1 INTRODUCTION Introduction In the period following World War II paediatrics first appeared to be

294 Pages·2003·1.03 MB·English

1

INTRODUCTION

Introduction

In the period following World War II paediatrics first appeared to be viable medical
specialty in Australia, and over the next twenty years became firmly established. The
impetus for its development was the child. Children were individuals requiring special
care for their own sakes and they were also objects of special scientific interest to
aspiring paediatricians. Since early in the twentieth century the child had also been a
social resource for the benefit of the nation, attracting the attention of governments,
medical bodies and committees of inquiry. Their views on child health and welfare are
exemplified by the findings of a Federal Government Committee, the Medical Planning
Committee of the Joint Parliamentary Committee on Social Security in 1940:

In our present need the growing child is our most important asset; the foremost
consideration in any plan for social security should be the adoption of measures
to increase the birth of an increasing number of healthy children and to ensure
the mental and physical health of the growing child.1

Similarly the 1926 Commonwealth Royal Commission on Health repeated:

The health of the child determines the future health of the adult and on the health
of the adult depends the obligations of citizenship including those of defence
and parenthood.2

The reports emphasised that children were important for what they might become and
what they might do for the State, reflecting the importance attributed to human capital,
to the quest for national efficiency and to eugenics.3 What children were for themselves
as individuals was of less relevance.

1 Commonwealth of Australia, Eighth Interim Report of the Joint Committee on Social Security, with
Appendix A, Interim Report of the Medical Planning Committee, March 1944, para.7a. (Canberra:
Government Printer, 1945).
2 Commonwealth of Australia, Report of the Royal Commission on Health ( Melbourne, Victorian
Government Printer, 1926), Appendices 8, para.20.
3 J.H.L.Cumpston, ed. M.J. Lewis, Health and Disease in Australia (Canberra: Australian Government
Publishing Service, 1989), 9.
2
The reports did not initially stimulate the development of paediatrics, largely because
many of their recommendations could be met by the public health services through such
organisations as the infant welfare clinics and the school health services. Curative
services could be provided by general practitioners and the children’s hospitals.4
However, by 1945 with improvements in the health of the population the needs for
public health services declined. New knowledge and technology stimulated the
development of specialization in the clinical disorders of childhood. At this time
aspiring paediatricians faced questions about their potential professional roles. Were
children sufficiently different from adults to warrant a separate subdivision within
medicine? Was the study of the diseases of children sufficiently challenging
intellectually to be of interest to the enterprising doctors who would be required for the
successful development of a new specialty? Over the next twenty years these questions
were increasingly answered in the affirmative as children were recognised to be in a
separate medical category. This formed the basis for the rise of paediatrics, but
paediatricians had to pursue various power and status indicators before the specialty
could claim to be viable.

Paediatrics was relatively late in coming to Australia compared with countries such as
France, Germany and the United States where it appeared in the late nineteenth century,
and in United Kingdom where paediatrics began in the 1920s. The Australian children’s
hospitals, which had always been centres for child health service development, were
established in the late nineteenth century. The Royal Alexandra Hospital for Children
(RAHC) in Sydney, for example, first admitted patients in 1880, but most of the doctors
who worked there were not paediatricians in the sense that the term subsequently came
to be used. Instead, they were general practitioners or specialists in other fields who had
some interest in the disorders of children. There were only a few doctors in each State
who could call themselves paediatricians. In 1945 there were probably fewer than
twenty in the whole of Australia.5 Paediatrics came into prominence a long time after

4 Public health has been defined as the formal collective practices undertaken by a community, usually
through various levels of government, to prevent disease. It is largely concerned with groups of people
rather than individuals. Curative or clinical medicine deals with individuals who are sick, in the traditional
healing role. Douglas Gordon, Health Sickness and Society (Brisbane: University of Queensland Press,
1976), 10, 16, 17.
5 Lorimer Dods. Notes for an address, 7 August 1960, Dods papers, P172, Series 3, Item 1, University of
Sydney Archives, Sydney. The figure of twenty is probably a rough estimate, as the definition of a
paediatrician was often difficult.
3
the other major specialties in Australia; ophthalmology, surgery and gynaecology, for
example, were established early in the twentieth century.

