Sydney Hospital

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Sydney Hospital’s interest in medical education was publicly stated as early as 1837 which was before the University was established and even before the Hospital, then a humble outpatient Dispensary, had beds. Creation of a clinical school was one of the objectives enshrined in the Sydney Hospital Act of 1881 whereby the former Sydney Infirmary also changed it name for the last time. Detailed analysis of the delay until 1909 before its ambitions could be realized must await publication of the hospital’s own history which will be entitled The Mother of Institutions. It will suffice to note here that the umbilical tie between Medical School and Prince Alfred Hospital, described elsewhere in this book, prevented the formation of a clinical school at Sydney Hospital for twenty-six years from 1883.

During those same years, Sydney Hospital lost its hitherto undisputed status as power-broker in the medical politics of the State. The seat of this power, thenceforth, lay neither with the University of Sydney nor with Prince Alfred Hospital, but in the combination of the two in pursuit of educational aims common to them both. Sydney Hospital did not resign without a fight and there are some published hints concerning the efforts of its supporters to disrupt planning committee meetings for the new Prince Alfred Hospital. Such behaviour did not augur well for future happy relations between the two hospitals.

Even so, the University could not afford to ignore Sydney Hospital entirely: (i) Prince Alfred Hospital (‘Royal’ from 1903) did not build up a reservoir of patients to rival the Sydney Hospital clientele for many years, particularly in Casualty and some special services. Of necessity therefore, Sydney Hospital was recognized by the University as a centre for clinical teaching and, with the possible exception of a brief period between 1889 and 1894, there was always a small student presence at Macquarie Street.

(ii) Five of the first six part-time Lecturers in the Faculty of Medicine, had or were to have long associations with the Sydney Hospital honorary medical staff and the sixth, Frederick Milford (q.v.), had walked the old Infirmary wards with his colleague James Charles Cox (q.v.), when both were apprentices in the 1850s. Furthermore, two of the Lecturers, Thomas Chambers and W. H. Goode (qq.v.), were also foundation members of the Prince Alfred Hospital staff and subsequently lost office there. Chambers was long remembered by students for his tart remarks about Prince Alfred Hospital, after he had failed in his bid for election as Gynaecologist in 1883. He resigned as Physician at Prince Alfred Hospital in April 1884 and was appointed Gynaecologist at Sydney Hospital in 1886.

(iii) Thomas Evans was Ophthalmologist at Prince Alfred Hospital in 1882–1888, but he had few beds and the eye patients of New South Wales flocked to Sydney Hospital which had a Special Eye Department from 1879. Evans was on the staff there in 1882–1903 and succeeded Cecil Morgan as Head of Department in 1885. Morgan, who was probably the first true ophthalmic specialist in the State, had been officially designated Clinical Lecturer in Ophthalmology by the University Senate in December 1884. There was really no question as to where the best eye care and training in Sydney could be had. When Evans resigned from the Prince Alfred Hospital staff in June 1888, the reason given was his unwillingness to accept the proposed new office of University Lecturer in Ophthalmology. Perhaps the lack of beds was nearer the truth. F. A. Pockley succeeded Evans at Prince Alfred Hospital and obtained the Lectureship in September 1888. His specialist hospital experience up to that time had consisted of about three months’ postgraduate work in Vienna, and six months as junior to Evans at Prince Alfred Hospital from December 1887. Pockley’s main rival, W. Odillo Maher, had been Assistant House Surgeon at Moorfields Eye Hospital, London in 1882 and was on the Sydney Hospital ophthalmic staff from January 1886.

(iv) The Faculty Examiners included the surgeon, Sir Alfred Roberts, guiding spirit of Prince Alfred Hospital, who in 1871 had been voted off the Sydney Infirmary staff after sixteen years’ service because of his reformist agitation, and the Sydney Hospital President, physician Arthur Renwick, who was also a Fellow of Senate and in that capacity, a regular attendant upon the deliberations of the Conjoint Board of the Senate of the University and the Directors of the Prince Alfred Hospital.

Co-operation between rival hospital camps was scarcely to be expected in the circumstances. Nor was the situation improved when, after some two years of discussion, the University and Prince Alfred Hospital came to an agreement in 1888 whereby University Lecturers were appointed to the honorary medical staff of the Prince Alfred Hospital ‘in virtue’ of their Lectureships. This agreement was interpreted so as to exclude Sydney Hospital staff from part-time University Lectureships — excepting the appointments already referred to — and there is no doubt that the intention was to close the shop. This could be justified for as long as Prince Alfred Hospital remained the only general teaching hospital. It was discriminatory after 1909.

