Sister Tucker was affectionately called) and I had trained as diagnostic technicians (there was no such category as `technologist' in those days). Sue was well installed in X-ray therapy when I came to the hospital, with Tuckie doing relieving work when Sue was on holidays. This was the only time that she worked in the Therapy Department.

At this point, my memory is vague, but I think I must have become familiar with the therapy machines (400 & 200 KV units) in case of emergency or to help Tuckie during Sue's absence on leave, etc.

So, while Sue was away in Melbourne, I was attending to the radiotherapy machine and Tuckie was supervising, which pleased her much more. I am sure she hated radiotherapy. To be truthful, I did not like it myself. My great fear was of not checking to see that the right filter was in place for the type of treatment required.

Although our attitude was of great cheerfulness, the end result for most of the patients was quite depressing. Shin cancers were fine; but oh, the joy of treating a peritendonitis cal calcarea (I believe that this treatment is out of fashion these days, but the results with a minimal dosage were dramatic).

One of many cases presenting with this syndrome was a local medical practitioner who was in great pain. After a course of 50, 75, and 100r delivered on either successive or alternate days, the calcification disappeared entirely and the pain subsided after the first dose. The treatment was always 100% effective.

When Sue returned from study she was delighted to have me as an assistant and there was no more talk of returning to diagnostic X-ray. At this time, I had become more interested in photography, at what now I see was a very primitive level. If anyone wanted photographs taken I would happily do them.

As the demand increased, it was proposed to start a separate clinical photography unit, if I was interested. I was! The X-ray morning tea room was converted to a dark room and the room opposite Casualty became the office studio - still within the location of the X-ray Department.

In 1950, when I was 21, I married Michael Shoobridge, the hospital Pathologist. He and Dr Holman were the source of most of the photographic work. Michael arranged and supervised monthly clinicopathology meetings attended by practitioners from as far away as Devonport.

173

I continued working until I was six months pregnant (an unheard of thing at the time) and left only for the birth of my first child. The photography position became vacant again when she was six months old and I returned gratefully to work as Michael was about to leave for London to continue his postgraduate studies with an unsupported leave-of-absence from the LGH. We were very poor and I had to support myself and the baby.

The pathology locum was Angus Stuart, a very charming and eccentric Scot.

Reading through my letter so far I see that I have not given any pen pictures of the people you are interested in.

First we have Dr Bill Holman, loving known as WHP â&#x20AC;&#x201C; tall and erect and a model of sartorial elegance â&#x20AC;&#x201C; he was the only man I know who wore spats. The attitude of all his staff was one of reverence to the great man, and there was a hush when his crisp steps came down the passage for his morning reporting sessions.

Dr Holman's reporting session were a feature of life at the LGH. The room was always crowded with visiting and hospital medicos who made a special point of attending whenever possible. In addition, resident medical staff and technicians added to the crowd when time permitted. Dr Holman was fascinated by his work and his enthusiasm was infectious.

I shall always remember standing behind him during a barium meal screening and hearing his delight at seeing reverse peristaltic waves in the patient's stomach, with the inevitable drastic results to Dr Holman's head.

Sue was absolutely devoted to him. She herself was engrossed in her work and a model of efficiency.

I was rather frightened of her myself. At this point in time, I can see that was very immature of me and I must have been quite ingenuous. She was very quick in her movements and gave the impression of energy and fervour. Apart from a short visit to see Tuckie on my recent visit to Tasmania, I have not seen her for many years, although I did keep up with her for some time after leaving Launceston and during that period she always seemed to be the same. At the hospital, she always wore her fawn sister's uniform with stiff white veil. She was very thin and angular, wore horned rimmed glasses, moving from place to place with great speed. I knew Tuckie personally and always found her kind, with a great sense of humour. She told the story of the radium clinic patient who she pushed into one of the rooms, asking to remove his sock and shoe - in spite of his, "But sister ...". It was only much later when she returned that he was able to say "But sister, it is my finger!".

Basil Beirman was the first radiology registrar to be appointed at the LGH. He was a very bright student from Sydney, and he too had a great sense of humour, which I hear from a mutual friend is still in working order. I saw him myself last year. Basil imagined that any difference of opinion was due to his Jewish background. When Dr Fletcher, in his usual direct way, disagreed on a point, Basil was sure it was because he was a Jew. And then, when the same man invited him to his home for Christmas dinner, Basil was beside himself with joy. "Imagine him asking me to Christmas dinner", he said. We all liked Basil, but he found it difficult to believe that we liked him for himself.

Angus Stuart (pathologist and supervisor of the experiments with radioactive iodine for goitre patients) was quite different again; a handsome Scot with an engaging personality and accent. He knew everyone liked him for himself. He became quite delighted with the antipodes, which he must have found to be so at variance with life at home. His manner was confident and charming and he affected an absent-mindedness, which proved to be very convenient for him at times. With a twinkle in his eye, after a return trip to Melbourne, he told me how a friend had driven with him in his car to the airport.

"And you know", he said, "it was only when I was halfway across Bass Strait that I discovered the keys were still in my pocket!"

