CRYING IN THE DARK - 

Marjorie Gordon's X-Ray Vision

David McLoughlin, North and South, Nov 1994.

In the early 1980s, radiographers - the (mostly woman) technicians who take x-rays in the nation's hospitals and clinics - began complaining of a range of confusing symptoms. Some became so ill they were forced to give up their profession.

Thanks to the dogged research of Marjorie Gordon, a Horowhenua radiographer who was one of the first affected by the mysterious illness she dubbed "darkroom disease", the cause was eventually identified as glutaraldehyde, a chemical in the solution used to develop x-ray films.

Glutaraldehyde was introduced with fast automatic processing machines in 1967, but Gordon discovered the amount added to the developer was significantly increased in 1980, after which radiographers began falling ill.

Gordon alerted her colleagues here and overseas to the problem and campaigned tirelessly for better protection from the fumes from x-ray processing machines.

Extraordinarily, years after every radiographer in New Zealand became aware of the danger, some are still succumbing. Even more extraordinary, the first major trials of a glutaraldehyde-free developer are only now taking place.

Most surprising of all, it seems some health professionals still doubt there even is a problem, despite overwhelming evidence.

In June1982, Marjorie Gordon started to get bad attacks of tinnitus, the awful ringing in the ears that can drive sufferers crazy. Next she developed a painfully sore throat and terrible hoarseness. She became weaker and weaker. Her first grandchild had been born that April. By September she was so weak she couldn't pick the baby up.

All this was in addition to a heart arrhythmia she'd developed the year before which kept her awake at rights as her heart raced at 170 beats a minute. A cardiologist had put it down to nervous tension. An ear, nose and throat specialist couldn't find the cause of her tinnitus and raw throat.

Marjorie Gordon loved her work. She was a radiographer at a private medical centre in the lower North Island coastal township of Otaki, 75 kilometres north of Wellington, 20 kilometres south of Levin. As her illness worsened, however, it got to the stage she could only go in for emergencies. One afternoon, after she'd been off work for several days, she went in and suffered a massive attack of tinnitus and racing heartbeats.

One of the GPs at the centre examined her throat and said she had the inflamed membranes of a heavy smoker. But she didn't smoke. "You work with some very toxic chemicals," he told her. "Yes," she replied. "I've just thought that, too."

Gordon took three weeks off to holiday in the Bay of Islands. Her symptoms settled down. She felt so much better she cancelled an upcoming appointment with the cardiologist, who by now wanted to admit her to hospital and put her on the powerful but toxic heart drug dygoxin, neither of which she wanted.

She returned to work and the symptoms immediately recurred. The cardiologist now diagnosed a toxic chemical reaction. But what chemical? She'd been surrounded by chemicals, particularly those used to develop x-ray films, since she began training as a radiographer at Wellington Hospital in 1947. In those days the developing was done laboriously by hand. Automatic processing machines, which did the job in three minutes and avoided most of the dirty work, didn't appear until 1967, the year Gordon started at Otaki after 15 years out of the profession raising four children. Even then, all her processing was done manually until 1980 when the medical centre got a state-of-the-art developing machine.

The new machine meant less direct chemical contact, not more, but the exhaust fan from its hot-air dryer was not vented to the outside. In fact, it blew straight into her face. Not that anyone realised that might be a problem.

"Never in any of my training was there any mention that the chemicals might be hazardous," Gordon recalls. "Of course, it had been known since 1908 that x-rays were. We used to have to take four weeks' consecutive holidays because of the radiation and we had to wear a film badge that measured our exposure. You were always excessively tired and that was put down to the radiation, but I never knew anyone whose badge showed excessive exposure. I believe now it was the chemicals."

The chemical culprit or culprits could be in the emulsion on the x-ray film itself, in the developing solution used in the first stage of the film processing, or in the fixing solution used in the second stage to make the film image permanent. All three products of course had labels, but the labels didn't list the chemical constituents. Gordon had no idea what was in them and decided the best way to find out was to visit the factory that made them, Agfa-Gevaert in Antwerp, Belgium.

1Fans were installed to extract fumes in Gordon's x-ray area. She struggled along at work for a few months until May 1983 when she left for Europe for a three-month private trip. Little did she imagine she was embarking on a crusade that was to continue to this day and make her a recognised international expert on the health problems of radiographers.

