Harnessed to Heal
The Early Years of Radiation Therapy and Oncology
Portland radiologist Ivan M. Woolley, M.D., authored a text in 1955 titled, Roentgenology in Oregon: The First Fifty Years. Dr. Woolley delves into the use of radiology for treatment and diagnosis by sharing his own experiences and those of other physicians in Oregon, providing an informative and often delightful tale of both men and machines.
Dr. Woolley graduated from the University of Oregon Medical School (1919) and eventually served as a faculty member in the Department of Radiology. His interest in radiology began in 1915 when he first made radiographs in the office of Dr. Frank W. Wood. An "impecunious" student, he slept on the sofa in the doctor's office in the Morgan Building in downtown Portland. To justify his presence there he performed duties for Dr. Wood, which included making radiographs and giving x-ray treatments to patients who found it more convenient to come to the office in the evening. A support for the gas x-ray tube was clamped to the back of a chair and resting the small suitcase sized copper coil apparatus on the seat, the wires were attached to the tube. When the correct apple-green color appeared in the bottom half of the tube, indicating its readiness, he would first test it using a hand fluoroscope. If he could see his own bones, the examination or treatment would begin without any protective device, using a watch to time the exposure. Fortunately, Dr. Woolley began to study radiology in earnest at the University of Michigan Medical School in 1930. He practiced x-ray medicine the rest of his life, becoming Portland’s leader in the field until he retired in December of 1962.
Dr. Woolley selected 1903 as the year to begin his history of clinical roentgenology in Oregon. He found that it was on this date that the first papers on the topic were presented before the Oregon State Medical Society and were then published in the Medical Sentinel. From this starting point, Woolley sent out a questionnaire to physicians around the state asking for information about their experiences using radiology to diagnose and treat disease.
Even though Woolley states that we will probably never know who first produced x-rays in Oregon, we have been made to understand that Herbert Merton Greene (UOMS class of 1904) ran the first x-ray machine in Oregon in the Robert C. Coffey Clinic and Hospital. According to Woolley, however, UOMS medical students Ralph Walker and George A. Torgler, built and sold some x-ray machines prior to their graduation in 1904, but he never mentions Greene, a fellow student.
By his own telling, Dr. George Houck of Roseburg had the first x-ray machine in the state, purchased in 1902. Dr. Houck presented a paper before the Oregon Medical Society (only 8 years after Wilhelm Roentgen announced his discovery of x-rays) and it was published in the 1903 Medical Sentinel. Many other prominent Portland physicians also published on the subject in this volume, including Drs. Robert Coffey, Kenneth MacKenzie, Luther Hamilton and George Wilson.
It was not widely known at that time that over-exposure to x-ray could cause x-ray dermatitis. Many pioneering physicians who worked in radiography often developed badly injured arms and hands. Even in later years, when the danger was known, carelessness and overexposure from removing foreign bodies and setting fractures or holding dental film caused severe damage. Dr. Greene reported that he once sat for an hour under x-ray light to remove a gramophone needle from a patient's hand. It was not only the physician who suffered; patients also received severe burns. Dr. Woolley recalled one case in which a physician was attempting to remove a small fragment of a needle from the hand of a woman. She received such a long exposure that it severely damaged her hand to the degree that amputation of the entire hand was considered. Perhaps this is our same Dr. Greene.
Misdiagnosis due to inadequately powered equipment was also a problem in the early years; one such tale is recounted by Dr. Woolley: Having taken a radiograph of a young pregnant woman, the physician found that she was expecting twins. At this news, the patient had hurriedly enlarged the layette and had prepared her family for the new additions. The doctor delivered one baby then waited with consternation for the twin, which never came. Upon closer examination of the radiograph, it revealed that during exposure, the baby had turned over in the uterus, creating a double shadow.
Good Samaritan was the first hospital to own its own equipment having purchased Dr. Houck's original machine. St. Vincent also had its own equipment. It was said that it required so much power to produce radiographs from the hospital's own power plant that the elevator could not be used at the same time.
X-ray Department at the People's Institute and Portland Free Dispensary
Despite being plagued with difficulties of diagnoses, the potential for damage to the skin of both physician and patient, the crudeness of equipment and the limited knowledge and experience of technicians, the papers first published in 1903 demonstrated that the practice of radiology had gotten off to a very "lusty" start in Oregon.