There were a number of forces which delayed paediatrics becoming a viable specialty in
Australia until after World War II, and they had to be overcome before paediatrics could
advance. Many related to prior possession of occupational space by other groups in
medicine, the general practitioners and physicians who cared mainly for adults. Also,
before 1945 doctors treating children were relatively powerless therapeutically. There
were few forms of treatment which positively affected the outcome of childhood
disease. The arrival of new scientific knowledge and technology in the post-war period
provided valuable opportunities for the specialty to develop. Paediatricians were able to
convince the medical profession and society generally that children were different to
adults and warranted the provision of special medical care, which they were uniquely
equipped to provide.

The development of a new specialty required an application of power and authority. As
other professional groups had found, it was difficult for individuals alone to argue their
case for specialty recognition; they needed to work together in an organized manner and
establish a formal association to represent them and to negotiate on their behalf. This
move, however, proved to be difficult and paediatricians were slow to establish their
own independent association.

The thesis will examine the development of paediatrics in NSW between 1945 and
1965, and the forces responsible for that development. As members of a new specialty
in Australia, paediatricians experienced particular difficulties in explaining who they
were and what they did. This was partly because paediatrics was different to other
specialties in looking after the members of a population group, whereas most other
specialists were concerned with specific diseases or with particular body organs. The
early paediatricians created other confusions amongst their colleagues; they did not
always practise on children alone, as it was too difficult to make a living by doing so.
They were often involved as physicians in adult internal medicine, or they were in part-
time general practice. The development of the new specialty was also dependent on
certain cultural, socio-economic and political circumstances. For example, there were
cultural changes through which people perceived that medical specialists had more
4
skills to offer than general practitioners, who had in the past provided most of the care
of sick children. The availability of effective health insurance schemes from
governments and other sources allowed many more families to consult specialists.
Financially, private practice for paediatricians became more feasible, and permitted a
substantial growth in their numbers.

Definitions

Paediatrics has been defined as that sphere of medical practice which applies to infants
and children. Sometimes the term is used in a broad context, implying both curative and
preventive components of care, for which the term child health has also been used. At
other times paediatrics is applied narrowly to the diagnostic and curative component.6 In
Australia through the twentieth century paediatricians increasingly adopted the latter
approach and progressively abandoned preventive services, which became the
responsibility of the government public health departments. Between 1945 and 1965
paediatricians worked entirely or almost entirely with children. They were physicians
and did not undertake surgery. During that time most paediatricians were generalists
who treated the whole range of childhood disease. By the 1960s some of them began to
embark on subspecialization, in for example, such areas as cardiology, neonatology and
gastroenterology. This was some time after the development of subspecialization in
other areas of medicine.

Paediatricians in NSW spent much of their time in their private consulting rooms seeing
patients referred by general practitioners. They were not doctors of first contact or
primary care doctors as they were in some other countries — in the US, for example. In
their rooms the paediatricians diagnosed and treated a wide range of medical problems,
including the feeding problems of infancy, which had been the mainstay of the few
paediatricians who practised before the war. By the 1960s they were beginning to
expand into new areas such as the treatment of children with behavioural and emotional
problems, and learning disorders. Most paediatricians had appointments as honorary
physicians to the Royal Alexandra Hospital for Children (RAHC), which was the only
children’s hospital in Sydney until the establishment of the Prince of Wales Hospital’s

6 A. White Franklin and R.D.H. Boyd, “Paediatrics.” in The Oxford Companion to Medicine, ed. John
Walton, Paul B Beeson and Ronald Bodley Scott (Oxford: Oxford University Press, 1994), 712.
5
children’s unit in 1964, the predecessor of the Prince of Wales Children’s Hospital.
They regularly attended the outpatients department where they saw children who had
problems similar to those who attended their rooms, but often aggravated by adverse
socio-economic circumstances. The more senior honorary physicians also had
obligations to provide care for in-patients. Many of the paediatricians had appointments
to other hospitals in Sydney; they visited the children’s units in suburban hospitals and
the nurseries in midwifery units around the city. Paediatricians had a number of
different responsibilities, all competing for their time. Like other professionals, they
experienced a conflict of interests in their work, because they had to try to balance their
need to maintain their private practices (because there was no other source of
remuneration) against the duty they owed to their patients in the public hospitals, who
also were important for the development of their professional careers.