First, Marjorie Gordon went to England for the conference of the British Society and College of Radiology. She described her experiences and was told of a number of radiographers who could not go near darkrooms because of allergic reactions. The editor of the journal Radiography News got her to write an article, which she finished before heading for Antwerp.

At Agfa-Gevaert she met senior company chemists. "I told them they didn't label their chemicals. 'You don't warn us of the hazards.' They gave me all their product information sheets which listed all the chemicals they contained, plus their various safety warnings. I couldn't believe how hazardous they were. The head chemist told me that factory workers who developed health problems were transferred away from the chemicals. But it was the first time anyone had come to them with my heart symptoms."

She returned to England to find 25 letters from people who'd read her Radiography News article, telling her they'd had similar health problems. She learnt of 50 more. But she still had no idea which of the many individual chemical ingredients were the problem.

After returning to New Zealand in August 1983, she ad-dressed the Society of Radiography (now the Institute of Medical Radiation Technologists). "But they weren't keen [on hearing from her], as I would be rocking the boat with the photographic companies." She started finding other New Zealand radiographers with unusual health problems.

She also went back to work. Three months off had restored her health. "I didn't go back to the darkroom, but by then, the slightest exposure was enough. Within a few minutes the tinnitus and heart arrhythmia went off. After four days of it, my OP said 'get out'. By Friday I was terribly ill again and I was advised to give up work and apply for accident compensation."

In medical terms, Gordon had become "sensitised" to the chemicals she worked with. Her immune system had been affected to such an extent that the slightest exposure to the darkroom chemicals triggered an allergic reaction. To avoid the reaction she had to avoid the chemicals. Her career as a practising radiographer was over.

The Accident Compensation Corporation accepted Marjorie Gordon's claim in just six weeks, entitling her to earnings-related compensation of 80 per cent of her salary, now $380 a week net after inflation adjustments. She believes she was the first radiographer in the world to have such a claim accepted as personal injury by accident. It meant she also had the time to find out what had caused her problem. She won a seat on the Palmerston North Hospital Board and used the hospital library's computer to scan data bases worldwide seeking clues. The computer spat out one likely paper, Reactions to Glutaraldehyde [in] Radiologists and X-ray Technicians, by an American dermatologist, Alexander Fisher. It mentioned a survey by a University of Wisconsin radiologist, Robert Zach. Radiologists are the doctors who interpret the x-rays taken by radiographers. Zach believed a chemical called glutaraldehyde was responsible for dermatitis and respiratory problems in people who handled x-ray film. He wanted to find how widespread the problem was.

"I didn't know what glutaraldehyde was when I read that," recalls Gordon. "But I looked up my Agfa product information and, sure enough, there it was as an ingredient in the developing solution."

She phoned Zach, who told her he'd sent survey forms to 2000 radiologists and had got 400 replies when, abruptly, the university authorities closed down his research programme for fear of upsetting photographic and chemical companies which donated money to the university.

Glutaraldehyde is similar to formaldehyde, the latter a well-known chemical widely used as a disinfectant and preservative. Although glutaraldehyde is a known irritant of the skin and respiratory tract, it is regarded as the safer, because unlike formaldehyde it is not a cancer causing agent. It is a colourless crystal which forms a colourless liquid when mixed in water.

Marjorie Gordon discovered glutaraldehyde has many uses - in embalming fluids, in laundry fabric softeners, wallpaper hardener and in the tanning of animal hides. It kills germs and bacteria, so it is used as a biocide in air-conditioning systems and it is very widely used as a cold sterilising solution for surgical instruments in hospitals and in doctors', dentists' and veterinarians' surgeries.

More to the point for Gordon, she found it was used as a hardening agent both in x-ray film and the x-ray developing solution. She discovered it was first used for these products in 1967, when automatic processing machines were introduced. The developer in the machines needed to be at a much higher temperature than with the old manual processing methods, and it was found the heat caused the photographic emulsion to drop off the film. Glutaraldehyde was added to both the emulsion and the developer to prevent this happening.

No single company has a monopoly on glutaraldehyde. All the major photographic companies, including Agfa and Kodak, use it in their developers. Numerous chemical companies use it in their many and varied products. It is regarded as an unremarkable but versatile chemical.

