The Blood Transfusion Service and Royal Adelaide Hospital

Robert Beal, Interim Director, Blood Department, International Federation of Red Cross and Red Crescent Societies, Geneva

This address was delivered at the eleventh Foundation Day Address Ceremony held at Royal Adelaide Hospital on 12 July, 1989.

It is a signal privilege that you have given me today in asking me to deliver this historical service on the occasion of the hospital’s Foundation Day Commemoration Service. As the eleventh such occasional speaker, I am honoured to be included in the list of those who have been asked to provide insights into the hospital’s history. I have titled my address ‘Lifelines’ from a text in Leviticus (17,14) which says ‘…the life of all flesh is in the blood…’.

Why do we look back on a day such as this? I offer just two reasons. First in the lucid words of the Viennese surgeon, Theodor Billroth ‘only the man who is familiar with the art and science of the past is competent to aid in its progress in the future’ while second, we look back to give thanks to God for the lives of countless thousands of men and women involved in the whole gamut of blood transfusion throughout the years.

In a relatively short address such as this, it is not possible to provide the kind of detail, essential in a definitive historical study, nor is it apposite or timely to regale you with a list of names, dates, times and places. I shall endeavour simply to highlight the important landmarks in the history of blood transfusion, in this hospital in particular, and to identify some of the unusual features of transfusion, as practised on this site, together with the changes which have occurred.

In putting these words together, I have naturally drawn on Mr Escourt Hughes’  invaluable history of the hospital, and on the Institute of Medical and Veterinary Science Fiftieth Anniversary Review, but I relied most, on a treasured twenty-seven-page document in my files entitled ‘An Anecdotal Account of the History of Blood Transfusion in South Australia’ by Dr. J A Bonnin dated November, 1984. The events of the past twenty-five years I comment upon from my personal recall however risky and potentially biased this might be.

The first experiments in blood transfusion were conducted on both sides of the English Channel in the early 1660s. Members of the Royal Society of London, among them Robert Boyle and a certain Christopher Wren, carried out exsanguination/reinfusion experiments on dogs, in a manner which would be totally unacceptable in the Britain of today. In France, the experiments went one step further, and attempted to transfuse blood from animals to man – when they succeeded against the odds, the patient, not surprisingly to us, succumbed, and the experiments were forbidden to continue. Similar bans were imposed by the Royal Society in 1668, and the Vatican in 1669. For the next 150 years, blood transfusion disappeared from the doctor’s therapeutic armamentarium.

The father of clinical blood transfusion was James Blundell, a British obstetrician, who successfully transfused a number of patients from 1818 onwards. He was renowned for his careful observation and documentation. The father of blood group serology was Karl Landsteiner, a Viennese scientist, who, in a Nobel Prize-winning career spanning forty years, discovered the ABO blood groups in 1900, the MN and P systems with Philip Levine in the late 1920s, and the Rhesus system in the early 1940s.

Warfare has played a pivotal part in shaping the history of countries and dynasties; war has certainly contributed to the extension of knowledge of transfusion practice. From World War I, or even earlier, to Vietnam, lessons learned in the field have been applied rapidly to clinical practice in civilian life.

The discovery, in 914, that the simple chemical sodium citrate stopped blood from clotting was applied first in a Canadian military hospital, in the battlefields of France, in 1916. This was the birth of the concept of blood banking.

It is generally accepted that Dr Charles Turner. Medical Superintendent, Royal Adelaide Hospital, gave the earliest transfusions in the mid-1920s, probably 1925, using a 20 ml syringe with a two-way stopcock. By the 1930s, other practitioners still alive [1989] such as Dr Douglas McKay and Dr Denys Hornabrook, recall their use of transfusion; Dr McKay at the Adelaide Children’s Hospital, following his return from London, and Dr Hornabrook, in general practice in Freeling, in 1932, using a jug, a funnel and a sterile gauze filter.

