A Brief History
Servire ac Docere
Royal Adelaide Hospital 1840-1990
The late J. Estcourt Hughes
Emeritus Surgeon, RAH
On 15 July 1840, Lieutenant-Colonel George Gawler, Governor of South Australia, laid the foundation-stone of the first building to be called the Adelaide Hospital. This has been regarded as the hospital's Foundation Day, although the first patients were not admitted until January, or possibly February, 1841. Since then, the hospital has had a continuous record of service to the people of Adelaide and South Australia and it is pleasing to know that this achievement will be suitably commemorated in 1990.
This brief account of the origins and development of the hospital has been written at the request of the committee responsible for the sesquicentenary celebrations, for the information of those who are not acquainted with the history of the hospital, and it will also attempt to describe the problems of establishing and maintaining a hospital service in South Australia.
The title Servire ac Docere was chosen for this article, not in an attempt to confuse those who might read it, but because these words are the motto on the hospital's coat-of-arms, and state in the briefest possible way, the main functions of the institution, namely to succour the sick and to act as a place of instruction for nurses, medical students and others, matters which will be dealt with in what follows.
The suggestion that a colony should be established on the southern coast of Australia was originally made by a group of people meeting in London. They were interested in the 'systematic colonization' theories of Edward Gibbon Wakefield, and hoped to set up in this remote area, a community in which religious and personal freedom would be assured, and where there would be an opportunity for advancement for those who were prepared to work hard, conditions which they believed were not to be found in Britain at that time. Control of the sale and price of land so that it would be available to all was an essential feature of their plan.
In 1833 the supporters of this project formed the South Australian Association, which on 15 August, 1834, managed to have the South Australian Act passed through the British Parliament. Under this Act, the control of the proposed colony was in the hands of the Colonial Office, which was authorized to act through a 'Board of Colonization Commissioners for South Australia', and various financial restraints were imposed to ensure that the colony did not become a burden on the Home Government. These penny-pinching provisions were unfortunate and were responsible for a lot of trouble later on. Between them, the Colonial Office and the Colonization Commissioners selected a group of officials to go to South Australia, and by an injudicious division of authority between the Governor, Captain John Hindmarsh, and the Resident Commissioner, Mr James Hurtle Fisher, sowed the seeds of endless discord as long as these two men held office. The remainder of the officials were an ill-assorted group in every respect, including ability, personality and religious and political beliefs, and they certainly did nothing to promote harmony in the new settlement. One successful appointment, however, was that of Colonel William Light who, as Surveyor General, was given a clear mandate from the Commissioners to select the site for a capital and to plan the layout of a future city.
It was not until 28 December, 1836 that Captain John Hindmarsh, RN, the Governor, and the official party arrived at Holdfast Bay in St Vincent Gulf, in the old naval transport, HMS Buffalo. During the five months taken by the voyage from England, mutual antipathy had developed between Hindmarsh and Fisher, and, from the start, this hostility prevented their proper cooperation and promoted the development of friction and discord in the colony.
One of the officials who did not come out with the main party was the Colonial Surgeon, Dr Thomas Young Cotter, who arrived on 12 January, 1837. His appointment was the only evidence of any planning for medical services in the colony, but his list of duties was a long one, and his remuneration a princely £100 a year. Immediately on his arrival, he found himself involved in the need to provide care and accommodation for sick and indigent colonists, and it was through his efforts that the Colonial Infirmary was established. The story of this institution is a sad and sorry one, but it was Adelaide's first attempt at what might be called a hospital, and must be regarded as a lineal antecedent of the Royal Adelaide Hospital.