So glutaraldehyde had been around in x-ray dark-rooms since 1967. But the health problems Gordon was discovering in radiographers virtually worldwide had surfaced only in the early 1980s. Why the delay? Her own problems had begun when the Otaki clinic got its automatic processor, but other radiographers had used the machines for years before falling ill.

For Gordon, the clincher was discovering the proportion of glutaraldehyde had been increased significantly in 1980. That year, there was a "silver crisis". Silver is one of the main ingredients of photographic film emulsion. In 1980, a shortage caused the price to rocket. Photographic companies responded by reducing the amount of silver in the emulsion. To compensate, they had to raise the amount of glutaraldehyde.

Thus the innocent progression of technology led to unexpected hazards. First came the automatic processors, then glutaraldehyde, then more glutaraldehyde to make up for the reduction in silver. But nobody thought to consider whether there'd be any health problems.

Ten years on, it's generally accepted that Marjorie Gordon got it right, but she faced widespread scepticism at first and it hasn't all gone away. The chemical manufacturers denied there were problems. Many health professionals equally doubted her. How could she explain the fact that only some radiographers experienced health problems, while most appeared well, despite exposure to the same chemicals?

One explanation for the latter is that not everyone will be-come sensitised to a particular chemical, just as only a minority of the population reacts badly to a bee sting. Often the first bee sting won't seriously harm an allergic person, but the second or third might kill them. Likewise, a reaction to a toxic chemical can take time to develop. Some overseas studies suggest that perhaps five per cent of people exposed to "safe" levels of glutaraldehyde will become sensitised, though many more exposed to high levels will develop irritations of the skin, mouth and throat.

It's also likely that glutaraldehyde is only one of many chemicals in a complex mix of ingredients that is causing ill-health, but Gordon and many others are convinced it's the rnajor problem.

Part of the difficulty Gordon had getting taken seriously was the fact she was a woman - a grandmother at that - on an obscure crusade in a profession overwhelmingly dominated by women. The National Women's Hospital debacle was far from alone in proving women's health issues have not always been taken seriously.

The great majority of the 1000 radiographers working in New Zealand today are women, though that is slowly changing - a quarter of the radiography students at present sitting polytech courses are men. Once they were virtually all women. Until formal radiography courses began in 1946, the year before Gordon began her training, the job was done by nurses who'd acquired a familiarity with x-ray machines.

According to Christchurch radiographer Shirley Laws, president of the Institute of Medical Radiation Technologists, many radiographers in the past probably didn't stay in the job long enough to become sensitised to chemicals. "A lot of them left after a few years to have their families," says Laws. 'These days, though, they're staying in the workforce longer, or not even leaving it, or returning to work much sooner after having children, so problems are showing up."

One glutaraldehyde victim, Margaret Mulligan, the charge radiographer at Dunstan Hospital in Clyde, Central Otago, says some health authorities ignored the problem because the complainants were women. "In Dunedin, one of our girls was having problems in the cat-scan unit," says Mulligan. "They took no heed of her. Then an engineer, a man, had an asthma attack there and they checked things out. They discovered the ducting was wrong. I'm not talking about years ago here. It was six or eight months ago."

Whangarei radiographer Marjan Creusen-Foot's doctor initially said her symptoms of memory loss, irritability, hoarseness, pain in the joints and general weakness were signs of early menopause - a good decade early!

Early in her crusade, Marjorie Gordon began writing scholarly papers for medical journals and giving lectures here and overseas on the need for better darkroom safety precautions. She approached Massey University. Two of its researchers did a survey of radiographers which showed a correlation between ill-health and the chemicals they worked with.

Much more work was needed, but she was convinced some-thing had to be done to alert radiographers to the problem. In December 1984 she accompanied the Massey researchers to the Health Department in Wellington to argue a case before a boardroom full of senior health officials including the then director of public health, John Stokes.

"For one-and-a-half hours those doctors tried to tear me apart," she says. "But I had no reason to make anything up, nothing to lose. At morning tea they told me I'd convinced them. They went on to send a warning about glutaraldehyde to all hospitals."