174

His reputation for absent-mindedness was further enhanced by his being observed in the hospital wearing one green sock and one red. It was an undeserved reputation, owing to the fact that he had helped himself to spares from the housekeeper's odd sock basket. Also, he was not afflicted by my compulsion, at that stage of my life, to be on time. In fact, a trip to Paterson River to play his bagpipes made him very late indeed for an appointment for Nuclear Medicine. Also, he considered 10:00 o'clock in the morning quite early enough for any pathologist to start working.

Perhaps I am giving you the wrong impression of Angus Stuart, because he was very intelligent and later became a professor in a Scottish University. Angus was another very enthusiastic person and he was a delight to work with. I am fairly sure that it was he who first conceived the idea of investigating endemic goitre in Tasmania by the use of radio-active isotopes. It was certainly he who did the arranging and the first injection and all the preliminary work. I suppose seeing a condition in such profusion was a golden opportunity for research. Dr John L. Grove was also very much concerned, but, in my opinion, not in an active capacity.

When the radioactive counts were begun, Dr Holman had left Tasmania for Melbourne and Michael (my husband) had left for England. The activity in the photography department had slackened considerably and it seemed inevitable that I should do the technical work on the Geiger-counter. The machine was installed in a four-bed room in Ward E and it was here that the patients were injected with therapeutic and tracer doses of radioactive iodine. The iodine itself was flown in from `the mainland', collected by Dr Basil Beirman who â&#x20AC;&#x2DC;swung the small heavy lead container from a piece of rope as far away from his gonads as possibleâ&#x20AC;&#x2122;. It was stored in a special room in the Outpatients Department, from which I collected it prior to injection. It was my job to have the patient in position in bed and arrange for the sterile tray to be prepared, to conduct the counts with the Geiger-counter and calculate the results mathematically afterwards.

In the beginning, Angus Stuart always injected the patient and tipped the residue down the laboratory sink. He must have tired of this after a while as the injections were then done by a resident doctor.

Coming from my background in radio-therapy and handling radium buttons, etc., I had a healthy respect for everything radioactive. In my opinion, this attitude was not shared by the residents handling the iodine. I remember contriving to have a therapeutic patient approach the ward when a resident was waiting with me in the Geiger room. On a pre-arranged signal, I switched on the machine as the patient approached. The clicking became a crescendo as he entered the room. The resident was most impressed and far more careful after that incident.

Angus Stuart also prepared the specimens of thyroid for auto-radiographs which I made in the clinical photography dark room. As you can imagine it was a simple and primitive process. This was 1952.

After resigning from the position of clinical photographer, to join Michael in London (14 months was a long time to be separated at this stage of our marriage), I was able to train Fred Brown, a pathology technician, to work the Geiger-counter. Markivitz also had a period of familiarisation as medical photographer.

When Michael and I returned to Launceston, some four months later, Angus Stuart had just left.

Michael was not asked to become involved in the project, but, because of his concern about possible contamination, checked the laboratory sinks where Fred Brown had indicated that all the excess radioactive material had been dumped. It was clean. I presume that the experiments had ceased 8 when Angus Stuart left Tasmania.

Professor David Kelly has provided the following account of nuclear cardiology at RPAH. 175

In mid-1976, cardiology and nuclear medicine, both departments within medicine, initiated a nuclear cardiology programme. The purpose was to conduct clinical research in cardiology and establish a hospital diagnostic service for patients.

The first studies were conducted on ambulant patients with chronic disease, but it was felt important to develop a system to study patients with acute cardiac syndromes in the coronary care unit and post-operatively in intensive care.

Money for a mobile gamma camera was obtained from the University of Sydney and the Ramaciotti Foundation. On delivery, it was found it would not fit under a bed and so was hastily replaced!

Nuclear medicine was developing software programmes for analysis of data and cardiology promulgated the advantages of nuclear studies on cardiac patients to the physicians.

The main investigations were of three types: 1. Prophylactic scanning, which identified areas of cardiac necrosis up to 14 days after infarction. These scans were helpful in patients where (i) the ECG was not diagnostic or noncontributory (eg. LBBB or patients with pacemakers), and (ii) enzymes were not diagnostic or unhelpful (ie. several days after infarction and also in patients following cardiac or general surgery).

These studies were easy to do and analyse, and did not require sophisticated computer analysis.

2. Thallium Scanning, with the permission of the Federal Government, we were able to import thallium 201 into Australia. It was a new perfusion agent to identify ischemia in the myocardium and thus coronary disease with a higher degree of sensitivity and specificity than exercise testing. The isotope has a relatively short half-time and studies had to be planned in advance. Its main areas of use were (a) exercise testing to diagnose and localise coronary artery disease, (b) assess the results of by-pass surgery or other revascularization, (c) eliminate suspicion of coronary disease (ie. false positive ECG), and (d) acute assessment of acute coronary syndrome, to measure the site and extent of myocardial infarction and jeopardised myocardium.

3. Technetium studies - this technique labelled red blood cells and so imaging of the blood pool could be done to measure the volume and function of the left ventricle.