In his approach to the authorities Dr Cotter described how three of his newly acquired patients were camped under an old sail, which gave no protection from the weather; his patients were receiving neither food nor attention. Their surroundings were filthy and they depended for relief on the charity of passers-by. The authorities were not unsympathetic, but their resources, both financial and material, were so limited, that they could do no more than rent a hut, eighteen feet by twelve feet, to provide shelter, and thus the Colonial Infirmary was born. This hovel, for it was nothing more, was situated on or adjacent to North Terrace, close to where Holy Trinity Church now stands. This interim arrangement ended in May, 1837, with the purchase of a 'small thatched cottage' for £71.3.9. This was also on North Terrace towards its western end. Even this modest expenditure was criticised as extravagant, and what was worse, Dr Cotter was not satisfied and complained that, like its predecessor, it was uninhabitable, one major defect being that the roof leaked so freely that the floor was constantly awash in wet weather. There was no space for cooking and no privy, while basic supplies of all sorts were in incredibly short supply. Public concern about conditions at the Infirmary led to criticism in the newspaper, The Register, which led to the appointment of a Board of Management. Even with the guidance of this Board, the old Infirmary hut was not abandoned until December, 1839, when it was moved to a building in Immigration Square in the West Parklands, close to where Adelaide High School now stands. It remained there until the first Adelaide Hospital was ready for occupation in January, 1841. Dr Cotter, who was suspended in December, 1838 for alleged neglect of his duties, was reinstated in April, 1839 with an increase in salary to £200 a year, plus three shillings a day for a horse, but two months later he was again suspended, and Dr James George Nash took his place as Colonial Surgeon. During the controversy about the Colonial Infirmary, the Colonial Office in London grew weary of the constant bickering between Hindmarsh and Fisher, and in May, 1838, recalled Hindmarsh and dismissed Fisher. The former returned to England where he eventually became a rear-admiral and was knighted, but Fisher stayed in South Australia, had a distinguished career in public life, and like his old enemy, was knighted.
The new Governor was Lieutenant-Colonel George Gawler, a soldier with a fine record, who unfortunately lacked the administrative skills required by his new appointment. When he arrived in South Australia, the colonial treasury was in a parlous state and economic conditions in general were poor. He was forced to undertake various public works to relieve unemployment, and one of the most pressing problems he faced was the provision of a replacement for the Colonial Infirmary. He espoused this cause with enthusiasm, and proposed to use £300 which was at his disposal for charitable purposes, as the nucleus of a fund to build a hospital. He invited the public to contribute to this fund, but although the population of Adelaide had risen to 8,500, only £300 was derived from this source. Governor Gawler, realizing that public money would have to be provided to build the hospital, went ahead, and finally had to draw bills on the United Kingdom Treasury to meet the cost of this and other public works, a method of financing which eventually proved his undoing.
Plans for the building were prepared, a site selected, and a contractor appointed towards the end of 1839. The tender for the work was £2,260. The site chosen was in the parklands to the north of Botanic Road and near Hackney Road, and was considered a better one than that proposed by Colonel Light, who had died on 6 October, 1839. The construction work was sufficiently advanced by the Governor to lay the foundation stone on 15 July, 1840 [sic]. The residents of Adelaide showed as little interest in this function as they had in subscribing to the cost of the building, but the small attendance was attributed, rather apologetically, to the distance from the city and the inclement weather. When completed, the building provided accommodation for thirty patients in three wards, two rooms for staff and a central room which served as required, as front hall, dining room, boardroom and operating theatre.
One storage omission was that there was no kitchen. When attention was drawn to this deficiency in June, 1841, the Board agreed to provide 'a small place for wood and culinary materials', but declined, on grounds of expense, to appoint a male cook, who, it was suggested, could also act as handyman.
The exact date of the opening of the hospital is not known, but it was in either January or February 1841. Possibly discouraged by the small attendance at the laying of the foundation stone, no official ceremony marked the occasion. Over the years, many additions and alterations were made to the building, and after the second Adelaide Hospital was built on North Terrace in 1856, the older building was used to increase accommodation in the Lunatic Asylum, which was nearby, but it ultimately returned to the Adelaide Hospital as the Consumptive Home and Cancer Block. It was closed in 1931 and demolished in 1938.