Justifications for the Thesis

The development of paediatrics provides valuable opportunities for historical analysis in
a number of areas. It is a specialty directed at a particular section of the population and
involves more than a single disease or a body system, unlike most other specialties. A
history of paediatrics must involve a consideration of the place of children in the society
of the time. It offers substantial challenges because it should seek to analyse two social
phenomena; firstly, how a medical specialty developed at a particular time and in a
particular environment; and secondly, how certain practitioners as a group sought to
meet the needs of this special section of the population, the children.

There are published histories of all the Australian children’s hospitals that refer to the
specialty, but they do not examine the full range of issues which affected paediatrics. In
particular, they have not sought to examine the experiences of children in the
professional development processes. Most are histories commissioned by the hospitals
concerned and hence are celebratory in nature with little attempt at analysis. An
exception is an account of the development of the Royal Children’s Hospital (RCH)
Melbourne, which describes the enterprising role of the President of the Hospital, Lady
Ella Latham.7 A more recent history of the same hospital examines its evolution in

7 H.E.Williams, From Charity to Teaching Hospital: Ella Latham's Presidency 1933-1954 The Royal
Children's Hospital Melbourne (Melbourne: by the author, 1989).
6
much more detail, including its approach to medical staffing that is relevant to the
development of paediatrics in Victoria and which provides valuable comparisons with
what happened in New South Wales.8 Both histories will be discussed in more detail in
Chapter Five.

Another recent history of an Australian children’s hospital is found in the thesis of
Bruce Storey, a paediatrician and historian. This covers the period from the
establishment of RAHC in 1880 to the 1930s, with a brief epilogue about the period
following World War II. It examines the socio-economic status of Sydney during the
course of the development of the hospital and the roles of the nursing and medical
professionals. Storey also discusses how doctors began to take an interest in the
disorders of children. Even then in the 1880s they were experiencing conflicts of
interests between their obligations to the hospital as honorary physicians and their
commitments to private practice.9 The same conflicts played an even greater part in the
later development of RAHC. Storey attempts to examine the role of the children and
their parents, but that is obviously difficult given the paucity of written and oral sources.

There have been numerous books written about the medical profession in general which
cover the period 1945 to 1965. One, by J.C.H. Dewdney, written in 1972, provides a
broad description of the organisation of the Australian health services. Children and
children’s hospitals are briefly mentioned, and the only reference to paediatrics is in a
table recording specialist numbers.10 There are other publications that examine the
changing relationships between the medical profession and the Federal and State
Governments. They do not discuss paediatrics directly, but provide useful information
about the medico-political scene against which the specialty developed. They help
explain the conflicts arising from proposals to change the way children’s hospitals were
staffed to meet the needs of scientific medicine, and the fears of doctors about a loss of
professional independence when threatened with increasing government involvement in
health matters. They explore the evolution of health insurance schemes which
eventually provided financial benefits enabling many more Australian families to

8 Peter Yule, The Royal Children's Hospital: A History of Faith, Science and Love. (Sydney: Halstead
Press, 1999).
9 Bruce Storey, “The Emergence of Paediatrics as a Medical Specialty in Sydney 1870s through 1930s: A
Prolonged and Difficult Delivery,” (Master of Philosophy thesis, University of Sydney, 1997).
10 J.C.H. Dewdney, Australian Health Services (Sydney: John Wiley and Sons Australasia, 1972), 279.
7
consult paediatricians in private practice about their sick children.11 With that subsidy,
paediatric practice became financially more secure, and the numbers of paediatricians
could expand. The discussions, however, are of a general nature and only cover some
aspects of medical specialization; the development of paediatrics is barely mentioned.

Historians and others have written much about one particular aspect of paediatrics —
the development of infant welfare and infant feeding practices, which have produced
fierce controversies in medical, nursing and public health circles. There have been
lengthy debates about whether the infant welfare services were responsible for the
improvement in infant mortality that was observed in the early part of the twentieth
century, or whether it was due to changes in socio-economic circumstances. These
debates and their relevance to the development of paediatrics are discussed in Chapter
Three.