Gordon next asked the Health Department to write guidelines on the safe use of x-ray processing equipment. The department promptly asked her to do it. She ~ and Ian Laird, a lecturer in occupational health at Massey University, prepared a draft document which ~ they sent for comment to organisations like the Health Department, the Department of Labour and the Employers' Federation. It took 13 months to complete. Gordon's son, Gilbert, a building services engineer, wrote its section on ventilation. It was published by the Accident Compensation Corporation in 1986 and immediately became an important reference work in demand locally and overseas.

In 1992, the occupational health and safety service of the Labour Department relied heavily on Marjorie Gordon's work when it published new guidelines for the safe use of glutaraldehyde in the health industries. Nobody regards her as some half-batty grandmother now.

These days the hazards of x-ray darkrooms are well known. The 1992 Labour Department guidelines for safe work practice require adequate ventilation and fume extraction, including exhaust hoods and extraction systems for processing machines and chemical mixing equipment. Protective gear including respirators to guard against glutaraldehyde fumes is prescribed for certain conditions. There are strict limits on the acceptable level of glutaraldehyde fumes.

All this is thanks to Marjorie Gordon's work and there probably isn't a radiographer in the country who doesn't know of her or who isn't grateful to her. She is one of the unsung community heroes who' ve helped to make New Zealand a better place for their fellow citizens.

Given the body of knowledge about the dangers, and the published guidelines, it's surprising that radiographers (and increasing numbers of other health workers, such as nurses) are still being exposed to unacceptable levels of fumes and chemicals, sometimes by mistakes in the maintenance or installation of darkroom equipment.

Northland is just one region where hospital x-ray staff have had serious problems in recent years. Three radiographers are still off work as a result of exposure to fumes from faulty equipment at Kaitaia and Whangarei hospitals three years ago.

In a test case being watched with interest by radiographers around the country, Marjan Creusen-Foot is suing Northland Health Ltd, the crown health enterprise (CHE) that runs Whangarei Hospital, for $150,000 in exemplary damages over exposure to glutaraldehyde fumes that has left her so sensitised to a variety of environmental pollutants she is finding it hard to get a job doing anything at all, let alone return to the job she loved.

Marjan (pronounced Marian - it's Dutch, she was born in the Netherlands) Creusen-Foot trained as a radiographer 26 years ago, when she was 18. She moved to Whangarei from Wellington in mid-1989 to be with the man she was to marry. She took a job at Whangarei Hospital, where she was subsequently promoted to manage the hospital's new state-of-the-art CT scanner.

The CT suite was opened in February 1991 Staff there soon complained about the temperature and fumes. Over many months, Creusen-Foot developed memory losses, a granuloma on her vocal chords, crippling pains in her joints and other alarming symptoms.

"I was constantly sick and no one could pinpoint what was wrong because the symptoms were so odd," she says. "My GP said it was probably premature menopause - I don't blame him for that, because the symptoms were the same."

She didn't realise her illness might be linked to the fumes until November 1991, after her husband-to-be, Ian, took her on a three-week South Island holiday and her health improved immediately: "As soon as I got back to work, I was ill again in hours. It was the first time it clicked it might have been work related."

Creusen-Foot then complained very loudly about the fumes. She was seen by Eunice Nutman, the hospital's occupational health nurse who told her she was very ill. She was referred to a doctor who told her to stop work.

The hospital authorities immediately had the air-conditioning equipment in the CT suite ripped out and replaced.

According to a subsequent investigation by engineer Stan Saw, the hospital's director of physical resources, that quick action was commendable but meant it became impossible to measure the level of toxic fumes in the CT suite prior to the modifications.

Stan Saw's 11-page report, completed in February 1992, found the cause of the fumes which led to Marjan Creusen-Foot's illness was "the ineffective air-extraction system". Contributing factors were "the omission of professional advice for the air-extraction system design... the absence of commissioning and acceptance tests of the extraction system after its installation [and] the failure to act on complaints raised by staff following occupation of the CT suite."

It was not as if the hospital authorities were ignorant of the dangers. Saw's report notes that the safe working practice guidelines Marjorie Gordon wrote for the Health Department and ACC in 1986 were used as a reference when the CT suite was being designed.

After being forced to stop work, Marjan took six months' leave. During that time she got married, her health improved significantly and she decided to resume work in May 1992.

"I was feeling really good and excited about going back to work. It was the only way to find out if I'd been sensitised. I had to expose myself to the environment again."