As ejection fraction was a major determinant of prognosis after acute myocardial infarction and in chronic cardiac failure of varying aetiology it was important to measure and sequentially follow this in patients.

Thallium scanning is not easy to perform and requires experience, diligent technique and sophisticated programmes for analysis. All of this was developed at RPAH and utilised later in my department in Australia. Thallium 201 was later produced for diagnostic studies by ANSTO in Australia.

Blood pool scanning was widely used and did not inconvenience patients but required again experienced operators and very good computer analysis. The nuclear medicine department developed analytic programmes that were utilised widely in Australia and overseas.

With technetium studies, the group developed an original gated heart pool scanning method, using Tc labelled red blood cells and the R wave of the electrocardiograph as the trigger with a camera aligned on the septum between RV & LV, to record blood radioactivity, so that left ventricular volume and output were determined in various circumstances. A busy data exchange developed with a similar group in the USA. From 1977 to 1987, the combined departments published over 30 papers in peer-reviewed overseas journals on nuclear cardiology, and RPAH became an internationally-recognised centre for its contribution to research and training. The enthusiasm and cooperation between departments, not usual at this time, enabled this research to be done.

176

An important and early development was the use of mobile cameras to facilitate acute study in the CCU or intensive care unit without moving the patient to a diagnostic department. The non-invasive use of nuclear studies was an important and additive diagnostic modality in the overall assessment of acute and chronic cardiac disease.

Miriam Murray recalls her experiences as a nursing sister in the radioisotope clinic at Wakari Hospital, Dunedin, from 1967 to 1970.

During 1967, while working in a convalescence ward at Wakari Hospital, Dunedin, I was asked by the principal nurse, Miss Isabel Whiteford, if I would consider working in the radioisotope clinic attached to the physics department. She told me she had been approached to supply some nursing cover to this area as the department was showing signs of being extended, because of the increase in patient numbers being investigated by this rather new system of diagnosis. â&#x20AC;&#x153;Would I consider taking on the position on a part-time basis, as many of the patients needed nursing care during their stay in the department?â&#x20AC;? This was, in some instances, a period of three to four hours.

Radioactive iodine had been used in this hospital for some considerable time in the diagnosis of thyroid malfunction. The increase in patients was due mainly to the advent of the Magnascanner in other organ imaging (eg. liver, lung, brain and later bone scanning).

This was an unknown field to me, but I accepted it as a challenge. Here, I was a nurse who trained in the 1940s. Physics did not feature in our curriculum, but it wasn't long before I realised that in Hugh Jamieson, Fergus Thomson and Colin Medcalf, I had three excellent teachers who were very supportive; and I was willing to learn. I am sure that, at times, during those first few months, we all questioned whether I had done the right thing in accepting the combined position of nurse technician, mathematician, secretary and appointment clerk. It was my first introduction to flashing figures on a screen, something I am sure stimulated my interest in computers, to the extent of buying one to fill my retirement hours.

My role in the unit, then known as the physics department, involved the organisation of diagnostic tests for thyroid malfunction, using radioactive iodine, brain, liver and lung scans, using radioactive technetium and other radioactive substances that were used in treatment and tests for haematological disorders.

The Cliniscanner was housed in the radiotherapy clinic at Wakari Hospital when I started in this field.

The machine was on a mobile stand, but it was not very long after this that the machine became airborne and was ceiling mounted. This was quite a feat of engineering carried out in the department and I well remember the day the addition of colour type showed up on the scanner paper. This all went very smoothly, with me in control of the scanner, until one day, some months later, a male patient was being scanned and a machine malfunction caused sparks to fly onto the patient's very hairy chest. My training as a nurse being to consider people before machines did not appear to go very well with my physics department bosses, as I shot the machine along the rails to the other end of the room and proceeded to attend to the burning hairs on the chest of my patient. Soon afterwards, we became the proud licensees of Invercargill's new scanner.

The thyroid uptake tests were mainly carried out on outpatients. It was a three-day test; the patient coming for a baseline count and then being given the isotope orally, returning on the next two days for neck counts and, on the third day, for a neck scan. The total urine for the three days was counted as isotope output. These tests were routine on Mondays, Tuesdays and Wednesdays, but were dependent on the airlines delivering the isotope from Amersham in England.

177

As I became more and more familiar with the work of the department, I extended my nursing service to visiting the inpatients, especially the children, to explain what was going to happen to them and by taking them to the department, some days before their tests. This, in many cases, did allay some fears and we found it yielded better results for our tests. I also did repeat visits to patients receiving therapeutic doses of radioactivity and, in this way, acted as support person to staff in both education and service.

The next three years went fairly smoothly with a gradual increase in demand, as our service became accepted by medical staff seeking further help in diagnosis and using it as a back-up to radiological procedures. Times were changing and, with staff increasing and the need for extra space, it was decided to shift the department to the remodelled X-ray block at Dunedin Hospital.

So, in 1970, the department of nuclear medicine was born. Six months later, after it was established, the role of the nurse changed to one of patient chaperone. A radiographer took over the scanner, all clerical work became the responsibility of the secretary; and patient-visiting was done by medical staff on ward rounds. The physics department had grown up. At this time, I was offered a position as charge nurse of Bachelor Ward, another challenge which I accepted.

