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Author/s:
HUNTER, CECILY ELIZABETH
Title:
Doctoring old age: a social history of geriatric medicine in Victoria.
Date:
2003-02
Citation:
Hunter, C. E. (2003). Doctoring old age: a social history of geriatric medicine in Victoria. PhD
thesis, Department of History and Philosophy of Science, University of Melbourne.
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Doctoring old age: a social history of geriatric medicine in Victoria.
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DOCTORING OLD AGE
A SOCIAL HISTORY
OF
GERIATRIC MEDICINE IN VICTORIA
Cecily Elizabeth Hunter
Submitted in total fulfilment of the requirements
of the degree of Doctor of Philosophy
February 2003
Department of History and Philosophy of Science
University of Melbourne
ABSTRACT
The pattern of medical practice that emerged in Victoria, following the
introduction of a national system of publicly subsidised voluntary hospital
and medical insurance by the Liberal-Country Party Coalition government
in the early 1950s, was dominated by the provision of individualised,
curative medical services based upon a reductionist model of disease.
Older adults, classified officially as ‘aged’ according to age of eligibility
for the Age Pension introduced in 1909 by the Commonwealth
government, were prominent in this pattern of practice. The number of
adults over the age of sixty-five increased over the early decades of the
twentieth century, and the technical advances made in postwar medicine
led to a growing clinical engagement with the degenerative diseases
associated with old age.
The growing medical involvement with ‘old age’, the basis of the
specialist fields of medical practice that proliferated throughout the 1960s,
was recognised as such only in relation to the work of general
practitioners. Specialist practitioners defined their clinical engagement
with old age in terms of pathologies of bodily organs or systems. In
contrast, the special role of the GP in relation to elderly patients was
defined in terms of that practitioner’s personal knowledge of patients as
individuals. Formal designation of the general practitioner as specialist in
caring for the sick aged was confined to the Pensioner Medical Service, a
component of the national system of remuneration for medical services.
Within this pattern of medical practice infirm old people, whose afflictions
could not be readily resolved by curative medical services, occupied a
residual category outside the field of active medical practice.
When
poverty compounded the difficulties experienced by these infirm old
people they were categorised as a ‘social’ problem to which the
appropriate response was the provision of adequate infirmary beds through
the charitable efforts of local communities.
This pattern of practice emerged out of decades of internal professional
debates,
and
intermittent
negotiations
with
successive
federal
governments. Social medicine, particularly as it developed in Britain, was
2
a source of ideas for some participants. However, overall, the emphasis
upon fee-for-service reflected a widely held view amongst doctors, of the
medical practitioner as an apolitical expert in identifying and treating
specific disturbances in individual bodies.
In Victoria this view was
associated with a long-standing tradition whereby individual doctors, local
communities and the colonial/state government cooperated to develop
acute hospital services. It was as a background to these developments that
the benevolent homes in Victoria, funded largely by the state government
and managed by voluntary committees, assumed the role of chronic
hospitals. They were repositories for patients unwanted in the general
hospitals but without anywhere else to go, and infirm old people, - that
residual category, ‘the aged’ – were prominent amongst them.
The
demarcation in Victorian medical practice, between ‘medical’ and ‘social’
problems ensured this change took place without any alteration in the
palliative work of the doctors employed there.
In the professional environment of Victorian medicine, the introduction of
a medical role in the management of infirm old people arose out of a
policy decision on the part of the Minister for Health, to manage a
growing demand for hospitals and increasing public expenditure. John
Lindell, appointed first medical chairman of the Hospitals and Charities
Commission in the early 1950s, introduced the role of ‘geriatrician’ into
the benevolent home environment, as part of a broader process aimed at
organising a fragmented array of local hospitals into a state-wide system
serving regional populations. Medical services provided by a general
practitioner ‘geriatrician’ outside the acute hospitals would enable the
ready discharge of infirm old people, following treatment during acute
episodes of illness.
At the same time these services were aimed to
minimise the need for long-term accommodation (another growing area of
state government expenditure).
It was, however, events at the national level that influenced the integration
of this socio-medical role into the broader profession although under
conditions that reinforced the objectives of the Hospitals and Charities
Commission.
The reform-minded Whitlam Labor government (1972-
1975) funded the development of the socio-medical services promoted by
a segment of the medical profession, together with an appropriate
3
knowledge base.
This revival of ‘social medicine’ opened up the
possibility of integrating the role of ‘geriatrician’ into mainstream medical
practice. It did so however, under conditions that meant that geriatric
medicine was situated within the broader field of medical rehabilitation on
one hand, and on the other hand, the term ‘geriatric service’ referred not so
much to the setting for a specialist medical role as to a range of
community-based welfare services. The physician geriatrician in Victoria
emerged not in response to the specific health problems of elderly people,
but as a means of managing increasingly expensive publicly funded
hospital services, a response shaped by the organisation of the Australian
medical profession.
This is to certify that this thesis comprises only my original work towards
the PhD, that due acknowledgment has been made in the text to all other
material used and that the thesis is less than 100,000 words exclusive of
the bibliography and appendices.
4
ACKNOWLEDGEMENTS
I am very grateful for the consistent encouragement and perceptive
guidance of my supervisors, Associate Professor Warwick Anderson, Dr
Anna Howe and Associate Professor Janet McCalman. I thank Dr Helen
Verran for her encouragement to take up this challenge and Professor Rod
Home and Dr Marilys Guillemin for their kind assistance.
Many of the individuals involved in the events described in this thesis
have generously given their time to speak to me about their work. These
informal conversations were very helpful in enlarging my understanding
of the context in which a specialist medical role in treating the infirm aged
developed. I would like to thank: Drs D.H. Blake, Herbert Bower, John
Hurley, Boyne Russell, Malcolm Scott, and John Shepherd and the late
Drs Bruce Ford and Sidney Sax; Professors R.B. Lefroy, Derek Prinsley,
and Len Gray and Assoc Prof. Edward Chiu. Dr Shepherd also allowed
me the use of his private papers. Mrs Marion Shaw, formerly Executive
Officer, Geriatrics Division, Hospitals and Charities Commission, was
very helpful in giving me some insight into the work of the Division and,
in addition, providing access to the archives of the Australian Association
of Gerontology. Miss Shirley Ramsay, one of the first social workers
appointed to a position specifically responsible for elderly people, was
also generous with her time.
I must also acknowledge my family - Alix, Ben, Faith, John, Justin, Rex –
each one has, in his or her own particular fashion, helped me in this
endeavour.
5
TABLE OF CONTENTS
ABSTRACT
2
ACKNOWLEDGEMENTS
5
INTRODUCTION
7
CHAPTER 1
30
OLD AGE IN THE PATTERN OF MEDICAL WORK IN VICTORIA
CHAPTER 2
THE
UNKEMPT
68
GARDEN
OF
CHRONIC
SICKNESS
AND
INFIRMITY
CHAPTER 3
116
BUREAUCRACY, PHILANTHROPY AND MEDICAL INNOVATION
CHAPTER 4
157
PSYCHIATRY AND OLD AGE
CHAPTER 5
198
GERIATRICS AS MEDICAL WORK
CHAPTER 6
238
PERCEIVING THE ‘SICK MAN’ IN THE OLD PERSON IN TROUBLE
CHAPTER 7
289
MEDICINE OF SENESCENCE OR MANAGING THE SYSTEM?
BIBLIOGRAPHY
316
APPENDICES
348
6
INTRODUCTION
This thesis addresses the question of how it has been possible for health
and illness in old age in Victoria to emerge as the focus of a specialist field
of medical practice. Superficially, the answer is quite clear: the first
attempts to develop a special medical role in the provision of services for
the elderly in the late 1950s coincided with the appearance of increasing
numbers of elderly individuals in the Victorian population, although
proportionately they remained a small group because of the high birthrate
and level of immigration. In the period since the early 1970s, when the
Australian Geriatrics Society was formed with the aim of promoting
geriatric medicine, the proportion of the population classified as ‘aged’ has
grown, making the association between the development of geriatric
medicine and the shift towards an older population quite explicit.1 It
appears only ‘natural’ in these circumstances, that there should develop a
geriatric medicine defined as, ‘that branch of general medicine concerned
with the clinical, preventive, remedial and social aspects of illness in the
elderly’, and that the Society should nominate as its first aim, the
promotion of the highest standards of medical care for the aged.2
However, this change in the constitution of the population has meant that,
overall, medical practitioners in all fields are concerned with health and
illness in old age. The elderly, classified as such on the basis of age of
eligibility for the Age Pension, since the 1940s at least have made up a
significant proportion of patients in both hospital and community. Since
the 1960s, doctors working in specialist areas of practice such as medicine
1
Between 1954 and 1976, the period covered in this thesis, the percentage of the Victorian
population aged 65 years and over, changed little, from 8.6 per cent to 8.9 per cent. In
absolute numbers the change was more noticeable; 210,000 in 1954 to almost 334,000 in
1976. A high birth rate and sustained immigration accounted for stability in the proportion
of the population in this age group, A. Howe, ‘Report of a Survey of Nursing Homes in
Melbourne’, Working Paper no 10, October, 1980, p.18. In 1981 the percentage of the
Victorian population over the age of 65 was 9.8; in 1991, 11.1; in 1994, 12.1, A. Borowski
& G. Hugo, ‘Demographic Trends and Policy Implications’, in Ageing and Social Policy in
Australia, eds A. Borowski, S. Encel, E. Ozanne, Cambridge University Press, Cambridge,
1997, p.26, Table 2.1.
2
R.B. Lefroy, ‘The Development of Geriatric Medicine in Australia’, MJA, vol 161, 1994,
p.18. The Society began its existence in 1972 as the Australian Geriatrics Society and it is
now known as the Australian Society for Geriatric Medicine, for a history of the Society
see, R.B. Lefroy, ‘The History of the Geriatric Society of Australia’, in To Follow
Knowledge, ed J.C. Wiseman, The Royal Australasian College of Physicians, Sydney,
1988.
7
and surgery have found most of their patients amongst the elderly.3 In
general practice, also, there has been a shift in the everyday work of
doctors from an emphasis on delivering babies and the diseases of
childhood in the postwar period, to a concern with the degenerative
conditions associated with advancing age. Indeed the general practitioner
is often promoted as the ‘specialist’ in matters relating to health and illness
in old age.4 In Victoria, the specialist geriatrician is most likely to provide
his or her services in complexes located outside the acute hospitals. In this
environment the geriatrician’s role may overlap the general practitioner’s
and be difficult to distinguish from that of the specialist in medical
rehabilitation who also treats patients whose disabilities arise from the
degenerative conditions associated with ageing.
It is the definition of ‘geriatric medicine’ in terms of specialist, age-related
expertise in circumstances where problems of health and sickness in old
age play such a large part in the overall pattern of medical work, that gives
rise to the question at the heart of this thesis. It is a question that addresses
the categorisation of old age in Australia and the emergence of
specialisation within the work of Australian doctors. This specialisation
reflects a range of interactions that are, at the same time, practical, social
responses to need and a community acknowledgment of value. The aim of
this study is to clarify what it means for medical practitioners to ‘know’
about health and illness in old age in an increasingly fragmented field of
medical practice. At the same time I want to identify the consequences of
the appearance of age-related medical expertise for social understandings
of the experience of growing old and for the expression of public
responsibility for the aged members of the community. The concern that
animates this thesis is, how has the emergence of this particular field of
medical expertise shaped responses in the Victorian community to the
3
The entry on ‘Geriatrics’ in the Companion Encyclopaedia of the History of Medicine,
notes that with the exception of the contraceptive pill, ‘all of the major break-throughs in
medical technology since the late 1950s, have had their most widespread impact on people
who are past their fifties, and the further past their fifties, the greater the impact.’, P.
Thane, ‘Geriatrics’, in Companion Encyclopaedia of the History of Medicine, vol 2, eds,
W. Bynum & R. Porter, Routledge, London, 1993, p.1110.
4
For example, when Sidney Sax emphasised the importance of the diagnostic process in
ensuring that old people get the care they need, he concluded, ‘This is the field in which the
family doctor is so clearly able to show the hospital doctor a clean pair of heels’, S. Sax,
‘The Consultation in Geriatric Practice’, Annals of General Practice, September, 1964,
pp.172-175; see also an anonymous editorial, ‘Geriatrics’, MJA, vol 1, 1975, p.87.
8
fundamental question as it applies to old age: What shall we do and how
shall we live?5
In the decades since Max Weber so succinctly defined the predicament of
modern life – how to have a meaningful understanding of life in a world
dominated by intellectualisation and rationalisation - social theorists and
historians have devoted much attention to explaining the widespread
changes that appear to be characteristic of the social life of western,
capitalist democracies.6 The concept of ‘professionalisation’ has been
developed to describe the predominant form of occupational organisation
that has emerged around specific techniques and bodies of knowledge.7
The concept of ‘medicalisation’ has been used to describe the process
whereby medical practitioners have become the principal authorities in
matters related to health and aspects of everyday life which in other
historical periods may have been interpreted in legal or religious terms.8
The process of medicalisation has been linked to a number of aspects of
modern society. For Ivan Illich it is associated with the rise of industrial
society and the erosion of traditional ways of living.9 The sociologist Eliot
Freidson links it to the social power of the medical profession, and
feminist theorists extend this notion to emphasise the social dominance of
men.10 Other interpretations associate the medicalisation of society with
the capitalist mode of production.11 Michel Foucault has interpreted the
development of modern medicine as an aspect of the ‘science of
5
Max Weber quotes this question as it was put by Tolstoy, reiterating the point that while
science may clarify a particular situation, answering this question is beyond its capacity.
M. Weber, ‘Science as a Vocation’ in From Max Weber, eds H.H. Gerth & C. Wright
Mills, Routledge & Kegan Paul, London, 1977, p.143.
6
Ibid. p.139.
7
A. Abbott, The System of the Professions, An Essay on the Division of Expert Labor, The
University of Chicago Press, Chicago, 1988, Introduction, provides a summary of attempts
to develop the concept of professionalisation; see J. Habermas, ‘Technology and Science as
“Ideology”’, in Toward a Rational Society, trans J.J. Shapiro, Heinemann Educational
Books, London, 1971 for an examination of the questions raised by replacement of a
normative social order by technical-operational administration.
8
I.K. Zola, ‘Medicine as an Institution of Social Control’, in The Sociology of Health and
Illness, 2nd. edn, eds P. Conrad & R. Kern, St Martins Press, New York, 1981.
9
I. Illich, Limits to Medicine – Medical Nemesis: The Expropriation of Health, Penguin,
Harmondsworth, 1976.
10
E. Freidson, Profession of Medicine, Harper & Row, New York, 1970; E. Martin, The
Woman in the Body, Oxford University Press, Milton Keynes, 1987.
11
V. Navarro, Crisis, Health and Medicine: A Social Critique, Tavistock, London, 1986;
H. Waitkin, The Second Sickness: The Contradictions of Capitalist Health Care, Free
Press, New York, 1983.
9
government’ characteristic of modern liberal democracies.12 Williams and
Calnan survey a range of responses during the 1980s and 1990s, to earlier
formulations of the notion of medicalisation, suggesting that the
relationship between medicine and society is more critical and dynamic.13
The sociologist Bryan Turner has responded by proposing the
development of a sociology of health and illness to equip the sociologist to
contest the process of medicalisation by acting as healer ‘alongside the
physician, the psychiatrist and other professional health agents’.14
Charles Rosenberg has suggested that conceptual frameworks like
‘professionalisation’ and medicalisation convey, in general terms, a sense
of the interaction between the needs of society and the ‘norms and ideas’
of occupations such as medicine.15 However, they do so with a degree of
schematisation that may in fact provide a misleading interpretation of the
development of institutions and definitions of legitimacy in specific social
settings.16
Henning Kirk’s summary of the emergence of geriatric
medicine in the neat formulation of national enterprise – ‘the Germans
developed the theoretical framework, the French gave it a clinical impact,
and the British demonstrated the results’ - gives some indication of the
complexities that may underlie a ‘generic’ geriatrics emerging in response
to broad-scale changes in the constitution of modern populations.17 There
is nothing haphazard in these complexities: they reflect a range of
interactions at the level of the individual, the institution and the system as
knowledge-makers negotiate the conditions they require with the society
that supports them, as institutions shape the emergence of disciplines and
individuals make careers.18
12
M. Foucault, The Birth of the Clinic, trans A.M. Sheridan, Routledge, London, 1971,
‘Governmentality’, in The Foucault Effect, Studies in Governmentality, eds G. Burchill, C.
Gordon, P. Miller, The University of Chicago Press, Chicago, 1991.
13
S.J. Williams & M. Calnan, ‘The ‘Limits’ of Medicalization?: Modern Medicine and the
Lay Populace in ‘Late’ Modernity’, Social Science and Medicine, vol 42, no 12, 1996,
pp.1611-1617.
14
B. Turner, Medical Power and Social Knowledge, 2nd ed, Sage Publications, London,
1995, p.10.
15
C. Rosenberg, ‘Toward an Ecology of Knowledge: On Discipline, Context, and History’,
in The Organization of Knowledge in Modern America, 1860-1920, eds A. Oleson & J.
Voss, Johns Hopkins University Press, 1979, p.442-3.
16
Ibid. p.442
17
Thane 1993, op. cit; H. Kirk, ‘Geriatric Medicine and the Categorisation of Old Age’,
Ageing and Society, vol 12, no 4, 1992, pp.486-489.
18
Rosenberg, 1979 op. cit. p.442-443.
10
Rosenberg makes a similar point about the schematising potential of broad
sociological theories in interpreting an apparently changing experience of
old age in modern society.19
From the perspective established by
conceptual frameworks such as ‘modernisation’, ‘development’ or
‘demographic transition’, a long-term shift has occurred in the course of
which the status of the aged has changed so that they are isolated from
family and community and any wider system of kinship. The accumulated
knowledge resulting from long life experience has become redundant as
other forms of knowledge become socially important.20 Historians have
responded to the challenge posed by these conceptualisations of ‘old age’
to produce a body of work, covering historical periods from antiquity to
modernity in the United States, Britain and Europe, which makes it clear
that ‘old age’ varies with the social setting in which it is experienced.
Even the most precise of demographic studies is underpinned by a social
process in which certain attributes are given to specific age groupings so
the study can be made. Pat Thane summarised the position in her survey
of the field of historical study of ‘old age’ in 1995. Despite the universal
biological characteristics associated with old age – greying hair, wrinkled
skin and stiffened joints – the category ‘old people’ is ‘neither single,
simple nor continuous’. It is one that is shaped by ideas, class, gender,
race and social status.21
As Rosenberg points out, and these studies emphasise, the fit between
broad descriptive categories and the data that is available soon becomes
obscure.22 Yet there are widespread changes such as that seen in the
emergence of ‘retirement’ as a generally experienced period of life in
Western societies in the second half of the twentieth century.23 On a
smaller scale, the emergence of geriatric medicine as a specialist field of
19
C. Rosenberg, ‘The Aged in a Structured Social Context: Medicine as a Case Study’, in
Old Age in a Bureaucratic Society, eds D. Van Tassel & P.N. Stearns, Greenwood Press,
Connecticut, 1986.
20
Turner, op. cit. p.127.
21
P. Thane, ‘The Cultural History of Old Age’, in Ageing, Australian Cultural History, no
14, 1995, pp.23-33.
22
Rosenberg, 1986, op. cit. p.231-232.
23
R. Inall, ‘Gerontology, Geriatrics and Retirement’, The Australian Quarterly, 42, no 2,
1970, pp.86-94, is an early attempt to direct the attention of the local ‘gerontology
community’ to the ‘problem of retirement’, one aspect of the social and medical problems
of ageing. W. Graebner, A History of Retirement, The Meaning and Function of An
American Institution, 1885-1878, Yale University Press, New Haven, 1980; L. Hannah,
Inventing Retirement, The Development of Occupational Pensions in Britain, Cambridge
11
medical practice in Victoria may be seen as representative of another such
widespread shift. Until the late-1970s geriatric medicine in Victoria was
developing as a special interest area of general practice.
For local
purposes, that is staffing the state’s Geriatric Hospitals and providing
special interest training and work for general practitioners, this was more
or less satisfactory. However, the emergence of an overriding national
structure in the organisation of medical practice in which the cultivation of
special interests was formalised at the level of consultant specialist, and
the growing role of the Commonwealth in funding hospital and welfare
services, rendered local solutions superfluous.
Rosenberg has proposed the strategy of using the study of the ‘middlelevel social system’ as a means of investigating the links between the type
of broad-scale changes that are generalised in concepts such as
‘medicalisation’ and ‘demographic transition’, and the persistence of
continuities in specific environments.24
In reference to old age, he
nominates three such systems – work, welfare and medicine.
The
advantage of this approach is that, while the scope of inquiry is limited to
a discrete site - hospital or factory for example - that site itself is located
within a broader social structure.
Focus on the discrete site forces
consideration of ‘the ways in which the system’s characteristics relate to
each other within the more limited context.’25 The middle-level social
system has the potential to expose systemic characteristics, local and
mediating characteristics and individual experience. In this thesis, the
category ‘old age’ emerges out of the interactions between ‘the medical
corps, in the broadest sense of the work, and society; or … physician and
patient, whereby, however, the two meet not only as individuals but also
as members of society with obligations to it’.26
This thesis then, is an exercise in the social history of medicine, drawing
in particular on the social history of specialisation in medicine.
The
parameters of this diverse, but not extensive field, were first delineated in
George Rosen’s study of the development of the specialty of
University Press, Cambridge, 1986; D. Troyansky, ‘Why Do People Retire? Some
Historical Answers’, Review Essay, The Gerontologist, vol 39, no 5, 1999, pp.624-626.
24
Rosenberg, op. cit. 1986, p.234ff.
25
Ibid. pp.232-235.
26
H. E. Sigerist, A History of Medicine, vol 1, Primitive and Archaic Medicine, Oxford
University Press, New York, 1951, p.15.
12
ophthalmology in the United States, published in the 1940s. Rosen’s
study highlighted the part played in shaping medical specialism by the
‘various social forces operating within the medical profession itself, as
well (those) impinging on physicians from the larger environment of the
society in which they operate’.27 The expansion of knowledge and the
development of techniques were but one aspect of a situation in which
many factors combined to make specialisation in the field of diseases of
the eye possible. The potential patient base in the population of a large
city was important, as was the willingness of the public to pay for
specialist services, the benefits of which were readily demonstrated in
ophthalmology. Competition between doctors for paying patients meant
that market forces played a considerable part in shaping specialist practice,
leading to a proliferation of medical organisations formed to supervise
accreditation and training. The tradition of charitable provision of medical
services for the poor also contributed to the development of the
institutional settings in which skills were developed and practitioners
trained.28
Despite Rosen’s clear acknowledgment of the complexity of the
circumstances in which this specialist field of medical practice emerged,
the structure of his work - into chapters concerned with specialisation
amongst ‘primitive’ people, with the ‘logic’ of nineteenth century
medicine and with the social background - suggests a privileging of
‘scientific’ medicine.
Rosemary Stevens’ studies of specialisation in
England and the United States, published 1966 and 1971 respectively, also
suggest that specialisation is driven primarily by advances in medical
knowledge.29 Nevertheless, in both cases, the context in which this claim
is made makes it clear that these advances are embedded in specific
historical circumstances.
Stevens makes the point herself, in the
introduction to a new edition of the American study, that science and
technology cannot be regarded as ‘independent constructs’ that underpin
27
G. Rosen, The Specialization of Medicine with Particular Reference to Ophthalmology,
Arno Press & The New York Times, New York, 1972, p.30.
28
Ibid. p.62ff.
29
R. Stevens, Medical Practice in Modern England, The Impact of Specialization and State
Medicine, Yale University Press, New Haven, 1966, p.4, American Medicine and the
Public Interest, A History of Specialization, Updated Edition, University of California
Press, Berkeley, 1998 (first published in 1971), p.xv.
13
the specialisation process.30 Her subsequent essay on the development of
internal medicine in America clarifies this point. The persistence of this
‘late and reluctant entry to specialty certification’ is due to the strategic
skills of its advocates. They have promoted their interests by stressing
their generalist and humanistic orientation in a fragmented profession, and
their capacity to deal with uncertainty in a professional climate where
decisions about treatment have become less clear-cut.31
Two other studies of specialisation in American medicine highlight the
part played by ‘social’ factors in the specialisation of medicine. In a
profession that is open to market forces, status and effective organisation
underpin the emergence and persistence of the specialist field of practice.32
Sydney Halpern’s historical sociology of the specialty of paediatrics sidesteps the knowledge-making aspect of paediatrics by making a distinction,
which she notes is not free from ambiguity, between specialties that are
associated with scientific advances and those that are ‘social-problem
based fields of medical expertise.33 Glenn Gritzer and Arnold Arluke
suggest that in a competitive market for professional services, knowledge
and technology can be resources used by groups to justify their claim to
specialty status and dominance in a division of labour.34
In contrast to the studies of paediatrics and medical rehabilitation which
concentrate on the organisational aspects of specialisation, Judith Walzer
Leavitt provides a seamless account in which the practices that define the
specialty of obstetrics emerge out of an evolving interrelationship between
medical practitioners and well-to-do childbearing women.35
Leavitt
concludes that the knowledge and techniques that define twentieth-century
obstetrics were forged within a confluence of medical ideas and practices and women’s disposition to control the experience of childbirth through
30
Stevens, op. cit. 1998, p.xv.
R. Stevens, ‘The Curious Career of Internal Medicine: Functional Ambivalence, Social
Success’, in Grand Rounds, One Hundred Years of Internal Medicine, eds R.C. Maulitz &
D.E. Long, University of Pennsylvania Press, Philadelplia, 1988, pp.357-364.
32
G. Gritizer & A. Arluke, The Making of Rehabilitation, A Political Economy of Medical
Specialization, 1890-1980, University of California Press, Berkeley, 1985; S. Halpern,
American Pediatrics, The Social Dynamics of Professionalism, 1880-1980, University of
California Press, Berkeley, 1988.
33
Halpern, op. cit. p.11-12.
34
Gritzer & Arluke, p.7.
35
J. Walzer Leavitt, Brought to Bed, Childbearing in America, 1750-1950, Oxford
University Press, New York, 1986.
31
14
the choices they made - in a social context characterised by growing
affluence, social fragmentation and a propensity to look to ‘science’ as an
authority.36 The relationship, as Leavitt acknowledges, was not an equal
one, nevertheless, by the 1950s, a ‘social norm’ of childbirth was
established within a relatively stable network of associations, the stability
of which depended on both women and doctors being able to play their
part.37
The study of specialisation in British medicine offers a different
perspective from that in the United States, as the organisation of medical
practice there leaves less scope for the operation of market forces. Thus
Christopher Lawrence’s study of the shift in perspective that underpinned
the emergence of cardiology as a specialist field of practice between 1880
and
1930,
encompasses
ideas,
medical
associations,
techniques,
institutions and changing attitudes regarding the clinical practice of
medicine and the use of technology.38 In a closed medical world where
specialisation in practice developed within an existing division of medical
labour between general practitioners and consultant physicians and
surgeons, and where access to specialists came through referral from the
general practitioner, the most pressing task facing medical innovators was
to convince their colleagues and hospital governors of the merits of
proposed innovations.39
The scope for developing innovations in the
course of providing medical care for the indigent patients who filled the
wards of the voluntary hospitals was extended during the First World War
when the War Office officially recognised the special categories of disease
perceived within the ‘new cardiology’ and appointed men with special
abilities to deal with these problems.40
36
Ibid, pp.207-212.