When the first Adelaide Hospital was opened, the authorities hoped that it would meet the needs of the community for many years, but by 1850 the growing population was already making it inadequate. It was decided that a new hospital would be needed, and the site chosen for it was the front section of the extensive area which the Royal Adelaide Hospital occupies today. In 1851, however, the colony went through a most difficult time as the result of the discovery of gold in Victoria. This led to an exodus to the goldfields of a large number of the male inhabitants, who, in order to meet their expenses, withdrew a considerable amount in gold coins from the Adelaide banks. This seriously affected the banks and the economy as a whole, and it took firm action on the part of the Governor, Sir Henry Edward Fox Young, who fortunately had available to him a group of competent advisers, to bring it back on course. The goldrush and its complications probably explain why work on the new hospital was not commenced until 1855. The contractor, Mr Charles Farr, was paid £680 for work on the foundations, and a further £13,512.17.6 for building the central block and the west wing of the new hospital. This was completed in September, 1856, and Dr William Gosse who, as Acting Colonial Surgeon, was to take charge of it, was notified. The west wing contained eight wards, four on each floor, and the central block, a surgery, a dispensary and quarters for the house surgeon. The east wing was built in 1866-67 and provided four extra wards, two on each floor, some bedrooms, some padded rooms, and a nurses' dining room, which also did duty as a chapel.
Additions were made to the central block in 1857 and 1863, while in 1858, a boilerhouse, kitchen, drug store and mortuary were built. From here on, it is beyond the scope of this article to describe all the changes which were made to the buildings which made up the hospital, but we find that in 1891 and 1892, a new operating theatre block and a two storey wing containing two large wards were added, and were hopefully referred to as the nucleus of a new hospital. While the increasing population was one important reason for extending the hospital, another was that the whole face of medicine was changing and the hospital had to change to meet the new conditions.
When the first Adelaide Hospital was opened, anaesthesia was not yet available to medical practice, and when its successor was opened in 1856, Lister's epoch-making work on antiseptic in surgery was still a decade away. The discovery of X-rays in 1895, and the continuous advance of radiology and radiotherapy since then have necessitated the installation of equipment for which accommodation has had to be provided. Pathology, to take just one other example, has made tremendous advances also, and has demanded increasing space and facilities, culminating in the foundation of the Institute of Medical and Veterinary Science in 1938. When the rebuilding of the Royal Adelaide Hospital was under discussion in the 1950s, there was a total of forty-seven buildings on the site and there were thirty-two wards in the hospital. It has been said that between 1856 and the 'great demolition' of 1963, no building in the hospital had been discarded until the last ounce of use had been extracted from it.
By 1950 it became apparent that the demands of the hospital had increased to such a degree that the number of beds available was inadequate, and that the condition of the buildings and services in the older parts of the hospital were unacceptable by modern standards. Surveys were carried out from 1950, and showed that general surgery, the surgery of trauma, and the investigations and treatment of patients suffering from malignant disease, were principal causes of the increases in the workload. The length of the waiting lists was also causing concern, and does not seem to have been resolved satisfactorily even today.
Although an extensive rebuilding of the Hospital was regarded as inevitable, no coherent plan for this existed, but all those concerned with the problem, realized that the first step would have to be the provision of accommodation for patients while the rebuilding took place. Naturally, many interests were involved in the discussion about so large a project. These included the Government, the Public Buildings Department, the Public Works Standing Committee, the Board of Management of the hospital and its administrative staff, the honorary staff of the hospital, the university and the British Medical Association, and it was difficult to achieve agreement between these diverse bodies as to what should be done. The press also became involved, and at intervals articles critical of the lack of action were published.
The first move of importance was to build the new East Wing, which would accommodate the Radiotherapy Department, and provide five floors of wards to take patients during the rebuilding. Contracts for this were let in August, 1958 and it was opened in July, 1962.
In an attempt to get something done, a Building Advisory Committee was formed in 1957, with members representing the Hospital Board, the honorary staff and the University of Adelaide. This committee did a tremendous lot of work, although it often found that it was harassed by cross currents of advice which cut across the mainstream of its planning, but it received a most valuable collaborator when the first Administrator of the Royal Adelaide Hospital was appointed in February, 1959.
By 1961 several plans had been prepared and abandoned, although a general consensus regarding the administrative, medical and teaching requirements of a new building had been reached, and a feeling of frustration was creeping into the discussions.