I must say that I enjoyed this period of my nursing career, being a member of a multidisciplinary team.

It was a time during which I am sure each of us learnt to understand from the others that our personal goals were the best service we could achieve for our patients.

References 1. Blackburn, C. R. B., pers. corresp. to W. D. Refshauge (Director General of Health for Commonwealth), 23 January 1960.

2. Blackburn, C. R. B., pers. corresp. to Vice Chancellor, 20 October 1960 and 6 December 1960.

3. Blackburn, C. R. B., pers. corresp. to Vice Chancellor, 25 January 1961.

4. Blackburn, C. R. B., pers. corresp. to E. F. Thomson (CEO at RPAH), July 1958 (and Thomson, E. F., reply, 6 February 1961.

5. McRae, J., â&#x20AC;&#x2DC;Medical Use of Radioisotopes in Australiaâ&#x20AC;&#x2122;, Atomic Energy in Australia, April 1963, p.5.

6. Blackburn, C. R. B., pers. corresp., January 2007.

7. McLaughlin, A., pers. comm., December 2007.

8. Shoobridge, A., pers. corresp., 1990.

178

Chapter 10

WORLD CONGRESS IN NUCLEAR MEDICINE AND BIOLOGY Sixth World Congress of Nuclear Medicine and Biology, Sydney 1994 The World Federation of Nuclear Medicine and Biology (WFNMB) is a voluntary non-profit making organisation with the following objectives: • • • • • •

•

•

•

•

to organise congresses, workshops and other educational activities in the field of nuclear medicine, covering all aspects; to develop co-operation between groups, societies and associations formed on a national level and active in the role of nuclear medicine and biology; to promote the development of nuclear medicine and biology; to facilitate the exchange of scientists between the member groups, societies and associations and to set up a body which will centralize and help such exchange; to prepare and recommend the organization of a unified programme of teaching and training in the field of nuclear medicine and biology; to establish technical standards, to aid in the diffusion of knowledge and exchange of scientific and technical information by means of conferences, colloquia, symposia and courses on regional, national and international levels; to publish, alone or in collaboration, monographs, studies, teaching, courses, reports from conferences, colloquia, symposia and congresses concerning nuclear medicine and biology; to represent with one voice all nuclear medicine activities to the World Health Organization, the International Atomic Energy Agency and other appropriate organizations; to organize whatever commissions and meetings are necessary to attain such objectives, in particular convening specialists in nuclear medicine and biology in a congress of the federation; to work with and support WFNMB subsidiary organizations and related organisations to promote worldwide expansion of nuclear medicine and biology.

The WFNMB has held a world congress every four years from 1974. The first congress was held in Tokyo and Kyoto under the presidency of Professor Ueda. Subsequent congresses have been held in Washington DC (1978), Paris (1982), Buenos Aires (1986), Montreal (1900), Sydney (1994), Berlin (1998), Santiago (2002), Seoul (2006) and Cape Town (2010).

The president of the WFNMB holds office for four years and takes up office at the close of the previous world congress. The election for the presidency is held two years earlier at one of the regional nuclear medicine congresses. The incoming-president selects and nominates the site for the congress which is held at the end of his four-year term.

In 1988, the ANZSNM decided to bid to hold the 1994 world congress in Sydney and for Professor Provan Murray to be the president of the WFNMB from 1990-1994. A bid was prepared by Provan Murray, Richard Smart and Brenda Walker, and written endorsements were obtained both from industry and all levels of government, including Prime Minister, the Honourable Bob Hawke. A meeting of the WFNMB was held during the fourth Asia and Oceania Congress of Nuclear Medicine, in Taipei, in November 1988. Provan Murray was 179

unanimously elected president of the WFNMB from 1990 to 1994, with Richard Smart as secretary-general and Brenda Waker as WFNMB treasurer.

A local organising committee was established comprising Michael Kelly (chairman, scientific program), Brian Hutton (vice-chairman, scientific program), Vince Antico (chairman, sponsorship committee), Vivienne Bush (chairman, technologist committee) and Patrick Butler (convenor, pre-congress symposium). ICMS Australia Pty Ltd, under the directorship of Pauline Beckton, was selected as the professional organiser of the congress. The newly-opened Sydney Convention Centre at Darling Harbour was selected as the congress venue.

One of the first tasks for the committee was the congress logo, as this would be needed for all the publicity leading up to the congress. The chosen design featured the Sydney Opera House and an atomic structure centred on the sun (and the sun did shine throughout the congress!).

Qantas agreed to be the official congress airline and provided support by way of air tickets to enable committee members to attend various international meetings to promote the Sydney congress. In this way, the Sixth World Congress had booths at the Montréal Congress, the SNM and EANM annual meetings and at the fifth AOCNM in Jakarta, in 1992.