B. Latour, Science in Action, Open University Press, Milton Keynes, England, 1987,
p.256. Leavitt’s review essay, ‘Medicine in Context’ displays a growing field of
scholarship defined not by the ‘particular approach, training or departmental affiliation of
(the) practitioner’ but by subject matter, the processes of healing and their meaning, J.
Walzer Leavitt, ‘Medicine in Context’, American Historical Review, vol 195, no 5,
December, 1990, p.1473.
38
C. Lawrence, ‘Moderns and Ancients: The ‘New Cardiology” in Britain 1880-1930’ in
The Emergence of Modern Cardiology, eds W.F. Bynum, C. Lawrence, V Nutton, Medical
History, Supplement No 5, 1985, Wellcome Institute for the History of Medicine, London.
39
A leading participant in the process was James Mackenzie, a general practitioner who
wanted to establish general practice as the seat of clinical research, who viewed hospital
medicine and specialisation as necessary evils, and who believed the instruments
developed in a physiological approach to heart disease would, in the long run be jettisoned
in favour of the clinical skills of the doctor, ibid, p.15-16, p.21ff.
40
Ibid. p.21.
37
15
Roger Cooter has focused on the period he calls the ‘adolescence’ of
orthopaedics to highlight the ‘interrelations between society, economy and
medical politics’ that underpinned the emergence of this specialist field of
practice.41 During a period when it was far from clear that orthopaedists
could justify their claims to specialist status in terms of specific expertise,
it was the capacity of these practitioners to align their interests with other
social groups that led to their being in a position to claim specialist status.
These social groups included industrialists, trade unions, charity
organisations and officers of the state in times of peace and war.
Orthopaedists achieved a position of authority through their involvement
in a range of social issues (similar to the paediatricians Halpern studied).
They
did
so
however,
not
as
‘science-or
technology-wielding
professionalizers, nor as policy informing medical politicians’, but as
‘ideologues of corporatism, rationalisation, and statism: at a time when the
state was reaching out to embrace professionals in its effort to efficiently
manage its welfare’.42 The end product of this process, the post-NationalHealth ‘specialty’, was negotiated as orthopaedists tried to align their
claim to a ‘generalist’ expertise in restoring function to impaired
productive social units – workers, soldiers, disabled children – with the
possibilities for existing as a specialist field of medical practice within the
National Health Service.
With the introduction of National Health Service medical practitioners at
the level of consultant gained a degree of control over the regional
allocation of central government resources and to this extent orthopaedists
had achieved their managerial aims. The authority of local government
officials and lay hospital governors was diminished and consultants were
recognised as a privileged elite. However where previously orthopaedists
had been able to justify their claim for authority by reference to their
standing as medical practitioners and their technical expertise, now they
had to establish a claim to authority that was recognised within the
medical profession. Securing and holding a footing in the medical
41
R. Cooter, Surgery and Society in Peace and War, Orthopaedics and the Organization of
Modern Medicine, 1880-1948, Macmillan, Basingstoke, 1993, p.4.
42
Ibid. p.6.
16
hierarchy – that is in the university medical schools - meant abandoning a
‘social’ and ‘low-tech’ profile and justifying their role in terms of
scientific and technological research.
In the late 1940s when British
orthopaedists set off to do this by visiting leading orthopaedic centres in
America, the past history of the specialty was denigrated, ‘it had foolishly
inverted its constitution, and ‘put art before science’.’ 43
There are no studies of the practice of medicine in Australia that are
comparable to Cooter’s examination of the interactions between society,
profession and state that underpin the modern specialty of orthopaedics.
Neville Hicks noted in 1982 that some general historians of institutions
have paid attention to the context in which medical practices and ideas
have been developed and established, but on the whole the social history
of medicine has received limited attention.44 The situation has changed
little since then. Hicks commended T.S. Pensabene for bringing the skills
of the economic historian to bear on the question of how doctors in
Victoria have achieved the position of being the principal authority in
matters relating to health and illness.45 Pensabene, who was influenced by
Henry Sigerist’s approach to the history of medicine, concluded that it was
the strength of their professional organisation that made it possible for
advances in medical knowledge to contribute to the rising status of doctors
in Victoria in the eyes of the lay public, and that made it possible for the
profession to establish a relationship with the state so doctors controlled
43
Ibid. p.237-238.
N. Hicks, ‘Medical History and History of Medicine’, in New History, Studying
Australia Today, ed G. Osborne & W.F. Mandle, George Allen & Unwin, Sydney, 1982,
p77. Possibly Hicks himself was more intent on questioning the power of the medical
profession than promoting inquiry into how medical knowledge emerged as a social
process. His own work, ‘This Sin and Scandal’: Australia’s Population Debate, 18911911, Australian National University Press, Canberra, 1978, a study of the debate about
population decline in Australian in the early years of the twentieth century, indicates that
he believed that there was some empirical reality that was distorted by social interests. In
this case, the conservative moralists who dominated the inquiry, ‘The Mackellar
Commission provided a forum which some of them (‘men with a grip on the past’) used in
a manner inimical to the discovery of evidence …’, p.157.
45
T.S. Pensabene, The Rise of the Medical Practitioner in Victoria, The Australian
National University, Canberra, 1980, p.1-2.
44
17
the conditions in which legitimate health services were provided.46
However, just as Rosen’s study of specialisation in America is based on an
implicit division between the context of medical knowledge and its
content, so is this study by Pensabene.
Evan Willis brought a Marxist interpretation to the question of how the
medical profession became dominant in the division of labour around
health services.47
He concluded that the emergence of ‘scientific
medicine’, a field of practice ‘carried out by graduates of training
institutions which teach the scientific, clinical and research orientations of
the occupation known as the Australian Medical Association’ paralleled a
long-term shift in Australia from ‘laissez-faire to monopoly capitalism’.
The focus on individual and biological phenomena in the paradigm
associated with ‘scientific’ medicine, and the exclusion of the political and
social elements in illness, contributed to the conditions that were required
for maintaining the production and reproduction of capital.48 Willis also
appears to recognise an underlying ‘scientific’ reality in answering the
question of how ‘certain sorts of knowledge gain class and state patronage
so as to permit the holders of that knowledge to achieve a position of
dominance’. He does this by making a distinction between ideology and
science and showing that scientific and technological elements ‘intruded’
on the political process through which the medical profession achieved its
dominant position.49
Pensabene’s and Willis’ studies illustrate Rosenberg’s point that the
frameworks provided by generalisations such as, in this case, professional
autonomy and the operation of the capitalist mode of production, obscure
the ‘fine’ structure of the interactions ‘between knowledge and the society
that supports its accumulators and practitioners’.50
J.A. Gillespie
addresses the questions raised by such generalisations in his study of the
events that led to the introduction of the National Health Service by the
46
Ibid. p1-2, pp.177-179.
E. Willis, Medical Dominance, The Division of Labour in Australian Health Care, Allen
& Unwin, Sydney, 1983.
48
Ibid. p.20ff.
49
Ibid. p.90.
50
Rosenberg, op. cit. 1979, p.442.
47
18
Menzies’ government in the early 1950s.51 Asking why the matter of
remuneration for medical services has loomed so large in medical
concerns, Gillespie uncovers a range of complex interactions within
profession concerning relations with the state and the content and
organisation of medical services, and outside it as the federal government,
according to the political orientation of the party in power, sought to
control a growing involvement in funding health services, while at the
same time bringing lay understandings of the form health services should
take into the public arena.
The medical profession did emerge as a dominant force in the National
Health Service that was introduced in the early 1950s. However, it did so
within a broad consensus about the form health services ought to take; a
consensus that included doctors and politicians and one that existed
alongside political differences about how hospital and medical services
should be paid for. Lay support for a specific model of medical practice
underpinned professional dominance and obscured intra-professional
dissension on this matter. The dominance achieved by the Australian
medical profession in the 1950s was further tempered by the requirement
for fiscal responsibility on the part of the Federal government regardless of
what party was in power.52
Gillespie’s study is useful for this examination of the conditions in which
geriatric medicine emerged as a specialist field of practice in Victoria for
two reasons. First, it provides an example of the type of study Rosenberg
calls for, one that identified the specificity of the linkages that are
established in the course of broad-scale changes in the organisation of
social life, changes that are represented in concepts such as
‘professionalisation’ and ‘medicalisation’. Gillespie’s work highlights the
strength of lay knowledges and the often contradictory relationships within
medicine and between medicine and the community that supported it, as
51
J.A. Gillespie, The Price of Health, Australian Governments and Medical Politics 19101960, Cambridge University Press, Cambridge, 1991.
52
Ibid. p.234ff
19
the state became more involved in the funding and provision of health
services in Australia and the medical profession assumed a dominant role
in their organisation.
Gillespie’s work is also important for this study of the emergence of the
specialty of geriatric medicine because it shows that the development of a
medical role in providing age-related services was lodged within a longstanding, although intermittent, debate within the medical profession about
the organisation, orientation and funding of health services. The emphasis
on individualised, curative medical services in the organisation of medical
practice that was established in the early 1950s represented the defeat of
another, potentially complementary, orientation to the provision of health
services, one which can be loosely described by the term ‘social
medicine’. This term will be discussed in detail in chapter two but in
general, social medicine, as it was understood by Australian doctors in the
first half of the twentieth century, referred to the provision of publicly
funded health services focused on prevention and rehabilitation, salaried
medical service and an interpretation of illness and disability that
recognised the multi-causal nature of ill-health. When the opportunity
arose in the mid-1970s, for the advocates of geriatric medicine to develop
their field of practice, it did so in a political environment favourable to the
public provision of medical services, and a professional context where
‘social medicine’ was beginning to be accepted as a legitimate approach to
managing disease and disability. Twenty years later when geriatricians
lamented the slow development of their specialty, citing the association
with benevolent homes, fee-for-service forms of remuneration for medical
services, and Commonwealth legislation for age-specific welfare
measures, they were identifying long-standing problems associated with
integrating a ‘social medicine’ perspective into the mind-set of the
Australian medical profession.
There is little in the history of old age in Australia to draw upon in this
examination of the relationship between medicine and old age in Victoria.
If the historical study of old age has been slow to develop in other
countries, it has been almost non-existent in Australia.53
The most
53
For a survey of this work see, D. Troyansky, ‘Progress Report, The History of Old Age
in the Western World’, Ageing and Society, 16, 1996.
20
sustained attention to this topic occurred in 1995 when the editors of
Australian Cultural History published a collection of essays under the title
Ageing.54
Local contributors to this volume suggested there was an
association between the social categorisation of ‘old age’ and poverty, and
identified a form of ‘ageism’ in a colonial society infused with ideas of
youthfulness and nation-building.55 In this latter respect the building of a
‘modern’ society on very old Australian soil, was accompanied with a
similar denigration of old age that historians have discerned in the
processes that accompanied the emergence of the Republic of the United
States of America.56 A subsequent paper by Dawn Peel, reporting on the
experiences of a cohort of early settlers in country-Victoria, highlighted
the problem of defining what is meant by ‘old age’ and the variety of
experience in the lives of ageing adults.57 She did not aim to establish
linkages between local changes and the type of broad-scale shifts in social
organisation that historians of old age in the United States have sought to
demonstrate. Prior to the publication of this edition of Australian Cultural
History, most material related to old age was to be found in the histories of
charitable provision for the poor and welfare legislation, an association
that suggests a long-standing link between old age and poverty but so far
the relationship has not been closely examined.58
In the general lack of attention on the part of Australian historians to the
categorisation of ‘old age’ there has been no direct attention to the role of
medicine in this process.59
Consequently the background for this
examination of the emergence of a specialist medical role in relation to
health and illness in old age in Victoria, is set entirely by studies relating
to other countries. In general, historians have drawn on medical ideas
about health and illness in old age to reconstruct representations of old age
54
‘Ageing’, Australian Cultural History, no 14, 1995, eds D. Walker & S. Garton.
G. Davison, ‘Our Youth is Spent and Our Backs are Bent’; G. Karskens, ‘Declining Life:
On the Rocks in Early Sydney’; S. Cooke, ‘Terminal Old Age’.
56
D.H. Fischer, Growing Old in America, Oxford University Press, New York, 1978,
p.111.
57
D. Peel, ‘Towards a History of Old Age in Australia’, Australian Historical Studies, vol
117, 2001, pp.257-275.
58
T.H. Kewley, Social Security in Australia, 1900-1972, 2nd. edn Sydney University Press,
Sydney, 1973; B. Dickey, No Charity There, A Short History of Social Welfare in
Australia, Nelson, West Melbourne, Victoria 1980; S. Garton, Out of Luck, Poor
Australians and Social Welfare, 1788-1988, Allen & Unwin, Sydney, 1990.
59
Graeme Davison is an exception to the extent that he does draw on the ideas of Dr Philip
Muskett in completing his picture of old age as the new Commonwealth of Australia was
established, Davision, op. cit. p.53-54.
55
21
at various periods, in Europe, North America and England.60 In addition
some historians have identified a role for medicine in the ‘ageism’ they
have associated with the long-term historical movement in which modern
society emerged with its emphasis on innovation and competition, market
economy and fragmented social life.
From this perspective the
introduction of age-related welfare measures such as old age pensions
have also played their part in stigmatising old people in modern society.61
Thomas Cole has used medical texts, amongst a range of textual material,
to illustrate a shift in the conceptualisation of old age in American society
in the last decades of the nineteenth century. This change meant that old
age was represented not as the end of a spiritual journey in the life of the
virtuous Protestant, but as a period when the middle-aged self required
reconstruction under the tutelage of scientists and the helping
professions.62
The limitations of projects such as Coles’, is that in
focusing on ideas about old age the question of how these ideas are
actually received is not considered.
Carole Haber has also discerned a shift in ideas about old age in America
from around the late nineteenth century. She also sees a role for medicine
in this process as American doctors took up the ideas developed in the
French and German hospitals (ideas that are, in general, nominated as the
beginning of ‘geriatric medicine’).63 Thus I.L. Nascher ’s construction of
‘geriatrics’, in America, the medical specialty concerned with health and
illness in old age, played a leading part in formalising a body of
‘scientific’ medical knowledge related to old age and the emergence of
professional expertise in the field of care of the aged.64 From Haber’s
perspective, the formalisation of medical ideas about old age at the end of
60
G. Minois, History of Old Age, From Antiquity to the Renaissance, trans S. Hanbury
Tenison, Polity Press, Cambridge, 1989; H.J. Von Kondratowitz, ‘The Medicalization of
Old Age, Continuity and Change in Germany from the Late Eighteenth to the Early
Twentieth Century’, in Life, Death & The Elderly, Historical Perspectives, eds M. Pelling
& R.M. Smith, Routledge, London, 1991; Kirk, op. cit. pp.483-497.
61
Fischer, op. cit. p.109.
62
T. Cole, The Journey of Life, A Cultural History of Aging in America, Cambridge
University Press, Cambridge, 1993, pp.220-222.
63
See, for example, M.D. Grmek, On Ageing and Old Age, Basic Problems and Historic
Aspects of Gerontology and Geriatrics, Vitgeveris W. Junk, The Hague, 1959.
64
C. Haber, Beyond Sixty-Five, The Dilemma of Old Age in America’s Past, Cambridge
University Press, Cambridge, 1983.
22
the nineteenth century and the beginning of the twentieth, contributed to a
growing public view of old age as a period of unrelievable decrepitude,
requiring special institutional arrangements in the form of housing and
pensions, organised under the supervision of expert professionals.
However, Haber develops her argument by reference to measures
introduced specifically to address the needs of poor old people or the
working class with limited resources. This approach raises the question of
whether the medical model in which old age was represented as a period
of decrepitude was one that was class-based. While it seems clear from
the evidence Haber provides that there was a shift in social ideas about old
age, even if they were confined to the lower classes, the interactions
between medicine and society in which it was embedded are obscured in
the broad-ranging approach she adopts. For example were the physicians
who began to exclude elderly patients from the Wisconsin State Hospital
for the Insane, patients they had been prepared to admit at younger ages,
acting simply under the influence of a medical model in which old age was
represented pessimistically or were there other influences?65 Had requests
for admission increased, were resources limited, were these paying
patients? These questions are not addressed. Nor is it clear how the small
group of doctors who promoted geriatrics as a field of specialist expertise
could be so unsuccessful professionally and yet so influential in shaping
the ideas of other doctors.66
Peter Stearns’ history of old age in France comes closest to a social history
of medicine perspective and it is one that seeks to link broad-scale social
change with the experiences of ageing adults. In one of the earliest of the
studies of old age that began to appear in the 1970s, Stearns examines the
changing experience of old age in France, in the period from midnineteenth century into the early decades of the twentieth, including
medical responses to the problems of ill-health experienced by these
people.67 Stearns dissects a medical ‘cake’ constructed during this period
as medical knowledge about health and illness in old age emerged as a
65
Ibid. p.90.
C. Haber, ‘Geriatrics: A Specialty in Search of Specialists’, in Old Age in a Bureaucratic
Society, eds D. van Tassal & P.N. Stearns, Greenwood Press, Connecticut, 1986, p79.
67
P. Stearns, Old Age in European Society, The Case of France, Holmes & Meier
Publishers, New York, 1976, Chapter Three.
66
23
specialist field in the work of physician researchers (whose work was done
in institutions set up to house the indigent and sick aged), and a growing
population of elderly people, benefiting from improved social and
economic conditions, actively sought relief from the ailments they
experienced from doctors working in the community.
Until the twentieth century doctors in everyday medical practice
contributed little to the remedies used by old people either because more
elderly people lived in the country where doctors were fewer, or because
they did not have much to offer.
When doctors were able to offer
successful treatments, they had been developed, not by the researchers in
geriatric medicine, but in other areas such as endocrinology and the
treatment of infections. Often their use in the treatment of the elderly
occurred in response to demands by patients who were more aware of
innovations that were available than were their doctors.
Stearns’ examination shows that medical practitioners were closely
involved in the efforts made by a growing number of elderly people to
deal with problems of ill-health they experienced. These were not the
specialists in geriatric medicine however, but the doctors in everyday
practice. The early theoretical advances by French doctors did not affect
the lives of most old people and they were soon overtaken by the work of
researchers in other countries. This medical ‘cake’ emerged as part of a
long-term shift in the constitution of the French population, and changing
social and economic circumstances.
Ageing adults contributed to its
content as they sought to adjust to old age by making demands upon
medical attendants. The greatest influence of the specialist researchers in
geriatric medicine was to enhance an existing pessimism in French culture,
about old age. The pessimism of practising doctors was tempered by their
contact with healthy and active old people and they were obliged to take a
more active stance in relation to old age infirmity by the refusal of old
people themselves to accept the difficulties they experienced. Stearns
shows how medicine both worked with a new experience of old age and
worked against it, but also that the more prominent representation of
elderly people in a population did not necessarily lead to a strong field of
specialisation in the medicine of old age.
24
Stearns’ interpretation of the involvement of medicine in the
categorisation of old age indicates that the intersection of medical
knowledge and a changing experience of old age is more complex than
Haber suggests as she links the marginalisation of old people, a process
characteristic of ‘modernity’ and the emergence of geriatric medicine.
Stearns also associates a pessimistic view of old age with the development
of geriatric medicine but at the same time shows how little geriatric
medicine had to do with the experience of most ageing men and women in
France. Pat Thane’s history of old age in England, over a period from
medieval times to the present, makes a point similar to Haber’s.68 Thane
suggests that in emphasising the special characteristics of ill-health in old
age some of the early practitioners in the field of ‘geriatrics’ may have
contributed to a general view that the elderly were difficult and
unrewarding patients.69 However, like Stearns, Thane also makes the
point that the medical contribution to a changing experience of old age in
the twentieth century came, not from specialists in geriatric medicine, but
from other fields of medical practice.70
The advantage of Thane’s work is that these observations are lodged
within a perspective built up in the course of a survey of processes that
shaped the categorisation of old age in a single culture, over a long period
of time. The category ‘old age’ is shown to emerge out of the social and
political interactions around community responses to a range of matters –
poverty, work, and family life. These responses are enlivened by the
reflections of old people themselves on the condition of old age, and by
the representations of old age that emerge out of, and are used to justify
these endeavours. Thane’s work is important for the purposes of this
thesis, not only because of the close historical links between England and
Victoria, in relation to medicine and welfare. More importantly, the broad
sweep of her study highlights the systemic changes that underpin shifts in
the experience of old age and public understanding of it. For example, the
dependence of some old people on publicly funded welfare is ‘not a
68
P. Thane, Old Age in English History, Past Experiences, Present Issues, Oxford
University Press, Oxford, 2000.
69
Ibid, p.450.
70
Ibid. p.458ff; see also Thane 1993, op. cit.
25
twentieth century invention’, but the social and political environment of
the twentieth century ensures that old age is represented in a qualitatively
different fashion from the representations that accompanied Poor Law
relief.71
The latter was associated with conditions under which the
recipients were excluded from the right to vote. Poverty relief measures in
the twentieth-century measures were not associated with exclusion from
participation in political activity and thus worked, albeit imperfectly, to
include the recipients in everyday social and political life. Poor Law relief
was funded and administered by local communities so to the extent that
they represented a public understanding of old age, it was a fragmented
and local understanding. In mid-twentieth-century, local understandings
of old age were gradually superseded as a ‘specific set of widely held
images of elderly people’ emerged along with a range of age-related
welfare measures. As the British government addressed concerns about
the effects of a longstanding low birth-rate, and the operation of a publicly
funded, universal health service, old age emerged as a specific and
universal, ‘stage of life’, with its associated normative characteristics.72 In
identifying continuities and discontinuities over a long period of time
Thane sets the scene for investigations into the ‘linked changes between
the most general aspects of social and economic organisations and the
smaller worlds of the school, the factory, the business firm, the hospital’.73
This investigation of the network of associations from which geriatric
medicine emerged in the late 1970s as a specific field of medical practice
is initiated in chapter one. Here the point is made that in the pattern of
medical practice in Victoria, in the early 1950s, ‘the aged’ were most
likely to be those individuals who were poor, dependent on publicly
funded care, and whose afflictions could not be cured by individualised
medical services. This ‘framing’ of old age combined a longstanding view
in the general population that the adjective ‘old’ was more appropriately
applied to those who occupied the lowest rungs of the social ladder, a
community proclivity to see the poor aged as worthy objects of charity,
and a general community view that the provision of individualised,
71
Ibid. p.7-8.
S. Harper & P. Thane, ‘The Consolidation of ‘Old Age’ as a Phase of Life, 1945-1965’,
in Growing Old in the Twentieth Century, ed M. Jeffreys, Routledge, London, 1989.
73
Rosenberg, 1986, op. cit. p.232.
72
26
curative medical services was the best approach to managing problems of
ill-health.
The second chapter examines the ideas and institutions that underpinned
this view of old age infirmity. It does so by tracing the reception of ideas
associated with social medicine by the Australian medical profession and
the attempts made to implement a local interpretation of this approach in
the provision of medical services.
This outline of social medicine is
amplified by an account of institutional changes in Victoria from the
1920s to the 1950s. The intention is to show that, in Victoria, ‘social
medicine’ was absorbed into a set of interactions surrounding the
provision of hospital services. The medical profession sought to establish
the public hospitals as training and research institutions. The community
continued its tradition of involvement in providing hospitals. The state
government, facing an increased demand for hospitals by a burgeoning
postwar population, took the first tentative steps in abandoning a role
limited to supervising the use of public funding by community groups as
they responded to their own perceptions of need, and replacing it with
policy driven funding programs for a system of hospital services.
The third chapter is concerned with the introduction of a medical model
into a longstanding tradition of charitable provision for the aged. This
enlargement of the medical role led, not to the dominance of medicine, but
to an enhancement of community activities in caring for the aged and
infirm by the introduction of special forms of expertise in administration
and services.
Chapter four deals separately with the introduction of
services for the infirm aged into psychiatric services, a specialism entailed
not by the needs of this patient group, but by the division of hospital
services between physical and mental illness.
Chapter five situates Victorian developments in the provision of ‘geriatric
services’ and the medical role of ‘geriatrician’ within a national context.
This is necessary because while the Victorian general practitioners who
established this role were satisfied to work within a local framework, their
physician colleagues in other states took a broader view. The possibility
for establishing geriatric medicine as a specialist field of practice at
consultant level arose out of the actions taken by doctors in other states as
27
they sought to achieve acceptance within the profession and at the level of
government, for publicly funded, socio-medical services to complement
the medical services provided in the acute hospitals. These were oriented
towards the complex needs of the chronically ill and disabled and
emphasised prevention, rehabilitation and the incorporation of the services
of a range of health professionals. The early 1970s saw a revival of the
ideas associated with social medicine and their implementation in a
specifically local form. Chapter six examines this process in Victoria as
local interests adapted it to address the needs of the infirm aged. Local
‘geriatricians’ played a minor part in the process through which the role of
specialist physician geriatrician emerged. This role was shaped instead by
the concern of the state bureaucracy to make the most efficient use of
public facilities, by federal funding provisions that defined geriatrics as the
provision of community-based services, and by the opportunistic actions
of parties ready to support geriatric medicine as a means of promoting
their own interests.
This thesis is limited in the contribution it can make to understanding the
experience of old age in Victoria in the last half of the twentieth century.
The people who were the focus of attention in the developments recounted
here, can only be taken as representative of ‘the aged’ in the sense that
they were over the age of eligibility for the Age Pension - the predominant
mode of separating out the aged from other adults during this period.
They are, on the whole, silent participants in the construction of a field of
medical practice around health and illness in old age. Furthermore they
are only a segment of the category ‘old people’; a segment that, because of
infirmity and often poverty, was obliged to seek publicly funded assistance
of one kind or another.
On the other hand this examination of the conditions in which the role of
the specialist physician geriatrician emerged does offer some insights that
are relevant to policy making in relation to hospital services and
provisions to assist the dependent members of society. First it raises the
question of whether age-specific measures are the best approach to dealing
with problems of illness and dependency. Health and activity in old age
have become a more common experience throughout the course of the
twentieth century because of general social and economic improvements
28
and it has been within an ‘ageless’ model of disease that advances have
been made in dealing with the degenerative conditions associated with
ageing. Nevertheless the needs of some old people were not met in the
way hospital and medical services were organised but recognition of these
needs was obscured as specific interest groups in Victoria took up the
generalised ‘problem of old age’ as it was elaborated in other countries.
Relatively straightforward measures such as the provision of appropriate
acute care hospital services for those old people at risk of needing
custodial care, in addition to coordinated domiciliary services, were
submerged in the undifferentiated mass of the ‘problem of old age’.
29
CHAPTER 1
OLD AGE IN THE PATTERN OF MEDICAL WORK IN
VICTORIA
Introduction
The following exploration of how old people figured in the work of
Victorian doctors in the 1950s covers a ‘mundane’ territory where doctors
dealt with patients whose afflictions were not readily resolved by death or
cure. Beginning early in the twentieth century this chapter traces a process
in which the organisation of medical practice in Victoria and a changing
experience of old age are intertwined.
