THE AUSTRALASIAN

MEDICAL GAZETTE.

SYDNEY, 20TH FEBRUARY, 1902.

MEDICAL EDUCATION IN AUS

TRALASIA.

THOSE who have read the discussions which have taken place in recent years at the meetings of the General Medical Council in London, on the question of medical education and the medical curriculum will know what a difference of opinion exists on this subject; and a review of the curricula at the different medical schools in Australasia, which we present to our readers in this issue, will confirm this statement so far as this part of the world is concerned. While we are all agreed that at least five years of study is necessary to enable the student to acquire a knowledge of the fundamentals of medicine, there is much difference of opinion as to how those five years can be spent to the best advantage. With the great increase in the last few years in our knowledge of the preliminary sciences, such as biology, anatomy, and physiology, greater demand is made upon the student's time in acquiring a knowledge of those subjects sufficiently extensive to be of service to him in his later studies of practical medicine and surgery. But a longer time spent in preliminary scientific study must of necessity cut short the time for hospital and practical work, and the difficulty is to arrive at a fair adjustment of the work of the different years of the curriculum which will enable the average student to acquire a knowledge of his professional work, not only sufficient to satisfy the examiners, but what is of more importance, to fit him to carry on his studies after he has left his school, and to practise his profession with credit to himself, and benefit to his patients.

The exact period in the curriculum when students should begin hospital work varies in different schools. In Sydney, for example, students do not seriously enter upon hospital work until the beginning of their fourth year, while in Melbourne they are required to attend the surgical department of the hospital in their second year. There is something to be said in favour of both of these regulations. If, during the first three years students acquire all the preliminary knowledge, and are free in their last two years from attending a number of courses of systematic lectures, and able to spend practically the whole day in the wards and out-patients' rooms, then we think no better system could be adopted. For the students then enters upon their strictly professional work, well grounded and fitted to make practical use of their knowledge of the fundamental sciences. But unfortunately, at present, during the fourth and fifth years the students are burdened with attendance on systematic lectures, demonstrations, etc., which cut largely into their time for work in the wards and out-patient departments, and they are expected to acquire a knowledge of the principles and practice of medicine in the course of nine or ten months in the last year of their career, and are expected to pass the final examination not only in the general subjects of medicine, surgery, obstetrics, and gynaecology, but also in some special subjects, as psychological medicine, ophthalmology, and public health.

If, however, students enter upon hospital attendance during their second year of study, they are early in the course introduced to the practical subjects of their professional work; but at the same time it is impossible for them to seriously profit by hospital attendance if they are ignorant of the essentials of anatomy and physiology; and the time spent in hospital attendance at this early period of their career would more profitably be spent in acquiring a sound, practical knowledge of anatomy and

physiology. But there is much to be said in favour of attendance in the surgical department of the hospital, with tutorial instruction in surgery in the third year, and the commencement of the study of medicine in the fourth year. At present, this appears to us to be the best adjustment of the work of the curriculum.

The able paper by Professor Wilson of the Sydney University, which we publish in another column, on the Medical Curriculum, is the result of much thought and practical acquaintance with this subject, and his suggestions on the principle of specialising by the student in the course of his career are well worth serious consideration.

THE FEE FOR MEDICAL EXAMINATION FOR LIFE INSURANCE

WE understand the Australian Mutual Provident Society desire to reduce the fee for medical examination for life insurance in all

cases under £250 to half a guinea. It is said that this Society has now to pay such large sums by way of commission to induce the assuring public to enter its doors that it can only make a reasonable profit by cutting down the doctors' fees. Whether the profits which this Society has been declaring of late in the shape of bonus can be fairly described as reasonable is a question; from the flourish of trumpets which usually accompanies the annual report of the Australian Mutual Provident Society, a dispassionate observer would probably characterise the profits as very large, but whether they be very large or only reasonable, we feel quite sure that not a single person who is assured in the Australian Mutual Provident Society would desire that his bonus should be kept up to an unjust figure by sweating the profession of medicine. That this proposal is neither more nor less than sweating in the worst form is obvious to everyone. An extremely wealthy

