Tuberculosis Control in South Australia

Roger Clare Angove, Emeritus Physician, Royal Adelaide Hospital

This address was delivered at the thirteenth Foundation Day Address Ceremony held at Royal Adelaide Hospital on 17 July, 1991. 

Past and present friends of the Royal Adelaide Hospital.

It is my duty today to address you on the 151st anniversary of the founding of the Royal Adelaide Hospital. It is no easy to task to follow in the footsteps of the Most Reverend Keith Rayner, Primate of Australia and Archbishop of Melbourne who delivered the Foundation Day Sermon at Scots Church, North Terrace, Adelaide. The archbishop took as his theme ‘The Service of the Medical Profession to the Community at Large’. The Foundation Day Address 1990 was given by Dr P Cahalan entitled ‘Hope, History and the Royal Adelaide Hospital – 150 years’.

I intend to enlarge on these concepts by taking up one of the facets of community service in which the staff of this hospital has rendered not only a local but also a truly national service. It is a record of which we should all be proud.

I will refer to personalities, hospital management and the technology in the partial control of tuberculosis in the South Australian community as it has evolved over the past 100 years.

Tuberculosis was to the forefront from the foundation of South Australia.

Tuberculosis remained the main killer in the adolescent and young adult age groups until almost World War II.

The second issue of the South Australian Gazette and Colonial Register was the first to be published in South Australia in June, 1837. The first issue having been published in London on 18 June, 1836. It records the first birth in the colony on 29 December, 1836, of a baby to Mrs Robert Gouger and the baby was named Henry Hindmarsh Gouger. Then in the same Colonial Register two deaths were reported: on 14 March, 1837 – Harriet, wife of Robert Gouger at Glenelg of consumption and on 15 March, 1837 – their son Henry Hindmarsh Gouger died aged eleven weeks and one day but cause was not stated. Two years later in 1839 Colonel William Light died of consumption. Thus tuberculosis was from the very beginning of South Australia to cut short the lives of those who could be ill spared in the community.

Tuberculosis then remained the main killer in the adolescent and young adult age groups until almost World War II. Its only competitor was trauma and violence and in the younger age groups, bowel infections.

Today tuberculosis is under partial control but not so trauma, particularly on the roads, and this is still perhaps our greatest killer of the young and in fact of all age groups.

Sir Joseph Verco entered medical school in London in 1869 (St Bartholomews) – he was later house surgeon at Carts. By 1880 he had returned to Adelaide and joined the honorary staff at the Adelaide Hospital. He served in this capacity until 1912 only to return again during the years of World War I.

He was primarily a general physician but took a special interest in chest diseases. This may have come about as the latter part of the nineteenth century was the heyday of physical chest signs as introduced by Laennec. And even in our day as medical students in the 1930s this aspect of clinical medicine was paramount. The finest array of physical signs were found in the chests of consumptives. Probably some of you remember the ‘tinkling coin’ sound or the ‘bleating aegophony’ sign and others of similar exotic nature.

Much clinical weight was put on their elicitation in order to guess at the underlying pathology. Even today the ‘splashing sound’ of air and fluid in the pleural space must be rare. Modern technology in the imaging field has made these fascinating relics of the past quite irrelevant.

Sir Joseph Verco’s comments in his British Medical Association (South Australian Branch) presidential address in 1919 are of interest. I quote:

Even at the Adelaide Hospital on my appointment to the Honorary Staff in 1882 medical and surgical cases of all kinds were placed in the same ward without discrimination except males and females were in different rooms. Broken bones, pneumonias, wounds and bruises and putrefying sores, typhoids, hip diseases, bad eyes and everything else as they happened to come in were put into a bed which chanced to be vacant and the GP went from one to the other. There was no specialisation.

J C Verco as honorary physician was given the curious privilege of operating on patients with hydatid disease of the thorax. I think our modern generation of thoracic surgeons may perhaps frown on this. But the advent of public health measures in rural Australia has largely eliminated this disease from our midst.

The hospital facilities for the housing of Adelaide’s consumptives has an interesting story.

In 1849 the North Terrace Lunatic Asylum was built on the south east corner of the present Botanic Gardens. Parkside Asylum was opened in 1870 and the old asylum became the consumptive home and cancer block as part of the Adelaide Hospital. It continued to operate as such until 1932 when it was closed down only to be final demolished in 1938. It was a drear and depressing place somewhat reminiscent of the era of Dickens and how it lasted so long I cannot understand. It was built of bluestone and must have witnessed many tragic final days of the poor inmates in the terminal stages of consumption and cancer. No wonder the now banned linct. heroin was abandoned with regret by the medical profession.