In their involvement in infant welfare, doctors were responsible for the development of
milk formulae to feed both normal and sick babies. In the period when doctors working
in child health had few effective remedies, the modification of cow’s milk and the
prescription of additives to milk occupied much of their time and intellectual energy.
This was the beginning of what, for the time, was scientific research in paediatrics, and
the start of specialized medical work with children in Australia. The so-called science of
infant nutrition had many interpretations, which contributed to the bitter arguments

11 Some examples are James A.Gillespie, The Price of Health: Australian Governments and Medical
Politics 1910-1960 (Cambridge: Cambridge University Press, 1991). Anne Crichton, Slowly Taking
Control: Australian governments and health care provision 1788-1988. (Sydney: Allen & Unwin, 1990).
Sidney Sax, A Strife of Interests: Politics and Policies in Australian Health Services (Sydney: George
Allen and Unwin, 1984). Claudia Thame, “Health and the State: The Development of Collective
Responsibility for Heath Care in Australia in the First Half of the Twentieth Century,” (Ph.D. thesis,
Australian National University, 1974).
8
about the subject.12 During this period a number of doctors established reputations in
the management of sick babies, such that they can be called the pioneer paediatricians in
Australia.

After World War II infant feeding became much less important to paediatricians. There
were other more interesting clinical challenges, better commercially prepared milk
mixtures became available and mothers were better educated and were more likely to
make their own decisions about baby care. Infant feeding, which before the War was a
major part of the work of the few paediatricians in NSW, had little impact on the
development of paediatrics after 1945.

There are few publications on medical specialization and professionalization in
Australia comparable to the works of George Rosen and Eliot Freidson in the US, and
Rosemary Stevens in Britain.13 British comparisons may have been useful to the thesis
because Australian paediatrics was based at first on the UK pattern, but that changed
with the establishment of the National Health Service in 1948, when paediatricians
became part of the welfare state. In Australia, Evan Willis has written about a number
of professions allied to medicine, namely midwifery, optometry and chiropractic. His
remarks about professionalization can be applied in general terms to the development of
paediatrics but there are no specific parallels.14 The same remarks might be applied to
the thesis of Peter J. Lloyd, which discusses medical professionalization in NSW from a
sociological viewpoint and devotes little attention to the separate problem of
specialization.15

12 The literature relating to infant feeding is discussed in Chapter Three. Some examples include include,
W.G. Armstrong, “The Infant Welfare Movement in Australia.” The Medical Journal of Australia 2
(1939): 641-648. M.J. Lewis, “Populate or Perish: Aspects of Infant and Maternal Health in Sydney 1870-
1939” (Ph.D.thesis, Australian National University, 1976). Philippa Mein Smith,. “Infant Welfare
Services and Infant Mortality: A Historian's View,” The Australian Economic Review 1st Quarter (1991):
22-34. Ibid., “Truby King in Australia: A Revisionist View of Reduced Infant Mortality.” New Zealand
Journal of History (1988): 22-43. Wendy Selby, “Baby Clinics, Infant Mortality and Mothers : Another
Side of the Story,” Oral History Association of Australia Journal 15 (1993): 64-73.
13 George Rosen, The Specialization of Medicine with Particular Reference to Ophthalmology (New
York: Froben Press, 1944). Ibid., “Whither Specialization.” in Medicine and Society Contemporary
Medical Problems in Historical Perspective, ed. The American Philosophical Society (Philadelphia: The
Society, 1971), 196-219. Eliot Freidson, Profession of Medicine A Study of the Sociology of Applied
Knowledge (New York: Dodd Mead, 1970). Rosemary Stevens, Medical Practice in Modern England:
The Impact of Specialization and State Medicine (New Haven: Yale University Press, 1966). .
14 Evan Willis, Medical Dominance: The Division of Labour in Australian Health Care. 2nd ed. (Sydney:
Allen and Unwin, 1989).
15 Peter J. Lloyd, “A Social History of Medicine: Medical Professionalization in New South Wales 1788 -
1950” (PhD. thesis, University of New South Wales, 1993).
9
Milton Lewis and Roy MacLeod have analysed early medical professionalization in
NSW up to 1901. They argue that it was important for the profession to be well-
organised if it wished to achieve recognition by the State and the people as the
legitimate provider of medical services, against the competition of unorthodox
practitioners. In NSW the medical profession lacked cohesion and was slow to develop
an effective professional association. In comparison, doctors in Victoria were better
organised; consequently they enjoyed a higher status and gained legislative
endorsement of their profession earlier.16 The value of the organised group to the
establishment of a profession has also been discussed in the general literature on
professionalization. Two examples are works by Andrew Abbott and, particularly,
Geoffrey Millerson.17 Chapter Two will show that paediatrics was slow in gaining
acceptance as a specialty because it had difficulties in forming an effective association.
Lewis and MacLeod make use of comparisons between circumstances in NSW and
Victoria in arguing about professionalization. Comparisons of the patterns of
development of paediatrics in the two states also help in understanding how the
specialty developed in Australia.