society which boasts of its accumulated millions finds a difficulty in keeping up its bonuses at an inflated figure. Instead of attempting to reduce its expenses in other directions, the General Manager hopes to squeeze needy practitioners of medicine, and compel them to accept just one half what the universal custom of Australia has declared a

just and fair remuneration. It seems by this process of squeezing or sweating, the Australian Mutual Provident Society hopes to make a profit of between a thousand and fifteen It is certainly a hundred pounds a year. confession of weakness that this society so long supposed to be great and flourishing should be compelled in order to keep up its rate of profit to scrape together £1,500 by taking toll of the modest earnings of the profession of medicine. But the author of this proposal has reckoned without his host. We can assure him that he will not find the profession of medicine that cohesionless body which he imagines us to be. We shall resist his unworthy attempt to sweat us, and the public will be greatly edified by the spectacle of a great and wealthy society endeavouring to obtain skilled services for half

their real value.

THE MONTH.

The A.N.A. and the British Medical Association.

"The Australian Natives' Association Board has

decided to agree to the terms of the British Medical at £200 per annum. Association fixing the wage limit for benefit members This will solve the difficulty in regard to the appointment of a medical officer for the branch which has been experienced since its establishment."

The above appeared in the Sydney Evening News of the 7th instant. We wish to point out that the last portion of the paragraph is, to say the least, premature and possibly misleading. The fact is that the whole question as to whether, under any circumstances, relations with the Australian Natives' Association would be deemed desirable, is referred to a general meeting of the New South Wales Branch of

the British Medical Association, to be held on March 7th. In the meantime, the position as between the Australian Natives' Association and the British Medical Association remains unaltered; and we would warn members of the British Medical Association against allowing themselves to be appointed Medical Officers of the Association without their consent, as has already been done in some instances. Such unwarranted appointments should be at once repudiated.

In this issue we have endeavoured as far as our space would allow, to give a concise account of the medical curricula at the different Australasian medical schools. We have tried to secure the latest information on this subject, but owing to some changes in the curriculum pending at some of the schools, the statements given must be understood as being at present approximately accurate. The comparisons thus afforded between the different medical schools will furnish information to students about to enter on the study of medicine, and will also be of some interest to those who are concerned in the question of medical education in these lands. The Adelaide University Medical School. It must be a source of considerable satisfaction to the authorities of the Adelaide University, and also to the students of the faculty of medicine, that after the past few years of trouble at the Adelaide Hospital, peace has been restored, and medical students are again able to complete their full course in Adelaide. For some years past students have only been able to obtain their first three years instruction in Adelaide, and have been obliged to migrate to Melbourne or Sydney to complete their course. The revival of the medical school was playfully represented by the students during their part of the proceedings preliminary to the official function at the annual commemoration at the University in December last.

The Resident Appointments at the Adelaide Hospital.

The Board of Management at the Adelaide Hospital have recently elected four lady medical graduates and one gentleman to fill the posts of resident medical officers. We believe this proportion of ladies to gentlemen on the resident staff of a large general hospital to be unprecedented. The position of affairs is

interesting in the light of the present crisis at the infirmary at Macclesfield in England, where the expressed wishes of the honorary visiting a lady house surgeon was appointed contrary to staff, and the latter have consequently resigned in a body. Some interesting correspondence on would appear that there is some personal the subject has appeared in the Lancet, and it feeling against the lady in question. Still there can be no doubt of the truth of some of the statements made in this correspondence, and that it is hardly decent to compel a respectable man to submit to catheterisation by a lady house-surgeon; and on the other hand, the constant direct contact with cases of disease and injury of the genital organs must tend to deaden that sense of refinement and delicacy, which is essential to a woman's character. The directors of the large metropolitan hospitals in Sydney have, in the past, consistently refused to elect lady graduates to the posts of resident medical officer, and we believe that the authorities of the Sydney Children's Hospital are also averse to such appointments. However, at the Coast Hospital, the senior resident medical officer is a lady, and she has been in residence at this hospital for three years, and has given every satisfaction to all in the discharge of her duties.

Reception House for the Insane, Melbourne.