The old Adelaide Hospital Infectious Diseases Block, also known as the Isolation Hospital, Ca 1906

From the ashes of this Phoenix has now risen the State Herbarium, a place full of light and progress.Then, until Frome Ward was built in 1942, the tuberculosis patients were housed and treated in the general medical wards of Royal Adelaide Hospital with the long term patients going to Kalyra Sanitorium and Bedford Park.

The tuberculosis problem was ever-increasing in South Australia after World War I.

The first outpatient tuberculosis clinic was established in the lodge of the old consumptive home on the southeast corner of the Botanic Gardens in 1917 – it still stands. This continued to operate until the new chest clinic was opened in 1938. This lodge is currently used by Botanic Garden’s staff. It is in need of preservation.

The first honorary assistant physician in charge at the Adelaide Hospital was Dr C H G Ramsbottom.

It was in 1936 that the South Australian branch of the British Medical Association strongly urged the establishment of a chest clinic referred to above.

It was also at this time that Dr Cowan encouraged the production of BCG vaccine by Dr Nancy Atkinson at the Institute of Medical and Veterinary Science thus making it available in Australia for the first time.

Frome Ward was opened in 1942 for active tuberculosis patients and thus became the first medical ward exclusively for tuberculosis patients at Royal Adelaide Hospital.

In 1932 the Morris Hospital took over from the Northfield Consumptive Home an took patients from the Adelaide Hospital  and later shared the inpatients with Frome Ward.

Dr J G Sleeman was in charge at the Morris Hospital after relinquishing his duties as medical superintendent of Adelaide Hospital from 1925-1937.

Slee as he was called, was an active clinical teacher while medical superintendent and his rounds were very popular with residents and students. He was a great bedside teacher and most evenings would be in the wards. He was a strict though just disciplinarian. He became Honorary Assistant Physician, Royal Adelaide Hospital, but retired before reached senior status. Slee lived in hospital grounds in a colonial style house just north, I think, of the Margaret Graham Building. The house was demolished and he moved to another situated on the western perimeter of the Botanic Garden. This was also demolished to make way for the East Wing of Royal Adelaide Hospital.

Frome Ward opened in 1942 and also Kalyra, Bedford, and Morris Hospitals were the scene in the 1940s and 1950s for ling collapse therapy with air being installed either in the pleural or peritoneal cavities. This was the favoured procedure in the pre-antibiotic era for collapsing and resting the diseased lung.

It was fraught with complications and Royal Adelaide Hospital was fortunate that this era coincided with rapid progress in modern thoracic surgery. Many a patient had the results of pneumothorax therapy rectified by surgical intervention.

The late 1940s and early 1950s saw the introduction of effective chemotherapy which increased in efficacy with the passage of time.

It was all a far cry from the end of World War I. At that time the young consumptives were frequently sent to the north of South Australia where the clear, dry, warm air was thought to be beneficial.

‘Go north young man’ was the medical cry of advice.

Angorichina Hostel came into being in the lovely Parachilna Gorge to enable ex-servicemen patients to benefit between the world wars from this regime. It was probably the first organised rehabilitation in South Australia for tuberculosis patients and Darcy Cowan was a moving force.

And so the story moves on with the demolition of Frome Ward to make way for the new Adelaide Hospital.

There were many professional conflicts during the life of Frome Ward. These were brought about largely by the criteria for admission. Until a positive sputum test for mycobacteria tuberculosis became the yardstick for admission, there were inevitably some patients who were admitted to Frome Ward only to be later diagnosed as lung cancer or bronchiectasis. They all presented with spitting blood or having pleural fluid.

The ever-increasing incidence of lung cancer in the 1950s made this confusion understandable and I like to think that From Ward really had very few admissions that were not due to tuberculosis ad many of the wrong admissions were due to incorrect radiological diagnosis.

Perhaps at this time I should now comment on the chief personalities in this stage of tuberculosis in South Australia. They were all members of the Adelaide Hospital staff and the majority, graduates of the Adelaide University Medical School. Many of them had strong personalities.