Though the fumes were no longer a problem in the rebuilt CT suite, even the much lesser exposure to chemicals and fumes was too much. She quickly fell ill again and was forced to leave work permanently after four weeks. The ACC accepted she had suffered a work-related accident caused by exposure to toxic fumes which caused glutaraldehyde sensitivity. It has paid her weekly compensation since.

"I loved my job. If they could change the chemicals I would go back tomorrow. The hardest thing has been trying to find another job. I'm too highly trained. I've applied for work as a doctor's receptionist but they fear it wouldn't be stimulating enough for me and the pay would be much lower. I'm 44 and on ACC. Who wants someone at 44?"

Her health has been slowly improving. She's had therapy for the problem with her vocal chords but her voice appears to have changed irrevocably. Her hair is still a lot thinner than it was. She will always need medication for her joint pains and she can no longer wear contact lenses because they now irritate her eyes. She's been left sensitive to a wide range of chemicals, not just darkroom ones - even air conditioning can make her ill.

"My husband is a professional photographer but we can't have a darkroom in the house because of the chemicals. My son can't paint in the house for the same reason. Basically it causes brain damage. I'm like a glue-sniffer now."

Her court action against the hospital is a test case because the accident compensation laws make it almost impossible to sue for damages in such instances. It's costing her a lot of money and there's no guarantee she will win, or even get enough to cover her legal expenses if she does. "I'm doing it because I think it's really important to make a stand and say, 'Hey, employers have to be more careful how they look after their staff.' I'm doing it to bring attention to the problems radiographers have with the chemicals we work with. Even if I don't win, I will still expose in court what happened."

As this went to press, no date had been set for a court hearing. Northland Health Ltd has filed papers with the Whangarei District Court, where the case will be heard, denying Marjan Creusen-Foot's claim that its negligence caused her to suffer personal injury by accident through being exposed to toxic fumes.

A decade after Marjorie Gordon first identified glutaraldehyde as a health risk for radiographers, not much progress has been made eliminating the chemical from hospital darkrooms. In the same period, its use as a cold sterilising solution has risen sharply, partly in response to the AIDS epidemic (glutaraldehyde efficiently kills the HIV virus) and partly because of the huge increase in non-invasive endoscopy techniques such as laparascopes, in which thin, flexible tubes are guided by a tiny camera through the body via the mouth or a small incision. Dunstan Hospital has been using a glutaraldehyde-free developer from the British firm Photosol for two years now. Dunedin Hospital began a major trial of a new glutaraldehyde-free Kodak product during September. As far as is known, no other New Zealand hospital has so far followed their lead.

Dunstan Hospital chief radiographer Margaret Mulligan is one of several staff there who became sensitised to glutaraldehyde. Her predecessor had to retire because of glutaraldehyde poisoning and two years ago Mulligan feared she would have to follow.

"The first time it hit me I thought I was having a heart attack," says Mulligan. "There was a tightness in my chest and I couldn't breath. Then I realised what it was and got away from the source."

Mulligan had to stop work for a time. The hospital manager was supportive but wanted proof similar problems were happening elsewhere. They surveyed a dozen other hospitals at random and discovered the problem was indeed widespread. And Mulligan contacted Marjorie Gordon, who told her about Photosol.

In 1984, while back in Britain for another radiology conference, Gordon had met Photosol director Geoff Care, whose company made x-ray chemicals. They discussed the problems then becoming apparent with radiographers and he decided to produce a glutaraldehyde-free developer, now known as CD77. Curiously, it has never been actively marketed in New Zealand.

After talking to Marjorie Gordon, Mulligan rang Photosol in Britain herself and ordered the product. Dunstan Hospital has been using it successfully for two years.

"Photosol also manufactures a fixer with less sulphur dioxide [an-other problem chemical]. If you use both glutaraldehyde-free developer and a low sulphur dioxide fixer it's better still. We also have new, better ventilation now - we've totally enclosed the [processing] machine to keep the fumes in."

Mulligan, of course, was sensitised to glutaraldehyde which puts her at continuous risk of an allergic reaction. She and another affected Dunstan radiographer, Helen Walker, recently went to Christchurch to undergo a novel chemical detoxification course based on a Texas system that has been around for about four years.