Brian Hutton, Brenda Walker & Richard Smart promoting the Sixth World Congress

A pre-congress symposium was held in Cairns from 18-20 October 1994, with the theme ‘Emission Tomography: Controversies & Future Directions’. The programme was arranged as a number of workshops entitled ‘Controversies in Clinical Nuclear Medicine’, ‘Controversies in Nuclear Medicine Physics’, ‘Controversies in Radiopharmacy’ and ‘Controversies in Nuclear Medicine Technology’. Early morning starts provide sufficient time 180

for delegates to enjoy the Great Barrier Reef before travelling to Sydney for the main congress.

The opening ceremony of the Sixth World Congress was held in the concert hall of the Sydney Opera House on Sunday 23 October 1994. The congress was officially opened by the Honourable Bill Hayden, Governor-General of the Commonwealth of Australia. Other members of the official party were Professor Provan Murray, President WFNMB; Professor Jim Conway, President SNM; Professor Peter Ell, President EANM; Dr Enrique Olea, PastPresident ALASBIMN; Prof Kanji Torizuka, President AOFNMB; and Dr Shane Morony, President ANZSNM. Delegates were entertained by the Bangarra Dance Company performing ‘Ochre Dreaming’ and by the SBS Youth Orchestra playing ‘Rhapsody in Blue’.

The soloist was a very young Simon Tedeschi. After the ceremony, Bill Hayden and his wife joined the committee at the reception.

Brian Hutton, Brenda Walker, Richard Smart, Provan Murray, Mrs Hayden, the Hon Bill Hayden, Vivienne Bush, Michael Kelly & Vince Antico at the reception

Jackie James gave the following review of the congress: Freshly back from Australia, but now over the jet-lag which provided a perfect excuse for taking it easy, I am finding the cool, damp environment compares unfavourably with the daily o 31 C in Queensland. The World Congress of Nuclear Medicine and Biology held in Sydney in October was an excellent meeting attended by over 2,400 delegates, of whom 48 were from the UK, 54 from Germany, 178 from the USA, 184 from Japan and 373 from Australia. The congress began with an opening ceremony held at Sydney Opera House. As well as the usual greetings and good wishes, the program included a superb piano recital by an angeliclooking schoolboy and an Aboriginal dance movement. I can only speculate that including topless dancers in this four-person troupe might be an Australian solution to jet lag. It certainly

181

seemed to be working for some members of the audience! The performance was followed by drinks and refreshments in a gallery of the Opera House which overlooked Sydney Harbour.

The view, as the lights came on around the Harbour Bridge and passing boats, was spectacular. Being vegetarian, I was a little perturbed when 'roo kebabs' were served, and had to rely on liquid refreshments.

The conference centre was situated at nearby Darling Harbour adjacent to a modern shopping complex. In front of this venue was a leisure area and playground with a number of fountains and water jets. I was highly amused to note that every morning a worker was to be seen around 8:00 am, vacuuming any fallen leaves out of the water, presumably to improve the overall appearance and clarity of the water.

In my view, the highlights of the conference were the education sessions, which took place at 8:30 am every morning. Unfortunately, however, as three sessions ran in parallel, it was not possible to listen to the views of experts on all areas of nuclear medicine. I also enjoyed the paediatric 'free paper' sessions and can never understand why these well-attended sessions always seem to be scheduled in the smallest room. As usual, the debate between the 'experts' from various countries was illuminating and informative. A further paediatric highlight was the quiz, held over lunchtime on the last day, with teams from Europe, Australia and North America competing, complete with buzzers, silly hats, team tee-shirts and much goodwill. Following projection of one or more paediatric images, a short clinical history would be given and the teams asked for a diagnosis. As negative points were awarded for wrong answers, the whole performance was highly amusing, with renowned pillars of our community throwing paper, contradicting the referee and generally being disruptive. At one point, the European team distinguished themselves by a score of minus 30. The North American team, falling behind, opted to double their points â&#x20AC;&#x201C; a great risk, as this also meant doubling the deduction for a wrong answer. However, this was obviously the correct strategy as the North Americans triumphed in the end. For those not present, I suppose this sounds a rather 'childish' event, but the audience were unanimous in their appreciation with people of all nationalities finding it hilarious. The questions posed were by no means easy and, as the compere gave further information with the correct answer, it was also an educative session.

The closing ceremony, like the opening ceremony, was fairly spectacular, with gymnasts, a school choir and a singer (someone had managed to compose a whole song with nuclear medicine lyrics and set it to a fairly catchy tune). The inaugural Masahiro Iio prize, worth US$5,000, was awarded to Dr Marco Chianelli for work on the development of 99Tcmlabelled interleukin-2 for nuclear imaging of autoimmune disease. Dr Chianelli, who works with Dr S. J. Mather's group at St Bartholomew's in London, was called upon to present his paper in an enormous lecture theatre to all of the delegates attending the closing ceremony. It is wonderful to see a British group winning such a prestigious award â&#x20AC;&#x201C; well done to all concerned. I am sure that everyone who attended the conference was impressed with the hospitality of our Australian hosts and the general philosophy expressed in the phrase 'no worries', which seemed to come up in response to any enquiry or request for information. We must pay tribute to Provan Murray, the conference organizer, and his team, who did an 1 extremely good job.