At Royal Adelaide Hospital in the 1930s, Dr Jim Bonnin records that the medical and surgical registrars were those responsible for organising the transfusions required. Among them were Dr Mark Bonnin and the late Dr Richard Pellew. They had to ABO group the patient, find an appropriate donor, take the blood and then administer the transfusion. The technique in the early days for the donor usually involved a cut-down over the antecubital vein, the insertion of a cannula and the use of a jug with citrate as the container. Initially, there was no filter used.

Another Dr. Bonnin, this time Noel, whose passing just last week we mourn, made an important contribution when he recognised the occurrence of pyrogenic reactions in blood recipients and showed that chromic acid cleaning of the glassware would remove the protein material responsible for causing this reaction.

By 1939, blood was transfused through a glass drip chamber and a fine gauze filter. Locally, Noel Bonnin had devised a fine metal gauze filter which could be cleaned, sterilised, and reused. He also developed a prototype of the ubiquitous drip stand.

The early days of donor recruitment in Adelaide owed much to Mr Dudley Foy, a successful vehicle mechanic and coachbuilder and an active member of Toc H. Mr Foy had seen during World War I the value of blood transfusion in the field. Following personal involvement in a transfusion at the Adelaide Children’s Hospital, Dudley Foy established the first donor panel in Adelaide in 1928 based on Toc H membership, a year before Dr Lucy Bryce is credited with establishing the first blood transfusion service in Australia in Melbourne.

It was not long before the Toc H members were insufficient to meet demands and approaches were made to the South Australian Motorcycle Club, of which Mr Wal J Murphy was secretary. It is of interest to note that the Motorcyle Riders Association of South Australia remains active and visible in its support of the transfusion service today.

In 1935, the South Australian Blood Transfusion Service Incorporated was established with Sir Henry Newland and president, W J Murphy as secretary and D S Foy documented as founder and organiser. Not only was Adelaide supported with donors, but panels were established in country areas such as Port Pirie.

In January, 1940, shortly after the outbreak of World War II, Red Cross came onto the blood transfusion scene in South Australia, and set about establishing an emergency service, in the best Red Cross tradition, to supplement the work of the existing transfusion service.

The Red Cross Blood Transfusion Committee for South Australia first met on 7 February, 1940. The initial recruitment of Red Cross donors was targeted at 500 women – shades of Hazel Hawke and the AIDS scare of November, 1984. A certain doctor Ivan Bede Jose joined the committee in 1941.

A blood bank at Royal Adelaide Hospital was proposed, as early as May 1942, by Dr Helen Mayo. Approval was given by the board of the hospital on 7 July, 1943, and £50 was given by Mr Mortlock towards its establishment.

The Resuscitation Unit or Resuscitation Clinic, Royal Adelaide Hospital, was formed in early 1945, in the McEwin Building to which the transfusion service has returned in recent years. Dr Hugh Gilmore credits Sir Ivan Jose with the concept of the Resuscitation Clinic. Dr Sandy Stewart, a member of the Red Cross Blood Transfusion Committee until a few years ago, performed many of the venesections in his role as medical superintendent. Fortunately by this time, in the interests of donor continuity and further involvement with the blood donation, the cut-down onto and tying of the vein had ceased.

In 1945 Sister Mary Cudmore was sent to Melbourne to learn Rh typing and to bring the new technique back to Adelaide.

Soon after the war, the concept of transfusion sister grew up, again it is said at Dr Mayo’s suggestion. Dr Bonnin believes that Sisters Myra Noblet and Irene Kennedy, later a director of nursing at this hospital, were the first appointed, followed soon after by Sister Bridgie Cooper who ran Resus for many years, Sister Sharp and Sister Iris Richter, who joined the team in 1947, and was seconded to Red Cross in 1954, when it moved to its present site. There she served with distinction until her retirement some ten years ago. The contributions of these women to the art of blood transfusion and intravenous therapy was unusual in the Australia context, if not unique, and the influence of this small group of dedicated sisters is still apparent.