In November, 1961, the honorary staff protested that, after years of effort on the part of a great many people, rebuilding plans were bogged down by indecision and procrastination, and it asked the government for an immediate statement of its policy, but it was not satisfied with the answers it received.
The British Medical Association entered the field with a request for extensive changes to the authority of the hospital's Board of Management, a matter which had been brought up several times, while the chairman of the Public Works Standing Committee denied that it had been responsible for undue delay in bringing the rebuilding to fruition.
In February, 1962 a new plan which provided 1,128 beds was presented. It suggested a series of buildings, each with its special function, and it was thought that this would allow earlier occupation of the buildings than if one all-inclusive block were built. The buildings envisaged were a services block, with administration, casualty and outpatient and theatre sections; a ward block, the North Wing; and the staff block, later named the Nurses' Residential Wing. The cost was estimated at £8 million. It was feared that any criticism of this plan would lead to further indefinite postponement of the venture, and so it was accepted, with the honorary staff pledging full cooperation. At long last the final hurdle had been cleared, and in 1963 the 'great demolition' of the old buildings began. A number of buildings were not demolished, but were left for refurbishment and conversion later. The new buildings were occupied progressively between 1966 and 1969.
The foregoing account of what happened to the bricks and mortar of the Royal Adelaide Hospital might appear at first to be a record of improvisation and delay, and it would be easy to accuse those responsible of lack of vision or lack of courage, and successive governments of parsimony and a disregard for health matters. These accusations, however, would be largely unjust, because as has already been pointed out, these have been times when there was a genuine shortage of money, as well as times of war and economic stress, which have acted as powerful brakes on various schemes, more or less ambitious, for improving the Hospital.
We may now look at the important matter of the administration of the hospital. A Board of Management had been appointed to try to do something about the deplorable Colonial Infirmary, and when the first Adelaide Hospital was opened, a Board of Management was appointed to manage its affairs. This Board had three government and three non-government members, but was soon doubled in size. Almost immediately it struck trouble; first because the Honorary Medical Officers appointed to the hospital sought representation on the Board, and when their request was refused, all but one of them resigned, and secondly, because of the government's objection to an account rendered by the Board for services to members of government departments. Rather unwillingly, the government eventually agreed to pay the bill which was for £167.3.6, but announced that it would dispense with the services of the Board, and the Colonial Surgeon, Dr J.G. Nash, would take charge of the hospital. It appears very likely that, although not officially appointed, various private practitioners helped the Colonial Surgeon in the execution of his duties.
In 1864 because of certain complaints and allegations against the hospital, a Commission was set up to enquire into the management of the institution in general, to determine whether it was being imposed upon by people who sought gratuitous treatment when they could well afford to pay, and whether a system of Honorary Medical Officers should be restored. When, following the Commissioner's report, the Hospitals Act of 1867 was passed, a Board of Management was re-established, and, in one form or another, has been part of the hospital scene ever since. The Act decreed that the Board should be appointed annually, and that it should be made up of 'any number of medical practitioners or others as shall be determined'. Further legislation in 1884 set the membership of the Board at sixteen, with not more than eight doctors, of whom not more than three should be members of the honorary staff. The University of Adelaide, no doubt because of the imminent opening of the Medical School, and the Commissioners of the Adelaide Hospital, were each to appoint a member.
From 1896 to 1921, female members served on the Board, but in the latter year, the Hospital Amended Act established the three member Boards, and no woman was appointed to one of these until 1957, when to the delight of several feminist organizations, Miss D. Carroll, Matron of the Queen Victoria Hospital, was appointed.
At various times between 1867 and 1921, the Board made use of sub-committees to help in its work. One of these, the Medical Committee, was responsible, inter alia, for making recommendations regarding appointments to the honorary staff. The fact that a Board, composed partly of laymen, should have a final say in this matter was, to say the least of it, unsatisfactory, but the practice prevailed until the Act of 1921 resulted in the creation of the Advisory Committee of the University of Adelaide and the Adelaide Hospital, which took over this important function.