A total of 1,090 abstracts were received from 54 countries with Japan (15%), USA (11.7%), Australia (11.6%) and China (8.4%) providing the largest number of entries. Over 2,000 people attended the Congress including 1,479 delegates from 68 countries, 239 accompanying persons and 360 industry representatives. The congress provided financial support to 27 young researchers from developing countries, who would otherwise have been unable to attend.

182

Congress banner outside the Sydney Convention Centre.

The congress exhibition was held in the adjoining exhibition hall. All major suppliers of equipment and/or radiopharmaceuticals had stands at the exhibition. Many companies had to invest in purpose-built exhibition stands as it was too costly to bring their stands from the US or Europe. The major sponsors of the congress were ADAC Laboratories, DuPont Pharma, GE and Siemens. Additional sponsors include Mallinckrodt, Toshiba, Australian Radioisotopes, Radpharm Scientific and Picker.

The congress was not all work. The social program included an Australiana event at Tobruk Merino Sheep Station at Moroota NSW (on the Old Northern Road, near Wisemans Ferry).

Delegates feasted on hot damper and billy tea on arrival and then could wander around the many activities including wood chopping and sheep shearing, or try their hand at whip cracking.

Getting the delegates out of Sydney was a logistic challenge and every available bus in Sydney lined up behind the convention centre to transport the delegates.

Of course, Australiaâ&#x20AC;&#x2122;s marsupials were on hand to entertain the delegates. The event culminated with a bush dance, when delegates 183

could really let their hair down.

The congress banquet was held in the convention centre on Thursday 27 October. The banquet menu invited the delegates to: Enjoy being pampered and feted in the hedonistic atmosphere of an ancient Greco-Roman court. Be the emperor’s guest as you feast on tempting delicacies whilst listening to the melodious sounds of the imperial musicians. Let the athletes entertain you as they perform for your amusement. Wend your way to the dance floor past elegant columns, statues and pools and dance with other members of the imperial court. As you sit in the shadow of the volcano, watch it glow and grumble – will tonight be the night everyone fears?

Provan Murray (as Julius Caesar) enters the Banquet Hall

Sydney had already been selected to host the 2000 Olympic Games, so every opportunity was taken to promote the Olympics. The evening’s entertainment included displays of gymnastics and javelin-throwing and even an exploding Mount Vesuvius.

At the closing ceremony, the highlights of the congress were presented by Professor Peter Ell. This was subsequently published in the European Journal of Nuclear Medicine, 22, 159176, 1995. The final task undertaken by Provan Murray as WFNMB president was to hand the presidency to Professor Hans Biersack, who was to convene the 1998 congress in Berlin.

It is very pleasing that the WFNMB will be returning to Australia for the Twelfth World Congress, in Melbourne, in 2018. Congratulations to Professor Andrew Scott and the society’s international relations committee for securing the bid at the WFNMB Assembly held during the 2012 EANM Scientific Meeting.

References 1. James, J., Nuclear Medicine Communications, 16, 123-124, 1995.

184

Chapter 11

NUCLEAR MEDICINE TODAY 'NEW CLEAR MEDICINE' A New Reactor for Australia Australia has been well served by local producers and distributors of radionuclides throughout the local history of nuclear medicine. Australia's first large-scale nuclear reactor, HIFAR, came on-line in 1958 at the AAEC, Lucas Heights, Sydney and provided medical radionuclides such as 99Mo/Tc99m, 131l, and C06O. This was supplemented in 1992 with the introduction of the National Medical Cyclotron, owned and operated by ANSTO, which supplied cyclotron-based radionuclides including 123l, 67Ga and 201Tl for the nuclear medicine community. This was in addition to providing PET radionuclides following the introduction of PET scanning into Australia.

The decision to replace the ageing HIFAR reactor with a new breed of reactor based on lowenriched uranium (LEU) fuel sources was finally realised with the opening of the OPAL ("Open Pool Australian Light-water reactor) reactor in April 2007 by the Prime Minister John Howard. OPAL was the first LEU reactor to be installed worldwide for producing medical radionuclides and represented, at that time, Australia's largest investment ever in a single piece of scientific apparatus ($437m). This was a judicious decision as at around this time the US Congress approved a bill to eradicate all highly enriched uranium-based reactors from medical radionuclide production within five years.

During 2010 there was an unexpected shutdown of a number of nuclear reactors around the world that had been relied upon to produce the majority of the world's 99Mo for use in the molybdenum/technetium generator, used for the majority of nuclear medicine investigations.

Of particular note, the US had not invested in any nuclear reactors to produce radionuclides for medicine and hence was totally dependent on other countries, especially Canada. A high-level international working party was convened to optimise the availability of 99Mo during a critical phase when only Opal and the South African reactor, Safari, were operational. Australia played its role by sharing its radionuclides as it could, but, for the most part, the domestic nuclear medicine community was able to continue to operate from its local supply and thus the majority of patient is to get in is required were able to be performed with little or no interruption or delay.