D.G. Hamilton, a Sydney paediatrician, has written a brief history of the Australian
Paediatric Association (APA), later called the Australian College of Paediatrics (ACP),
which was the professional association created by paediatricians to further their claims
for recognition. This work provides the best available account of paediatric
development, but it is written for the Association about the Association and does not
cover or analyse all the important issues, such as the conflicts between private and
hospital practice engendered by the attempts to introduce scientific medicine to RAHC
and other hospitals.18

Paediatrics was firmly established in some other industrialised countries long before it
was a viable specialty in Australia. There are certain aspects of its development in other
places which help explain events in Australia, but much of what has been written

16 Milton Lewis and Roy MacLeod, “Medical Politics and the Professionalization of Medicine in New
South Wales, 1850-1901” Journal Of Australian Studies 22 (1988): 69-82.
17 Andrew Abbott, The System of Professions An Essay on the Division of Expert Labor ( Chicago: The
University of Chicago Press, 1988). Geoffrey Millerson, The Qualifying Associations : A Study in
Professionalization (London: Routledge and Kegan Paul, 1964).
18 D.G.Hamilton, A History of the Australian College of Paediatrics 1950-1980 (Parkville, Victoria:
Australian College of Paediatrics, 1990).
10
emphasises that the evolution of a medical specialty is closely related to time and place
and the political, economic and social environment. In other parts of the world,
however, an earlier wave of knowledge in the late nineteenth century had stimulated an
interest in the disorders of children and resulted in the establishment of paediatrics in a
number of countries. The illnesses of childhood were included in the scientific medical
research that began in France in the first part of the nineteenth century with structural or
anatomico-pathological research and were followed by functional studies in Germany,
particularly in biochemistry and physiology.19

The real leader in the establishment of the paediatrics that was to influence the specialty
in Australia, was the United States. The scientific medicine of France, and particularly
that of Germany, was carried to the US by European doctors who settled there and by
Americans who had studied in Europe. They established hospital departments of
paediatrics that were closely associated with university medical schools.20 They enjoyed
a high status in the international medical academic scene; American paediatrics led the
world by the late nineteenth century and in 1880 it was designated a specialty by the
American Medical Association.21 Sydney A. Halpern has examined in great detail the
evolution of paediatrics in the US, which has a medical culture very different to
Australia, and where a second, much larger, group of paediatricians became involved in
primary care. The book provides a revealing picture of professional ambivalences — a
specialty created to meet the health needs of children of all social classes moved its
focus of attention to provide care for the children of mainly middle-class families,
bringing considerable financial rewards to the paediatricians.22

19 Angel Ballabriga, “One Century of Paediatrics in Europe.” in History of Paediatrics 1850 -1950, ed.
Burford L. Nichols, Jr., Angel Ballabriga and Norman Kretchmer (New York: Raven Press, 1991): 1-20.
W.F.Bynum, Science and the Practice of Medicine in the Nineteenth Century (Cambridge: Cambridge
University Press, 1994), xi,xii,192.
20
Howard A. Pearson, “Paediatrics in the United States” in History of Paediatrics 1850-1950, ed. Buford
L Nichols, Angel Ballabriga, and Norman Kretchmer (New York, Raven Press, 1991), 55-63.
Thomas E. Cone, History of American Paediatrics, (Boston: Little Brown and Company, 1979),
71,72.British paediatrics provided a model for the organizational structure of paediatrics in Australia. It
was US paediatrics which provided the stimulus for the development of a scientific approach to
specialized services. .
21Cone, 104.
22 Sydney A. Halpern, American Paediatrics: The Social Dynamics of Professionalism 1880-1980
(Berkeley: University of California Press, 1988).