The necessity for the establishment of a reception house in connection with the hospitals for the insane in Melbourne has been impressed upon the authorities, and a site at the Royal Park reserve has been suggested for this institution. It is elevated, picturesque, and healthy, not too near any residences, and has been inspected and approved by the Chief Secretary and Dr. McCreery. It has also been suggested that some provision should be made for paying patients, either in a special asylum, or in special wards.

The Fear of Tuberculosis.

The large amount of attention which has been directed to the dangers of infection from tuberculosis in the public newspapers, while having a beneficial effect on the spread of the disease, has unfortunately brought disabilities on the heads of the poor consumptives. Boarding houses object to take in persons suffering from pulmonary phthisis. This fear of taking infection from phthisical patients has, we understand, extended to the trained nurses, and the Committee of the Queen Victoria Home for Consumptives at Thirlmere are at present

IN AUSTRALASIA.

regretted, and by way of re-assurance, we may remind the trained nurses that amongst the large number of nurses and resident medical officers at Brompton Hospital for Consumption in London, no case of infection has ever occurred. In the present day with our knowledge of the risk and of the proper precautions to be taken, there is not the slightest danger of a nurse who understands her duties contracting the disease, and we hope that this re-assurance will have the effect of removing the difficulty which now besets the authorities at Thirlmere in securing a satisfactory nursing staff for their institution which is, at the present time the only public institution of its kind in this State.

Abolition of Compulsory Vaccination in South Australia.

The Act to abolish compulsory vaccination was passed by Parliament last session and is now in force. Clause 1 of the statute provides that no parent or other person shall be liable to a penalty if within six months from the birth of the child he makes a declaration before a justice of the peace that he conscientiously believes that vaccination would be prejudicial to the health of the child, and within seven days

thereafter delivers to the vaccination officer such declaration. It is to be regretted that such an Act should have been passed, in view of the serious outbreak of smallpox in London.

Victorian Association for the Preven

tion and Cure of Tuberculosis. The committee of the Victorian Association

for the Prevention and Cure of Tuberculosis held its first meeting at the Town Hall, Melbourne, on January 27th last. Dr. Jamieson occupied the chair, and stated the objects of the Association and the work of its committee. An executive committee of 20 members was

then appointed. Mr. F. R. Godfrey, president of the Melbourne Hospital, was appointed treasurer, and Dr. Daish agreed to continue to act as hon. secretary. It was decided to make the member's subscriptions 5s. per annum, with the view of obtaining a large enrolment, and proportionate increase of personal interest.

The next Annua! Meeting of the subscribers to the Children's Hospital, Sydney, is to be held in the Town Hall, on the evening of February 27th. The Mayor will preside. Musical selections will be given, and a display of physical drill by some of the public school chilrden.

IV. Victoria.

IN the war waged against tuberculosis in Victoria a strong frontal attack against an enemy, entrenched behind barriers of ignorance and so strongly supported by prejudice, has hitherto been deemed inexpedient by those charged with the care of the public health, it being realised that a heavy and long-continued educational bombardment must precede any successful general advance. Still, there have been affairs of outposts and flank attacks whereby advantages have been gained, and the enemy's position weakened, and the appearances promise that the psychological moment will arrive in the near future when a vigorous, aggressive movement may be looked for against this most deadly, but yet, if met with all available weapons after proper reconnaissance, most vulnerable of foes to human life. The

recorded death rate from the disease in all its forms had not till recent years shown any marked improvement, but a downward tendency ultimate decade, and it has now reached a was noticeable about the middle of the penlower level than before recorded. The date from a valuable report on tuberculosis by accompanying chart, copied with revision to Permanent Head of the Public Health DepartDr. Gresswell, Medical Inspector, and now also ment of this State, shows clearly the gradual fall since 1887. The most marked decrease has been in the metropolitan area, and this was to be expected if sanitary activity might be credited with being a contributing cause to the verbially slower in more sparsely populated improvement; for sanitary progress is proareas, and the tendency is for the increased sanitary vigilance exercised in large centres of population to approximate the death rate to that of corresponding country districts. The specially marked decrease in the phthisis mortality is what might be reasonably anticipated if the modern outlook on the disease is rational, and the efforts of the Public Health authorities chiefly extend in the direction of clean soil, freely sunlighted streets and buildproviding an environment in which pure air, ings, and wholesome meat and milk supplies are leading factors. Apart from efforts directed to the education of public opinion, and especially

It must be remembered, however, with reference to the phthisis mortality that there has been a somewhat compensating upward tendency of the recorded death rate from other forms of respiratory diseases during the same period.

of those concerned in local government, it has been on these lines that the energies of the Public Health authorities in this State, have mainly been expended.