A significant increase in the number of medical students from 1905 onwards outstripped Prince Alfred Hospital’s capacity to supply them with clinical experience. It was no accident that the Hospital was then as obsessed with expansion as the Medical School was, for the Dean, Anderson Stuart, was also Chairman of the Prince Alfred Hospital Board of Directors from 1901. But hospitals cannot be expanded over-night and especially not when they are dependent upon Government money. So the University opened negotiations with Sydney Hospital in September 1907, with a view to establishing a second clinical school. The proposal was warmly welcomed by the Sydney Hospital Board and its honorary medical staff. It took two years for the arrangements to be completed which indicates, if not opposition, at least a certain reluctance on the part of the Faculty as a whole. Only two Lecturers, Joseph Foreman and Sir James Graham, overtly opposed the Sydney Hospital clinical school and resented a request that they should alter their University teaching times. Both men had been Government nominees on the Sydney Hospital Board since the 1890s. Anderson Stuart was tactfully commended by Sydney Hospital for his ‘cordial assistance’ but most of the credit for the organisation of the school belonged to the Medical Superintendent, Archie Aspinall (Jessie’s brother, see Chapter 6), who had the thankless task of re-arranging hospital clinics to fit in with University lectures, and conciliating all those inconvenienced in the process. Aspinall was to become Clinical Lecturer in Surgery 1931–1941.

The official opening of the school by Hospital President John Pope on 20 October 1909, was also the occasion of one of Thomas Fiaschi’s finest public addresses. This was an early attempt to place the history of Australian medical practice within the context of the European teaching tradition whence it derived. Fiaschi had been honorary University Lecturer in the History of Medicine since November 1902. A general surgeon of Italian extraction and flamboyant reputation, Fiaschi was first Chairman of the Sydney Hospital Board of Medical Studies and remained so until war duties obliged him to retire in 1914.

The development of the clinical school was not without its difficulties. The Hospital never had adequate accommodation and teaching facilities for its students. The fine chapel of 1894 did duty as the only lecture hall until the Maitland Theatre was built on top of the Renwick Pavilion in 1920 and even so, the chapel continued to be used for lectures until the mid-1960s. The Travers Pavilion of 1927–1930 (on the Domain boundary) was the last major construction possible on the restricted site. All improvements thereafter were piecemeal and models of ingenuity rather than architectural style. There were no ward- or side-rooms used by students for clinical examinations and laboratory purposes until 1934 — which helped to explain their notorious predilection for smoking and card games (they did have a common room). Nevertheless, two existing and still unrivalled teaching aids had their origins with the foundation of the clinical school, namely the Medical Library of 1910 and the Pathological Museum of 1912. Both owed much to Sydney Jamieson, Honorary Pathologist and foundation Lecturer in Clinical Medicine at Sydney Hospital. Neither was properly housed until 1964.

Student numbers at the Sydney Hospital clinical school commenced with twenty-eight in 1909 and fluctuated for no obvious reasons until 1917 when war created a demand for practitioners reflected in the fourth year intake, which peaked at sixty-four in 1920 and never exceeded that figure again until 1962 (73)[1]. The two World Wars placed a heavy strain on all hospital medical staffs because the boost in student numbers was accompanied by a drain of experienced practitioners into military service. Sydney Hospital’s pride in an increasing student population changed to despair at its inability to provide for them. The first female students had registered in 1912 — there were two. It was rare for there to be a lone woman on the books in any one year. By 1922 there were said to be over 200 students in all years. Classes were far too big and individual instruction impossible; there was insufficient clinical material to go round. Because of extreme conservatism and financial constraints, both Hospital and University periodically rejected attempts by the medical staff to increase the number of official clinical teaching appointments. Conscientious tutors doubled up their work in order to ensure that students met University requirements and members of staff who did not have teaching appointments took students willingly enough, or were compelled to do so in terms of the Hospital by-laws.