This multi-faceted process
encompassed the emergence of an official definition of old age in
Australian society, public provision of health and welfare services, the
emergence of a reductionist interpretation of sickness in the Australian
medical profession and the associated responses to problems that were not
amenable to this approach.
As medical practitioners deployed their ingenuity and entrepreneurial
skills in applying the therapeutic advances made in medicine in the first
half of the twentieth century, ageing adults benefited.
They did so
however, not because doctors advanced in their understanding of the
actual ageing process, but because they advanced in their mastery of
technique and knowledge of pathological processes. The same approach
had led to greater skill and effectiveness in treating illness in the very
young. It was when these technical skills failed to restore elderly patients
to good health that their condition was accounted for in terms of ‘old age’
– a residual category awaiting further advances in medical skill. The most
visible group in this category were the patients in the public hospitals who
could not be discharged because they had nowhere to go.
Even as ‘old age’ emerged as a residual category in medical practice, some
general practitioners began to nominate the medical care of the ‘the
elderly’ as a specific aspect of general practice. This emphasis on age was
prompted by the appearance of a range of texts, produced mainly in the
United States from the late 1930s onwards. Some focused on health and
illness in older adults, and others reported the results of a growing field of
30
research into various aspects of the ageing process. When the Australian
College of General Practitioners was established in the late 1950s the
possibility arose of formalising education and training relating to the
medical care of older adults. As it was, the clearest indication that the
general practitioner was emerging as the specialist in relation to health and
illness in old age in the 1950s was found in the Pensioner Medical Service.
Introduced in 1951 as one element in the system of hospital and medical
insurance established by the Menzies government, it remunerated general
practitioners for medical services provided to eligible pensioners.
Specialist services were not included; pensioners had to attend one of the
public hospitals for specialist attention. At the same time as age was
beginning to be eliminated as a factor in therapeutic decisions, it was
increasingly emphasised in social life. The Pensioner Medical Service
was one of a number of age-specific welfare measures that appeared in the
1950s to contribute to a process whereby ‘the aged’ were increasingly
marked out as a specific social group.
While the ailments of ageing adults played a larger part in the everyday
work of doctors the medical profession in Victoria was unanimous in the
view that the infirm aged, unless in the acute stage of a disease process,
had no place in active medical work. This point of view was made clear
by Dr Alan McCutcheon, medical officer at Mount Royal Home and
Hospital for the Aged, at the Australasian Medical Congress in Melbourne
in 1952, where for the first time there was a session on the ‘medical care
of the aged’.1 McCutcheon referred to a group of elderly patients, the
long-term sick and irremediable, whose needs were to be met through the
provision of hospital beds that were distinguished from those in the
general hospitals by being less costly. Where medical and lay opinion
were beginning to diverge on the matter of what conditions associated
with old age were treatable (other contributors to this session emphasised
this point), they shared the view that the provision of long-term care beds
was the most appropriate response to the needs of infirm old people.
McCutcheon’s description of the needs of this group as a social problem,
not a medical one, therefore reflected community and professional
1
MJA, vol 2, 1952, p.489-490.
31
opinion. His use of the term ‘geriatrics’ to refer to this group and the
‘problem’ implied an inherent link between the needs of this group and old
age in general. However poverty and dependence may have been just as
prominent in the plight of these unfortunates, and the group did include
younger adults as well as those past the age of eligibility for the Age
Pension, the existing public definition of old age. Posing this problem in
such terms arose as much from the existing proclivity in the Victorian
community to emphasise the ‘aged’ as having a special place in
community responsibilities, as from any other factor.
The professional setting in which McCutcheon defined the infirm aged as
a ‘social’ and not a ‘medical’ problem became more clearly defined in the
1950s. The roles of specialist and general practitioner were more clearly
demarcated and the hospital and medical insurance scheme introduced by
the Menzies government provided an assured system of remuneration.
The ‘new order’ reinforced professional autonomy over the conditions of
providing
medical
services
and
emphasised
individualised, curative medical care.
the
provision
of
It also entailed a greater
involvement on the part of the federal government in subsidising such
services, which, in relation to hospitals, had previously been the
responsibility of the states. The principal preoccupation of leaders in the
Victorian medical profession at this time was to establish conditions
similar to those they saw overseas, in hospitals, research facilities and
medical training, for the development of a reductionist and standardised
approach to problems of ill-health in the Victorian community.
The
designation of the infirm aged as a problem requiring a social solution, not
a medical one, meant that the care of this group was located outside the
realm of active medical practice, opening up the possibility for it to be
included in an emerging field of age-specific welfare.
Making Old Age Public
What was meant by the expression ‘old age’ in the early decades of the
twentieth century? In Australia the main source of information on this
topic is the discussions that attended the introduction of Age Pension
legislation, first by Victoria and New South Wales around 1900, and then
32
in 1909 by the newly installed Commonwealth.2 This legislation marked
the first formal acknowledgment of old age in the life of the young
Australian nation, and in that sense, the public history of old age in this
country begins with an administrative measure to relieve poverty. In his
account of the Age Pension legislation, T. H. Kewley notes that when the
bill was presented to the Commonwealth parliament, no reason was given
why the age of eligibility was set at 65 years (with the proviso that when
funds permitted women would qualify at the age of 60). In a report on
social insurance in 1910, George Knibbs, the Commonwealth Statistician,
noted in passing that the choice of age of eligibility was an arbitrary one.3
From the last decade in the nineteenth century, the proportion of people in
Victoria over the age of 65 years had begun to resemble that in countries
such as Great Britain and the United States, that is between four and five
per cent of the overall population.4 Unlike these other countries, this
group in Victoria in the 1890s, consisted mainly of men due to their
predominance amongst the immigrants attracted by the discovery of gold.
It was not until well into the twentieth century that the numbers of women
exceeded men.5
Knibbs’ comment suggests that Australian legislators did not go to the
lengths their English counterparts did when the Age Pension was
introduced there in 1908.
The committee that drafted the English
legislation sought advice on the question of age of eligibility from a range
of sources in the trade unions, occupational pension schemes and poor
relief organisations.
Jill Roebuck concludes that the age of 70 was
accepted as the beginning of old age on the basis of combining a broad
common understanding about the capacity of men and women to work
after the age of 60, with a pragmatic regard to the increased costs
associated with accepting a lower age of eligibility.6 Kewley notes that
2
In comparison with the constitutions governing other federal states, the Constitution of
the Commonwealth of Australia was unique in establishing assistance for the aged as a
statutory right through the Invalid and Old-Age Pensions Act 1908. In the United States
for example, this was not achieved until the 1930s, P. Gunn, ‘Legislating Filial Piety: The
Australian Experience’, Ageing and Society, vol 6, June, 1986. p.136-137.
3
Kewley, op. cit; p.74-75, J. Dixon, Australia’s Policy Towards the Aged: 1890-1972,
Canberra College of Advanced Education, Canberra, 1977, p.27.
4
Davison, op. cit. p.43-44.
5
Dixon, op. cit, Table 1.1, p.2.
6
J. Roebuck, ‘When Does Old Age Begin? The Evolution of the English Definition’,
Journal of Social History, 12, no 3, 1979, pp.416-428. Roebuck outlines a range of
community understandings of old age, which were expressed in schemes for the relief of
33
concern with cost certainly prevented an age of eligibility lower than 65
being adopted by Australian legislators.
There are no indications that these legislators were aware of a new form of
common understanding about old age, the ‘scientific’ truth of old age
which Henning Kirk maintains informed the deliberations of Continental
legislators regarding age of eligibility.7 Kirk accords Adolphe Quetelet
the honour of inventing the category of ‘the elderly’ defined by age.
Quetelet, was a Belgian astronomer and mathematician who wanted to
develop a ‘social physics’ by applying statistical methods to human life.
He derived his definition from statistical observations relating to
diminishing body mass and height after the age of 50, combined with the
further observation that the survival curve declined significantly between
the 60th and the 65th year of life.8 Kirk suggests that Quetelet’s definition,
together with the view of ageing which emerged in French and German
medical circles in the late nineteenth century based on the sciences of
biology and chemistry, was absorbed into popular health literature,
encyclopaedias and dictionaries to provide the basis of a new ‘scientific’
common understanding which influenced Continental legislators.9 There
is, however, no evidence in the secondary sources that either English or
poverty and occupational pensions. An estimation of the capacity to work was common to
them all, pp.417-419. In older societies in England and Europe, there was also a tendency
to associate old age with the ages around 60 to 70 years, and the advent of old age was
marked by diminished responsibilities and expectations of what an individual would
contribute to the social life of the community, S. Shahar, ‘Old Age in the High and Late
Middle Ages’, in Old Age from Antiquity to Post-Modernity, eds P. Johnson & P. Thane,
Routledge, London, 1998.
7
Kirk, op. cit. p.489-490. The influence of European thinking about the role of the state in
the health of the nation was more explicit in the ideas of J. H. L. Cumpston and J. S. C.
Elkington, two advocates for the establishment of the Commonwealth Department of
Health in the period following the end of the First World War, M. Roe, ‘The Establishment
of the Australian Department of Health: Its Background and Significance’, Historical
Studies, vol 17, no 67, 1976, p.182 and pp.183-188. Both men spent time in England and
Europe around the turn of the century where their plans for public health in Australia were
shaped by ideas that linked disease to conditions of work, housing and poverty, M. Roe,
Nine Australian Progressives, Vitalism in Bourgeois Social Thought, 1890-1960,
University of Queensland Press, Queensland, 1984, p.92 in regard to Elkington and p.119
regarding Cumpston. For further discussion see chapter two.
8
Ian Hacking describes Quetelet (1796-1874), as a man fond of numbers and happy to
jump to conclusions, who enthusiastically applied the methods of statistics to the
interpretation of human social life in a project aimed at laying the groundwork for a ‘social
physics’ for the management of populations, I. Hacking, The Taming of Chance,
Cambridge University Press, Cambridge, 1990, p.105.
9
Kirk, op. cit. pp.492-495.
34
Australian legislators were influenced in their thinking by a rationalised
European categorisation of old age.10
The everyday experience of legislators may have led them to associate the
age of 65 with diminished physical strength. Unless they were lucky in
entrepreneurial ventures, most men and women made their place in
colonial society by dint of unremitting hard labour which took an
inevitable toll on their bodies. The effect of hard work was exacerbated by
poor nutrition and, for many, by the peripatetic way of life imposed by the
pursuit of success and security. Even in their fifties many people looked
old.
Some men may then have had to face the added burden of
unemployment, or lower wages than younger adults, because employers
were ready to conclude that age impaired productive capacity. In the
factories that sprang up in the inner suburbs of Melbourne an older man
might take home one fiftieth of the wage due to him according to Wages
Board prescribed rates. For women the labour associated with childbirth
and child rearing added to the toll on their physical resources.11 The
opening pages of The Fortunes of Richard Mahony, set in the central
Victorian goldfields in mid nineteenth century, give a preview of the men
whose difficulties in competing with younger men for scarce work in the
depression of the 1890s led to the introduction of the Age Pension in
Victoria. Life on the diggings ensured that young bodies aged quickly.
Working for days up to their waists in water, miners’ bodies were attacked
by ‘dysentery in the hot season and winter cramps’. Joints became knotted
and knarled with rheumatism and in time, drink taken to blunt the effects
10
The only direct association made between the Australian scheme and European models
was made by L. Tierney in ‘The Pattern of Social Welfare’, in A. F. Davies and S. Encel,
eds, Australian Society. A Sociological Introduction, Cheshire, Melbourne, 1967, p.114.
Tierney states that the Australian scheme was based on the Danish one but does not give
references. His comment was referred to by G. Kaplan, ‘Ageing in Australia’, in
Australian Welfare, Historical Sociology, ed R. Kennedy, Macmillan, South Melbourne,
1989. However Kewley, whose account appears to be most comprehensive, does not link
the Australian scheme directly to the Danish one. He notes that J.C. Neild compared the
New South Wales pension scheme with the Danish model but the model adopted by the
Commonwealth appears to have been largely shaped by local influences and the New
Zealand scheme. Kewley, op. cit. p.49, p.73.
11
Davison, op. cit. p.45; S. Macintyre, The Oxford History of Australia, vol 4, 1901-1942,
The Succeeding Age, Oxford University Press, Melbourne, 1986, pp.31-35; J. McCalman,
Struggletown, Public and Private Life in Richmond, 1900-1965, Melbourne University
Press, Carlton, Victoria, 1984, pp.29-34; Australia 1888, eds G. Davison, J.W. McCarty, A.
McLeary, Fairfax Syme & Weldon Associates, New South Wales, 1987, p.329; J.
McCalman, Sex and Suffering, Women’s Health and a Women’s Hospital, Melbourne
University Press, Carlton, Victoria, 1998, Chs 1 & 2; J. Godden, ‘A New Look At Pioneer
Women’, Hecate, vol v, no 2, 1979, pp.7-21.
35
of exhaustion and disappointment, took its toll also.12 On the land, life
was no less exhausting and some colonists made an analogy between
pioneering and the trials of warfare - both threatened life and limb and
both should be viewed as service to the nation.13
The introduction of the Age Pension provided the occasion for the first
public discussion of the place of older adults in the life of the new nation.14
Legislators were responding to the plight of those who were poor, but they
appear to have taken the opportunity to locate this measure within a
broader public reflection on, and acknowledgment of the meaning of old
age in Australian society. This stance may have been prompted by the
effects of the economic depression of the 1890s in Victoria, where even
the most provident and industrious of citizens were rendered destitute
through no fault of their own. Such ill fortune was an affront to the
evangelical Protestantism that imbued public life, but the likelihood that a
state-funded pension would undermine filial responsibility or encourage
fecklessness was just as affronting.15 These sentiments were taken up in
Commonwealth legislation to produce a measure which acknowledged an
earlier contribution to communal prosperity by these ‘worn-out wealthcreating human machines’, but which also, through its conditions of
12
H. H. Richardson, The Fortunes of Richard Mahony, Penguin Books, Ringwood,
Victoria, 1982, p.12.
13
Davison, 1995, op. cit. p.52.
14
Australia was unusual in that the Age Pension was the first official recognition of
‘service to the state’ by any section of the population. In other countries pensions for war
veterans and public officials preceded old age pensions. Quadagno states that in the United
States for example, enthusiasm for providing age pensions was constrained by the
patronage system, which had grown up around war veterans’ pensions, J. S. Quadagno,
‘The Transformation of Old Age Security’, in Old Age in a Bureaucratic Society, eds D.
Van Tassel & P. N. Stearns, Greenwood Press, New York, 1986, p.138-139. Theda
Skocpol, in a more extensive examination of the state funded benefits for Civil War
veterans, concludes that within the structure of the nineteenth century US state, patronage
certainly needs to be taken into account but there was another dimension. The opposition
to publicly funded welfare programs such as those introduced in Europe and Australia and
New Zealand at the turn of the century, was just as strong amongst those who advocated
benefits for veterans as it was in later generations. Veterans benefits were made available
to those who had ‘earned aid’ through service to the nation, Civil War pensions ‘privileged
both the political party and those among the citizenry who had participated victoriously in a
morally fundamental moment of national preservation’, T. Skocpol, Protecting Soldiers
and Mothers, The Political Origins of Social Policy in the United States, The Belknap
Press of Harvard University Press, Cambridge, Massachusetts, 1992, Chapter2.
15
Gunn, op. cit. argues that although separate states enacted legislation to compel families
to provide for their needy relatives, it was directed more towards the needs of deserted
mothers and their children than the aged, and was rarely enforced. Despite the emphasis in
pension legislation on filial responsibility, the state had already accepted responsibility for
the destitute, particularly in Victoria, by heavily subsidising the benevolent societies in
their work.
36
eligibility, ensured that need had to be fully justified.16 The ethos of
individualism and respectability was thus preserved; demonstrating to the
better off that those in need had indeed acted responsibly. The Age
Pension was to be granted as a right, not a charity, and it was not
considered that it should furnish the whole of any individual’s income. It
was to be ‘something in the nature of a retiring allowance’ available to the
‘deserving poor’.17
The alacrity with which legislators in both state and Commonwealth
parliaments enacted proposals for an Age Pension may have reflected
genuine communal acceptance of responsibility for its aged citizens.18
Individuals from all sides of politics supported the measure in sentiments
suggesting that it was indeed prompted by some sense of collective
responsibility to those who had contributed towards the collective wellbeing. The introduction of the Age Pension provides an apt example of
the analogy Stuart Macintyre made between the early years of selfgovernment in the Australian states and the Sunday School Superintendent
at the annual picnic who, in times of relative plenty, ensured that amongst
the activities of settlement, there were ‘prizes for everyone’.19 Although
the Age Pension was formally acknowledged as a right and not a charity,
the notion of deservingness, associated with charity, persisted in a form
peculiar to the culture of the new nation. The generosity of spirit and the
desire to acknowledge a responsibility to every ‘single unit’ within the
nation sat uneasily with the ethos of possessive individualism that
underpinned national life, in which a plea for public assistance was
associated with moral weakness. This first public acknowledgment of old
age as a stage in the life of Australian men and women was, however, an
16
Kewley, op. cit. p.76-77; Dixon, op. cit. p.22, pp.27-31. Applicants put their claim to the
Registrar of Pensions for their district who examined it before passing it on to a magistrate
who could call upon the applicant to support the claim.
17
Kewley, op. cit. p.81-83, Commonwealth legislation reflected the sentiments expressed
in earlier state legislation in Victoria and New South Wales as well as that enacted in New
Zealand where a similarly uneasy recognition existed that the principles of self help, family
obligation and Christian charity did not suffice to address the needs of destitute old people,
D. Thomson, ‘Old Age in the New World: New Zealand’s Colonial Welfare Experiment’,
in Old Age from Antiquity to Post-Modernity, op. cit.
18
A non-contributory scheme assured the equal treatment of men and women. Where
pension schemes were tied to working life, women were not so well off, Thane, 2000, op.
cit. pp. 330-332
19
Macintryre, op.cit. p.100.
37
aside, and perhaps even a somewhat absentminded one, to the more
pressing business of building a new nation.20
The Public Meaning of Old Age
In this first official demarcation of old age, the condition was characterised
as a period of physical decline, beginning at the ages of 65 for men and 60
for women. The conditions of eligibility for the Age Pension ensured that
‘the aged’ were those who were of good character, had resided in Australia
for 25 years and were of acceptable racial origins.21 The means test
ensured it was also a period, particularly for men, of exclusion from one of
the principal activities of citizenship – productive activity. At worst it
could be seen as an indication of failure in the civic enterprise of providing
a respectable degree of self-support. Macintyre has included the Age
Pension amongst the measures that were aimed at reconciling the working
class to the social order of industrial capitalism in the early years of the
twentieth century. The working man was guaranteed a ‘living’ family
wage, with assistance in the form of free education and maternity
allowances to foster the development of the coming generation, and the
age pension to cushion the effects of exclusion from an increasingly
uniform and regulated workforce.22 At the same time, the acceptance on
the part of the Commonwealth government of such an open–ended
20
P. D. Phillips, ‘Federalism and the Provision of Social Services’, in Social Policy in
Australia, ed J. Roe, Cassell, Australia, 1976, p.256. Phillips concludes it is likely this
aspect of welfare was assigned to the Commonwealth government without much
consideration of what was entailed. The Commonwealth funded pensions from a trust fund
established for the purpose under the Surplus Revenue Act, 1908, which permitted funds to
be set aside and not available for distribution to the States. The Royal Commission on Old
Age Pensions, 1905-6, does not appear to have considered the matter of financing Age
Pensions in any detail. Two factors may have influenced the Commission’s judgement that
conditions in Australia and Germany (the leading example of a contributory pension at the
time) were different. First, the measure was intended to address immediate problems of
poverty faced by the state governments, particularly Victoria and New South Wales,
second, Labor members of parliament were against a contributory scheme because it
maintained the distinction between rich and poor, Kewley, op. cit. pp.70-72, p.86-87;
Gunn, op. cit, p.154ff; Dixon, op. cit. p.3.
21
The conditions of eligibility in Australia, initially confined the pension to those who
passed the means test, who were British subjects (excluding some Aborigines, individuals
of Asian ancestry, Pacific Islanders, Africans and New Zealanders), and who had resided in
Australia for 25 years. The applicant’s good character was also taken into account and
inmates of benevolent asylums, hospitals, goals and insane asylums were excluded, Dixon,
op. cit. p.27.
22
Macintyre, op. cit. p.100. In contesting the view that the United States government did
virtually nothing about publicly funded welfare until the New Deal period of the 1930s,
Skocpol contrasts the paternalism of measures such as the Age Pension in Australia with
the development in the US of the foundations for a maternalist welfare system in the period
between 1900 and the 1920s. The various social benefits and protective labour regulations
that were introduced at this time were a response to the demands of female dominated
38
financial commitment towards one segment of the poor, at a time when its
financial resources were uncertain, meant that every year in the budget
deliberations the sentimental recognition of the place of the elderly clashed
with financial exigency.23
The somewhat grandiose aspiration to
recognise the place of the aged in Australian society produced a sacred
cow before which all political parties were obliged to bow, but whose
worship was constrained by the demands of fiscal responsibility.24
The categorisation of old age through the introduction of the Age Pension
suggests that old people were marginalised within the general population
of active ‘independent’ working people.25
The process appears to
reinforce the ‘ageism’ Graeme Davison has discerned in colonial society
where grandparents were a rarity, and the virtues of community life were
those ‘of youth - energy, optimism, readiness to experiment, impatience
with tradition’.26 Witnesses called to give evidence in coronial inquiries
into the deaths of old people by suicide suggested on occasions that the
fatal act arose out of shame at having to claim the pension. Although in no
instance was it found that this was in fact the case, the comment itself
implies there may have been a tendency in general to regard the status of
‘pensioner’ as shameful.27
Nevertheless, the steady rise in numbers
drawing the pension in the first twenty years after the 1908 legislation
suggests that old people were not reluctant to avail themselves of this
agencies whose objectives were to establish beneficial conditions for women and their
children, Skocpol, op. cit. p.253ff, pp.367-372, p.522-523.
23
The unanimity with which this measure was enacted into Federal legislation reflects
Rowse’s characterisation of this period of federalism (1906-1916) as one of ‘collective
liberalism’ in which both liberals and socialists viewed the state as a neutral instrument to
be used through parliamentary representation, T. Rowse, Australian Liberalism and
National Character, Kibble Books, Melbourne, 1978, p.40.
24
In his discussion of the National Insurance legislation introduced by the Lyons’
government in 1938, Watts indicates that there may well have been a view within Treasury
from the beginning, that the non-contributory character of the Age Pension scheme was
‘morally irresponsible and fiscally unsound’. Concern about funding pensions was central
in the fiscal crises faced by Australian governments from the 1920s up to the Second
World War, R. Watts, Foundations of the National Welfare State, Allen & Unwin, Sydney,
1987, pp.8-15.
25
The expression ‘old people’ is used throughout this thesis as it is used during the period
under discussion. The same approach is taken to the term ‘inmates’ as it was used to refer
to the individuals cared for in the benevolent institutions.
26
Davison, 1995, op. cit. p.41-42. The rarity of grandparents is questioned by Dawn Peel
on the basis of a small study of 286 adults who lived in the area that was to become the
Shire of Colac, in 1857, and who lived or retained their links with the district until their
final years, Peel, op. cit. p.269.
27
S. Cooke, ‘’Terminal Old Age’: Ageing and Suicide in Victoria, 1841-1921’, in Ageing,
Australian Cultural History no 14, 1995, p.84-85.
39
benefit.28 This impression is reinforced by the numerous alterations to the
eligibility conditions in subsequent years that, although not far-reaching in
scope, do indicate a legislative response to community demand.
As Pat Thane points out in her recent history of old age in England, the
introduction of the Age Pension there meant the most impoverished were
relieved of the degrading business of scrabbling around for a meagre
living.29 Claiming the pension may have been an affront to respectability
that some found hard to stomach, but it was less of an affront than the
degrading poverty that was the only alternative. The value of the Age
Pension in enabling the elderly poor to continue to play some part in the
everyday life of their communities should not be underestimated.30
Regardless of how elderly Australians regarded the Age Pension, it is
more likely that in this process of defining old age we have a definition of
the elderly poor rather than a reliable guide to the meaning of old age per
se.
A passing comment by fifty-five years old Frederic Eggleston, a
Deakinite Liberal and social critic, to the effect that Australian institutions
in the early 1930s were dominated by old men, suggests that in the early
decades of the twentieth century, ‘old age’ was defined in very different
ways at different levels of Australian society.31
In her essay on the place of old people in the everyday life of the Rocks
area of Sydney in the 1820s, Grace Karskens suggests that an assessment
of age was based more on appearance and capacity than actual years, thus
was more likely to be a distinguishing mark of the poor than the wealthy.
Those who survived into old age, which may have been any time from the
age of 50 onwards, lived in much the same fashion as they had in earlier
years. Men and women continued working and marrying, perhaps for the
second or third time, and conducted business. They were lampooned
when they acted in a fashion considered more appropriate to younger ages
- women whose choice of dress was regarded as more suited to younger
28
Kewley, op. cit. Table 3, p134 shows that in 1912, 17.3 per cent of the Australian
population were receiving the Age Pension. In 1939, the percentage was 33.5.
29
Thane, 2000, op. cit, p.227-228.
30
During worst of the Depression, pensioners in the working class suburb of Richmond
were the mainstays of the local economy because they had regular income, McCalman,
1984, op. cit, p.197.
31
W. G. Osmond, Frederic Eggleston, An Intellectual in Australian Politics, Allen &
Unwin, Sydney, 1985, p.158. Eggleston’s remark is quoted by G. Bolton, The Oxford
40
bodies and men who showed an interest in carousing and sex - but ageism
was always tempered by respect for rank.32 It is not unreasonable to
conclude that similar attitudes prevailed in the early decades of the
twentieth century.33
The introduction of the Age Pension gave a clearer definition of old age as
a stage of life than in the earlier period described by Karskens although it
was, at the time, as much a definition of poverty as old age. It set a
precedent for separating out the needs of older Australians from those of
the poor and dependent in general, one that led to the ‘aged’ being seen as
a special object of social and political attention in the following decades,
an unassailable verity of social and political life. The response of medical
practitioners to the dependent and infirm aged was also shaped within this
cultural mind-set which found further scope for age-related welfare
measures in the postwar prosperity of the 1950s and 1960s. Measures that
began to shape the experience of old age, not just for the poor, but for all
classes except the very rich.
Old Age in Medical Work
Up to the 1940s at least, there are few signs that older adults constituted a
special category of patient for doctors in Victoria, or elsewhere in
Australia, and yet many doctors would have found a substantial number of
their patients amongst this group.34 Well into the 1950s most doctors in
Victoria, like their colleagues in the other states, worked in general
practice so older adults would have been included amongst their feepaying patients.
Older adults also belonged to the various Friendly
Societies established by working people to provide insurance against
History of Australia, Vol 5, 1942-1988, The Middle Way, Oxford University Press,
Melbourne, 1990, p.5.