Devoting a whole chapter to the Medical School and Multnomah County Hospital, Dr. Woolley tells us that the first x-ray services at the Multnomah County Hospital began in 1915 when it was located at 2nd and Hooker. Dr. Lupton, an MCH intern at the time, shared that radiography became a routine duty of interns. It became necessary, he said, for the superintendent of the hospital to forbid enthusiastic interns from examining student nurses' chests. Perhaps this delayed routine chest surveys that are so useful to today's diagnosticians, said Dr. Woolley.
The Department of Radiology was established at the medical school after the school moved to Marquam Hill in 1919. When the Multnomah County Hospital also moved to Marquam Hill in 1921, a Wantz Jr. X-Ray machine was installed for diagnostic work. Later, a Victor machine was installed and the Wantz Jr. continued to be used for therapy. When the Doernbecher Hospital was completed, an x-ray department was opened and a combination fluoroscope and radiation Victor machine was employed. The Outpatient wing, joining Doernbecher and the Hospital was built with a new department on the third floor. The machines from the Hospital were moved to the new location but the Doernbecher machines were left to be used solely for pediatric patients. In 1930, Dr. Woolley became department chair.
Dr. Selma Hyman joined the department in 1944 and took an active part in radiation therapy and performed the first angio-cardiography in the department. The technique of multiple rapid radiographs of the angiography proved to be a challenge. Remembering the first trial procedure, Dr. Woolley divulges that the machine was installed too close to the outside wall to accommodate the plate changer, so during a procedure, it was projected through an open window. The unexposed slides were placed in the changer one after the other, like "train cars". Using a stick, the assistant would advance the slides based on grooves in the stick. Dr. Hyman would stand with a stop watch in hand, "Inject", she would call out. The assistant would then rapidly inject the Diodrast into the patient. "Number 1", was her next command, pause, "Shoot" – number 2 – "Shoot" – number 3, and so on. Standing for a PA position, the patient collapsed only to be revived for the lateral and oblique projections. No matter how primitive the procedure appears to us now, Dr. Hyman advanced radiation therapy significantly. When Dr. Charles T. Dotter came to UOMS, he brought with him a Fairchild roll film cassette and angio-cardiography became a much simpler and more precise process. In 1952, Dr. Dotter was appointed as the first full time professor of radiology.
Since these very early developments in radiology, the field has grown exponentially in knowledge, collaboration, technology and division of specialty. Dr. Kenneth R. Stevens Jr., Chair Emeritus & Professor of the Department of Radiation Medicine in the OHSU School of Medicine, sheds light on the key factors in the development of modern radiation therapy and oncology in Oregon. He explains that essential to this development were specific full-time training for physicians in radiation oncology, innovation in technology, collaboration with other medical specialties, and improvement in patient care.
Radiology room in the Tuberculosis Hospital, Salem Oregon
Fully trained radiation physicians in Oregon were practicing full time radiation therapy and oncology as early as 1943. Doctors Milton and Selma Hyman came to the Portland Veteran's Administration Hospital and University of Oregon Medical School in 1943 as, general radiologists with special training and interest in radiation therapy. Milton left his position at the VA in 1949 to open a private practice in Portland, and in 1956 the Hymans introduced the first Cobalt-60 machine on the West Coast in their office in Northwest Portland.
Irving Horowitz, another pioneer, after a stint in the Army and residency at the University of Michigan, returned to Portland to work with the Hymans in their clinic from 1958-1988.
Both the Hymans and Dr. Horowitz were highly respected by the medical community. Patients came from throughout the state and region for treatment and radiologists came to observe their approach to patient care. They used a clinical rather than a mathematical approach, using diagnostic x-rays to set up target fields, took radiation port films and documented these fields with Polaroid photos producing impressive results, especially with head and neck tumors. They utilized a reducing-field technique that gave a higher central dose and a lesser dose to sub-clinical volume.
Another Oregon pioneer, Dr. Clifford V. Allen, M.D., known as a splendid and caring physician, was a noted pre-op rectal irradiation pioneer. Coming from general practice in Longview, Washington, he became the director of the UOMS Department of Radiotherapy (1960-1967) and served as departmental chair from 1967 until 1972.
William T. Moss, M.D., pioneer in radiation oncology received many awards during his career. He served the American Society of Therapeutic Radiology and Oncology as President and Board Chair in the mid-1970s. In 2006, Dr. Moss was inducted into the inaugural class of Fellows of ASTRO (American Society for Therapeutic Radiology and Oncology). He is the author and editor of the classic text Radiation Oncology: Rationale, Techniques, and Results (currently in its 8th edition) written prior to and while at UOMS.