The situation eased after 1924 when a new curriculum with an additional (sixth) year of study was introduced and a new clinical school at St Vincent’s Hospital established. The Sydney Hospital intake dropped sharply and students in all years combined during the 1930s usually numbered well under one hundred. Economic depression would have played its part here, but many factors influence a student’s choice of a teaching hospital, including the University’s own allocation policy which attracted constant criticism during and after the years of the Second World War. The Sydney Hospital Board of Medical Studies feared that it did not get its fair share of the better students. Even if this were so on occasions, it was not always the result of direct institutional interference since the best students traditionally had their pick of the hospitals.

The annual student intake averaged about fifty-three throughout the 1940s and 1950s, and fifty-seven in the 1960s, with great deviations from year to year in this last decade. It may generally be said to have reduced steadily thereafter so that the intake of thirty-three students in 1982 was very close to that of fifty years before. In short, the political fortunes of Sydney Hospital are accurately reflected in the unsteady rhythm of student enrolments at its clinical school.

New curricula and additional teaching hospitals brought other problems such as time-tabling, which was always a mystery to hospitals lacking Royal Prince Alfred Hospital’s privileged connection with the Medical School. An alleged absence of consultation in this matter remained one of Sydney Hospital’s most persistent grievances because insensitive alteration of time-tables disadvantaged students who had to travel some distance to their clinical work. Sydney Hospital partially solved this problem with a special student bus service which ran for some twenty years from 1958.

Up to 1931 the burden of student administration and discipline had fallen on successive Medical Superintendents who performed extraordinarily well considering their youth and inexperience. Yet they really had no time to devote to this branch of their work, whilst the Board of Medical Studies met too infrequently to provide the necessary continuity. The appointment of the full-time Bosch Professors in Medicine and Surgery by the University in 1930 marked a distinct change in the approach to student management at Sydney Hospital. On the recommendation of the Faculty of Medicine, the Hospital appointed its first Student Supervisor, (Sir) Kenneth Noad, in 1931. Noad held office for nine years. In 1956 the Hospital seconded a Registrar to the post of Assistant Student Supervisor and also created the appointment of honorary Warden of Clinical Studies. The latter was intended partly to aid the Student Supervisor, but mostly as a way of retaining the services of the recently ‘retired’ physician, Eddie Stokes. Stokes had been a Hospital student 1915–1917 and had devoted himself to clinical school affairs from 1925 as Tutor, Lecturer and Honorary Secretary to the Board of Medical Studies 1946–1956. As Warden he had general supervision of the work of the school and published its jubilee history in 1960. Ill-health forced a real retirement in 1961 when the post of Warden lapsed. It was revived in 1967 as a part-time University post with the surgeon J. E. Reimer as the first incumbent.

In 1936 the constitution of the strictly domestic Board of Medical Studies was amended to allow direct University participation in the management of hospital-based student activity. The new constitution was drafted by the Faculty of Medicine and provided for the Dean to become ex officio Chairman of the Board of Medical Studies at each main teaching hospital. Thus when Fiaschi’s successor, gynaecologist Ralph Worrall, retired as Chairman at the end of 1936, the Dean succeeded him. Such University involvement was long overdue.

Anderson Stuart’s 1909 flirtation with Sydney Hospital had proved the most casual of affaires, conducted without heart, for reasons of policy. The subsequent estrangement encouraged confrontation politics which made it difficult for participants to appreciate any point of view other than their own. The Hospital, for example, resisted any proposal that the University ought to have representation on medical appointments committees. Anderson Stuart had mentioned this desirable feature at the opening ceremony for the Sydney Hospital clinical school. The University looked upon the principle as a necessary step towards quality control with respect to the teaching capacity of hospital medical officers. A Conjoint (Appointments) Board had been agreed with Prince Alfred Hospital at the outset. But Sydney Hospital always interpreted the suggestion as a threat to its autonomy. The most it would allow was consultation between University and Hospital about the selection of clinical teachers from medical officers already in post. For the rest, it took sanctuary in its Act which specifically assigned to the Hospital Board, power of appointment over all senior medical and administrative posts.