32
G. Karskens, ‘Declining Life: On the Rocks in Early Sydney’, in Ageing, Australian
Cultural History, 1995, pp.65-66.
33
A. Hartshorn, ‘The Presentation of Old Age in Selected Twentieth Century Australian
Novels’, Masters Thesis, University of Queensland, 1993, Hartshorn examined selected
novels in order to understand attitudes to old age in Australia in the twentieth century on
the reasonable assumption that novelists’ characters reflect community views of their time.
Her conclusion is similar to Karskens; older adults were respected while they were
protected by wealth and social institutions. Those who were poor, decrepit and isolated
were not.
34
Pensabene, op. cit. Table 4.10, Doctor-Population Ratios, Victoria, 1871-1933, p.74-81.
In the relatively young population of early to mid nineteenth century Australia, the
degenerative diseases of old age were not prominent in medical work except as they were
related to alcohol and syphilis. This situation changed from the turn of the century when
the sicknesses of a growing population of older adults became more prominent, B.
Gandevia, ‘A History of General Practice in Australia’, MJA, vol 2, 1972, p.382.
41
sickness and unemployment.35 Medical practitioners contracted with the
Societies to provide services to members on a capitation. Although, from
the inter-war period, there was growing discontent amongst the medical
profession about their relationship with the Societies, Lodge practice
provided a level of income for doctors in industrial areas that was often
not possible in more affluent suburbs where there was more competition
for fee-paying patients. Also Lodge practice provided medical services to
the working class that were otherwise not affordable.36 The doctors who
provided honorary services in the large metropolitan hospitals would also
have treated the poor aged in the course of treating the poor in general, for
whom the outpatient departments in these hospitals provided means–tested
medical services.37
The only doctors whose work did focus on illness in the aged were the few
employed as medical officers in one of the several benevolent asylums in
the state.38 These institutions were established in the period between the
late 1840s and the 1860s, by charitably minded citizens of Melbourne, and
the provincial cities that grew up on the goldfields. The asylums were part
of a complex network of indoor and outdoor relief, provided under the
direction of voluntary committees of management, funded initially by
public subscription, but ultimately receiving the bulk of their funding from
the state government.39 They offered refuge to all age groups but while
younger adults were able to move on when times improved, those who
were older and infirm had little choice but to remain there. The assistance
provided to the elderly was prompted by sentiments similar to those
expressed in discussions attending the introduction of the Age Pension:
The Melbourne Benevolent Asylum succours those who have failed
in the effort to help themselves while helping onwards, by their
35
D. G. Green & I. G. Cromwell, Mutual Aid or Welfare State, Australia’s Friendly
Societies, George Allen & Unwin, Sydney, 1983, p.139-149.
36
Gillespie, op. cit. pp.7-11.
37
Pensabene, op. cit, p164, Tables 10.1, 10.2.
38
The Melbourne Benevolent Asylum, located in North Melbourne (moved to Cheltenham
in 1911 because of lack of space), the Immigrants Aid Society Home in St Kilda Rd which
moved to Royal Park around the same time (after several changes the institution was
named Mount Royal Home and Hospital for the Aged), and the large asylums in the
goldfields cities of Ballarat, Bendigo, Castlemaine and Beechworth, R. A. Cage, Poverty
Abounding, Charity Aplenty, The Charity Network in Colonial Victoria, Hale & Iremonger,
Sydney, 1992, Ch 6; B. Dickey, ‘Health and the State in Australia 1788-1977’, Journal of
Australian Studies, no 2, Nov, 1977, p.54-55. More detail on the benevolent institutions
will be found in chapter two.
39
Cage, op. cit. p.21.
42
labours the progress of the Colony of Victoria … That they have
broken down in the battle is their misfortune, and it is now for the
more fortunate to help those whom old age and sickness prevent
from any longer helping themselves and us.40
The benevolent asylums were obliged as a condition of their operation to
provide medical care, and doctors were employed as either visiting or
resident medical officers.41 Some of these practitioners were motivated by
the same sense of Christian duty which inspired the institutional
enterprise, and some conscientiously made the best of the opportunities
they found there because other avenues of medical work were closed to
them. Others, less committed to either Christian values or professional
duty, used these positions as casual stopgaps while they found more
congenial work.42 In the period from the late 1890s to the early 1950s,
when doctors had to rely on their own entrepreneurial efforts to make a
living in competition with their colleagues, especially in the metropolitan
area, work in the benevolent institutions had its place, albeit not the most
prestigious, within medical practice in Victoria.
The medical practitioners who cared for the inmates of the benevolent
asylums do not appear to have written about their work.
If the
professional journals of the late nineteenth and early twentieth century are
any guide, the medical care of the aged, and the broader question of
longevity, that attracted the attention of doctors in the northern hemisphere
at this time appears to have raised little interest amongst Australian
doctors.43 If some ageing Australians and their medical attendants were
interested in the range of rejuvenatory measures publicised at this time
their interest was not aired in the Australasian Medical Gazette or its
40
Quoted in M. Kehoe, The Melbourne Benevolent Asylum, The Annals of Hotham, vol 1,
Hotham History Project, Melbourne, 1998, p.16.
41
For example see, Kehoe, op. cit. p.16 and J. Uhl, Mount Royal, A Social History, Mount
Royal, Hospital, Parkville, 1981, p.5-6. The Melbourne Benevolent Asylum, located
nearby the Melbourne Hospital, also had the benefit of the attention of Melbourne’s most
prominent medical practitioners in an honorary capacity. Kehoe notes that in 1868 this
institution had a reputation for the quality of care provided there, including medical
attention, p.24, p.32.
42
Uhl, op. cit. p.78ff and p.85ff; Kehoe, op. cit. p.51-52.
43
The material that may have been available at the turn of the century to Victorian doctors
interested in questions relating to the medical care of old people and longevity is described
in Grmek, op. cit who provides a succinct account of how doctors from antiquity to the
twentieth century, have though about health and illness in old age. See also G. Gruman ‘A
43
successor, The Medical Journal of Australia.44 The doctors employed to
oversee the care of poor, infirm old people were preoccupied with
ensuring that committees of management provided adequate food, living
conditions that did not endanger the health of their charges, and an
environment in which those who required nursing care could be suitably
accommodated.45
In the same spirit of benevolence that Australians
acknowledged the needs of the aged poor through the Age Pension,
medical practitioners joined their committees of management in providing
care for the aged and infirm. It was, however medical care for the poor
aged, not the aged in general.
At no time did they have the resources available to those French
physicians who, by mid-nineteenth century, had ‘formulated a definition
of old age that separated it medically from all other age groups and
required the physician’s complete attention’.46 Much of this work was
done at the Salpêtrière in Paris where Jean-Martin Charcot was appointed
chief of medicine in 1862. Under his supervision the institution, funded
directly by the state and at the height of its fame in the 1880s, had been
transformed from ‘an establishment known for its riots, plagues and
exorbitant mortality rates to one recognised for its laboratories, lecture
halls, and licensed practitioners.’47 The only connection the benevolent
asylums had at this time with the post-mortem work that provided the
basis of the French physiological and anatomical model of old age was to
supply the unclaimed bodies of deceased inmates to the anatomy
department in the medical school at the University of Melbourne.48
History of Ideas About the Prolongation of Life’, Transactions of the American
Philosophical Society, vol 56, no 9, 1966.
44
For example Brown-Sequard’s experiments with injections of animal testicles or
Metchnikoff’s phagocytic theory of cellular rejuvenation and others, Grmek, op. cit. pp.4749 and for a more detailed exposition of Metchnikoff’s ideas which were popular in
America, W. A. Achenbaum, Crossing the Frontiers, Gerontology Emerges as a Science,
Cambridge University Press, Cambridge, 1995, pp.25-23.
45
Kehoe, op. cit. p.60; Uhl, op. cit. p.85ff.
46
Carole Haber points out that this model was a by-product of the development of a
conception of disease in terms of changes in tissues and cells which emerged in the Paris
hospitals in the early nineteenth century. By mid-century ‘at least fifteen French
physicians had published monographs on the unique character of the elderly’, Haber, 1983,
op. cit. p.58.
47
M. S. Micale, ‘The Salpêtrière in the Age of Charcot: An Institutional Perspective on
Medical History in the Late Nineteenth Century’, Journal of Contemporary History, vol
20, 1985, p.722.
48
Uhl, op. cit. p.113-114.
44
The model of old age developed in the French hospitals, represented in
general histories of geriatrics as the intellectual basis of the specialty, was
based on pathological changes in bodily structure and function in the aged
body.49 Similar changes had been described before, but from a point of
view that did not align age-related changes with changes in the
individual’s constitution and susceptibility to disease. In the French model
age-related changes were seen as changes in the composition of the body,
indistinguishable from the changes in composition due to disease. From
this point of view all physiological and anatomical changes were
pathological and the ageing process itself appeared as an inevitable
deterioration of the ‘fundamental elements of existence’. Medical care of
the aged, from this standpoint, presented such difficulties in pathology that
it required special study and long experience.50 Such intensive attention
however, was not accompanied by any therapeutic possibilities.
In
addition, the inherent pessimism in this conception of the aged individual
was compounded by its derivation from observations of individuals in
public institutions, who, by virtue of their situation, may be described as
having been overcome, physically and mentally, by the vicissitudes of life
in general, not just the experience of growing old.51
Doctors in Victoria did not follow the French lead, and their reluctance to
do so was not unique. Carole Haber suggests that English and American
doctors were, by training and experience, disinclined to adopt the model
developed in the Paris hospitals.52 The medical profession in Victoria
developed as an off-shoot of the British profession, and until the early
1960s, continued as part of the professional organisation of British
doctors, as a branch of the British Medical Association, so it may be
assumed that a similar point of view prevailed there.53 From the Anglo-
49
Haber, 1983, op. cit.; Grmek, op. cit.
Haber, 1983, op. cit. pp.57-63.
51
Micale, op. cit. p.711-713; P. Stearns, ‘Geriatrics’, in Old Age in European Society, The
Case of France, Holmes & Meier, New York, 1976, p.85
52
Haber, 1983. op. cit. p.68.
53
British medical training dominated the medical profession in Victoria. First, through the
immigrant doctors who came to the colony, and then later as local students elected to train
in the British system rather than in the more expensive and longer course offered by the
medical school at the University of Melbourne. Doctors continued to go to Britain for
postgraduate training until after the Second World War, Pensabene, op. cit. p64-68.
Despite the close ties with the British medical profession, Gandevia notes that doctors in
Australia did develop a very different type of practice, one characterised by individuality,
competence in a great variety of situations, and a relatively high social standing, Gandevia,
op. cit. p.381-382.
50
45
American perspective, debility was also acknowledged as a consequence
of long life, but with the additional insight that the effects of ageing could
be ameliorated by the adoption of a regimen of daily life in which
anything that might overtax the body was avoided. The point at which an
individual needed to pay attention to these matters was identified as the
climacteric, a critical age or period in life for both men and women when
special changes occur.54
Phillip Muskett, a Sydney doctor whose interest in instructing the
Australian public in the art of preserving good health by means of diet
marked him as somewhat eccentric at the time, defined the climacteric as
the point where involution set in. By involution he meant the ‘shrinking or
withering of the tissues of the body, accompanied by a degeneration or
deterioration of their structure’.55 For women the climacteric took place
around the age of 55 and for men, around 60 to 65. In an earlier text, The
Art of Living in Australia, he outlined a daily routine for the elderly which
he believed would diminish the effects of the ageing process.56 The notion
of the climacteric appears to maintain the same association between old
age and inevitable decay as does the French model. However, where the
French physicians left little or no room for the possibility that the effects
of ageing could be modified by constitutional or social factors and, into
the bargain, presented the medical care of old people as a complex and
esoteric skill, the Anglo-American approach had the potential to be more
pragmatically optimistic.
The more optimistic view taken by Australian doctors is conveyed by the
response to a remark made in the course of a lecture by Sir William Osler
in the United States in 1905.57 Osler referred to a ‘fixed period’ of life
when men were at the height of their powers, a period that came to an end
at the age of 60. At this point he said, having achieved all they were likely
to, they should be chloroformed.58 An anonymous commentator in the
54
Haber, 1983, op. cit. p.69-72.
P.E. Muskett, The Attainment of Health and the Treatment of the Different Diseases By
Means of Diet, 2nd. edn, William Brooks & Co. Ltd, Sydney, 1909, p.487ff.
56
P.E. Muskett, The Art of Living in Australia, Eyre & Spottiswoode, London, nd, (Preface
is dated 1893).
57
Cole, op. cit. p.170. Sir William Osler gave this lecture on the occasion of his retirement
from the medical faculty at the Johns Hopkins University Medical School at the age of 56.
58
Cole, ibid. pp.162-174, In referring to the ‘fixed period’ Osler was drawing on a notion
current in the last quarter of the nineteenth century, particularly in America, developed by
55
46
Australasian Medical Gazette, taking Osler’s remark seriously, rejected it
and in doing so assembled other authorities to justify his contention that a
regimen of moderation would help ensure an active and prolonged old age
despite the burden of genetic inheritance and the trials of modern life.59
In view of the tendency amongst Australian doctors to see health and
sickness in old age as simply an aspect of everyday medical work, it is not
surprising that the first text in which it was presented as a specialist field
was not even reviewed in the Medical Journal of Australia.
I. L.
Nascher’s text, Geriatrics: The Diseases of Old Age and Their Treatment,
Including Physiological Old Age, Home and Institutional Care, and
Medico-Legal Relations, was published in 1914. Nascher, an American
physician, coined the word ‘geriatrics’ to describe the special field of the
medical care of the aged.60 He combined the anatomical and physiological
investigations of the French and German physicians and the empirical
studies of the British and Americans to develop an approach to health and
sickness in old age which emphasised two principles. The first was that
just as there is a normal physiological condition of childhood, so there is
for old age; disease in old age therefore should be seen as a pathological
state occurring in a normally degenerating body, not disease as it occurs in
maturity. From this point of view treatment would be aimed at restoring a
diseased organ or tissue to the state normal in senility, not the state normal
to maturity.61 The second principle was that social factors, that could be
ignored with impunity when treating younger adults, were of primary
importance in the aged. In this respect Nascher’s call for medical attention
to the sick aged also included a call for the provision of welfare measures,
because in bodies weakened by advanced age, they played an important
the physician George Miller Beard. It was satirised in a work of Anthony Trollope with the
title, The Fixed Period. Cole notes that there is good reason to believe Osler may not have
intended his remark to be taken as seriously as it was throughout the English-speaking
world.
59
Editorial, ‘The Prolongation of Life’, Australasian Medical Gazette, August, 1906,
p.403-4.
60
This description of Nascher’s approach is taken from the Introduction to The Care of the
Aged (Geriatrics) 5th edn, The C. V. Mosby Company, St Louis, 1946, written by
Nascher’s disciple, Malford Thewlis. Thewlis took over the task of publicising geriatrics
from Nascher and his text is intended to follow on from Nascher’s.
61
Nascher seems to use the term senility here in its pre-nineteenth century meaning, that is
anything suited to old age. By the end of that century the term was generally used to
describe age-related ailments. To become senile was to advance into a state of debilitating
illness. Haber, 1983, op. cit. p.74.
47
part in determining whether a patient recovered from an episode of
sickness or deteriorated further.
Nascher defined ‘geriatrics’ as a specific sphere of medical work that
required specialist knowledge in order to distinguish the pathological
changes of ageing from those that were normal, together with the clinical
judgement that came with wide experience and a sympathetic approach to
elderly patients.62 The presentation of his case may have done little to
stimulate conscientious Victorian doctors with an interest in this topic.
These practitioners would already take this approach with their elderly
patients, especially when they were private patients able to pay for the
doctor’s time.
Despite lacking the finer details of the physiological
changes exposed by laboratory investigation, experience and familiarity
with their patients would provide the basis for deciding whether any
alteration in a patient’s condition was pathological or not, and it would
also govern any assessment of likelihood of recovery from an episode of
illness. Patients who could afford to pay the doctor’s fee were also likely
to have to the social support necessary to facilitate recovery.
In the
asylums, doctors already cared for individuals who lacked the social and
financial resources that may have diminished the onset and extent of
debility. An indication that medical work in the asylum was considered as
somehow separate and different from general practice may be found in the
1933 review of F.M. Lipscomb’s Diseases of Old Age, which the reviewer
recommended ‘for doctors taking appointments in hospitals for the aged’,
not for general medical practice.63
Nascher’s notion of geriatrics, like that of the French and German
physicians who inspired him, was derived from his experience with
institutionalised and impoverished old people. His point that the diseases
and infirmities of old people should not be attributed to old age and left
untreated, was perhaps as much a comment on current medical practices in
relation to the care of poor old people, as the grounds on which a specialist
field could be built.
This connection between geriatrics and poverty
persisted as English and Scottish doctors further developed the field in the
62
Thewlis, op. cit. Introduction. Grmek, op. cit, notes that in the early twentieth century
the medicine of old age was most developed in Germany, Austria and France, but within
the framework of internal medicine, not as a speciality, p.69-72.
63
MJA, vol 2, 1933, p.316.
48
1940s and 1950s, and it was to be an integral aspect of the establishment
of geriatrics in Victoria. However in the early decades of the twentieth
century in Victoria there was no impetus, from either within the medical
profession or outside it, to transform the medical care of indigent and
infirm old people from a charitable venture into a specific medical
enterprise.
Even in the United States Nascher’s call to the medical
profession to establish geriatrics as a specialty along lines similar to
paediatrics received little response.64
In Australia, medical attention
centred instead on the marvellous potential opened up in the 1890s by
advances in surgery and microbiology that were seen as signalling the
beginning of a ‘golden age’ of technical advancement. In this climate of
innovation and apparently unlimited promise, Nascher’s call for doctors to
pay more attention to failing old people fell on deaf ears.65
Old Age and a Technical, Laboratory-Based Medical Paradigm
There are indeed indications from the late 1920s on that such optimism
may have been justified.
The technical capacity of surgery and the
development of specific therapies was slowly beginning to alter the
experience of illness for elderly people although it wasn’t until the 1950s
that arteriosclerosis, the most ‘formidable’ cause of death and disability
associated with growing old, began slowly to succumb to medical
science.66
Nevertheless, the science of endocrinology had begun to
provide the basis for more sophisticated management of diabetes, and
treatment of fractures in the neck of the femur, a common affliction of the
elderly, began to be refined to the extent that immobilisation was required
64
Haber comments that despite Nascher’s hopes for the development of geriatrics as a
specialist field of practice, he had to admit it did not exactly parallel paediatrics. ‘For
children, the standards of health could be clearly charted as they gained strength and
intelligence; for the old, the standards of health implied progressive and incurable ailments.
The increasing debility of the elderly followed a course that led naturally to death.’ C.
Haber, 1986, op. cit. p.77.
65
Pensabene, op. cit. p.33ff, quotes a local practitioner who described the period between
1870 and 1930 as ‘the ‘Golden Age of Medicine’; Earle Page, surgeon and, as leader of the
Country Party, architect of the national health service introduced by the Liberal-Country
Party coalition in the early 1950s, considered himself fortunate to do his medical training
during the decade from 1890 to 1900 when these changes were most exciting, Sir Earle
Page, Truant Surgeon ed A. Mozley, Angus and Robertson, Sydney, 1963, pp.17-19.
66
R. Reader, ‘Heart Disease in Australia, 1960-1980, The National Heart Foundation’,
MJA, vol 1, 1979, pp.323-328.
49
for less time, thus reducing the potential for sepsis and pneumonia.67 The
latter were in turn rendered less deadly with the advent of antibiotic agents
after World War Two.
Even in the 1920s, in the unsophisticated
conditions of a country hospital, skill and technique could bring gratifying
results. David Browne, a general practitioner in Western Victoria, drew
on his experience at the Alfred Hospital in Melbourne when a family
brought their elderly mother to the local hospital after she had already
spent many weeks immobile on her back with a fractured leg in splints.68
The old lady was very weak; she had fallen while away from home, and
her family had brought her back to die, a justifiable expectation in view of
her 84 years. Having located the fracture, Browne instructed her carpenter
son in constructing an apparatus to suspend the leg in a sling to maintain
the broken ends in apposition and yet permit the patient to sit up
comfortably in bed and eat and drink with some enjoyment:
Our old ‘battleaxe’ as she was sometimes affectionately called,
rapidly improved in health and strength. The bedsores that afflicted
her previously healed up and the broken bone began to heal. She
went from strength to strength and was finally able to go home
using one walking stick only, as she had done before the accident ...
(and went on to die at the age of 97).69
The inclusion of a special session on the medical care of the aged, in the
deliberations of the Australasian Medical Congress in Melbourne in 1952
illustrates the extent of the changes that took place during the 1930s and
1940s in ordinary medical practice in relation to old people.70 This was
the first occasion on which sickness in old age was given such attention at
the Congress which had met, intermittently, since the 1880s.71
A
67
F. I. R. Martin, A History of Diabetes in Australia, Miranova Publishers, Camberwell,
Australia, 1998; MJA, vol 1, 1934, pp.518-520, vol 1, 1936, pp.743-747, vol 2, 1935,
pp.521-523; vol 1, 1936, pp.187-197.
68
A. Mitchell, The Hospital South of the Yarra, A History of the Alfred Hospital
Melbourne from Foundation to the Nineteen-forties, Alfred Hospital, Melbourne, 1977,
note 275 for details of Ian Hamilton Russell, Browne’s teacher in this field. He was, it
appears, renowned for his skill in identifying fractures without the benefit of X-ray and for
the techniques he developed for maintaining a broken limb in position, minimising the
chances of malformation during healing.
69
D. D. Browne, The Wind and the Book, Memoirs of a Country Doctor, Melbourne
University Press, Melbourne, 1976, p.26.
70
MJA, vol 2, 1952, pp.489-492.
71
The first of such meetings, the Intercolonial Medical Congress, was held in 1886. The
reason for convening these meetings was to replicate in the southern hemisphere, the ‘great
international congresses’ that were held in Europe and the meetings continued every
second or third year until the early 1920s. At this point the federal committee of the British
50
physician from Hobart began his discussion of the treatment of cardiovascular disease in elderly patients, by noting that three-quarters of the
beds under his supervision in the Royal Hobart Hospital were occupied by
adults between the ages of 65 and 85 years.72 The situation in the general
hospitals in Melbourne was certainly comparable.73 His main point was
that chronological age was not a good indication of an individual’s
physiological state; in cases of cardiac failure, coronary occlusion and
cerebro-vascular thrombosis, an accurate diagnosis should always be
made.
If a problem could be clearly identified it could often be
successfully treated. Other speakers made a similar point in relation to
anaesthesia and surgery in old people.
Careful consideration of the
individual often made it possible to undertake successful surgical
intervention regardless of chronological age.74
The comments made at this Congress session suggest that it was not so
much that doctors were gaining in understanding of the ageing body, but
that in dealing with growing numbers of patients who were over the age of
65 years, they enlarged their experience in applying the standard model of
disease to elderly adults. It was because doctors conceived of disease as a
specific, localised entity, recognisable in clearly delineated clinical
pictures, that they were able to apply intensive attention to certain
circumscribed problem areas. It was, in a sense, accidental that that these
just happened to include problems commonly found in ageing individuals.
The growing number of specialist practitioners in Australian medical
practice were interested in ordinary disease manifested in older adults.
They were not interested in ageing as a process or in specific diseases of
old age. In refining their skills in treating older adults, doctors identified
aspects of technique that needed to be taken into account in particular
Medical Association in Australia agreed that the Association would, in future, sponsor the
meetings and the first session under this new regime took place in 1923. Admission to the
Congress was conditional upon membership of the BMA or sponsorship by a member. The
new organisation was viewed as having a ‘strictly scientific’ purpose, medico-political
interests were left in the hands of the federal committee of the BMA, MJA, vol 2, 1919,
p.209, vol 2, 1921, p.91, vol 2, 1922, p.448.
72
MJA, vol 2, 1952, op. cit. p.490.
73
For example, the report of the medical superintendent at St Vincent’s Hospital in
Melbourne, for the years 1941-42 notes that ‘patients appear to be more elderly than
before’, B. Egan, Ways of a Hospital, St Vincent’s Melbourne, 1890s-1990s, Allen &
Unwin, St Leonards, NSW, 1993, p.178.
74
The development of neonatology in the 1930s meant that chronological age was also
disappearing as a factor to be taken account of in the medical care of premature and sickly
babies, McCalman, 1998, op. cit. p.244-5.
51
cases. In doing so they expanded their understanding of working within
the conventional model of disease, as older patients provided more
instances of the pathological conditions in bodily systems or organs
around which specialists were building their expertise. 75
The effectiveness of medical interventions in ageing adults in the 1950s
may be open to debate. In 1954 H. O. Lancaster, from the School of
Public Health and Tropical Medicine in Sydney, noted that ‘it is well
known that modern therapy has had little effect, with the notable
exceptions of diabetes and pernicious anaemia’.76
Where other
commentators associated the increasing numbers of infirm old people in
the 1940s with advances in medical capacity,77 Lancaster looked to
changes in mortality and morbidity amongst younger age groups leading to
the situation where more people lived into old age. On the other hand, in
1953, Eric Saint, a physician researcher in the Clinical Research Unit at
the Royal Melbourne Hospital and Walter and Eliza Hall Institute,
published a study of the health of 70 patients over the age of 65, attending
the outpatient department of the Royal Melbourne.78 He concluded, in
contrast to Lancaster, that the specialist medical care this group received in
the hospital had enabled those concerned to lead happier and more
satisfying lives.
Saint’s study also showed that relatively mundane
medical interventions brought significant changes in the quality of life of
elderly people as the pain and discomfort of ‘peptic ulceration, gall
bladder disease and prostatomegaly’, were relieved, and the ameliorative
treatment of degenerative conditions in otherwise capable men and
women, eased their frustration and made life more tolerable. In the case of
one 70-year-old a complex operation enabled him to return to his work as
a crane driver. Most of the men however, lived in retirement, growing
vegetables and keeping fowls to supplement their pension. The women, in
most cases, continued in their lifelong occupation of housekeeping.79
75
Rosen, op. cit. p.16.
H. O. Lancaster, ‘Aging in the Australian Population’, MJA, vol 2, 1954, p.550-551.
77
‘The Problem of the Aged’, anonymous comment, MJA, vol 2, 1946, p.459, ‘Medicine
cannot ignore the problem that has arisen. … the medical scientist has incurred grave
responsibility in creating vast numbers of old people …’.
78
E. G. Saint, H.F. Albrecht, C.N. Turner, ‘Old Age: A Clinical, Social and Nutritional
Study of Seventy Patients Over Sixty-Five Years of Age Seen in a Hospital OutPatient
Department in Melbourne’, MJA, vol 1, 1953, pp.757-764.
79
Ibid. p.762.
76
52
Not all old people did well within the new medical regime. Failure to
respond favourably in the ‘hygienic machine’ of the hospital where
diseased bodies could be ‘restored, recalibrated and repaired’, may have
arisen from the limitations of these activities. At the same time recovery
may also have been impeded by lack of attention to needs old people had
that were not met through recalibration and repair.80 David Browne’s
success in treating the 84 year-old was not only a matter of technical skill.