In the debate leading up to the decision to replace HIFAR with the new reactor there was much criticism of the cost, location, and ultimately the need for a reactor for medical purposes. Even a former senior scientist at ANSTO, Barry Allen, was quoted in an interview as saying "(The new) reactor will be a step into the past...(it) will comprise mostly imported technology and it may well be the last of its kind ever built. Certainly the $300 million reactor will have little impact on cancer prognosis, and the major killer strains today."1 While it is true that some medical radionuclides can be imported from overseas, in practice, uncertainty of supply, deliveries affected by adverse weather conditions, and high import costs certainly favour local technology for Australia, positioned as it is a long way from the main production centres of Europe and North America.

Today, local supply of reactor-based radionuclides for medicine is relatively robust from the Lucas Heights facility. The Federal government announced a $168m investment in 2012 for 185

the facility to upgrade its production capacity so as to be able to export a significant amount of its products to the rest of the world. This should in turn feedback into new investments in nuclear medicine technology and radiopharmaceutical developments locally.

Advances in Instrumentation - Hybrid Imaging Devices Over the last decade, significant advances in instrumentation have resulted in the widespread implementation of hybrid imaging technologies, with the use of both SPECT/CT and PET/CT considered routine in many centres.

The first SPECT system with a low dose CT available in Australia was the GE Hawkeye. The addition of CT allowed correlation of functional changes with anatomical findings in a single imaging session without the need to reposition the patient. However this system had limitation due to the quality of the CT component and the long acquisition time. The ideal system would couple and a imulti-slice CT with a high end SPECT system allowing faster acquisition times generating images of high diagnostic quality using low dose methodologies. At this time, a combined system did not exist and as a result the first hybrid SPECT/CT system installed in Australia was at Royal North Shore Hospital, Sydney in 2004 which used in-house design that combined a Phillips SKYLight SPECT system, with a Picket PQ5000 single slice CT. This allowed the acquisition of a SPECT/CT in a single session without the need to move the patient with the additional benefit of both CT-based attenuation correction and anatomical localisation.

SPECT/CT systems are now common place in the majority of nuclear medicine practices improving both the sensitivity and specificity with accurate quantification. The advantages for PET/CT have been more significant with vendors discontinuing the supply or manufacture of standalone PET systems. So we have now truly moved into the generation of 'New Clear Medicine'.

References 1. Search, Oct 1997 edition, quoted in â&#x20AC;&#x153;A New Clear Direction: Securing Nuclear Medicine for the Next Generationâ&#x20AC;? - report by the Medical Association for Prevention of War (MAPW). Aug 2004

186

Appendix 1

AIMS AND OBJECTIVES OF THE AUSTRALIAN AND NEW ZEALAND SOCIETY OF NUCLEAR MEDICINE LIMITED The objectives of the Society are as follows.

1. Promote: (a) the advancement of clinical practice of nuclear medicine in Australia and New Zealand; (b) research in nuclear medicine; (c) public education regarding the principles and applications of nuclear medicine techniques in medicine and biology at national and regional levels; (d) co-operation between organisations and individuals interested in nuclear medicine; and (e) the training of persons in all facets of nuclear medicine.

2. Provide opportunities for collective discussion on all or any aspect of nuclear medicine.

The Society has two standing sub-committees: (a) The Accreditation Board, which sets standards for the training and practice of nuclear medicine technology and recommends the issue of accreditation certificates to those technologists who attain the minimum standards of proficiency in nuclear medicine. The Society is the only accrediting body for nuclear medicine technologists in Australia and New Zealand. (b) The Technical Standards Committee, which sets minimum standards and develops quality control procedures for nuclear medicine instrumentation in Australia and New Zealand.

In addition, there are a number of special interest groups which maintain standards of practice for their particular specialty and provide a forum for their development in Australia and New Zealand. These include the Radiopharmacy, Technologists, Physics and Nurses Groups.

187

Appendix 2

HONORARY PRESIDENTS 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Dr Harry Lander Mr B. W. Scott Dr Peter Ronai Mr Rex Boyd Dr Ian B. Hales Dr Peter Hurley Dr Roger J. Connolly Mr Don W. Keam Mr Don W. Keam Dr John T. Andrews Dr John T. Andrews Dr E. H. Buttfield Mr Munslow-Davies Dr J. McKay Dr R. Hoschi Dr I. Surveyor Dr I. Surveyor Dr Rick Baker Dr Rick Baker Dr Victor Kalff Dr Victor Kalff Dr Agatha van de Schaaf Dr Agatha van de Schaaf Dr Shane Moroney Dr Shane Moroney Dr Michael Rutland Dr Michael Rutland Ms Heather Hodges Ms Heather Hodges Dr Joseph Wong Dr Joseph Wong Mr Daniel Buckie-Smith Mr Daniel Buckie-Smith Ms Vivienne Bush Ms Vivienne Bush Mr Peter Collins Mr Peter Collins Dr Iain Morle (1month); Mr Geoffrey Roff Mr Geoffrey Roff Mr Geoffrey Roff Dr Sze Ting Lee Dr Sze Ting Lee Ms Elizabeth Bailey Ms Elizabeth Bailey