The Hospital has never found it expedient to update its nineteenth century constitution because that would have required the full support of Government and there have not been many occasions when such support could be confidently expected. The major defects in the 1881 Act were the result of parliamentary interference in the first place, and the Hospital does not cling to its Act because of them, but in spite of them. It is true that age of itself does not imply administrative perfection. But it has never been safe for Sydney Hospital to assume that change would be for the better. Prince Alfred Hospital was new in 1882 and had nothing to give up, whilst Sydney Hospital was older than the University. It has always required evidence that the giving up of control over medical appointments would be to the advantage of Hospital staff and patients. All the University could do was argue from academic principle. It had no experience of hospital management and its early appointments to Lectureships in the Faculty of Medicine had not been remarkable for their objectivity.

The almost continuous Professorial presence on the Hospital Board since the appointment of Professor W. K. Inglis as a Director in 1946 may be interpreted as a placatory gesture, but the particular philosophical gulf was never bridged. It was a crucial factor underlying Sydney Hospital’s refusals: to switch Universities in 1961 and to become the main teaching hospital for the new Medical School at the University of New South Wales; and to move to the new hospital at Parramatta, now known as Westmead and opened in 1978. Time may judge such decisions to have been anachronistic and irrelevant, but they are understandable in the light of experience which is etched into the collective unconscious of the Sydney Hospital leadership.

The resolution to remain at Macquarie Street coincided with the injection of Federal and State Government money into student facilities at all teaching hospitals after 1961 (arising from the recommendations of the Australian Universities Commission). There followed the most positive and harmonious phase in the history of relations between Sydney Hospital and the University of Sydney. University Departments of Medicine (1961) and Surgery (1963) were located at the Hospital and elevated to full Professorial status in 1966. There were proposals for a new Chair in Ophthalmology, to be based at the Sydney Hospital Eye Department in Woolloomooloo (moved from Millers Point in 1922 and known as the Sydney Eye Hospital from 1960). Although the Chair did not attract an occupant until 1977, the University Department of Ophthalmology and Eye Health was established in 1964 — a mere eighty-two years after Sydney Hospital had put its Eye Department into a separate, 30–40 bed hospital unique in New South Wales.

Apart from the greatly improved physical environment for students, the most remarkable feature of the 1960s was the advance in clinical research. This had been firmly established within the Hospital under the guidance of Malcolm Whyte who was Director of Clinical Research from 1955. The new University teaching Departments took up the challenge with pioneering work in endocrinology (Posen), malignant melanoma (Milton and McCarthy), other forms of cancer (Stephens), and in the nature of medical education itself (McCarthy). The University also became more visible in the routine activities of the Hospital and as one result, there was greater interest on the part of its full-time Hospital-based staff in obtaining a voice in Hospital management. This created new tensions which could never be satisfactorily resolved in the Hospital as constituted and with the severe physical limitations which everybody recognized.

In a brief sketch such as this we can but note the existence of fascinating side issues which had a bearing on the clinical school, not least being the various ploys used by Sydney Hospital critics since 1905, to try to divorce the Hospital from its own Eye Department. Above all, it must be stressed that throughout the period under review, Sydney Hospital has been shaken by a series of crises without parallel in the history of any other institution. These revolved around bureaucratic attempts to move it from its prime site in Macquarie Street, which had been occupied as a hospital since 1816. Such crises were often associated with Government dreams to enlarge Parliament House (next door and part of the original Hospital complex); or schemes for inner-city renewal and beautification; or even plans to rationalize hospital services in the metropolitan area. This last, far from being a modern catch-cry, is older than the Hospital’s present main buildings which were started in 1880. Nor have the arguments for and against changed much since then.

An institution under threat as Sydney Hospital has been for so long, can never bargain as effectively as one which has an impregnable place in the community. Policy takes an unconscionable time to evolve in a politically vulnerable institution and what may have appeared to be lack of co-operation by Sydney Hospital on some vital issues in the past, was probably due to excessive caution. It is an unfortunate coincidence that the Medical School must celebrate its centenary so soon after traumatic events in 1982 which have led to a drastic reduction in Sydney Hospital’s services. What this will mean for its future as a teaching hospital is not yet clear. The Hospital’s extraordinary recuperative powers must not be overlooked; nor its history as one of very few institutions with a direct link to the foundation of European settlement in Australia in 1788.

It would not be a matter for congratulation if the oldest University in the country were to lose contact with the oldest hospital which will soon celebrate its second hundred years.

Source: Ann M. Mitchell[1] "Sydney University Medical Society" in Young J, Sefton A and Webb N, Centenary Book of the University of Sydney Faculty of Medicine. Sydney University Press, Sydney