It was due also to the nursing care she received, that she was able to
occupy a hospital bed for as long as she needed it, and that her family were
attentive to her needs. Elderly patients were often at a disadvantage as the
focus of medical treatment shifted towards the active manipulation of the
constituent structures of the body through routine and standardised
technical measures, and away from assisting the body to marshall its own
resources against trauma and disease, in its own time, aided by exemplary
nursing care.81
Old people were at a disadvantage because often the identification of their
disease was a less straightforward process than in a younger adult.
Clinical signs might not have the same significance as in youth and
maturity, and pathological processes were often superimposed upon those
associated with ‘involution and atrophy’.82 Second, in a publicly funded
hospital system, the pressure of putting expensive resources to the best use
meant that the turnover of patients was essential. As the tempo of hospital
work became faster, elderly people who were slower to respond suffered,
unless they had the resources to pay for their care.
An uneasy
acknowledgment of how badly they were served may underlie what
appears to have been a callous response in medical staff to the appearance
of a very old patient in the ward. Vernon Davies, a physician who took up
80
R. Stevens, In Sickness and In Wealth, American Hospitals in the Twentieth Century,
Basic Books, Inc. Publishers, New York, 1989, p.19. Rosenberg presents this process as
one in which patients are seen in terms that transcend their individuality, C. E. Rosenberg,
The Care of Strangers, The Rise of America’s Hospital System, Basic Books, Inc., New
York, 1987, p.152. From a Foucauldian perspective, the advent of scientific medicine was
a social process that produced the patient as an individual, in this case an ‘ageless’
individual, the characteristic ‘free individual’ of Western Liberalism, D. Armstrong,
‘Foucault and the Sociology of Health’, in Foucault, Health and Medicine, eds A. Petersen
& R. Bunton, Routledge, London and New York, 1997, p.22.
81
McCalman, 1998, op. cit. p.77; G. Canguilhem, ‘Bacteriology and the End of
Nineteenth-Century “Medical Theory”’, in Ideology and Rationality in the History of the
Life Sciences, trans. A. Goldhammer, The MIT Press, Cambridge, Massachusetts, 1988.
82
A. N. Exton-Smith, Medical Problems of Old Age, John Wright & Sons Ltd, Bristol,
1955,p.20.
53
psychiatry late in his career and worked with old people, tells of a
favourite pastime amongst his group of doctors training at the Alfred
Hospital in the 1920s. While one of them was enjoying an evening off
duty, the others amused themselves by filling in a blank admission card
with a fictitious name and provisional diagnosis for a new patient
supposedly admitted to absentee’s ward. The point of the joke was to
observe his or her reaction on realising that ‘the only vacant bed in his
ward had been occupied by a man, aged 80 years, suffering from
osteoarthritis and probable arteriosclerosis of the brain.’83
Throughout the early decades of the twentieth century old age became
increasingly medicalised in that the ailments of ageing adults were more
usually described in terms of disease conditions. The term ‘senility’, as
Haber points out, originally designated ‘that which is suited to age’, a
value-neutral term that in course of the nineteenth century came to refer to
disorders in the very old with a connotation of hopelessness.84 In Australia
the term gradually began to disappear from the medical lexicon in the first
half of the twentieth century.
In Cumpston’s history of disease in
Australia, written in the late 1920s, he listed heart disease, cerebral
haemorrhage and cancer as the active causes of death in old age, but then
also used the term ‘senility’ to refer to other degenerative conditions.85 If
the Victorian Year Books are any guide, during the 1930s and 1940s, ‘old
age’ disappeared as a cause of death and was replaced with diagnostic
terms relating to specific disease conditions. The term ‘senility’ was used
in some instances, but with the accompanying phrase in brackets,
‘unknown or ill-defined’, which suggests it had become some kind of
residual category. While the expression may, in some cases, have referred
to the incomplete knowledge of the medical practitioner who signed the
certificate, it also suggests that doctors were increasingly explaining the
cause of death in terms of disease conditions. ‘Old age’ became a residual
category, awaiting further developments in medical knowledge.
Stephen Katz situates the beginning of the process in which the aged body
became medicalised, - that is ‘invested’ with ‘the meanings of old age
83
MJA, vol 2, 1959, p.43.
Haber, 1983, op. cit. p.72-73.
85
J. H. L. Cumpston, Health and Disease in Australia, A History, ed. M. Lewis, Australian
Government Publishing Service, Canberra, 1989, p.133.
84
54
through a set of perceptual techniques that equated pathological disease,
decline, and incapacity with the normality of the aged body’ - in the Paris
hospitals in the nineteenth century.
86
Certainly theories relating to a
medically reductionist view of the aged body emerged from the work of
Charcot and his colleagues during this period, but in practice this theory
was sidelined by medical practitioners who were more interested in
enlarging their understanding of disease processes rather than aged bodies.
To the extent that old age was medicalised throughout the first half of the
twentieth century, it was on this basis and age was excluded from the
picture. Those old people whose conditions were not amenable to single
disease oriented interventions were, from the conventional perspective, out
of place in the acute hospital. When they could not be discharged because
they lacked social support, they were handed over to the almoner, later
given the title of social worker.87
The introduction of this role into
hospitals under medical patronage was, as Charles Rosenberg points out,
an acknowledgment of the role of social factors in illness, a residue of the
medical understanding of disease that preceded the medical reductionism.
It was the social worker’s role to attend to needs that could not be met by
medical services as they were provided in the hospital, and in this respect,
the aged were one segment of that group of patients who could not be
cured.88
Old Age in the Organisation of Medical Work
The argument to this point has been that advances in therapeutic capacity
in the first half of the twentieth century brought more patients suffering
from conditions common with increasing age within the everyday work of
medical practitioners in the hospitals. The introduction of a daily benefit
for each occupied bed in the public hospitals by the Chifley government in
1945, to replace means-tested hospital fees, made these therapeutic
advances available to a broader section of the population.89 Advanced
86
S. Katz, Disciplining Old Age, The Formation of Gerontological Knowledge, University
Press of Virginia, Charlottesville, 1996, ‘The Aged Body’, p.47.
87
R. J. Laurence, Professional Social Work in Australia, Australian National University,
Canberra, 1965, p.71ff.
88
Rosenberg, 1987, op. cit. p.312-313.
89
Kewley, op. cit. p.354, the Commonwealth contribution to the cost of acute care for
certain groups in public hospitals continued after the Menzies’ Liberal-Country Party
coalition came to power in 1949. The ideology shifted however from Labor’s recognition
of the right of citizens to free hospital care, to the Liberal’s provision for the ‘deserving
poor’, p.355.
55
medical skills in treating degenerative conditions were gained at the cost
of relegating age-related factors into a residual category for which the
social worker took responsibility. In practice, in Victoria, and indeed
throughout Australia, the incorporation of older adults within the
reductionist model of disease was not quite as cut and dried as has been
suggested.
The model was adapted to local medical practice by
entrepreneurial, self-educated practitioners; confident in their abilities and
unconstrained by the longstanding traditional division of labour between
consultants and general practitioners that characterised English medical
practice.90 Most doctors who cultivated specialist skills did so as general
practitioners: not all sought membership of one of the two Royal Colleges,
and many who did so continued in general practice.91
Under these conditions the conventional model of disease processes was
incorporated into an individual practitioner’s repertoire of skills and tacit
knowledge, an empirical approach built upon the combination of treating a
wide range of patients and a self-motivated drive to absorb and develop
innovations. David Browne’s treatment of the old lady’s fractured leg
exemplified this approach, as he applied what he had learnt in the
management of fractures at the Alfred Hospital under the direction of Ian
Hamilton Russell.92 It was the broad interest and wide-ranging skills of
90
R. Stevens, Medical Practice in Modern England, The Impact of Specialization and State
Medicine, Yale University Press, New Haven, 1986, p.4-5. Notwithstanding the traditional
division between consultants and general practitioners, specialisation was slow to be
accepted by the English medical profession. The original Royal Colleges of Surgeons and
of Physicians were defined by a culture of generalism and the growth of new professional
groups around special interests in the interwar period, each with its own status and control
over standards, was a threat, not only to general practitioners but also to the standing of
these Colleges, p.106.
91
Australian doctors were interested in acquiring specialist knowledge but as independent
and entrepreneurial practitioners, a situation that arose out of local circumstances.
Postgraduate training facilities were limited and the Victorian branch of the British Medical
Association established a permanent Post-Graduate Training Committee after 1920, to coordinate postgraduate training in the state, and to assist doctors who could afford to do so,
to organise training posts overseas. Also, particularly in locations away from the larger
metropolitan populations of Sydney and Melbourne, there was not the population to
support specialisation although after 1900 the level of patient demand rose as the cost of
private consultations fell relative to wage levels. Specialists grew steadily in numbers
during the period between 1947 and the late 1960s and the introduction of differential
medical benefits in the late 1960s made specialisation more attractive financially,
Pensabene, op. cit. pp998, pp162-165; for an account of post-graduate training up to the
early 1950s from a medical practitioner’s perspective, see, A.M. McIntosh, ‘The
Development of Post-graduate Training in Medicine in Australia’, MJA, vol 1, 1951,
pp.28-32.
92
Browne was interested in gaining the higher qualifications that would enable him to
qualify for membership of the Royal Australasian College of Physicians but was deterred
by the need to earn a living immediately. He studied for the examinations in his isolated
country practice but, to his great disappointment, did not pass them, Browne, op. cit. p.67.
56
Australian medical practitioners that made them disinclined to find
anything of interest in Nascher’s advocacy of the specialty of geriatrics.
The doctor providing personal medical services in Australian conditions
would consider that he or she already took note of the social factors that
might contribute to a patient’s illness, and look for a response to
therapeutic measures consistent with that patient’s individual condition
and this would include age. The medical care of old people was but one
element in the work of medical practitioners who prided themselves on
being able to attend to the every need of every one of their patients.93
As the medical profession sought to come to terms with the effects of
increasing specialisation however, the medical care of the ‘elderly patient’
as opposed to the ‘case’ of circulatory failure or endocrine deficiency,
began to emerge as a special area of work characteristic of general
practice. Throughout the 1930s and 1940s general practitioners without
specialist skills began to express their unease at the changes they saw
arising out of specialisation in medical work. One of them enumerated the
various aspects of this situation in 1937. Dr Winter-Ashton’s list included
diminished access to hospital beds and operating facilities; the loss of
patients as they went directly to specialists or when, having been referred
to a specialist, they were retained in the care of that practitioner instead of
being sent back to the referring GP; and the growing tendency for patients
to use the Outpatient Departments of the public hospitals for the type of
service that a general practitioner would otherwise provide.94 The trend
towards specialisation, Winter-Ashton wrote, was leading to the situation
where the general practitioner would be left with a practice that consisted
entirely of rheumaticky old ladies and children afflicted with the common
cold.95
93
C.B. Blackburn, ‘The Growth of Specialism in Australia During Fifty Years and its
Significance for the Future’, MJA, vol 1, 1951, p.21.
94
Around 1930 the working-class began to use hospital outpatient departments in
preference to the services provided through Friendly Society or Lodge doctors, Pensabene,
op. cit. p.98.
95
G. Winter-Ashton, ‘Common Problems in General Practice’, MJA, vol 2, 1937, p.256;
for a summary of the discontents of general practitioners see B. Gandevia, ‘A History of
General Practice in Australia’, MJA, vol 2, 1972, p.382-383. These included access to
hospital beds for their patients, and operating facilities and, not least, the desire to maintain
their level of income which they believed was being eroded by the emergence of specialist
practitioners.
57
Not all general practitioners viewed the care of old people as the least
interesting aspect of medical practice. The anonymous author of a leading
article in the Medical Journal of Australia in 1943 commended Malford
Thewlis, I. L. Nascher’s disciple, for drawing attention to the medical care
of the elderly in the pages of an American medical journal, although he
was scornful of the term ‘geriatrics’ to describe this aspect of medical
work, and ridiculed the notion of the specialist ‘geriatrician’.96 The family
doctor, the article continued, ‘is quite equal to the task of shepherding the
old people of his practice through their illnesses’, because he had a
thorough understanding of each patient’s individual general make-up and
family history, both of which were essential components of successful
treatment.
The special role of the general practitioner in relation to elderly patients
was also taken up by reviewers of the texts produced in the United States
in the course of the 1930s and 1940s in which a scientific interpretation of
ageing was combined with a clinical view of health and illness in old
age.97 E. V. Cowdry’s collection, The Problems of Ageing, Biological and
Medical Aspects, was commended for the quality of the research it
exhibited as well as the insights it provided into clinical practice.98 Similar
praise was evoked by E. P. Boas’ text, Treatment of the Patient Past Fifty,
96
‘Leading Article’, MJA, vol 1, 1943, p.349. These comments may have reflected
distaste, not only for specialisation, but also for Americanisms. When a small group of
English doctors formed a special interest group on the medical care of the elderly in the late
1940s, they initially chose the title, The Medical Society for the Care of the Elderly, to
avoid the term geriatrics which they regarded with suspicion because of its American
origins. This reluctance was overcome later and the group was renamed the British
Geriatrics Society in 1960, T. H. Howell, ‘Comment, Origins of the British Geriatrics
Society’, and F. Adams, ‘Comment, Origins and Destiny of British Geriatrics’, Age and
Ageing, vol 3, no 2, 1974, pp.62-72, and vol 4, no 2, 1975, pp.65-68.
97
See N.W Shock, A Classified Bibliography of Gerontology and Geriatrics, Supplement
One 1949-1955, Stanford University Press, Stanford California, a second volume,
Supplement Two 1956-1961, followed. Nathan Shock was Chief of the Gerontology
Branch, National heart Institute, National Institute of Health and the Baltimore City
Hospitals. He listed material from the United States, Britain and Europe, in categories such
as biology, law, physiology, psychology, social welfare, longevity, and historical works.
Shock visited Melbourne in 1970 to address the 19th Annual Meeting of the Victorian
Council on the Ageing, ‘A Time of Change’, Victorian Council on the Ageing.
98
Achenbaum, op. cit, describes this text as marking the point at which, in the United
States, knowledge about the ageing process in later life, gerontology, shifted from the
dubious status of the ‘Fountain of Life’ literature to a respectable field of scientific enquiry.
It occurred as respected investigators in a variety of fields, and associated with respected
institutions, directed their attention to the ageing process within their own disciplinary
fields. Cowdry was exemplary in this respect being a scientist experienced in the fields of
anatomy, zoology, and cytology, working in prestigious institutions such as Johns Hopkins
and the Rockefeller Institute and Washington University, pp. 62-76. The presentation of
this knowledge in the form of a handbook in which ageing was interpreted from the
58
the first in a series of American General Practice manuals, which was to
run to several editions.99 Boas was commended for providing information
to enable the practitioner to distinguish between ‘pure senescence and
disease’ as well as for his descriptions of common diseases.100
On the basis of texts such as these, general practitioners - so reviewers
claimed - would be able to extend their range of competence to become
‘the chief agent of preventive medicine in the field of chronic diseases’.101
Implicit in this conception of the role of the general practitioner is the
understanding that it will be undertaken by the personal doctor working in
solo practice, combining the most up-to-date biological and biochemical
knowledge with a personal knowledge of the constitutional and social
particulars of individual fee-paying patients.
By the late 1940s, the problems general practitioners had first described in
the 1930s, were compounded by a greater workload arising from the postwar expansion in population and a level of remuneration that, one
commentator notes, had been unchanged over the previous fifty years.102
The association between general practice and the medical care of the
elderly was reinforced at this time.
This occurred not through the
promotion of an organised body of knowledge in relation to old age, nor
the provision of age related medical services, but as a consequence of the
introduction of a national system of hospital and medical insurance. One
component in this scheme, the Pensioner Medical Service (PMS), ensured
that medical services for the poor elderly and the chronically ill, were
allocated to general practice. Even then, because doctors could choose
standpoint of a number of disciplines proved to be the model for later volumes of
gerontological knowledge.
99
E. V. Cowdry reviewed, MJA, vol 2, 1939, p.836, E. P. Boas reviewed vol 1, 1942,
p.318.
100
L. Davidow Hirshbein, ‘ “Normal” Old Age, Senility, and the American Geriatrics
Society in the 1940s’, Journal of the History of Medicine and Allied Sciences, vol 55, no 4,
2000, pp.337-362. The American Geriatrics Society was formed in 1942 with the objective
of promoting the medical knowledge to enable doctors to make the distinction between
normal old age, which did not interfere with function, and senile deterioration – the
evolution of serious deficiency and disease. The Society’s approach was based on
arguments for the need for intensive medical supervision in later life. As Hirshbein points
out, this is indeed what occurred in the 1950s and 1960s, but not under the control of selfappointed geriatricians but general physicians. Texts such as Boas’ illustrate this
development.
101
MJA, vol 1, 1943, op. cit.p.350.
102
R. Winton, A’Body’s Body, The First Twenty-One Years of the Royal Australian College
of General Practitioners, The Royal Australian College of General Practitioners, 1983,
p.13.
59
whether or not they would participate in the Service, the association was
up to the individual practitioner. The PMS, introduced in 1951, and the
Pharmaceutical Benefits Scheme which accompanied it, were two
elements in the system of hospital and medical insurance introduced by the
Liberal–Country Party Coalition Government which came to power in
1949. The focus on the elderly in this scheme did not represent any
attention to their particular needs, except in relation to the capacity to pay
for personal medical services. It was a side-effect of an overall process
orchestrated by the Australian branches of the British Medical Association
(BMA), directed towards protecting the economic position of the general
practitioner in which the Commonwealth assumed the responsibility for
paying for the highest risk patients – the poor aged and the chronically
ill.103
In taking this step, the federal government, led by Robert Menzies, was
responding to an agenda set by the previous Labor administration when it
attempted to install a national, publicly-funded system of hospital and
medical insurance similar to that introduced in Britain in 1948.104 Labor’s
venture was frustrated at an early stage when the state branches of the
BMA combined to secure a ruling by the High Court that the
Pharmaceutical Benefits Scheme, the first element of Labor’s scheme, was
unconstitutional.105 The succeeding administration, in which the Minister
for Health, Dr Earle Page - himself a surgeon and member of the BMA converted the idea of a universal, publicly-funded, health service into a
form more acceptable to the conservative elements of Australian society.
That is, his proposals included the provision of assistance to the ‘deserving
103
Kewley, op. cit. p.367; Gillespie, op. cit. Ch 11.
This agenda had been first introduced in the 1920s following the Royal Commission on
National Insurance, 1924-1927, and the Royal Commission on Health, 1925, when JHL
Cumpston, Director of the newly established Commonwealth Department of Health, urged
a national approach to the provision of medical services, J. H. L. Cumpston, The Health of
the People, A Study in Federalism, A Roebuck Book, Canberra, 1978, p.15-16, p.46-47.
Interest in a national insurance scheme (contributory this time) reappeared in the late
1930s, although without the comprehensive view of health services espoused by Cumpston
who gave equal prominence to preventive and curative measures. Nor did the noncontributory, national scheme for the provision of hospital and medical services, proposed
by Labor in the 1940s, extend any further than the provision of personal, curative medical
services, Kewley, op. cit. p.342ff.
105
Gillespie, op. cit. p.253ff, Gillespie makes the point that the situation was somewhat
more complex. Opinion regarding a fee-for-service within the BMA was divided and in
the course of the 1940s when the matter of postwar health services was under discussion,
there was support for a national salaried medical service which the Labor government
failed to take advantage of, concentrating more on access to services rather than provision.
p.130ff.
104
60
poor’, who by this time were classified as eligible aged or invalid
pensioners, at the same time as it encouraged the virtue of self sufficiency
in the rest of the population through the moral and financial support of
private hospital and medical insurance.
This solution was acceptable to the BMA because, among other things, it
preserved the fee-for-service basis regarded by the Association as vital to
the integrity of the doctor-patient relationship.106
The PMS provided
general practitioner services and free medicine to eligible aged and invalid
pensioners through the direct reimbursement of doctors, according to
tables of fees agreed to by the BMA, for the cost of consultations. It did
not include the cost of specialist consultant services. For those, pensioners
had to attend the outpatient departments of the public hospitals where
consultants provided their services on an honorary basis.
When
pensioners required inpatient care, hospitals were directly reimbursed by
the Commonwealth for the costs incurred.107
The Pensioner Medical Service, in addition to the services provided by
general practitioners for the Repatriation Department for returned service
personnel, provided an organisational basis for the role of the general
practitioner as the ‘chief agent of preventive medicine in the elderly and
the chronically ill’.108 In 1958, the establishment of the Australian College
of General Practitioners, with Faculties in the States, opened the way to
supplementing this organisational base with a knowledge base relevant to
general practice, to be included as an element of undergraduate training
and forming the basis of a postgraduate qualification.109 The College’s
objectives included the promotion of a ‘scientific approach to problems of
disease at the level of the individual and the family’; the prevention of
disease and the welfare of the community; the promotion of postgraduate
106
Gillespie, op. cit. pp.273-276.
Kewley, op. cit. pp.367-370.
108
MJA, vol 1, 1943, op. cit. The services available under both schemes differed in
comprehensiveness so that wherever possible, elderly persons who qualified for a
Repatriation Department pension would chose that benefit, Kewley, op. cit. p.425.
109
The primary aim of the College was to develop and maintain ‘the highest standards in
general practice’, an aim that took some time to realise because of differences within the
College as to how it could be achieved. Winton, op. cit. pp.18-25.
107
61
education for GPs; and research into ‘conditions most frequently seen and
appropriately studied in general practice’.
These objectives were
underpinned by the perception that the concept of clinical research could
be applied to patients in their homes and GPs’ consulting rooms in order to
clarify aspects of disease that were not apparent in hospitals.110 There
was, however, no indication of what form the knowledge that defined the
GP’s role would take, and from the beginning the possibilities of this
educative and training enterprise succeeding were limited.
Founding
members were divided amongst themselves as to how to go about
developing the educative role of the College, and its potential strength was
undermined because, unlike the other medical Colleges, fellowship of the
Australian College of General Practitioners was not a prerequisite to
entering general practice.111
Eric Saint’s study of a small group of elderly patients at the Royal
Melbourne Hospital suggests that by the 1950s the experience of ageing
had begun to change for many Victorians. Paradoxically, as chronological
age appeared to become less of a factor to be taken into account in
therapeutic decisions, it became more relevant socially as age-related
welfare measures opened up the possibility of more ageing Australians
benefiting from these advances.
In this postwar period, the growing
tendency to categorise the elderly as a social group, and old age as a
‘stage’ of life, was still closely related to the relief of poverty. Changing
social and economic conditions only made the classification process more
widespread. As ‘retirement’ became a more common experience for both
working and middle classes because of the Age Pension, old age began to
emerge as a discrete ‘stage’ of life in a fashion similar to the identification
of childhood and adolescence as ‘stages’ of life, earlier in the twentieth
century.112
110
Ibid. p.22-23.
Sally Wilde notes the founders of the College were more preoccupied with the trappings
of collegiality rather than the substance. The prefix ‘Royal’ was sought, and granted in
1969, well before the College had sorted out its role in establishing the specialist field of
general practice, S. Wilde, 25 Years Under the Microscope, A History of the RACGP
Training Program, 1973-1998, Royal Australian College of General Practice, South
Melbourne, Victoria, 1998, p.2-3.
112
S.Harper & P. Thane, op. cit.
111
62
From the technical, laboratory-based perspective of the specialist
practitioner in the general hospital, old age was a residual category,
applicable to those for whom medical science could provide no relief in
their afflictions. The situation was quite clear-cut. The social worker
assumed responsibility for elderly patients who were not improved by
medical treatment, but who could not be discharged because they had
nowhere to go.
In the community the position of elderly patients in
general practice was less clear.
On one hand the work of general
practitioners was informed by the same cognitive orientation found in the
hospital, an orientation in which there was no place for explaining any
patient’s condition simply in terms of advanced age. Yet on the other
hand, the medical care of the elderly, along with the chronically ill, had
emerged as the special preserve of the GP based on his or her personal
understanding of each individual patient’s condition. Within this context
there was scope for taking account of a patient’s age, and interested
medical practitioners could now extend their personal understanding of the
ageing process through the texts that became available in the postwar
period. However, any development of the GP’s knowledge base was
confined to the efforts made by the individual practitioner and there was
no institutional back-up for treating old people for whom individualised,
curative medical services were ineffective. In comparison with the GP’s
role in relation to younger patients, the care of infirm old people was
unchanged in its fundamental approach from that provided by that
practitioner’s nineteenth century predecessors.
In both hospital and
community, when the condition of an old person was not amenable to cure
or management through the standardised ‘recalibration’ of bodily organs
and systems, they were, to all intents and purposes, outside the realm of
active medical work.
At the session on the medical care of the aged during the Australasian
Medical Congress in Melbourne in 1952, Dr Alan McCutcheon, medical
officer at Mount Royal Home and Hospital for the Aged, expressed a view
of this group of patients that would have been representative of many other
doctors.113 He categorised old people into three groups. The first were
able to live a ‘fairly normal life’, keeping active almost ‘to the end’. The
113
MJA, vol 2, 1952, op. cit. p.489.
63
second included those who were unable to look after themselves because
of frailty or lack of resources. Both these groups were well provided for
through existing medical and welfare services. The third group, he said,
posed the most serious problem and they were those old people whose
condition was irremediable and who needed long-term care. They were
out of place in the general hospital because it was inefficient to use such
costly resources to provide the care they needed, and in any case these
resources could not provide any solution to their condition.114
He
concluded that what was needed in these circumstances was greater
provision of accommodation for this group, and that in this respect the
needs of the infirm aged constituted a social problem, not a medical one.115
In Victoria there was little change in the response of doctors to old age
infirmity in the period from the late nineteenth century to mid-twentieth
century. In contrast to the gradual divergence during this period between
popular and medical views of sickness, as far as old age infirmity was
concerned community and medical views coincided in calling for the
provision of custodial care through the activities of charitable citizens.116
Conclusion: Old Age Infirmity – A Medical or a Social Problem?
The argument in this chapter has been that as old people became more
prominent in the Victorian population in the first half of the twentieth
century, and more of the afflictions they experienced became amenable to
medical intervention, the category of ‘old age’ disappeared from legitimate
medical explanations. It was reserved for those old people who could no
longer be maintained in good health by the personal curative services
provided in hospitals and general practice. Their condition, especially
when they lacked the resources to provide for their own needs, was
recognised by both medical profession and the public at large, as a generic
problem of old age. It was merely a problem that required a community
response along long-established lines in Victoria – the marshalling of
charitable forces to made adequate provision for custodial care.
114
Ibid.
Ibid. p.490.
116
Alan McCutcheon exemplified this approach when, speaking at one of the regular
Pleasant Sunday Afternoons conducted at Wesley Church in Melbourne, he deplored the
possibility of a nationalised health service as it was proposed by the Chifley Labor
government, because it would diminish the charitable impulse in the community, The Age,
27/10/47.
115
64
It was not inevitable that generically infirm old people should be excluded
from active medical work.