188

Appendix 3

ANZSNM COUNCIL 2013 President: Vice President: Past President: Treasurer: Committee:

Ms Elizabeth Bailey Prof Dale Bailey Dr Sze Ting Lee Dr Susan O’Malley Ms Lyndajane Michel Assoc. Prof Roslyn Francis Mr Dominic Mensforth Ms Jennifer Guille Ms Sharon Mosley Dr Sam Berliangeri Dr Darin O’Keeffe

189

Appendix 4

HONORARY LIFE MEMBERS Roger J. Connolly (1986) Don Keam (1986) Ray De Goot Dr Ian Hales (1991) Dr John T. Andrews (1992) Professor Provan Murray (1993) Gerhardt Lowenthal Ivor Surveyor Dr Joe Savage Dr Harry Lander (1999) Heather Hodges (2005) Ms Vivienne Bush (2008) Ross Hanna (2010) Dr John McKay (2011) Mr Chris McLaren (2012) Associate Professor Richard Smart (2013) Dr Agatha van der Schaaf (2013)

190

Appendix 5

ABOUT THE AUTHOR Principal author Paul A. C. Richards has devoted half a century to the art of nuclear medicine. His career in radiotherapy commenced at the Launceston General Hospital on 14 January 1963. He spent his first year of studies in Launceston, followed by a year in Melbourne and a final year in Launceston. He developed an early interest in the use of radioisotopes and radium calculations and their internal applications for gynaecological carcinomas. The outstanding impression of those early days at the Peter MacCallum Clinic, in 1965, led to what was to become a full-time career in the emerging discipline of nuclear medicine.

Paul has studied nuclear medicine with Henry Wagner at Johns Hopkins University, conducted and published ground-breaking research, administered a busy public-sector department of nuclear medicine, played an active role within the ANZSM, developed mass screening programs for neonatal hypothyroidism in the United Kingdom and Tasmania, established the first nuclear medicine degree in a rural university, and developed and administered the societyâ&#x20AC;&#x2122;s web-based continuing professional development program.

Editor Philip Bachelor is a Melbourne-based social anthropologist whose literary works include dozens of journal articles and four previous books on social, environmental and historic themes.

191

Appendix 6

ACKNOWLEDGEMENTS Any historical account of a widespread society, incorporating diverse special interests, can only result from the distillation of tremendous contributions of numerous members and various interested parties. This book would not have been possible without the inspiration, assistance and guidance of the wonderful nuclear medicine fraternity, including many individuals scattered throughout the world and all professionals who comprise the Australian and New Zealand Society of Nuclear Medicine.

A special debt is owed to those pioneers who gave of their time to reflect and recall both the early development of the use of radioisotopes in medicine as well as the birth and growth of the ANZSNM. Special thanks to Emeritus Professor CRB (Ruthven) Blackburn, Professor Jim McRae, physicians Peter Ronai, John Andrews, John Morris, Frank Broderick, Andrew McLaughlin, Tony Walker, Fred Lomas and Tony Booth; physicists Bruce White, Bill Burch and Brian Hutton; technologists Jean Milne, Pat Lurie, Jenny Moran, Ruth McGennisken, Wendy North (née Kellsal), Rae Jamieson, Heather Patterson and Dianna Harrison (née Shelton); radiopharmacists/radiochemists Rick Baker and Rex Boyd; and sustaining members Peter Leaney, Roger Alsop and Wayne Melville.

The Society is particularly indebted to the following for generous direct literary contributions to this volume: John Andrews, Ruthven Blackburn, Frank Broderick, Tony Walker, Rob Howman-Giles, Monica Rossleigh, Roger Uren, Jim McRae, Peter Ronai, John Morris, Andrew McLaughlin, Barry Chatterton, Josephine Wiseman, Sue Lefmann (née Woolf), Wendy Kelsall (née North), Pat Laurie, Jenny Moran, Gary Minch and Millicent Marion Hughes.

Perhaps the greatest credit for compiling much of this book goes to ANZSNM member Paul Richards, who undertook extensive research and coordination and prepared the initial manuscript.

The editor also wishes to thank ANZSNM President Elizabeth Bailey and Councillors Dale Bailey, Sze Ting Lee, Graeme O'Keeffe, Geoff Roff, Lyndajane Michel, Dylan Bartholomeusz, Sue O'Malley and Jennifer Guille, who, with the assistance of Richard Smart, have offered support and their extensive commitment towards the ultimate publication of this volume.

In his 2006 book: ‘The Longest Decade’ (a study of the Keating and Howard governments in office), George Megalogenis notes that: “History, of course, is difficult to write, if for no other reason than that it has so many players and so many authors”. This was certainly the case with this present volume, in which those involved have endeavoured to give all due credit.

Regrettably though, it is quite possible that during various drafts, over several years of compilation, the works of some valued members and industry colleagues may have been inadvertently mixed. If the origin of any contribution has been omitted or misattributed, the ANZSNM Council offers its sincere apologies and requests such advice so that all contributors may be appropriately recognised.

192

193