Numerically, the expansion at this time was astonishing. In The Advertiser of April 1940, it was recorded that eight medical operatives – a most unfortunate term for women medical graduates -including Dr Helen Mayo, Dr Winifred Wall and Dr Elma Sandford Morgan, who much later worked got the Red Cross Transfusion Service, bled twenty-eight women donors under the aegis of Red Cross. Not to be outdone, Mr Murphy was quoted in the paper, on the following day, to say that South Australian Blood Transfusion Service Incorporated had collected twenty-nine units of blood during the month of March, 1940. Shades of things to come!

There came into my hands, most fortuitously, only two or three weeks ago, as the result of a clean-out of our stationery room, the records of blood drawn at the Resuscitation Clinic, Royal Adelaide Hospital, in what was termed a ‘progressive chart’. It documented a cumulative total of more than 50,000 units of blood from 1945 up to the time Red Cross became solely involved in 1954.

In the six month period from 1 October, 1945, to the end of March, 1946, a total of 854 units of blood was drawn, most of which seems to have been used of certainly issued. Then, as now, the greatest usage was for postoperative resuscitation. Some blood went to private hospitals. No less than fifty eight direct transfusions were given, no doubt utilising the equipment developed by the ingenious Julian Smith. One such piece of direct transfusion apparatus rests in the blood centre’s museum in the Ivan Jose Conference Room and Library.

Within a mere five years, the collection had increased nearly fourfold over the same six month period, to 3,039 units. Usage remained much the same, but there was a significant increase in the amounts being sent to private hospitals. Direct transfusion had already fallen from fashion and only four were noted for the six months.

This rapid growth was already producing strains and tensions. Record systems were required and the need to check the group of each donor at the time of each visit, a procedure recommended by the avant garde New South Wales blood transfusion service, were matters reported upon by Dr J Bonnin shortly after he joined the Red Cross Blood Transfusion Service Committee early in 1952. He even suggested that the Red Cross Blood Service may require a full time director, but this plea Red Cross found too radical at least at the time.

By mid 1952, there were over 3,700 donors on the panel, but the Board of Management, Royal Adelaide Hospital thought that the numbers as well as the stocks of blood were inadequate and established a donor sub committee to include the chairman, the director (when appointed), Mr Murphy and a full time secretary with the responsibility to increase, maintain and control a suitable panel of blood donors. Space problems were also being experienced and committee was formed to establish a new taking centre separate from the Resuscitation Unit.

On events at this time, I can do no better than to quote Dr Jim Bonnin at a little length

These changes virtually spelt the end for Mr Murphy and the South Australian Blood Transfusion Service Inc. His organisation was run on volunteer lines with occasional small grants from government. He could not alone keep pace with donor requirements and the immense value of his organisation of providing blood to be rapidly available on the ‘hoof’ was superceded by the even more rapid availability of blood in a bank. He also complained that he could not compete with the paid staff available at Red Cross, and this made him somewhat bitter. The simple fact was that transfusion technology and demand has outgrown his ability and that of a voluntary organisation to fulfil the requirements, a fact that Red Cross itself would also shortly discover. Mr Murphy and Mr Foy before him had done superb jobs, fulfilling a vital service to the community in their time, and preventing many deaths. Their hard work and selfless service, given totally without personal financial gain at all hours of the day and night over many years, should have been better recognised than it was.

It is strange that any successful organisations such as this was can outlive its usefulness and can eventually have a detrimental and retarding effect as development and progress occur.

Adelaide was way ahead in donor availability in the early 1930s, and less successful copies were established in New South Wales and elsewhere. Because it was so successful, South Australian services fell behind Sydney, Melbourne and Brisbane where the Red Cross had developed far superior services by the 1950s, with strong government financial support.

And one might add, aided by the experience of medical officers who has served in transfusion units during the war. Although formal separation of the Red Cross Blood Transfusion Service from Royal Adelaide Hospital and the Resuscitation Clinic took place physically around the middle of 1954, the association between these two organisations still only 400 metres apart, has remained close, interesting and fruitful. As mentioned earlier Sister Iris Richter came to the Red Cross Centre from Resus as the sister in charge under the directorship of Dr Elizabeth Puddy (the Prest) along with Miss Sheila Fisher, whose fifty years of Red Cross service was recently acknowledged. For some time after the transfer, the Red Cross Centre was dependent upon Royal Adelaide Hospital for the sister staff and nurses. Among the service’s earlier sisters was Sister Pamela Spry. The changeover of nursing staff was completed in February, 1956, and eleven nurse assistants were employed by Red Cross.