For example, had J.H.L. Cumpston been
successful, in the early 1920s, in establishing the Commonwealth
Department of Health as a provider of personal, preventive medical
services, so that ‘every individual human unit’ experienced ‘positive
health, being free of disease and disability’, the position of infirm old
people in relation to medical work may have been very different.117 One
aspect of the role Cumpston envisaged for the general practitioner as
public health officer was the supervision of a system of publicly funded
preventive and rehabilitative services, instead of the existing practice of
providing cash benefits in the form of the Invalid Pension, and charitable
care in institutions such as the benevolent asylums in Victoria.118 There is
no reason to believe that the infirm aged would have been excluded from
such services.
In fact from early in the twentieth century Australian doctors had shown
that they understood the multi-dimensional nature of illness and the
possibility that the medical role encompassed more than curative services.
In forms that varied according to conditions in individual states, the role of
public health officer whose concerns were principally with sanitary
conditions, was complemented early in the century by the role of school
medical officer and by the introduction of services directed towards the
health of mothers and babies.119 The services provided by the Repatriation
Department, to assist the return of permanently injured service personnel
to civilian life, following service in the 1914-1918 conflict, established a
model for a medical response to conditions that were not amenable to
curative medical services.120
It was the experience of doctors in
controlling and preventing disease amongst the troops that stimulated the
founders of the Commonwealth Department of Health to attempt to
establish a similar medical role in relation to everyday civilian life.121
117
Cumpston, 1978, op. cit, p.16, pp.46-47; Roe, 1976, op. cit.
Gillespie, op. cit. p.43-44; Cumpston, 1978, op. cit. p.8.
119
Cumpston, 1978, op. cit. lists these measures which, he hoped, could be extended in
some form to the whole population. p.46-47.
120
C. Lloyd & J. Rees, The Last Shilling, A History of Repatriation in Australian,
Melbourne University Press, Carlton, 1994, p.114.
121
Gillespie quotes Cumpston describing the enthusiasm of his medical colleagues on their
return to Australia ‘filled with a desire to apply to the civil community the great lesson of
118
65
The organisation of medical work that emerged in the early 1950s, one
that was to remain unchanged for the following twenty years, represented
the outcome of a number of intra-professional debates over the preceding
thirty years.
These debates addressed the question of how medical
services ought to be paid for, the place of the general practitioner in an
increasingly specialised profession, and the relationship between the
medical profession and government.
Differences of opinion on these
topics within the profession, were exacerbated by the varied approaches to
providing health services in the states and by conflicts between the states
and the Commonwealth. Nonetheless, the organisation of medical work
that emerged with the introduction of the Page scheme in the early 1950s,
reflected a degree of unity within the profession that in having settled on a
formula
for
government
subsidy
of
medical
services
without
compromising medical autonomy, the way was open for the advance of
medical expertise. It was the general acceptability of the view amongst
doctors that individual medical services based on a developing technical
expertise was the best approach to problems of disease that underpinned
the emphasis on systems of payment. In these circumstances the voices of
a minority of doctors who, like Chris McCaffrey, medical superintendent
of the Royal Newcastle Hospital in New South Wales, believed that health
policy should be concerned with broader matters than how doctors and
hospitals were to be paid for treating patients, were lost.122
The emphasis in Victoria in the early 1950s, on the provision of curative
medical services – in terms of both the organisation of medical services
and the reductionist research that underpinned them – is understandable to
some extent. Neglect of the State’s hospital services during the Second
World War, and the Depression that preceded it, and then the demands
placed on inadequate services by an expanding population, had led to the
situation where investigative, research and treatment facilities in all
Australian hospitals lagged well behind the models Australian doctors
successful medical control and prevention of disease which had been applied in the army’,
Gillespie, op. cit. p.31.
122
Gillespie, op. cit. pp.280-282.
66
found in Britain and the United States.123 The perceived deficiency of
these resources, and the desire on the part of Australian doctors to
participate in a worldwide medical fraternity based upon them, led to the
position where the whole emphasis in the development of postwar health
services was on the establishment of hospitals and laboratory research. It
was an emphasis that received community support also, the provision of
hospitals being generally regarded as the best means of dealing with
problems of illness.
Nevertheless, despite the overall emphasis on providing curative medical
services and establishing laboratory and clinical research programs, an
undercurrent of interest persisted amongst a small segment of the medical
profession which was interested in addressing the needs of individuals
whose conditions were not immediately amenable to these approaches. It
was the slow and uncertain melding of their concerns into a coherent
model of medical services that opened up the possibility for an active
medical role in relation to generalised old age infirmity to be established.
The remainder of this thesis examines, how, between the early 1950s and
the late 1970s, in Victoria, this emerging model was integrated into the
overall pattern of medical work, thus opening up the possibility of
establishing old age in general as a medical specialisation.
123
K. F. Russell, The Melbourne Medical School, 1962-1962, Melbourne University Press,
Carlton, Victoria, 1977, p.184ff; R. D. Wright, ‘Before and After’, The Halford Oration,
MJA, vol 2, 1950, pp.637-640.
67
CHAPTER 2
THE UNKEMPT GARDEN OF CHRONIC SICKNESS AND
INFIRMITY1
Introduction
The previous chapter concluded that, within the pattern of medical practice
that took shape in Victoria in the early 1950s, medical and community
opinion coincided in regarding the care of the infirm aged as a social, not a
medical problem. This chapter examines the ideas, community activities,
institutions, government activity and organisation of the medical
profession that underpinned this point of view. Themes that emerged in
the first chapter – community responses to old age, state/federal relations,
the public funding of hospital and health services, the relationship between
medical ideas about sickness and the organisation of medical services and
the interaction between the community and the profession in providing
services – are presented in greater detail.
In the mid-1950s, Dr John Lindell, first medical Chairman of the Hospitals
and Charities Commission in Victoria, proposed to introduce a medical
role in providing hospital-based services for candidates for custodial care.
The purpose of this chapter is to examine the professional and social
context in which this decision was situated, a process that leads to a
juxtaposition of ideas and institutions which, although focused on
Victoria, does extend into other states and the Commonwealth.
The
reason for doing this is to situate the role of ‘geriatrician’, a specifically
local response to local needs, within a broader, but fragmented,
professional context in which a segment of the Australian medical
profession sought to establish socio-medical services. This digression into
activities outside Victoria is intended to highlight the general lack of
interest in such services amongst Victorian doctors and to provide a
background for Chapter Five where I argue that ‘geriatricians’ in Victoria
1
Michel Foucault uses the term ‘unkempt garden’ to describe the wards of the Paris
hospitals prior to their reorganisation in the service of pathological medicine. In this
process sick bodies were ordered so that disease was displayed to the medical ‘gaze’ and
the hospital ward became a research and pedagogical tool. M. Foucault, The Birth of the
Clinic, trans. A.M. Sheridan, Routledge, London, 1991, p.17. When the medical ‘gaze’
shifted towards the infirmary wards of the benevolent homes in Victoria it met a similarly
undifferentiated mass of infirmity in which common characteristics were rejection by the
field of acute medical care and an increasing expense to the public purse.
68
were able to develop their role beyond its institutional confines because of
the activities of doctors in other states, particularly in New South Wales,
in establishing a nation-wide socio-medical model of practice in the 1970s.
When J.H.L. Cumpston, the first Director-General of the Commonwealth
Department of Health, turned to the social medicine perspective for
inspiration in developing services that addressed the complexity of disease
causation, he established something of a tradition within the Australian
medical profession for succeeding generations of doctors. From the 1920s
on, social medicine, particularly as it was developed in Britain, provided a
model for doctors who, recognising the multicausal nature of disease,
wanted to establish health services that extended further than
individualised, curative medical care. The terms ‘social medicine’, ‘social
hygiene’ and the social science of medicine are associated with a complex
of ideas about illness and the organisation of medicine, that emerged first
in mid-nineteenth-century Europe and somewhat later in England.
Developments in England reached a high point in the early 1940s when
J.A. Ryle, a prominent physician in England, was appointed Professor of
Social Medicine at Oxford.
Around the same time, at three other
universities in England and Scotland Chairs of Social Medicine were also
established. Only a small segment of the Australian medical profession
evinced any interest in social medicine and they gave it a particularly local
interpretation which resulted in a form of ‘social hygiene’ designed to
complement what J.A. Gillespie has described as a fundamentally
materialist orientation to understanding disease.2
The health services
established in Queensland in the 1930s, under the direction of Sir Raphael
Cilento, including a Chair of Social Medicine in the Queensland medical
school, were until the 1970s, the most developed form of ‘social medicine’
in Australian health services. Nevertheless, during the 1930s and 1940s,
this small segment of the Australian medical profession did establish a
rudimentary local ‘social medicine’ even if it was mostly only at the level
of ideas and where it was put into practice, only on the margins of medical
2
Gillespie, op. cit. p.34,
69
work. It was within this professional context that John Lindell, developed
his plans to introduce a socio-medical model of service to address the
needs of the infirm aged in 1950s Victoria.
On the whole, the medical profession in Victoria showed little interest in
problems of illness that were not amenable to a reductionist model of
disease and medical treatment directed towards cure. Their materialist
orientation to disease was complemented by a social conservatism that
discredited social medicine by associating it with socialism as a form of
government. Doctors that did not take this view were discouraged by the
inability of Federal parliamentarians to understand that the provision of
hospital beds and personal curative medical services was not a fully
adequate response to the health needs of the population. However, coexisting with the general trend in the 1950s in Victoria, to stress
individualised, curative medical services, there was a small community of
medical opinion, at the centre of the Melbourne medical world in which
social medicine was taken seriously by a few clinicians, researchers and a
lone general practitioner, all of who were influenced by social medicine in
postwar Britain. This centre encompassed the Royal Melbourne Hospital,
the Clinical Research Unit at the Melbourne and the Walter and Eliza Hall
Research Institute, and the medical school at the University. Lindell,
medical administrator in the state bureaucracy and former medical
superintendent of the Melbourne, moved through this world as he
confronted the task of developing Victoria’s neglected hospital system and
the system of educating and training doctors and other health
professionals.
I argue in this chapter that Lindell’s decision to introduce a socio-medical
role in the provision of geriatric services to complement the acute medical
services provided in the general hospitals, was framed by a local and
rudimentary notion of social medicine.
This modest innovation was
hedged around by the overall emphasis, in the community and in the
medical profession, on curative medical services and biochemical
research, and by the longstanding practice of substantial community
involvement in the provision of publicly funded hospital services. The
development of all hospital services in Victoria grew out of the
cooperative
activities
of
local
community
groups
and
medical
70
practitioners, activities that were funded largely by the state government.
From the 1950s, this relationship was subjected to a number of strains as a
financially-straitened state government attempted to impose a state-wide,
rationalised system of hospitals upon an uncoordinated multitude of local
responses to local perceptions of need.
Social Medicine in Australia
A social medicine orientation to explaining disease, as it was developed in
mid-nineteenth
principles.
3
century
Europe
and
England, incorporated
three
First, that the health of individuals is the responsibility of
society as a whole; second that social and economic conditions play as
important part in the development of disease conditions as physiological
changes; and third, that doctors, as a consequence, need to be involved in
studying, and perhaps changing, these social conditions.4 In England the
linkage between disease and social and conditions led first to the
emergence of the role of public health medical officer but in comparison
with European physicians such as Rudolf Virchow, English doctors were
slow to incorporate the mass of material on the living and working
conditions of the poor that they accumulated, into formulations of ‘social
goals and ideologies’.5 By 1905 when J.H.L. Cumpston went to England
to study for the Diploma of Public Health, social medicine was more
clearly recognised as a form of expertise in the ‘“corporate management of
communal life”’ and some education in the social sciences had been
introduced into the Diploma curriculum.6 If Cumpston did come into
contact with this attempt to standardise the social dimensions of illness,
the experience does not appear to have influenced his adaptation of social
medicine in his plans for the Commonwealth Department of Health. The
3
G. Rosen, ‘What is Social Medicine’, in From Medical Police to Social Medicine, Essays
on the History of Health Care, Science History Publications, New York, 1974, pp.64-68;
D. Porter, Introduction in Social Medicine and Medical Sociology in the Twentieth
Century, ed D. Porter, Rodopi, Amsterdam, 1997, pp.3-7.
4
Rosen, 1974, op. cit. pp.64-68.
5
Rosen, 1974, op. cit. pp.65-67.
6
Roe, op. cit. 1984, p.119. The influence of his time in England may be discerned in
Cumpston’s address on the ‘Nationalization of Medicine’ at the University of Melbourne
when he quoted Sidney and Beatrice Webb, ‘avid collectors’ of data to provide the basis
for social policy directed towards achieving specific social goals, p.129, also, Cumpston,
1978, op. cit. p.16, Porter, 1997, op. cit. ‘Introduction, p.6.
71
Department was established in 1921 with Cumpston as the first Director
General.7
Cumpston’s interest in public health was aroused by conditions that he
knew to be preventable, the cases of typhoid fever and hydatid infestation
that he saw in hospital wards. His response to a situation in which disease
was clearly associated with social and economic conditions, was to
propose an enlargement of the role of public health medical officer (a role
modelled on the English example), and the provision of health services by
the Commonwealth.
The role of salaried, public health officer was
intended to facilitate extended expert medical intervention in unhealthy
social conditions through the establishment of regional health centres with
the laboratory facilities not available to doctors outside the large cities.
From these centres data on health and sickness in the population would be
collected and the appropriate preventive measures developed and applied
as public policy. Cumpston’s practical response to the social dimensions
of disease is quite distinct from, for example, that of Virchow, for whom
the practical content of social medicine was a medical intervention in
political and social life.8 Cumpston, on the other hand, sought to develop
a form of national hygiene, an extension of existing public health
regulations, underpinned by a ‘medical materialism, in which political and
economic phenomena appeared as the social manifestations of more
fundamental medical causes’.9
Cumpston was led to a career in public health not because laboratorybased medicine provided an inadequate understanding of disease, but
because medical expertise was limited in its effectiveness by social and
economic conditions.10 The hygiene, or art of healthy living envisaged by
Cumpston, did not arise from a perception of the limitations of ‘scientific’
medicine.
It was associated with the view that in Australia, medical
practice was insufficiently scientific because an entrepreneurial medical
profession was blinkered in its outlook and impoverished by lack of
resources. Greater state intervention was needed to develop the capacity
7
Roe, 1976, op. cit. p.180.
Rosen, 1974, op. cit. p.65-67; Cumpston, 1978, op. cit. p.46-47.
9
Gillespie, op. cit. p.34, the phrase ‘medical materialism’ was coined by Gillespie.
10
Cumpston’s interest in public health was reinforced by the financial perils of setting up
private practice at the time, Roe, 1984, op. cit.
8
72
of medicine to shape the everyday life experience of individuals in the
name of national efficiency.11 Cumpston’s medical hygiene differed from
social medicine in that it was directed to extending the model whereby
disease was explained in biochemical terms. This was to be achieved by
first the introduction of a range of publicly funded medical services and
laboratory facilities by the Commonwealth government. Second, by an
enlargement of the role of the public health medical officer from the
supervision of sanitary measures to a concern with nutrition and the
environments in which they lived and worked.12 These services would
also include the supervision of individuals eligible for publicly funded
benefits such as the Invalid Pension. The provision of welfare was to be
aligned with rehabilitation and prevention.13
Overall, Cumpston’s ambitions for the Department of Health were not
realised for a range of reasons. They included the difficulties surrounding
any cooperative venture between the states and the federal government
because of the narrow range of responsibility allocated to the latter in the
Constitution, the lowly standing of the Department of Health in the
Commonwealth bureaucracy, and reluctance on the part of the medical
profession to align their work so closely with government policy.14 It is
likely also that Cumpston’s reliance on the rationality of his proposal to
justify his cause, blinded him to the necessity to appease those who
11
A similar interest in national efficiency inspired the founders of the Workers Education
Association during the 1920s. The Association was part of the National Efficiency
Movement in Australia, a movement that aspired to see that ‘our people shall lead healthy,
happy lives; that they shall work efficiently, and have pleasure in their work; that they shall
enjoy their leisure in the best and highest sense; and, above all, … be men and women of
the highest rank as human beings.’ The movement was associated with a form of
liberalism which looked to a ‘ “politically neutral technocratic wisdom”’ based on the
disciplines of economics, sociology and psychology, Rowse, op. cit. pp.44ff.
12
Gillespie, op. cit. p.49-50.
13
Roe, 1984, op. cit. p.126.
14
Gillespie, op. cit. p.31ff. Gillespie notes that the failure of the Commonwealth
Department of Health to develop along the lines Cumpston proposed, cannot be read
retrospectively as opposition to a socialistic oriented system of health services. Advocates
of social medicine could be found ‘across the political spectrum’, p51. Michael Roe, while
noting that Cumpston was influenced by the idealism of English Liberal, T. H. Green, and
the socialist Fabians, concludes that Rooseveltian progressivism was ‘the creed’ that best
characterises the set of ideas that underpinned his work, although over time Cumpston
tended to emphasise the English influence. Progressivism, like Green’s liberalism and
Fabianism, was also a response to the failures of laissez faire capitalism, recognising a role
for the state in counteracting the excesses of capitalism and the degradation of citizenship
through applied science and the work of expert technicians and bureaucrats.
Progressivism, Roe writes, was both radical and conservative in seeking conservative ends
by radical means. Roe, 1984, op. cit. pp.7-13.
73
believed their interests were threatened.15 The failure of the Department
of Health to take an active role in the provision of medical services was all
the more noticeable in view of the success achieved by the Department of
Repatriation in providing a range of services under medical control for
returned service personnel. Repatriation, established three years before
the Department of Health, provided an organisational framework for the
provision of extensive medical services to returned service personnel as it
supervised medical repatriation from the theatres of war, medical
treatment of invalids and convalescents, compensatory pensioning of the
disabled and provision of vocational training and community rehabilitation
for them.16
While Cumpston’s ‘national hygiene’ was not social medicine as it was
understood in Europe and England. His plans for the Department of
Health implemented certain features of social medicine, in the
acknowledgment that health of the population was a matter of collective
responsibility, and that the medical profession had a part to play in
formulating public policy on health matters.17 The tendency for Australian
doctors to look to social medicine for ideas persisted throughout the 1920s
and into the 1940s, as they continued to come to grips with the problem of
providing an organised response to the multi-dimensional nature of
disease, a response that was made more urgent in their eyes by the 1930s
Depression. The clearest indication of the influence of social medicine in
the pre-war period was seen in the system of health services, established in
Queensland in the 1930s under R. W. Cilento (later Sir Raphael), as
Director General of Health and Medical Services.
Cilento, whose
interpretation of social medicine, like Cumpston’s, could be described
more aptly as ‘social hygiene’, established the first Professorial Chair of
15
Sir Henry Gullett, member of the House of Representatives in 1925, journalist and
historian, noted there was no sign that Cumpston had any other ambition but to establish
the scientific means of preventing disease and advancing the health of the people. Quoted
in C. Thame, ‘The Development of Collective Responsibility for Health Care in Australia
in the First Half of the Twentieth Century’, PhD Thesis, Australian National University,
1974, p.348.
16
Lloyd & Rees, op. cit. pp.79ff and p.141.
17
The establishment of several divisions in the department - marine hygiene, quarantine,
and laboratories situated at strategic points throughout the country for diagnostic, research
and educative work, industrial hygiene, sanitary hygiene and tropical health – indicated a
commitment to the health of the nation and to contributing information for world-wide use,
Roe, 1976, op. cit. p.134.
74
Social Medicine in the medical school at the University of Queensland in
1937.18
In addressing issues such as the role of the social environment in disease,
the organisation and funding of medical services, and the balance in the
provision of medical services, between curative and preventive services,
local medical practitioners followed Cumpston in drawing upon features
of social medicine from Britain. After the end of the Second World War
there, social medicine gained the status of an academic discipline with the
appointment of J.A. Ryle as Professor of Social Medicine at Oxford
University in 1943.19 Subsequently three other chairs were established at
Edinburgh, Sheffield and Birmingham.20
Ryle was one of a small group of prominent individuals in the English
medical profession, including Sir William Jameson, Chief Medical Officer
at the Ministry of Health, who were dissatisfied with medicine as it was
then taught and practised.21
Medicine, Ryle wrote in 1943, was
specialised and technical to the extent that the needs of the patient as a
human being had been lost:
Investigation to the limit, mainly by objective methods and often
with too little said or done for the patients during or after the tedious
process, … especially in the case of the more chronic or seemingly
more obscure varieties of disorder and disease.
… too little
knowledge of morbidity and mortality figures, of the relative
incidence of diseases in the community, of the vast prevalence of
“illness” or “debility” without “physical signs” … too vague an
appreciation of the fact that these illnesses … have discoverable
18
F. Gould Fisher, Raphael Cilento, A Biography, University of Queensland Press, St.
Lucia, Qld, 1994, p.102-103. Cilento defined social medicine as ‘ “the study of the means
for the constructive preservation of health”’, and tropical medicine was its practical
application in Queensland, p.143.
19
Cumpston corresponded regularly with Ryle, Gillespie, op. cit. p.51.
20
Porter, 1997, op. cit. p.1-2; D. Porter, ‘Changing Disciplines: John Ryle and the Making
of Social Medicine in Britain in the 1940s’, History of Science, xxx, 1992, pp.138-140.
21
D. Porter, ‘John Ryle: Doctor of Revolution?’ in Doctors, Politics and Society:
Historical Essays, eds D. Porter & R. Porter, Rodopi, Amsterdam-Atlanta GA, 1993, N. T.
A. Oswald, ‘A Social Health Service Without Social Doctors’, Social History of Medicine,
vol 4, no 2, 1991, pp.296-305.
75
origins in social, domestic, or industrial maladjustment, in fatigue,
economic insecurity, or dietary insufficiency …22
Funded by the Nuffield Foundation, the Institute of Social Medicine was
to be devoted to the study of ‘social pathology’ in the form of studies of
sickness in communities rather than isolated in hospitals.23
Social
medicine was the discipline that would provide a social biology of human
life, of the sick person in their natural environment, in order to add ‘the
experience of disease from the patient’s point of view as much as that of
the experimental pathologist, biochemist or physiologist.’24
The ideas disseminated from England between the 1920s and the 1940s,
were used by Australian doctors in the discussions and debates that took
place in a number of different arenas over this period. Out of these a local
social medicine emerged which was, as James Gillespie notes, a derivative
and ‘vaguely linked set of doctrines’, but nonetheless the beginnings of an
organised approach to providing a social response to illness and
disability.25
Medical practitioners who were interested in addressing
social questions relating to medical services found a more encouraging
environment when, in the 1940s, the topic of health services was included
for discussion as part of the project of planning postwar national
reconstruction.
Under the aegis of the National Health and Medical
Research Council and of the Joint Parliamentary Committee on Social
Security, the question of organising health services to address the health
needs of the Australian population was canvassed widely.26
However, in the national health scheme that finally emerged in the early
1950s, introduced by the Liberal-Country Party Coalition government that
replaced the Chifley Labor administration in 1949, all issues had been
submerged in an emphasis on the system of remuneration for medical
services. It was left to the profession itself, and the State governments, to
determine what health services were to be provided and how they were to
22
J. A. Ryle, ‘Social Medicine: Its Meaning and Its Scope’, British Medical Journal, vol 2,
1943, p.633.
23
Social medicine in the form established by Sir Raphael Cilento in Queensland also
benefited from Lord Nuffield’s generosity, Gould Fisher, op. cit. p.143.
24
D. Porter, 1992, op. cit. p.143.
25
Gillespie, op. cit. p.51.
26
Gillespie, op. cit. pp.51-56; S. Shaver, ‘Design for a Welfare State: The Joint
parliamentary Committee on Social Security’, Historical Studies, vol 22, no 88, 1987,
pp.411-431.
76
be organised.
The advocates of what may loosely be termed ‘social
medicine’ were silenced by the earlier incapacity of the Chifley
government to grasp the point that there could be more to the provision of
health services than access to personal, curative services. After the war, in
the political climate of the Cold War, social medicine was discredited
because of the connection made, by both its defenders and detractors,
between socialism and social medicine. Furthermore, the support of many
practitioners for cooperation between the federal government and the
medical profession in the provision of health services had been weakened
in the processes of negotiation. In these circumstances, that segment of
the profession prevailed which favoured personal, curative services, paid
by fee-for-service, and provided according to the discretion of the
individual practitioner.27
There was some recognition of collective responsibility for the provision
of health services and of the part played by the social environment in
illness and disability in the national health service introduced in the early
1950s.28 The Australian medical profession, represented by the British
Medical Association, agreed to the inclusion of a comprehensive, publicly
funded program, including curative, preventive and rehabilitative services,
to tackle tuberculosis in the Australian community.29 Their agreement
suggests some awareness in the profession of a collective responsibility
for the provision of health services, and that to be effective these services
needed to take into account social factors such as security of income and
return to working life.
The acceptance by the Association, of the
Pensioner Medical Service and the Pharmaceutical Benefits Scheme, was
also an acknowledgment that economic status could affect health status.
Such expressions of collective responsibility were, however, minimal.
They were cautiously confined to the eligible poor with the exception of
vaccination programs and the provision of free milk to schoolchildren.
In the sense that these provisions reflected an acknowledgment of
collective responsibility for the health of the nation, they may loosely be
described as social medicine. It was, however, social medicine for the
27
Gillespie, op. cit. Chs. 9 and 10.
Kewley, op. cit. p.346ff.
29
Ibid. pp.370-373; see also Sir Earle Page, What Price Medical Care’, A Preventive
Prescription for Private Medicine, J. B. Lippincott Company, Philadelphia, 1960.
28
77
eligible poor, provided by the general practitioner, and in the main,
confined to curative services developed around the biochemical model of
disease. The critique of this model that was implicit in social medicine in
Britain was certainly not acknowledged in the Australian version of social
medicine. Nor was there any indication that a reductionist interpretation
of disease required any amplification from epidemiological studies. Once
the federal government elected to confine its contribution to the nation’s
health services to the provision of subsidies for the curative medical
services that now constituted mainstream medical practice, the only
avenue open to those medical practitioners who perceived the need for a
broader approach to the prevention and treatment of illness was through
the state government bureaucracies. Practices that could come under the
heading of social medicine - already located at the margins of medical
work because of the connection with poverty - were, in this association
with government bodies, even further marginalised in a profession that
regarded with odium the open involvement of medicine in the corporate
activities of the state.
Care According to Cost
In Victoria, in the 1920s, as the same time as Cumpston was engaged in
promoting a standardised and national approach to the management of
sickness in the Australian community, changes were underway in relation
to provisions for the chronically ill and disabled.
However, while
Cumpston advocated bringing the chronically ill within the ambit of
medical work and research, in Victoria, the trajectory of developments in
the twenties and thirties was to remove these patients out of the centre of
medical work – the general hospital – into the non-medical environment of
benevolent care. Cumpston’s principal concerns were to maintain the
‘efficiency’ of the Australian population. In 1920s Victoria, the principal
concern was to contain the cost of providing care for the chronically ill,
and to ensure the required turnover of patients was maintained in the
general hospitals so that they functioned efficiently as medical training
schools and research facilities.30
30
Y. Collins, ‘The Provision of Hospital Care in Country Victoria 1840s to 1940s’, PhD
Thesis, University of Melbourne, 1999, p.226.