The Christchurch course is run by Ted Pearson, a GP with an interest in alternative medicine, and takes a minimum of 10 days. Each morning, Mulligan and Walker worked out on a trampoline and rowing machine, then took a dose of niacin (a B-group vitamin) before spending several hours in a sauna with the aim of sweating out the toxins from their systems.

Pearson runs the course with the help of a nurse, Penny Clifford, who contracted glutaraldehyde sensitivity four years ago while working in the Christchurch Hospital radiology department.

"Penny used to have all kinds of problems," says Mulligan. "Two years ago she was awful. I couldn't get over how well she looks now she's had this treatment." Mulligan says she won't know for a couple of months how effective the course was. That's the minimum it takes to show results.

Dunedin Hospital is one of the first outside Japan to use a new Kodak x-ray system, called Rapid Access, which employs a special pre-hardened film that's enabled taking the hardening agent - glutaraldehyde - out of the process. The product was designed not for safety reasons but for new ultra-fast processing machines in Japanese hospitals which develop an x-ray film in 45 seconds, half the time of the latest ordinary machines.

According to Liz Holland, Dunedin Hospital's radiology ~ manager, two staff there have had to quit because of glutaraldehyde poisoning and two others are showing sensitivity "~ symptoms and must stay away from the processing area. "It's of real concern to us here," Holland says. "We set up a health and safety group in 1991-92 because of our concern. Our main focus was to glean as much information as we could. Each year we go out to tender for films and chemicals. This year, Kodak put in an offer for their new system. I took their offer to our health and safety group and said we could be the first hospital in New Zealand to try out these new chemicals. "It meant some changes in our working practices and it's expensive - about eight per cent more than our current product, or $35,000 to $40,000 a year. That equals the salary of a qualified radiographer, and my staff are worth more than that." Holland says the Kodak system has two other health benefits. It's free of acetic acid, another worrying chemical, and the processing machines can run at a lower temperature, which will reduce the risk from fumes as less solution will evaporate. Both Dunedin and Dunstan hospitals are owned by the same CHE, Healthcare Otago, which raises the question why Dunedin Hospital hadn't already switched to the Photosol system used at Dunstan

Liz Holland says Photosol's CD77 was trialled at Dunedin last year but the chemicals broke down too often. That hasn't happened at Dunstan. Holland says the cause was put down to the much greater volume of x-rays at Dunedin. At Dunstan, however; Margaret Mulligan says she doesn't think Dunedin Hospital gave Photosol a long enough trial.

Holland says Dunedin has contracted to use the new Kodak system for a three-year trial, which the company will help to monitor. if it proves unsatisfactory, the hospital can opt out earlier.

"I believe glutaraldehyde is only one factor in the health problems we've been seeing," says Holland. "I believe the overall problem is caused by the cocktail of chemicals used in film processing coupled with the higher temperatures in automatic processing machines.

'But I'm pleased we are trialling this new chemistry. With the provisions of the new Health and Safety in Employment Act [which puts stringent requirements on employers to maintain safe workplaces], I don't see how any hospital can ignore this new system if it works for us."

The Health Industry doesn't deserve its healthy image, says John Heydon, Healthcare Otago's occupational health physician. Chemicals like glutaraldehyde are only one problem. He says health workers suffer inordinately from infections (including contracting hepatitis B from needlestick injuries), stress and back injuries as well as chemicals.

"People are unaware of the sheer numbers of chemicals in this industry," says Heydon. "In radiology there is a whole cocktail of chemicals. Everyone's been going on about glutaraldehyde, but you have all these other active chemicals too, and some of them are also sensitisers."

Heydon says great care needs to be taken with glutaraldehyde and adds its use has increased in some areas, like sterilising, because it is able to kill the Hw virus.

"People want to be sure the steriliser they use is very effective. With endoscopy equipment, you have to use a cold steriliser because it can't take heat sterilising. With the worry about HIV, the amount of glutaraldehyde in the steriliser was doubled, from one per cent to two per cent. Laparoscopy is a very popular technique now, so the arnount of glutaraldehyde sloshing around is going up."

The latter probably explains why nurses are now showing the kind of glutaraldehyde-related health problems radiographers began coming down with a decade ago.