Innovations in technology
The first skin and bone sparing deep tumor treatment machine in the West was the Hyman's Cobalt-60 installed in 1956. This machine provided 31 years of constant service. The department of Radiation Therapy's treatment equipment prior to 1959 consisted of “deep-therapy” orthovoltage machines at the Medical School Hospital and also at the Portland VA Hospital. OHSU received one of ten VdG (Van de Graaff 2-MeV X-Ray machine) that were donated by the Donner Foundation in 1957.
The Van de Graaff 2–MeV X-ray Machine (aka The Jolly Green Giant)
It was installed in 1958 in a separate building off the Medical School Hospital where the Hatfield Center now stands. The department offices continued to be located partly within the diagnostic radiology department and partly in the basement of the clinic building until January 1972 when the department moved to the 4th floor in the South Hospital. The treatment machines in that location in 1972 consisted of the 2-MeV Van de Graaff accelerator, the Cobalt-60 machine, and a 24-MeV Allis Chalmers Betatron, as well as the orthovoltage machine. A treatment planning simulator was added in 1975. In 1981, a 6-MeV linear accelerator replaced the Van de Graaff generator. Shortly thereafter, the Betatron was replaced with a dual energy 18-MeV linear accelerator.
Innovations in Education
UOMS Radiology ~ Class of 1945
Key factors in the development of the field were continuing education courses and growing affiliations and consultation with surgeons, pathologists, diagnostic radiologists, medical oncologists and other specialists. Developing educational opportunities and drawing upon the expertise of other professionals were important to the development of a support staff of technologists and therapists, physicists, dosimetrists, aides, nurses, office staff, administrators, and financial and billing experts. At UOMS/OHSU there has been training of residents in General Radiology for many years. The first resident receiving training in only radiation therapy started his 3-year residency in 1964. Since 1967 there has been at least one resident per year in radiation therapy/oncology.
Innovations in Patient Care
In the early 1970's ground breaking studies were published concerning safe levels of radiation dosage. The tolerance of normal tissues to radiation was studied by experienced physicians in the early 1970s; publication of landmark journal articles with findings and related tables for improved dosage control had positive results. Treatment planning was improved by the use of simulators and computerized planning in the 1970s, CT imaging in the 1970s, MRI imaging in the 1980s, Stereotactic radio-surgery in the 1990s and intensity modulated radiation therapy in the 2000s.
The OHSU Department of Radiation Medicine
The UOMS Radiation Oncology program was established in the Multnomah County Hospital as X-ray Therapy in the 1930’s within the Department of Radiology. From 1943 to the early 1950s, Drs. Milton and Selma Hyman directed radiation therapy. Dr. Kurt R. Straube completed radiation therapy residency training in 1960 and practiced for a few years in the department. The establishment of the Department of Radiation Therapy/Oncology at UOMS in 1967 made it the first department of its kind in a U.S. academic center.
At that time, Dr. Clifford Allen was the only physician in the department. Dr. Allen was in charge of radiation therapy from the mid-1950s until his retirement in 1972 and was influential in the use of high-dose preoperative irradiation for rectal cancer in 1959, many years before other departments in the world adopted it.
In the 1980s the department name was changed to the Department of Radiation Oncology. In the latter half of 2006, the official name was changed to the Department of Radiation Medicine.
There have been four department chairs since the Department was formed: Clifford Allen, MD (1967-1972), William Moss, MD (1974-1989), Kenneth Stevens, Jr., MD, Interim Chair (1972- 1974), Interim Chair (1989-1992), and Chair (1992-2005), Carol Marquez, MD, Interim Chair, (2005), and Charles R. Thomas, Jr., MD, 2005 to the present.
Oregon Radiation Oncologists
The number of physicians practicing full-time radiation therapy/oncology in Oregon has increased from 2 in 1950, to 21 in 1980, and to approximately 75 in 2009.
Though written many decades before, Dr. Woolley's final words hold true today. "…although roentgenology in Oregon began in a small way it has progressed through the years to bigger things."
Larsell, Olof. The Doctor in Oregon, Portland, Oregon: Binfords & Mort, 1947
OHSU Department of Radiation Medicine Web site. Accessed December 19, 2008 http://www.ohsu.edu/ohsuedu/academic/som/radiationoncology/OHSU-Radiation-Oncology-Department-History.cfm
Stevens, Kenneth R., Radiation Oncology in Oregon: Pioneers & Pioneering, lecture slides, January 2009
Woolley, Ivan M. Roentgenology in Oregon: The First fifty Years. Portland, Oregon, 1955
Medical Sentinel (Vol. XI, 1903)
An Exhibit of the OHSU Historical Collections & Archives
January ~ March 2009