In 1888 one more committee was appointed to enquire into the administration of the hospital, and it reached the conclusion that the main difficulties in the past had arisen because the hospital lacked an experienced controlling head, and it recommended the appointment of a Medical Superintendent to be the principal executive officer of the Board. Dr Robert Howell Perks MD FRCS was appointed and started duty in 1890. The position still exists under the revised system of administration, but the occupant of the office is now called the Medical Director.
The next major change in the management of the hospital came in 1959 when, as already mentioned, an administrator became the chief executive officer. For some time the relative merits of lay and medical administrators in hospitals had been a matter of debate, but the greatly increased complexity of the problems facing administrative staffs had swung the weight of opinion in favour of lay executive officers.
Another change was precipitated by the passage of the South Australian Health Commission Act in 1975. Under this legislation, the Health Commission replaced the old Hospitals Department, and the provisions were made for a new constitution for hospitals and for their incorporation, aiming at greater autonomy for them.
The Royal Adelaide Hospital was incorporated on 22 January 1979, and the three-member Board was replaced by one of nine members. This Board has made extensive use of standing committees on which Board members serve with co-opted members.
An interesting innovation was made by the Board in 1981, when it appointed the Royal Adelaide Hospital Heritage and History Committee, the functions of which are to collect and preserve historical material relating to the hospital, and to decide upon ways to commemorate important events in its past. A widely representative and enthusiastic membership has already done a great deal in pursuit of its aims. The unveiling of a plaque to mark the site of the first Adelaide Hospital, which will be a feature of the sesquicentenary celebrations, has resulted from its activities.
This appears to be a suitable point at which to record something about the Commissioners of the Adelaide Hospital, now called the Commissioners of Charitable Funds, who have been referred to earlier in this article. Over the years, many public-spirited and generous citizens have made bequests to the hospital. These have been kept apart from ordinary hospital revenue, and since 1876, the management of capital and income has been in the hands of successive boards of three Commissioners, who have been appointed under the Public Charities Act. In the exercise of their duties, they have often come to the assistance of the hospital by making available large sums for new buildings or for repairing old ones, and by providing new equipment. Most recently they have undertaken to meet the cost of all reference books and journals for the hospital's library; they have supported financially the appointment of a Visiting Professor and have funded three valuable research fellowships.
For most of its 150 years, the medical care of patients in the Royal Adelaide Hospital was in the hands of the Honorary Medical Staff. Honorary Medical Officers were appointed to the first Adelaide Hospital in 1841, and although there have been breaks in its continuity, there is no doubt that the honorary staff has made a great contribution to the hospital. At first, its only concern was with patient care, but after the opening of the Adelaide Medical School in 1885, it accepted the important additional role of providing clinical instruction to medical students. The Adelaide Hospital was the only one available for this purpose at the time, but although a number of other hospitals are now associated with the Medical School, the Royal Adelaide is still the premier teaching hospital in the state.
The first period in the history of the honorary staff, as has already been mentioned, ended with the resignation of its members, but in 1849 Honorary Medical Officers were again appointed, although changes in those involved were frequent, and little use seems to have been made of their services. In 1851 Dr J.G. Nash, the Colonial Surgeon, complained to the Colonial Secretary that the Honorary Medical Officers were interfering with the running of the hospital, and by his action caused the development of hostility between himself and the Staff, the members of which, one by one, relinquished their appointments.
In 1867 when a Board of Management took over the administration from the Colonial Surgeon, Honorary Medical Officers were reintroduced, and from then on, except for one unfortunate break, which will be referred to later, the honorary staff served the hospital until the end of 1970, when it was replaced by a paid Visiting Staff. The next landmark for the staff was established in 1882, when the members were divided into Honorary Physicians and Honorary Surgeons, and then came the opening of the Medical School, which added considerably to the prestige of the honorary staff, appointment to which, from then on, was always keenly sought.
The composition of the honorary staff changed a great deal over the years. The development of various specialties was recognized by adding appointments to the staff, and then increasing specialization, in surgery for instance, has led to the establishment of special clinics, most of them in the period after the Second World War.
I wish it were possible to say more about the honorary staff, which during its existence included some great doctors and some very talented doctors, but it must suffice to say that it had a proud history of devoted service to the hospital.