There was and still is a direct telephone tie line between the Transfusion Service and the Red Cross Blood Centre, symbolic of the formal lines of consultation and the informal ones of constant communication which have existed for many years.

The skills of the resuscitation clinic staff in establishing and maintaining intravenous therapy were legendary, as was their reputation in patient assessment particularly in regard to the need for further transfusion. Thousands of patients benefitted, often unbeknownst to them, at the hands of these sisters and the management of bank stock was also skilful and subtle. However there was a downside to the excellent system and it was that there existed a generation of Adelaide University medical graduates whose skill at initiating and maintaining intravenous therapy was sadly lacking unless they were formally trained in anaesthetics. Dr Bernard Nicholson, Medical Superintendent, one feels at the suggestion of his then Deputy, Dr Peter Last, reluctantly agreed* to remove the responsibility for intravenous therapy other than blood transfusion from Resus and placed it in the hands of resident medical staff.

The final separation from direct ward contact came in the early 1960s and the sisters became sister technicians. It says much for their gracious characters that they continued to function superbly in this role, and continued to manage the blood supplies on hand with subtlety which would only come from long experience in the wards in hands-on transfusion practice. Sister Bridgie Cooper and her successor, Sister Claire Hannon, continued to provide a service outstanding in its skills and compassionate understanding of the people for whom they cared, even if it was at one pace removed. They were still part of the lifeline to which I referred at the outset, that link between the donor and the needy recipient.

The increasing complexity of modern immunohaematology has brought with it its changes and the sister technicians have largely been replaced today by hospital scientists and technical officers and technical assistants, although one wonders whether any will ever hold a candle to Rhonda Videon. Dr Heidi Taylor was appointed Medical Officer, The Transfusion Service, on secondment from, the Institute of Medical and Veterinary Science, in 1969, and then the service became part of the Division of Haematology, Institute of Medical and Veterinary Science, on 1 February, 1975. Another Taylor, Angus by name, was the first scientific officer employed by the service.

The clinical role of the Royal Adelaide Hospital/Institute of Medical and Veterinary Science Transfusion Service, was emphasised by the establishment of a plasmapheresis unit in 1975 under Dr Taylor’s direction and later that of her successors Drs Rick Abbott, Geoff Dart and now [1989] John Lloyd. Ken Davis, Principal Hospital Scientist, heads a large team of competent and proficient hospital scientists and technologists who contribute significantly to the safety of the transfusion practice in South Australia. Nursing staff still play a significant role in the therapeutic haemapheresis unit, as well as supplying outpatient treatment facilities for patients with Factor VIII deficiency which are second to none in this country.

It is clearly not possible to do justice to this theme in the time available. It has been possible only to note some of the more dramatic changes in direction, scope and style of a unique part of this hospital’s support services. Through all the changes, the developments, the progress, the tensions and the occasional set backs, there has been a single constant thread, a lifeline – for at any given time in the past sixty years, it has been the basic underlying aim of those involved to save a life, to sustain, to strengthen and to support. Whether it has been the voluntary donor, the voluntary helper, the nursing sister, the medical officer, the scientist the clerk, the storeman or driver, each has been part of the invisible chain, the lifeline which ensures that the donor’s priceless gift is brought rapidly, efficiently and safely to those in need. Today we thank God for all these selfless people of goodwill.

I feel certain that this hospital’s extraordinary transfusion service will continue to develop, to anticipate and to respond to change, and will still continue to provide that vital link in the lifeline which ensures that for so many each year, the donor’s gift of blood is transmuted within this hospital to become the very gift of life itself.

*Not so; I had always been of this opinion and acted at the first opportunity. Dr Bernard Nicholson, Editor