78
Since mid-nineteenth century in Victoria, charitably minded citizens,
doctors and the colonial/state government had joined forces to provide
institutional care for the sick poor in the form of hospitals. Their activities
led to a proliferation of institutions, especially in the metropolitan area,
which formed the basis of a system of hospital care aimed at the different
needs of various sections of the community.31 A parallel development,
although less specific in its organisation, was the provision of
accommodation for the incurable, the infirm and the dying, unwelcome in
the voluntary hospitals because their needs were indeterminate, but who
had nowhere else to go. The benevolent asylums took on this task as one
aspect of the range of needs they attended to for those impoverished
Victorians who called upon their assistance.
The benevolent asylums, established in the large Victorian provincial
cities and in Melbourne in the course of the 1850s, also included the
provision of some medical care for their charges.32 From its beginning in
the 1850s, the Immigrants Aid Society for the Houseless and the Destitute
included infirmary wards in its St Kilda Rd Home. The Society, set up by
philanthropic Melburnians to provide indoor and outdoor relief for those
newcomers to the colony who did not prosper in the gold-rushes, was
prepared to provide shelter for indigent patients discharged as incurable
from the Lying-In (Women’s) and the Melbourne hospitals. In 1862 the
infirmary could accommodate 62 inmates, many of them from the
Melbourne Hospital. In the face of the demand for long term care, the
Society had to relax its rule of not assisting those who had resided in the
31
For example, the Melbourne Hospital opened in 1848 (adding Royal to its name in
1935), K. S. Inglis, Hospital and Community: A History of the Royal Melbourne Hospital,
Melbourne University Press, Carlton, 1958; the Homoeopathic Hospital (later Prince
Henry’s) in 1869, J. Templeton, Prince Henry’s, The Evolution of a Melbourne Hospital,
1869-1969, Robertson & Mullens, Melbourne, 1969; the Women’s Hospital in 1865, J.
McCalman, 1998, op. cit.; the Alfred Hospital in 1870, Mitchell, op. cit.; also in 1870, the
Children’s Hospital, P. Yule, The Royal Childrens Hospital, A History of Faith, Science
and Love, Halstead Press, Rushcutters Bay, N.S.W, 1999; in 1893, St Vincent’s Hospital,
Egan, 1993, op. cit.; and in 1899, the Queen Victoria Hospital for women and children, E.
Russell, Bricks or Spirit?, The Queen Victoria Hospital, Melbourne, Australian Scholarly
Publishing, Melbourne, 1997; and the Queen’s Memorial Hospital for Infectious Diseases
(Fairfield) in 1904.
32
Cage, op. cit. Chapter Three. Benevolent asylums were situated at Ballarat, Bendigo,
Castlemaine, and Beechworth. In Melbourne, they were the Home run by the Immigrants
Aid Society and the Melbourne Benevolent Asylum; Dickey, 1977, op. cit. pp.54-55; S.
Swain, ‘The Victorian Charity Network’, PhD Thesis, University of Melbourne, 1977, a
study of the ‘voluntary principle in charity’ on a scale never achieved in Britain where the
model was conceived. For a comparison with the approach in New South Wales see
Dickey, 1980, op. cit. The government there played a more direct role in relieving poverty
by taking responsibility for providing as well as funding institutional services, p.46-47.
79
colony for longer than two years.33
Its companion institution, the
Melbourne Benevolent Asylum, also provided medical care of a quality to
induce the indigent from country areas to bypass their local benevolent
asylum and apply for assistance there.34 In 1882 the Austin Hospital for
‘incurables’ was established, also as a charitable venture.35
Up to the end of the nineteenth century, when surgery became safe, less
painful and more popular, there may have been little to distinguish the
wards in the hospital from the infirmary section of the benevolent
institutions.36 The introduction of surgery however, had the effect of
reinforcing the aim of the committees of management and their medical
staff, to maintain the voluntary hospital as a place for short-term treatment.
In addition, the emphasis on provision for the poor diminished, as hospital
care in sickness became more acceptable to all social classes.37 With these
changes in hospital practices, the infirmary wards of the benevolent
institutions became even more closely associated with long-term sickness
and poverty. Certain common attributes remained however: benevolent
asylums and hospitals were managed by autonomous committees elected
from subscribers, and both were increasingly dependent on government
subsidies.38 Although the benevolent asylums were set up with a system
of public subscriptions, from the very beginning these were inadequate.
As in the case of the voluntary hospitals, the colonial/state government,
became the ‘chief subscriber’ to the benevolent asylums.39
33
Uhl, op. cit. p.9. Uhl notes that the Society’s home was used as a hospital for three years
before the Lying-In (Women’s) Hospital was opened, Note 6, p.221.
34
Kehoe, op. cit. p.32.
35
E. W. Gault & A. Lucas, A Century of Compassion, A History of the Austin Hospital,
Macmillan, 1982, South Melbourne, 1982.
36
In some country districts the local hospital combined both functions although their
limited facilities meant that their services were more oriented to outdoor relief, Cage, op.
cit. p.33. This dual role was recommended by a Royal Commission into the provision of
services for the poor and the sick in Victoria in 1870 and it was a condition of municipal or
state government support that district hospitals were required to undertake both functions.
M. Ronaldson, ‘The Development of Social Services in Victoria’, MA Thesis, University
of Melbourne, 1948, p.156.
37
Inglis, op. cit. p.172-3.
38
Swain notes that the committees in the benevolent institutions were usually self
perpetuating bodies whose management decisions were approved at the annual general
meeting of subscribers. Swain, op. cit. p.45ff.
39
In relation to the voluntary hospitals, Inglis, op. cit. p.170-171, Mitchell, op. cit. pp.6874 and in relation to the benevolent asylums, Cage, op. cit. Appendix 5. In Victoria,
Kennedy notes, the state assumed direct responsibility for the insane and inebriate asylums,
the least appealing class of needy. The benevolent asylums satisfied a need that fell
somewhere between the least appealing – the insane, and the most appealing - modern
hospital services. R. Kennedy, ‘Poor Relief in Melbourne: The Benevolent Society’s
80
In the course of the 1920s the relationship between the infirmary wards of
the benevolent homes and other types of hospital provision in the State
became more clearly defined.
This clearer definition did not arise,
however, from any specific form of activity focused on these institutions.
It was rather a side-effect of steps taken on one hand, by doctors to
cultivate a hospital environment they believed to be conducive to the
highest quality medical work, and on the other, of steps taken by the State
government to regulate its funding of hospital and welfare services. As a
consequence different levels of hospital care emerged: care during
episodes of acute illness or injury in the large public teaching hospitals,
convalescent in designated wards or institutions; and long-term care in the
benevolent asylums.40
The differentiation of hospital care was not
accompanied by a similar differentiation in the scope of medical work; the
area of chronic care was designated as such by its exclusion from active
medical intervention. It was associated with palliative care, overseen by a
medical officer and provided under the auspices of charitable bodies.
In view of its increasing contribution to the funding of hospital services,
the State government in Victoria, moved to regulate the activity by
establishing the Charities Board in 1924.41 The Board consisted of a
number of part-time members, representatives of hospitals’ associations
and the committees of management of subsidised institutions.
The
Secretary to the Board was the only permanent official, a public service
officer whose role was to act as intermediary between the Board and
Treasury, which provided the funds the Board distributed.42
If the
structure of the Board implied any cohesion amongst the various hospital
committees, it is quite misleading. The formation of hospital associations
Contribution 1845 –1843’, Journal of the Royal Australian Historical Society, vol 60, pt4,
1974, pp.256-266.
40
A small private hospital industry had also emerged around the city and suburbs, by 1920,
many of them established by nurses returned from service during the First World War.
Where there were 476 of these in the 1920s, of which 195 had less than five beds, by the
late forties there were about 266 with a maximum capacity of 4,357 beds. R. Inall, State
Health Services in Victoria, Occasional Monograph, No 4, Department of Government and
Public Administration, University of Sydney, 1971, p.61. In the country the Bush Nursing
Hospital system provided a system of paid hospital services, subsidised by the State
government. So long as patients could pay for their care, their needs were not
distinguished in this fashion, see Collins op. cit.
41
Inall, op. cit. p.40-42.
42
Mr. C. L. McVilly occupied this position for the duration of the Board’s existence until
the late 1940s. Gillespie notes that in this position he was considered to be the most
powerful health administrator in Australia. Gillespie, op. cit. p.62, pp.204-206.
81
was a device adopted by the State government to oblige these disparate
and autonomous entities to cooperate in the most minimal fashion. The
Board itself had no power to compel hospital committees of management
to take any particular course of action although there was some limited
scope in the allocation of funds.43
The constitution of the Board by
members of the very committees that the government sought to restrain
suggests that the condition that called for the establishment of the Board –
namely the autonomy of committees of management – was extended into
supervising the allocation of funds. However, although the Board, as Ken
Inglis notes, did not operate as an instrument of the State, neither was it a
mere instrument of the institutions. It could be just as critical of one as of
the other.44
The measures adopted by the Board reflect a concern with restraining
expenditure, not with the provision of services.45 One such measure was
the introduction of the factor of average length of patients’ stay in hospital
into the estimation of an individual hospital’s subsidy.46 Another measure
to minimise patients’ length of stay made the Secretary to the Board
intermediary in the transfer of those patients who were medically certified
not to need the level of care provided in the public hospitals into other
43
L. Gardiner, Hospitals in Association, A History of the Metropolitan Hospitals
Associations 1918-1974, Mount Eagle Publications, Australia, 1977, ‘Origins’, p.1.
44
Inglis, op. cit. p.184. The administration of hospital services was indeed a fragmented
process. The Department of Health was itself directly responsible for some institutions –
tuberculosis sanitoria and the Cancer Institute, Inall, op. cit. p.27ff. Walker notes that
much of the expansion of hospital services during the 1920s, was possible because of the
fund raising capacity of committees of management. Having increased their services,
hospital committees of management then called for an increase in funding from the State
government. The establishment of the Board may be seen as a case of the State
government trailing the committees of management as they set an expansionist agenda. C.
Walker, ‘The Emergence of the Hospital System in Melbourne: 1846 to1975; PhD Thesis,
La Trobe University, 1994, p.194.
45
In refraining from being involved in the actual provision of hospital service, the
Victorian government, and to a lesser extent the government of New South Wales stood out
amongst the states. In states without an affluent middle class to support charitable
ventures, the colonial-cum-state governments played a more prominent role in the
provision and control of hospital services. Even in New South Wales, a Labor government
elected in 1910 began to take a more instrumental role in the provision of hospitals.
Gillespie, op. cit. p.60ff, summarises briefly the activities of the states in this respect in the
early decades of the twentieth century. See also B. Dickey, ‘The Labor Government and
Medical Services in NSW, 1910-1914’, Historical Studies, vol 12, no 45, 1967, pp.541555, and J. Bell, ‘Queensland’s Public Hospital System: Some Aspects of Finance and
Control’, in J. Roe, ed, Social Policy in Australia, Some Perspectives, 1901-1975, Cassell,
Australia, 1976.
46
This approach was not altogether novel. It had been first taken in 1860 when the State
government decreed that the average length of stay in hospital was to be no more than 25
days, when this was exceeded the grant was reduced. Mitchell, op. cit. p.9.
82
institutions.47 Country hospitals and the infirmary wards of the benevolent
asylums were considered to provide a level of care more suited to the
needs of such patients.48
In this manner the infirmary wards of the
benevolent asylums took on an administrative significance that confirmed
their role as chronic hospitals in the State’s hospital system.
The emerging role of the benevolent asylums as chronic hospitals became
more clearly demarcated in the mid 1920s, when the Charities Board
acquired wards no longer needed by the Repatriation Department in the
No 11 Army General Hospital at Caulfield. The intention was to use these
wards for patients, principally from the Melbourne Hospital, but also the
other metropolitan teaching hospitals, who were deemed convalescent.49
The category of convalescent included patients who had had surgery or
whose treatment for medical conditions would not exceed two months. It
excluded those with long-standing and incurable conditions, malignant
disease or disability related to tuberculosis or spinal injury.50 Acquisition
of the wards at Caulfield meant that the Melbourne Hospital finally
received a response to a request it had made to the State government in
every accommodation crisis since the 1860s, for ‘convalescent’ beds
where patients could be transferred after treatment until they were fit to be
discharged.51
Another source of non-acute hospital beds was found in the After Care
Hospital in Collingwood. The Melbourne District Nursing Society,
47
These patients could not afford to pay for their care. Some because of outright poverty,
others because they had exhausted their resources in private hospitals and rest homes.
Public hospital care was means tested until the Chifley government introduced a subsidy
payable to the states on the condition the fees for public wards were abolished in 1945.
Means-tested fees were reintroduced in the early 1950s when the Liberal-Country Party
Coalition government introduced the system of publicly subsidised, private, voluntary
hospital and medical insurance, Kewley, op. cit. p.353-354.
48
The measure was presented to country hospitals in danger of closing because of
insufficient patient numbers, as a means of remaining in operation. Although transfer was
presented to patients as a voluntary matter, they were subject to considerable pressure to
comply even though it often meant moving to areas that were remote and far from families
and friends. Collins, op. cit. p.182, p.207-208. In Chapter 6 Collins outlines the effect of
such transfers on the hospitals and some of the patients involved, during what she describes
as one of the less notable events in the history of the administration of hospital services in
Victoria.
49
VPRS 4523/P1/51/475; Mitchell, op. cit. footnote 61, p.272.
50
B. Ford, The Wounded Warrior and Rehabilitation, The Alfred Healthcare Group,
Caulfield General Medical Centre, 1996, p.88-89.
51
Inglis, op. cit. p.89.
83
initially set up in the late nineteenth century by philanthropic Melbourne
women, to provide nursing care for sick mothers and their babies at home,
enlarged the scope of its operations by building the After Care Home. It
opened in 1926 to accommodate the Society’s patients who were fit
enough to leave hospital but not to return home.52 Less than ten years
after it opened however, the Home was renamed the After Care Hospital
and accepted patients from the Melbourne Hospital who were considered
to need nursing care but not the sophisticated medical services of that
institution.53
Organising Medical Work
While the Charities Board attempted to rationalise the use of acute hospital
beds on the grounds of cost, another process of rationalisation was
underway at the Austin Hospital. The changes that were set in train at the
Austin from the late 1920s provide an insight into the reverse side of the
process taking place in the benevolent asylums, a process that underpinned
a growing differentiation between acute and chronic illness in the work of
medical practitioners.
The Austin, as noted above, was originally
established, as a philanthropic enterprise, to provide care for the dying and
incurable patients who were unwanted in the general hospitals. The
reorganisation set in train at this time entailed the removal from the
hospital of a particular segment of ‘incurables’ with the overall effect of
reducing the numbers of beds available for their care. Rupert Willis,
whose ambition to work in hospital pathology at the end of his medical
training, had been frustrated by lack of opportunity, was appointed
medical superintendent in 1926, after a period of general practice in
Tasmania.54 For the twenty years prior to his appointment, the matron of
the hospital had supervised patient care and one of the first steps he took
was to initiate a through medical examination of all patients.
52
N. Rosenthal, People – Not Cases, The Royal District Nursing Service, Nelson,
Australia, 1974, p.71ff.
53
Ibid. p.103-104.
54
R. A. Willis, ‘Recollections of Medicine at the Austin Hospital: Heidelberg in the
1920s’, MJA, vol 1, 1979, pp.15-17. Willis was one of the ‘notable company’ amongst
whom Macfarlane Burnet graduated, and his activities at the Austin were the beginning of
a distinguished career in his chosen field of pathology, C. Sexton, Burnet, A Life, 18621962, Oxford University Press, South Melbourne, 1999, p36. When Willis wrote this
article he was Emeritus Professor of Pathology at the University of Leeds, England.
84
Willis’ investigation revealed a ‘treasure house of largely unexplored
pathology’ but at the same time it also revealed many patients whose
conditions were not so interesting. Some had been admitted with an
incurable disease in younger days and had grown old there, others had
come more recently following a stroke, for example and there was a long
waiting list of such applicants.55 On the basis of his examinations Willis
began to separate out those patients whose conditions could be identified
in pathological terms from those he described as needing nothing more
than ‘a home to live in and nursing care’. Willis’ reorganisation did
ensure a place for patients doctors wished to exclude from the
convalescent wards of Caulfield Hospital – that is those with malignant
disease, tuberculosis and spinal injury – however, he also made it clear
that other patients were considered ‘beyond the pale’ of active medical
work. These old people, incapacitated by stroke or other conditions linked
to old age, were shifted to Cheltenham Old People’s Home, located many
miles distant from the Austin.56
In 1943 an officer of the Walter and Eliza Hall Trust Fund wrote to the
Secretary to the Charities Board, C. L. McVilly, asking about the status of
the benevolent asylum at Bairnsdale.57 McVilly replied that the infirmary
sections of the benevolent institutions were ‘akin to hospitals’ because
they accommodated many ‘cases’ that would otherwise have been in the
general hospitals.
However, while there may have been little to
distinguish infirmary wards from those in the general hospitals earlier in
the century, by mid-century they were distinguished by being classified as
a ‘home’ rather than hospital.58 The change in the meaning of the word
55
Willis, op. cit. p.15-17, Gault & Lucas, op. cit. p.116ff.
Willis’s decision to do this attracted public criticism in the newspapers. Apart from
cutting down the beds available for the infirm aged, the friends and families of patients
who lived near the Austin, north-east of the city, would have found it an interminable and
perhaps impossible, journey to visit them at Cheltenham in the south east. The distinction
Willis made, between patients suitable for the Austin and those needing ‘home care’, was,
even at that time, not so clear. In the late 1920s, cancer patients from the Austin were
removed to empty wards at the Bendigo Benevolent Home with the Charities Board
funding the necessary renovation of this accommodation, F. Cusack, Candles In the Dark,
A History of the Bendigo Home and Hospital for the Aged, Queensberry Hill Press,
Carlton, Victoria, 1984, p.159.
57
VPRS 4523/P1/91/888; when the District Hospital at Bairnsdale moved to new premises
in the 1940s, the vacated building became the Gippsland Benevolent Home. The
committee of management there had, it appears, written to the Trust requesting assistance.
58
The Bendigo Benevolent Asylum and Lying-In Hospital was renamed Bendigo
Benevolent Home in 1937. In the early 1950s, the provision of Commonwealth subsidies
for these activities, led to the general substitution of the term ‘home’ for asylum, possibly
56
85
infirmary illustrates the role of the benevolent institutions within the
overall system of hospital services in the State. In the nineteenth century,
and perhaps early in the twentieth, the word was used to designate any
institutional setting for the care of the sick.
By the 1940s the word
infirmary referred to an ‘institution for the housing and maintenance and
care of needy, infirm patients with chronic disability’, most of whom were
elderly simply because infirmity increases with age.59
The medical work of caring for infirmary patients was quite distinct from
that done in the general hospitals.
In the infirmary ‘conditions were
laissez-faire – feed them, bed them, and treat symptoms as they arose’.60
This approach was the opposite of the highly interventionist response to
disease and disability in the hospitals. It was difficult however, in the
everyday work of doctors in the public hospitals, to maintain the
distinction between acute and chronic patients. From the 1920s into the
1950s (and indeed thereafter), the files of the Charities Board and its
successor body the Hospitals and Charities Commission are filled with the
complaints of doctors about the problems they faced in discharging
patients who needed medical and nursing care but who had nowhere else
to go.
Benevolent Care
By the early 1950s the state government subsidised the following
benevolent institutions; Bendigo Benevolent Home, the Alexander Home
at Castlemaine, the Gippsland Benevolent Home at Bairnsdale,
Cheltenham Old People’s Home, Mount Royal in Parkville, the Ovens and
Murray Home at Beechworth, and the Queen Elizabeth Home at Ballarat.61
The majority of inmates in these institutions were elderly although
younger people with incurable conditions and disabling injuries from
as Kewley notes, because of the growing unacceptability of the term ‘asylum’, Kewley, op.
cit. p.305.
59
S. Sax, ‘Need for Infirmary Accommodation’, The Australian Journal of Social Issues,
vol 3, no 1, 1967, p.33.
60
A. McCutcheon, ‘Retrospect’, MJA, vol 1, 1958, pp.272-275.
61
Annual Report, Hospitals and Charities Commission, 1955. Mount Royal had four
infirmary wards, each with 53 beds, Cheltenham Old People’s Home provided a similar
number, including two wards set aside for diabetic patients from Prince Henry’s Hospital.
The two largest country institutions at Ballarat and Bendigo, each accommodated around
four hundred in their infirmary wards.
86
accidents could also be found in the wards.62 As well as the infirmary
wards where the aged predominated, other sections of the homes
accommodated old people who were able to get about but who had entered
the home to avoid being in the position of needing assistance at a later
date.
The homes had begun by offering asylum – ‘indoor relief’ as it was termed
- to distressed individuals, male and female, of all ages, but unlike similar
institutions in other parts of the world there were, in general, more old
men than old women. In the late nineteenth century the proportion of men
in the Victorian population was greater because of the earlier influx of
gold seekers who were most often single men. Dependent as they were on
their physical resources to earn a living, increasing age, and perhaps a
lifetime of itinerant labour, they had nowhere else to go except the
benevolent asylum.63 As they became more dependent, they moved from
the ambulatory sections to the infirmary wards. The lives of many of the
men accommodated in the benevolent homes, well into the 1950s, had
been shaped by poverty in childhood, and war and depression in
adulthood. After a peripatetic adulthood they went into old age without
ever having put down roots or established the relationships that may have
sustained them in their old age.64
By the early 1950s, women had come to outnumber men in the Victorian
population over the age of 65 but they were not so prominent amongst the
inmates of the benevolent homes.65 The homes continued to provide a
refuge for single men without family or material resources, a group similar
to those who sought admission in the 1890s. Women were more likely to
62
The introduction of a State sponsored scheme for compensating injured workers in
Victoria in 1914 meant that patients in this category admitted to Mount Royal provided a
source of income not available for other categories of patient. The various workers’
compensation schemes in the states, from their inception in the early 1900s, are briefly
described in the introductory pages of the Report of the National Committee of Inquiry,
Compensation and Rehabilitation in Australia, Chairman W. O. Woodhouse, 1974, AGPS,
Canberra. As Caulfield Convalescent Hospital and the After Care Hospital began taking
convalescent patients, Mount Royal was more often allocated those least likely to achieve
any degree of recovery, Uhl, op. cit. p.134.
63
Cage, op. cit. p.75.
64
Old people in the country particularly, if they had no resources of their own, had to apply
for admission to homes many miles from their own communities. The home at Ballarat for
example served the whole of north west Victoria, A. J. & J. J. McIntrye, Country Towns of
Victoria, Melbourne University Press, Melbourne, 1944, p.135-136
65
Table 3, p.19, A. H. and G. N. Pollard, ‘The Demography of Ageing in Australia’, in
Towards and Older Australia, Readings in Social Gerontology, ed A. L. Howe, University
of Queensland Press, Queensland, 1981.
87
have family to help them and may have been more welcome than men in
the church homes that also provided accommodation for elderly people at
this time. In general, the benevolent homes were impressive buildings,
located at some distance from the surrounding community but prominent
on account of both their situation amidst extensive gardens and their
grandiose style of architecture. They stood as monuments, testifying to
the extent of a community’s care for its aged members. Many of the
amenities the homes boasted - concert hall, library, a small shop to provide
cigarettes and sweets - were provided through the activities of ladies’
auxiliaries, and other community associations such as local Rotary groups.
The homes represented a conception of old age as a time of retirement
from active life and relief from responsibility, entailing a duty of care on
the part of the family or, in its stead, the community through institutions
such as these. The importance of their role was attested by the size of
their populations - both Mount Royal and the Cheltenham Old People’s
Home in the metropolitan area accommodated between six and seven
hundred inmates in total - and in the size of their waiting lists. The
waiting list in particular was an ever-present inducement to the
committees of management to expand their range of activities and
intensify fund-raising activities.66 The gradual emergence of the role of
de-facto chronic hospital was not accompanied by any diminution of the
role of the institution as ‘home’ for the aged, and accommodation for
ambulant old people expanded alongside the wards for the infirm.
In keeping with their home-like character, the position of medical officer
in these institutions was not a significant one, either in relation to the
home itself or in the medical profession at large. It was filled by a local
general practitioner, often in combination with private practice.
The
medical officer had no formal role in the management of the institution.
At meetings of the committee of management he, rarely she, may have
been invited to present a report on the health of his charges and then leave.
Conditions of employment were negotiated between doctors and the
individual institutions; in some cases this meant appointment to the
66
It was the practice, one that persisted into the early 1970s, for elderly people without
much in the way of resources, to put their names on the waiting list to avoid the situation of
needing care and not being able to get it. Many in this group were admitted when their
names were at the top of the list simply for reasons of security.
88
position of medical superintendent with the provision of a house for the
doctor and his family, but not in others. Up to the early 1950s, in general,
the one medical officer had the responsibility of providing medical care
for all inmates.67
In his survey of the lives of old people in Victoria in the early 1950s,
Hutchinson noted that neither aspect of the dual role of the institutions was
performed adequately.68 The standard of care provided in the infirmary
wards was low and the lives of the ambulatory inmates were regulated by
same routine as that prescribed for the bedridden.
There was little
opportunity or encouragement for these more able individuals to take part
in any kind of activity. A visitor to one of these institutions was likely to
be ‘overwhelmed by a terrifying atmosphere of boredom’. There was in
fact nothing to do apart from helping in the daily routine, preparing bread
and butter for tea, laying tables, and assisting in the care of the bed-bound.
In the infirmary wards, many of them accommodating fifty or so people,
aligned in rows of beds placed so it was possible to fit in as many as
possible, an atmosphere of ‘cold severity and colourless cleanliness’
prevailed.69 Nursing care was provided by untrained attendants, or the
more able inmates, attendants were always in short supply because the pay
was low and the work constant and arduous.70
Fleur Finnie went to Cheltenham Old People’s Home in 1940 because
she’d heard jobs were readily available there and she’d had failed her
Intermediate Certificate, the passport to her desired career as a
kindergarten teacher.71 She was frightened of men and had asked not to be
67
For example the Melbourne Benevolent Asylum, later called Cheltenham Old People’s
Home, and then Kingston Centre, provided the position of medical superintendent, and it
was held by Dr Carlisle from 1935 to 1960, at Mount Royal this position did not exist.
68
B. Hutchinson, Old People in a Modern Australian Community, Melbourne University
Press, Carlton, 1954, p114. In 1950 the Rotary Club of Melbourne sponsored the
formation of a Citizens’ Committee made up of representatives of the churches and other
philanthropic and community groups working to provide services for old people. The
Committee decided to conduct a survey of the ‘extent and nature of the problem of old age
in Victoria’ as the basis for coordinated measures to address it. An English social
investigator, Bertrand Hutchinson, was commissioned to undertake the study, which he did
with the assistance of the Department of Social Work at the University of Melbourne.
69
Hutchinson ibid. p.114ff.
70
In August, 1949 the manager of Mount Royal Home and Hospital for the Aged noted that
it was a good idea to mix the ambulant and bedridden patients because ‘… a patient who
could move around could be given the interest of doing jobs within his capacities and
assisting nursing staff.’ However he also noted that a growing number of applicants for
admission were not fit enough to do this. VPRS 4523/P1/260/2242.