Bill Glass, associate professor of occupational health at the Gtago University medical school, has become an acknowledged international authority on glutaraldehyde poisoning since coming across the case of the ill Christchurch nurse, Penny Clifford, four years ago. He has acted as an expert adviser in a number of compensation claims in this country as well as one in Perth, Australia.

"Penny Clifford was the first I'd seen," says Glass. "That got me interested. Then I started to get referrals from all over -from Kew Hospital at Invercargill, from GPs in Dunedin, then Whangarei, Central Otago and Wanganui. I've probably seen 20 or 25 altogether."

He says the problem began with radiographers but has now spread to other health workers, such as hospital nurses and GPs' practice nurses who come in contact with glutaraldehyde in cold sterilising solutions. He knows of cases where health workers have developed chemical sensitivity after using glutaraldehyde steriliser overzealously marketed as spray-and-wipe cleaner.

Glass says glutaraldehyde is like many chemicals - it is potentially dangerous, but the danger remains potential until it's misused or used in confined spaces. The danger depends on the level of exposure to it.

"The problems are known internationally and they've been well reported, but being known in medical journals doesn't mean they're known to GPs or hospital managers or users. It's a long process educating everyone."

He accepts there's still scepticism about the danger but says the sceptics are ostriches: "Conservative doctors question why everyone using glutaraldehyde doesn't have a problem. Well, if you let a flu germ free in a bus, not everyone will get the flu. Everyone's response is individual.

"Glutaraldehyde is an irritant on the upper respiratory tract and provokes allergies there and on the skin. The real problems begin with the one or two people who move from getting the more general response to sensitivity - this is where the sceptics come in. Some say it's all in the mind.

"A lot of doctors when confronted with someone who's ill don't take histories of the things their patient is exposed to at work. They tend to be sceptical about work as a cause of illness. But when you look at it logically, people spend eight or 10 hours a day at work and it would be surprising if work wasn't a cause of many illnesses."

Marjorie Gordon has won a lot of battles but she's still nowhere near ready to give up the war. She has been working with Eunice Nutman, the occupational health nurse at Whangarei Hospital who first realised how ill Marjan Creusen-Foot was. They want to see a simple blood test developed that will show with certainty whether someone is sensitised to glutaraldehyde.

At present there is no such test. The lack of one is a major reason for the lingering scepticism in some medical and scientific quarters about the dangers of glutaraldehyde.

Nutman found a scientific paper about Alan Broughton, a medical researcher at a laboratory in Santa Ana, California. Broughton had devised a sensitivity test for formaldehyde. Gordon wrote to him to ask if he could devise one for glutaraldehyde and he responded positively. Nutman sent him blood samples from Northland health workers. They're still waiting for an outcome.

"The idea is to test all the radiographers in New Zealand to see who is sensitised to glutaraldehyde," says Gordon. "That is my goal." The test would identify which radiographers were at risk, as well as proving once and for all whether glutaraldehyde is the cause of health problems in radiographers.

Gordon tried to set up a survey of radiographers in 1988, taking blood samples to test for raised antibody levels - that is, simple allergic reactions. But it fell foul of ethical considerations in the wake of the National Women's Hospital scandal.

Eunice Nutman did similar blood tests on Northland radiology staff in 1992 after the problems there. She found elevated antibody levels in 19 of 38 staff, or 50 per cent, when such reactions are usually found in just 20 per cent of the population at large.

Marjorie Gordon tires easily. Twice during a day-long interview she talks of slowing down when she turns 65 in December and the accident compensation payments that have helped to pay for her work for the past decade stop. But then she remembers all the other lines of inquiry she has to pursue.

"It's sheer persistence which keeps me going, really," she says. "You need good health to get the energy to do all this and I haven't got it."

Gordon's chemical sensitivity is so great and her health so bad she has been unable to work since going on accident compensation more than a decade ago. In between debilitating bouts of sickness, she's carried on her campaign from the home and market garden she and her husband, Bill (who died in 1990), bought in 1954 on the hillside above the tiny village of Manakau, south of Levin. The land is becoming unmanageable for someone in her condition; she'll probably sell most of it soon.

"There is a lot to do," she says. "Though it was known by 1908 that x-rays were hazardous, it took until 1958 before regulations were laid down for their use. We've known for 10 years now that glutaraldehyde is hazardous, but all we've got so far are guidelines. I wouldn't want it to take another 50 years to get stronger controls."