The two leading figures were Dr H W Wunderley and Dr D R W Cowan. They both were medico-politicians at heart but their approaches varied. Wunderley was renowned for his quiet persuasion and Cowan on the other hand, for his aggressive approach. As they were good friends, this combination made for progress in South Australia.

Harry Wunderley was a Victorian graduate in 1915, his course having been interrupted for a year with tuberculosis. He married Alice Barker of Mt Barker in 191 and first practised as a general practitioner at Mt Barker. He proceeded overseas to the United Kingdom and on his return began practice as a consulting physician and was appointed Assistant Pathologist, (Royal) Adelaide Hospital, and then Honorary Assistant Physician, (Royal) Adelaide Hospital. During his time overseas his tuberculosis relapsed and he spent a period in a Swiss sanitorium with tuberculosis laryngitis.

With the outbreak of World War II in 1939 it was Wunderley who, with his quiet persistence and powers of persuasion, established the routine chest X-ray for the armed services on enlistment and discharge. He finished the war as lieutenant colonel and Adviser in Tuberculosis, Army Headquarters in Melbourne.

After the war he was appointed first Commonwealth director of tuberculosis and later held appointment with the World Health Organisation but his Adelaide Hospital connections ceased. He was gentle in manner, quiet in speech and generous in every way. His administrative talents were epitomised by his remark to his secretary in Canberra:

‘I don’t want to know what I can’t do. I want you to tell me how to do it.’

He created the Wunderley Travelling Scholarships for the Royal Australasian College of Physicians in 1947 – and that is his only lasting memorial.

Sir Darcy Cowan was probably the best known of his generation in this field and it was my privilege to write an account of his life for the Roll of the Royal Australasian College of Physicians and I merely repeat the remarks I made in 1959 after his death.

COWAN, Sir Darcy Rivers Warren b. 8 Aug 1885 d. 9 June 1958 Kr(1955) MB BS Adel(1908) FRACP(1938)(Foundation).

Darcy Cowan was Australian born of a distinguished father who, after migrating from Ulster to South Australia in 1852, proceeded to make two modest fortunes in flour milling and investment in Broken Hill and became a member of parliament. He lived as a boy with his four brothers in the fine old home, ‘Erindale’, which was adjacent to ‘Undelcarra’, then owned by the Simpson Newland family. Darcy was educated with his brothers at Prince Alfred College and he Newland boys at St Peter’s College. Interschool rivalry was fierce and rife as the horse carts bore the respective families to and from school. Darcy excelled at sport, and was triple blue of the University of Adelaide. He was honorary organiser of the 1952 Davis Cup Challenge Round in Adelaide.

His life’s work was in the field of tuberculosis and chest diseases. His rugged personality and refusal to accept defeat in the medico-political world brought about many triumphs and he became regarded as a boisterous spirit in this field. Many were the arguments in the public press and at professional gatherings. He never gave up the fight for what he felt was right in principle and as a result was not popular with some of his colleagues.

He served his teaching hospital for many years as an honorary physician until his appointed as the first senior physician to the Chest Clinic in South Australia. He was a founder of the National Association for the Prevention of Tuberculosis in Australia. He was also a founding member of the Laennec Society in South Australia and still found time to be president of the South Australian Branch of the British Medical Association in 1935-36 and to found Bedford Industries which became the largest chest rehabilitation centre in Australia.

he was a master at out-manoeuvring his opponents

Angove in reference to Darcy Cowan

His endless endeavours in the field of public health were promoted with an acid and critical tongue and he was a master at out-manoeuvring his opponents at many a professional and public meeting. Politicians came to fear and respect his pronouncements both at Federal and State level. He was a foundation Fellow of College [sic] in 1938 but his energies were spent entirely in his chosen field of chest disease and its public health aspects.

His teaching life was latterly much in the Chest Clinic and the associated Frome ward for tuberculosis patients. His introduction of Mantoux testing and BCG vaccination for nurses at the Royal Adelaide Hospital found a deal of opposition among the honorary staff but he persisted, to the benefit of the nurses and medical students. He was much loved by his patients and his contribution to the control of tuberculosis in Australia was a momentous one I the public health field, which will ensure his place in the medical history of South Australia.

Time does not permit me to include more about such personalities or Dr Frank Hone, Dr Charles Savage, Dr John Hayward and Dr Nichterlein. But they must be left to another time in order to do justice to the role of the Adelaide Hospital staff in the fight against tuberculosis in Australia.