To deal now with some of the individual measures employed in this combat, and considering first the powers arising from existing law, it may be noted that the only direct references to tuberculosis in the Health Act, 1890, concern the sale of the milk or meat of tuberculous animals. In the attempt to safeguard milk supply, inspections of dairy premises have been and are still being carried out, and extensive applications of the tuberculin test have been made by Mr. Cameron, the Veterinary Inspector of the Board of Health, with a view to the elimination of diseased stock from dairy herds. Tuberculous cattle have also been destroyed in considerable numbers for many years past by inspectors under the Stock Act. Circulars of advice, and more recently a pamphlet prepared by Mr. Cameron, have been issued by the Board to dairymen, still the industry cannot be said to be conducted in anything approaching a satisfactory manner, owing to the very imperfect control frequently exercised by municipal councils, which constitute the local sanitary authority under the Health Act, and very few councils have, up to the present, appointed veterinary inspectors, dairy inspection being often but one of the duties of an officer, whose functions are as multifarious as those of Pooh Bah, of operatic fame.

Legislation, with the object of of further safeguarding the production and storage of milk, may be expected shortly, and will probably be along the lines of the recently introduced Meat Supervision Act, which requires that all meat intended for human consumption shall be inspected and adjudged free from tubercle or other communicable disease, and otherwise sound by a municipal officer, whose qualifications have been approved of by the Board of Health. This Act at present applies only to the metropolis, but its extension to other large centres can only be a matter of a short time.

In 1893, the report on tuberculosis, prepared by Dr. Gresswell and already referred to, was published by the Board, and has since passed through six editions, and has been widely distributed throughout the State. This report deals succinctly with the nature of the disease and its incidence, and detailed directions are given of the lines along which preventive measures should proceed. addition, municipal councils have been urged by the Board to invite information of the occurrence

of the disease and of the deaths therefrom from ratepayers and district registrars, and to undertake the disinfection of infected premises. In 1900, the city of Melbourne, as became the premier municipality of the State, took action somewhat on the lines suggested by the Board. Local registrars now report all deaths from phthisis to the Council, whereupon the sanitary inspector visits the premises and supervises a thorough cleansing and disinfection. The homes of phthisical persons attending the outpatient department of metropolitan hospitals are also visited, and householders advised as to the necessity of adopting precautionary measures against infection. It has not been found practicable to exercise direct control over private premises except to a very limited extent, and constant activity on the part of health officers and sanitary inspectors is required if those conditions in the home which favour the incidence of tuberculosis are to be overcome. More, however, has been done by the central health authorities with regard to public buildings, and great improvements have been and are still being effected in these in the direction of ventilation, sunlighting, and the prevention of over-crowding. The operations of the Factory Act also tend to improvement along somewhat similar lines.

In the matter of direct attack against the disease, the powers conferred by the Health Act, except in the directions already indicated, are limited Thus an amendment of the Act is necessary before the nuisance arising from indiscriminate expectoration in public places can be effectively dealt with. It may be mentioned that for some years past the gratuitous examination of suspected sputum has been undertaken for medical practitioners by the Board of Health. The great sign of a new departure in the campaign was the definition of pulmonary tuberculosis as a "dangerous infectious or contagious disease which appeared in the Government Gazette of August, 1901. Such a definition opens the door to the compulsory notification of this form of the disease, a step which, while calling for due circumspection, will yet, if carried out with judicious discrimination, prove a most valuable weapon of defence. But the effect of this definition reaches still further, as it renders many sections of the Health Act of 1890, which have reference to preventive measures in cases of infectious diseases potentially operative; some of these sections it will probably be found inexpedient, and indeed, unnecessary to enforce, but others, it may be expected, will be brought into active operation in the near future. Thus,