When the first Adelaide Hospital was opened, there were no trained nurses, and it has been said that the female attendants, in the absence of training, had to rely on instinct, experience and common sense. The pioneer work of Miss Florence Nightingale resulted in the establishment of the first nurses' training school in London in 1860, but it took a long time before her principles were applied in Adelaide. A detailed account of the evolution of nursing at the hospital, is beyond the scope of this article; it must suffice to say, that for many years, the Royal Adelaide Hospital has had a most competent and dedicated nursing staff, led by a succession of distinguished Directors of Nursing. The hospital has also established a fine reputation as a nurses' training school, which has constantly adjusted itself to the changing demands of its instructional program. It can be recorded, with assurance, that the medical staff has always been grateful for the skill and support of the nursing staff.
It now remains to discuss briefly the part the Royal Adelaide Hospital played in medical education in South Australia.
The University of Adelaide was established by an Act of Parliament in 1874, and in 1881 Queen Victoria issued Royal Letters Patent, which gave recognition to degrees conferred by the new University. This Act of 1874 mentioned medical degrees, but nothing was said about a medical school, and no move was made in this matter until 1881, when Edward Charles Stirling, a young South Australian, who had graduated in medicine at Cambridge and also held the diploma of FRCS England, proposed to the University Council that a lectureship in Human Physiology be established, as a first step towards providing medical education at the University. This was approved, and Stirling was appointed to the lectureship. Later he became the first Professor of Physiology at the University and remained so until 1919.
In 1883 it was suggested that, as a beginning, the subjects for the first two years of a five year course should be taught, but before the Medical School was inaugurated, it was decided that a full course would be provided, and lectures in the new school started on 17 March,1885, with six students, four of whom in 1889 became the first medical graduates of the University of Adelaide. Clinical instruction had been provided in the wards of the Adelaide Hospital, which at this time had 185 beds and was the only public hospital in Adelaide.
There has been only one break in clinical teaching at the Adelaide Hospital since it began in 1887. This hiatus was caused by the infamous 'Hospital row' of 1896-1901. Stated briefly, this lamentable affair arose from a disagreement between the government and the hospital's Board of Management, over an appointment to the nursing staff, and ended up with the resignations of the Medical Superintendent, the Matron, and the Honorary Medical Staff, which then numbered seventeen, the appointment of a Royal Commission, and worst of all, the complete disruption of clinical teaching at the hospital. This last dire result meant that in order to complete their studies the students had to transfer to Melbourne or Sydney or to go to the United Kingdom. Eventually this protracted and bitter dispute was settled and teaching was resumed in 1902.
The clinical teaching was in the hands of the honorary staff under various arrangements, culminating in the appointment of Directors of Studies in the principal subjects of Surgery, Medicine and Gynaecology and Obstetrics. These were part-time appointments, and added considerably to the work of medical people who were engaged in busy consultant practices, but they were very successful, and many have claimed that under their guidance, the clinical instructions of students reached a high water mark.
The first professor of a clinical subject in the University of Adelaide was H.N. Robson, who was appointed to the Mortlock Chair of Medicine in 1953. This inaugurated the professorial era which has firmly established itself, so that at present, the Royal Adelaide Hospital accommodates seven University Departments: Medicine, Surgery, Community Medicine, Psychiatry, Clinical Pharmacology, Anaesthesia and Intensive Care and Orthopaedic Surgery and Trauma.
Other hospitals have joined the Royal Adelaide Hospital as teaching hospitals, in association with the Adelaide Medical School, but it remains the leader in this field. The Adelaide Medical School has succeeded in the objective which the founders set themselves, in that it has produced well trained medical practitioners, many of whom have won national and international recognition. Between 1889 and 1896, the students were few in number and there were only thirty-one graduates, an average of four a year, while from 1902 to 1935, the year of the Jubilee of the Medical School, there were 409 graduates, with a yearly average of twelve. The largest number has increased steadily, and in the decade up to the school's centenary, the average was 105 graduates. In 1985 there were 661 students in the school.