71
F. Finnie, Don’t Stand on the Grass, Vista Publications, Melbourne, 1996, p17-18.
89
put on a men’s ward but at six o’clock on her first morning, she found
herself in a large ward facing ‘four rows of beds’ along the length of the
ward, every one of them occupied by a man. There were no curtains or
screens and these men were being washed as they lay naked, the bedding
pulled to the foot of the bed and their nightgowns removed. It was some
time before she became accustomed to the smell of urine and faeces that
pervaded the ward. Breakfast was served by two cleaners who then also
helped to feed the helpless inmates. They handed around porridge served
on enamel plates with a small amount of milk and sugar. Because there
were no backrests on the beds and pillows were scarce, many of the men
were obliged to eat their meals lying down with the plates on their chests.
The tea came already made up with milk and sugar, too bad for those who
didn’t like it that way.72
The benevolent homes also had their own ideas about acceptable patients.
They would not keep individuals who were disruptive and would not
accept mentally disturbed individuals – in some cases there may have been
a clause specifically excluding this group in their statement of purpose for
registration as a charity.73 Mentally disturbed old people were not wanted
anywhere and although doctors in the Mental Hospitals may have doubted
that certification as insane and incarceration was in their best interests,
there was usually no other choice. An incident in 1925, at Mount Royal
(then called Victorian Homes and Hospital for the Aged), serves to
illustrate the sad condition of these feeble old people. A special court was
convened at the hospital with a Justice of the Peace presiding and two
doctors in attendance to certify that the patients in question were indeed
insane. They were then conveyed, with police escort, to Kew Mental
Hospital.74 The Inspector General of the Lunacy Department, Dr Ernest
Jones, complained about this ‘inhumane’ action to the Inspector of
72
Ibid. p.21. Finnie noted that the shortage of workers in the wards became more acute in
wartime. She was told that all the cleaners in her first ward were prisoners on life
sentences who, because of the good behaviour, had been discharged after thirty years in
goal. They lived at the Home, accommodated in the cleaners’ dormitory, receiving their
meals and five shillings a week in wages, p.25.
73
VPRS 4523/P2/8283. For example Mount Royal had a by-law forbidding the admission
of the insane – the only form of classification at the time to distinguish mentally confused
old people from other infirm aged people.
74
VPRS/P1/153/1493.
90
Charities, emphasising the point that these people could be cared for in a
benevolent home, in a ward set aside for the purpose, by trained staff.75
Some of the homes, particularly the smaller country institutions that
sometimes found it difficult to keep up their numbers, did accept patients
from the Mental Hospitals who had reached a stage where the frailities of
old age had overtaken mental illness, and who were considered to be
manageable in the benevolent home setting. The advantage in taking these
patients was that their board and keep was paid for out of the Treasury
allocation for mental hospitals.76 The Castlemaine Benevolent Home was
happy to accept these quieter patients but in the opinion of the committee,
‘much of the work can be carried out efficiently by women trained in a
lesser degree than that demanded of a certificated nurse’. Dr Jones went
on to say in his letter, that out of 809 admissions to Kew Mental Asylum
in 1924; the condition of 102 of these individuals was attributable to
changes associated with ageing.
While technically it may have been
possible to certify these old people as insane, they were in fact ‘hospital
cases needing special care for the aged’, and this, he pointed out, was in
fact the stated purpose of the benevolent homes. It was to be another sixty
years and more, before mentally confused old people were provided with
care suitable to their needs and over the intervening years Dr Jones’
successors reiterated his remarks at regular intervals.
When the issue of a medical role in relation to old age infirmity was first
raised in the mid-1950s, the benevolent institutions were caught up in an
unsystematic and fragmented system of hospital provision in the State.
They had become repositories for those chronically sick and infirm
patients who had nowhere else to go and the practice of sending patients to
these institutions who were unacceptable in the convalescent wards
ensured that most of these were elderly and infirm. The institutions were
part of a state wide but uncoordinated, process in which two levels of
75
Ibid.
Because the Commonwealth viewed the upkeep of the inmates in the benevolent and
mental asylums as the responsibility of the States, admission to one of these institutions
was grounds for exclusion from eligibility for the Age Pension. If an individual was in
receipt of a pension before admission, it was stopped. In 1923 and again in 1947 changes
were made in respect of the inmates of benevolent homes but it was not until 1966 that the
Commonwealth responded to representations from state ministers of health and agreed to
pay pensions to eligible mental hospital patients. Kewley op. cit. p.120, p.304-305 and
p.422-423.
76
91
hospital services emerged.
One level provided acute care, where the
requirements for practising and teaching a laboratory based medicine
dominated; the other, a combination of convalescence and custodial care
defined principally in terms of its lesser cost, not the specific needs of
patients in this category nor the specific skills of medical staff.
As
hospital services provided by voluntary groups, although publicly funded,
the benevolent institutions, were incorporated into the State’s hospital
system in the course of pursuing their own particular objectives. The
predominance of old people amongst those accommodated in the infirmary
wards reinforced the other function of these institutions – that of ‘home’
for the aged.77
Medical Responses to Old Age Infirmity in Postwar Victoria
By the early 1940s, when the first signs of professional interest in old age
infirmity began to appear in the pages of the Medical Journal of Australia,
the provision of institutional care was firmly established as the appropriate
response to old age infirmity, in the minds of Victorians, medical
practitioners included. A few doctors did question this approach either
directly or indirectly, and as they did so social medicine once again
provided a source of ideas. In what appears to be the last gasp of the
national efficiency movement, C. V. Crockett, described as Director of the
Department of Medical Sociology and Research in the New South Wales
branch of the British Medical Association, advocated a sociological
approach to the management of an ageing population.78
The rising
numbers of older adults in the Australian population, Crockett wrote,
called for attention to the degenerative diseases characteristic of ageing
77
In their application for registration as a charity with the state government, which was
updated periodically, these institutions had to state their objectives. In 1923, Mount Royal,
then known as Victorian Home and Hospital for the Aged, for example, listed relief of the
aged and infirm, VPRS P2, /8283.
78
C. V. Crockett, ‘The Shift to Higher Age Levels in Australia and the United States: Its
Sociological and Medical Interest’, MJA, vol 2, 1943, pp.473-476. Crockett’s article is the
only mention of medical sociology in the Journal, apart from an editorial in 1941 which
suggested the formation of a special interest group devoted to the ‘study of medical
sociology’ to enable doctors to contribute productively to discussions then in train
regarding postwar reconstruction. The editorial was prompted by papers read at a meeting
of the Victorian branch of the BMA in that year. Dr. J. Dale, medical officer of health for
the City of Melbourne had called for social reform ‘not of any particular brand’ to address
the problems of sickness he found amongst the deprived residents of Melbourne, MJA, vol
2, 1941, p.143-144 and pp.135-140. There does not appear to be any record of Crockett or
his group in NSW. The tone of his article echoes discussions earlier in the century when
infant mortality and childhood sickness were posed as problems of national concern, P.
Mein-Smith, Mothers and King Baby, Infant Survival and Welfare in an Imperial World:
Australia, 1880-1950, Macmillan, Basingstoke, 1997, pp.30-36.
92
adults and he described this work as geriatrics. In addition, he encouraged
governments in Australia to emulate the example of the United States and
fund research into the normal ageing process so that preventive measures
could be better informed through the science of gerontology. Overall,
these disciplinary endeavours would provide the knowledge to address a
problem Crockett posed in an idiom characteristic of postwar social
medicine in Britain; ‘Should society be content with improving facilities
for the care of the aged – and there is much to be done in this direction –
or should it also interest itself in better utilising the capacities of the
ageing?’79
In 1946, an anonymous editorial advocated a more pragmatic approach.
The editorial cited the example of Marjory Warren, who, together with a
small group of like-minded colleagues, developed a model medical service
directed towards the needs of old people who were at risk of needing
custodial care.80 The ‘geriatric service’, as this model came to be known,
was also a pragmatic response on the part of these doctors to demands for
admission to the long-term care wards in the hospitals they managed.81
The ‘geriatric service’ as a response to the demands of the moment did, in
fact, put into practice the social medicine model, as medical treatment was
aligned with welfare measures in an acknowledgment of the part played by
social conditions in sickness and disability in elderly people.82 Further,
because the group of patients for whom geriatric services were developed
often suffered from multiple disease conditions as well as the effects of
age-related deterioration, the aim of medical treatment was the reestablishment of social function and not simply the eradication of
disease.83
79
Crockett exemplified another aspect of the social medicine movement also in that he/she
posed the problems presented by increasing numbers of elderly people as a problem of
‘national efficiency’. The program he proposed brought together two lines of development
that were present in the twenties and thirties in Australia. Cumpston’s effort to establish a
national hygiene through the Department of Health and the parallel development in the
National Efficiency Movement, Rowse, op. cit. p.44ff.
80
‘Current Comment’, MJA, vol 2, 1946, p.459-460.
81
Warren, Lionel Cosin and Eric Brooke, all with responsibilities for managing municipal
hospital beds, being either medical superintendents or deputies, independently developed
methods of dealing with the demands made on their services by infirm old people and their
families who looked to hospital admission and long term care as a solution to their
problems, Howell, 1974, op. cit.
82
M. Warren, ‘Activity in Advancing Years’, British Medical Journal, vol 2, 1950, p.922.
83
M. Warren, ‘Care of the Chronic Aged Sick’, The Lancet, vol 2, 1946, p.841.
93
The principles underlying the geriatric service and the medical approach to
the treatment of old people at risk of needing custodial care were
publicised in a report by the British Medical Association in 1948.84 The
report noted that these individuals should be treated in a special
department of the general hospital to ensure that the same investigative
resources were brought into use as were available for other patients, with
the aim of identifying treatable conditions. The same provision applied to
the restorative treatment given by occupational and physiotherapists,
aimed at making the most of any capacity an individual had to be
independent in the activities of everyday life.
Neither requirement
necessarily involved any degree of specialist technical skill although
overall, the application of conventional approaches to this group of
patients did require a degree of clinical acumen achieved only through
experience.85 The novelty of the approach advocated in the report lay in
the application of generally accepted methods of treating disease and
disability in adults to a group usually excluded on grounds of advanced
age and, it should be emphasised, poverty.
Warren’s more rigorous
approach to the medical care of old people did entail a reversal of previous
practices whereby old people who were unwell were routinely put to bed.
She particularly emphasised the part played by activity in maintaining
physical and mental well being in old people.86
The doctors who promoted the geriatric service did so in order to make a
place in the acute hospital for a neglected group of patients. In doing so
they shifted their orientation, apparently informally and as a practical
response to the pressure of demand on their institutions, towards that of
social medicine. In fact, the geriatric service highlights the association
characteristic of social medicine, between humanitarian response to need
and the efficient management of national resources. The service certainly
provided medical treatment for a group previously excluded from active
84
M. Martin, ‘Medical Knowledge and Medical Practice’, Social History of Medicine, vol
7, no 3, 1995, p.447.
85
Warren wrote of ‘geriatrics’ as a medical specialty comparable to paediatrics. In her
view the geriatric unit in a general hospital would provide the setting for undergraduate
teaching, where students would not only be shown chronic cases but ‘see them under
treatment and watch their seniors manage such cases from the beginning to the end.’
Warren, 1946, op. cit. However Martin makes the point that in the 1950s, when Victorians
became interested in the geriatric service, the medical work of geriatrics could best be
described as the medical treatment and appropriate dispersal of old people amongst a range
of welfare services, Martin, op. cit. p.458.
86
Warren, op. cit. 1950, p.921-922.
94
medical treatment. At the same time it provided an institutional setting for
the classification of dependency in elderly patients, and their distribution
amongst a range of welfare services ranging from long term hospital care,
to various types of assisted accommodation and domiciliary assistance. It
was no coincidence that the BMA report publicising this classificatory
system and its institutional setting was published as part of a larger report
titled The Right Patient in the Right Bed.87
Coincidentally, around the time the report was published one of the
earliest texts in postwar social medicine in Britain appeared, devoted to
the topic of health and sickness in old age. J. S. Sheldon’s The Social
Medicine of Old Age, was given an appreciative reception in the Medical
Journal of Australia.88 Sheldon was commended for providing a ‘social
biology’ of old age and providing insights into health and sickness in old
people that were not available in a hospital setting. The study, a random
sample of old people at home in the English town of Wolverhampton,
illustrated the difficulties of categorising the condition of adults over the
age of 70 according to standardised notions of what was normal.89 It also
demonstrated that active social involvement played an important part in
preserving good health and that in the elderly this state was best defined in
terms of capacity for engaging in the activities of everyday life, rather than
in terms of absence from disease. Not the least of Sheldon’s findings was
that impediments to participation in everyday life, on the part of elderly
people could be alleviated by simple measures – the provision of adequate
spectacles, teeth, chiropody services, and welfare measures to assist
people to overcome social and economic difficulties.
In the early 1940s in Britain social medicine emerged as a discipline with
the aim of facilitating ‘progressive human social and biological evolution’,
87
Martin, op. cit. p.447, footnote 15.
J. S. Sheldon, The Social Medicine of Old Age, The Nuffield Foundation, Oxford
University Press, London, 1948, reviewed under the heading, ‘An English Inquiry into the
Health of Old People’, MJA, vol 1, 1948, p.797-798.
89
Sheldon believed his study confirmed John Ryle’s point that there was no normal versus
abnormal in states of health, only points along a scale of normality, p.21. Canguilhem put
the matter of ‘normality’ into perspective with the comment that ‘No environment is
normal. An environment is as it may be. No structure is normal in itself. It is the relation
between the environment and the living thing that determines what is normal in both. A
living thing is normal in the true sense when it reflects an effort on the part of life to
maintain itself in forms and within norms that allow for a margin of variation …’,
‘Normality and Normativity’, in A Vital Rationalist, Selected Writings from Georges
Canguilhem, ed F. Delaporte, Zone Books, New York, 1994, p.354.
88
95
through the management of corporate welfare. Other Chairs of Social
Medicine were established at universities in Edinburgh, Birmingham and
Sheffield to provide the disciplinary material needed to educate doctors
about disease in its ‘natural’ environment.
Despite these successes
attempts to insert social medicine into the medical curriculum in England
at this time were not successful.90
In Victoria, despite the overall
emphasis in postwar plans for developing research and medical training
facilities focused on the biochemical model of disease, social medicine did
influence the thinking of some medical practitioners.91 As in the 1920s
and 1930s, it was an influence that existed as an undercurrent to other
concerns but one that, nonetheless, did contribute to the climate of opinion
in which the task of developing the State’s hospital services was
addressed.
At the Clinical Research Unit located between the Walter and Eliza Hall
Institute and the Royal Melbourne Hospital, the Director, Ian Wood, was
interested in studying chronic disease. Following the example of Ryle at
the Oxford Institute, Wood appointed a social worker to facilitate the
inclusion of the ‘social’ element into research in the Unit. A more direct
connection with social medicine was established when Eric Saint was
appointed to a post in the Unit following his distinguished effort in the
examination for membership of the Royal Australasian College of
Physicians.92
With the encouragement of Wood, Saint investigated
chronic disease in that ‘no-man’s land’ between ‘medicine and sociology’.
In his view the ‘near perfection … achieved in modern surgical
techniques’ and microbiology, had accentuated the sociological problems
90
Oswald, op. cit.
E.V. Keogh, ‘Fifty years of Medical Research in Australia’, MJA, vol 1, 1951, pp24-28,
Keogh noted ‘Little investigative work has come out of the clinical schools’ because of
lack of liaison between hospitals and universities where fundamental research was being
done and lack of rewards. In giving the annual Halford Oration, shortly after his
appointment as Professor of Physiology and Dean of the Faculty of Medicine, R.D. Wright
included the ‘vast store of sociological knowledge which is the birthright of medicine’ in
his call for the cultivation of academic skills in the medical school to develop and teach a
‘theoretical synthesis in medicine’, Wright, op. cit. p.639-640.
92
Saint’s achievement was notable not only because of the standard of his work, but also
because he had studied for the College examinations while working as a medical officer for
the Western Australian government in the isolated Pilbara region, R. B. Lefroy, On Good
Doctoring, Eric G. Saint, Foundation Professor of Medicine, The University of Western
Australia, Privately Published, Perth, 1998, p.6; E. G. Saint, ‘Reflections on Australian
Medicine’, in Lefroy, ibid. pp.132-135; F. M. Burnet, Walter & Eliza Hall Institute, 19151965, Melbourne University Press, 1971, p.40-42, p.148-149.
91
96
facing medicine.93
In addition to his work combining physiological
studies into liver and pancreatic disease with studies of chronic
alcoholism, Saint also studied a group of elderly patients at the Royal
Melbourne Hospital, incorporating clinical, social, and psychological
perspectives of these individuals in doing so.94
The focus on elderly patients in Saint’s research was not intended to
promote the speciality of geriatrics but to highlight the point that
sophisticated medical care was of no value while the conditions in which
people became sick were ignored.
The medical care of the elderly
exemplified this situation in ways not so apparent with other adults.
Moreover, because doctors in the hospitals and in the community, were
beginning to treat increasing numbers of elderly patients, clinical
philosophy needed to be clarified in order to provide balanced and
effective medical services.95 Saint’s teaching duties during his time at the
Clinical Research Unit gave him the opportunity to disseminate his ideas
to both medical and graduate students.96
However his influence on
Victorian doctors was cut short when he returned to Western Australia in
the mid-fifties to set up a Clinical Research Unit at the Royal Perth
Hospital and then, in 1956 to be appointed Foundation Professor of
Medicine at the University of Western Australia.97
Eric Saint came under the influence of social medicine as he completed his
medical training at Durham University in the early 1940s when met Sir
James Spence, Professor of Child Health at Durham.
Spence was
renowned for the study known as the ‘Thousand Families Survey’
conducted in Newcastle during the Depression where he established the
connection between social class, poverty, and sickness.98 Saint himself,
illustrated the relationship between disease and environment in his first
93
E. G. Saint, ‘Social Perspectives in Medicine’, MJA, vol 1, 1955, p.161.
Saint, et al, op. cit. 1953. Saint’s work on alcoholism was also unusual at the time. Prior
to this, at Burnet pointed out, heavy drinking had not been considered a suitable topic for
erudite medical attention, Burnet, 1971, op. cit.
95
Saint et al, 1953, op. cit. p.763. This point was reinforced in a study he conducted in
Perth, concluding that out of 250 new inpatients and 150 outpatients, medical staff at the
hospital failed ‘to place about a quarter of our patients either in productive employment …
or in living conditions which one could be confident would have no harmful influence on
future progress.’ Saint, 1955, op. cit., pp.161-165.
96
Lefroy, 1998, op. cit. p.7, notes that Sir Charles Best, who discovered insulin, described
Saint’s exposition at a clinical meeting at the Institute as one of the best he had ever heard.
97
Ibid. ‘Introduction’.
98
E. G. Saint, ‘Influences on Careers in Medicine’, in Lefroy, 1998. op. cit. p.102-103.
94
97
postgraduate study, on miner’s nystagmus, a condition in which a change
in eye function was associated with a low level of lighting and
psychoneurosis.
John Ryle’s representation of social medicine as the
rational discipline relevant to corporate welfare conveys a somewhat bleak
humanism. In contrast, Saint and Spence show social medicine as a ‘vast
social enterprise’ in which empathy and objectivity combine in a personal
encounter between physician and the ‘sick man’.99
Macfarlane Burnet observed that, ‘I am certain that Saint’s work on these
topics (alcoholism and the medical significance of old age), … played a
large part in building up the continuing attitudes that have made him …
one of the chief spokesmen for social medicine in Australia’. Burnet’s
comment leaves open the question of the extent to which Victorian doctors
were open to Saint’s influence.100 Indeed Burnet himself, despite being an
avowed admirer of Sir James Spence, does not appear to have grasped the
point of social medicine as a discipline. Many years after Burnet met
Spence in 1948 when he attended the Sixth Australasian Medical Congress
in Perth, Burnet described Spence’s contribution to medicine in terms of
enabling medical practitioners to ‘teach more cogently and clearly about
illness at it shows in the family’.
The fact that Spence’s Thousand
Families Survey highlighted the effects of social and economic conditions
on the health of families is completely bypassed. Burnet then went on to
comment that Spence, were he still alive, would be impressed with the
extent to which the study of the family had been advanced through the
science of genetics.101
Burnet’s comments suggest that despite his interest in disease in its
‘natural’ environment, he was unable to see beyond the medical
99
Ibid. Giving this lecture, ‘Influences on Careers in Medicine’ in the 1960s, Saint noted
there would probably not be a place for physicians such as Spence because the ‘cast of his
mind was literary’ and possibly he would not have gained the four ‘A’ level passes in the
physical and biological sciences that were then required for entry to the medical course.
100
Burnet, op. cit. 1971, p.149. The brief interlude in the 1950s in Melbourne, when social
medicine received this much attention may be represented as a period in the shift in the
mode of production of medical knowledge, from hospital medicine to laboratory medicine
which took place in Australia long after it had occurred in Europe and America, N. Jewson,
‘The Disappearance of the Sick-man from Medical Cosmology, 1770-1870’, Sociology, vol
10, 1976, pp.225-244.
101
F. M. Burnet, The Thousand Families, A Tribute to Sir James Spence, A Lecture
Delivered at the University of Southhampton, 1975.
98
materialism that underpinned his interpretation of disease.
The
appointment of a social worker at the Clinical Research Unit as a means of
ensuring the incorporation of social factors in studies of disease, reflects
the secondary position accorded to the ‘social’, even taking into account
the lack of development in the social sciences in Australia at the time. The
problem of re-integrating the social and medical elements in disease in the
discipline of social medicine will be discussed in more detail in Chapter
Four. The departure of Eric Saint appears to have brought to an end any
local ventures in the discipline of social medicine although Burnet notes
that Ian Mackay, who followed Ian Wood as Director on his retirement in
the early 1960s, was also interested in chronic disease and its social
components. Perhaps it was this interest that led Mackay to cultivate an
association with near-by Mount Royal Hospital for the Aged and, in the
late 1970s, accept a position as a member of the committee of the Mount
Royal National Research Institute for Gerontology and Geriatric
Medicine.102 By the late 1950s however, work in the Clinical Research
Unit was more closely focused on the isolated, individual body in the
study of autoimmunity, a shift in focus that Burnet suggests may have
arisen from the conditions imposed by the National Health and Medical
Research Council, in agreeing to continue funding for the Clinical
Research Unit.103
Further indication of support for social medicine within the Melbourne
medical world may be found in the decision J.S. Collings made to come to
that city in 1953, to establish a form of general practice which exemplified
the practical content of social medicine. Trained in the medical school at
the University of Sydney, he believed, unjustifiably as it happened, that
the medical school at the University of Melbourne may have been more
receptive to his plans for education in general practice.104 Collings’ ideas
on the funding and organisation of general practice and medical education,
were originally stimulated by his experience in group general practice in
New Zealand. They were developed further through research into general
practice commissioned by the Rockefeller Foundation in the United States,
102
See chapter Six.
Burnet, op. cit. 1971, p.143-44.
104
R. Petchey, ‘ “A Man Ahead of His Time” – Joseph Silver Collings (1918-1971)’,
Proceedings 6th Biennial Conference of the Australian Society of the History of Medicine,
103
99
and in England, by Sir William Jameson, Chief Medical Officer at the
Ministry of Health. Jameson, as noted above was one of John Ryle’s
associates in promoting social medicine.105
Collings believed that social medicine was the central pursuit of the
general practitioner and he put his ideas into practice by establishing a
health centre where the contributions of a range of health professionals
were integrated into general practice.106 He chose a location in Richmond,
an inner-city, industrial suburb, which meant that the practice was directed
towards the needs of the elderly who suffered with multiple ailments and
younger adults with chronic illness and disability arising from accidental
injury. The centre provided the services of a full-time surgeon, nurse,
physiotherapists, psychologist and social worker, radiologist and visiting
consultants. Collings – the general practitioner – retained responsibility
for each patient and treatment was coordinated through regular meetings
between the practitioners involved in each case.
The Clarke-Hiskens
Medical Centre was a community health centre where ‘holistic and
humane primary care’ was provided with the aim of keeping people out of
hospital, and in the community, at home, and at work.107
Collings’ attempt to put into practice a form of medical service that
acknowledged the contribution social factors made to illness and disability
failed for lack of secure financial backing. In the prevailing climate of
medical work in Australia in the first half of the 1950s, with its emphasis
on curative medicine and personal services remunerated by fee-forservice, income from Collings’ patients, most of them too poor to
contribute much, provided an insufficient basis for the practice.
The
system of hospital and medical insurance introduced by the Menzies-Page
Occasional Papers in Australian Medical History, No 9, University of Sydney, 1999,
(pages unnumbered).
105
The two surveys were published as follows: J. S. Collings, ‘General Practice in England
today, A Reconnaissance’, Lancet, vol 1, 1950, pp.555-585, and J. S. Collings & D. M.
Clarke, ‘General Practice Today and Tomorrow’, New England Journal of Medicine, no
248, 1953, pp.141-145 and pp.183-194.
106
Obituary contributed by the psychologist, Oscar Oeser, Emeritus Professor of
Psychology at the University of Melbourne, MJA, vol 1, 1971, p.1347. For Oeser, see
Chapter Four.
107
Petchey, op. cit.
100
government in 1951 provided payment for pensioners through the
Pensioner Medical Service but this did not extend to specialist medical
services. Even insured patients would not have had cover for the services
of the social worker or physiotherapist. For patients eligible for Workers’
Compensation payments, the provision for rehabilitative treatment was
likely to be limited.108 The British Medical Association was prepared to
make an exception in relation to provision for people suffering from
tuberculosis, and accept the public provision of a range of services
directed towards prevention, cure and rehabilitation, but it was not
prepared to extend this support for ‘social medicine’ to the rest of the
population.
Roland Petchey attributes the failure of Collings’ project
directly to the refusal of the Victorian branch of the association to provide
support of any kind.109
There is no apparent connection between Eric Saint’s attempts to establish
the discipline of social medicine at the Clinical Research Unit (which
straddled the Royal Melbourne Hospital and the Walter and Eliza Hall
Institute) and Collings’ attempt to implement the practical content of
social medicine in Richmond. Nor is there any indication of a relationship
between either of these two ventures in social medicine and the
discussions that were underway in the early 1950s between John Lindell,
medical superintendent at the Royal Melbourne, and the committee of
management of Mount Royal Home and Hospital for the Aged, regarding
the development of a geriatric service. Nevertheless, these concurrent
projects suggest that social medicine did exert a broad, if subtle, influence
on medical thinking, at what may be described as the geographical and
intellectual centre of the Victorian medical community – the cluster of
institutions around the inner-city public hospitals, research institutes and
the medical school at the University.
Burnet’s reference to social
medicine in his history of the Hall Institute and the Clinical Research Unit,
108
After he was forced to close the practice, Collings found another avenue for developing
a holistic approach to medical care. When Leigh Wedlick resigned from his position as
Medical Officer for Physical Medicine at the Royal Melbourne Hospital, Collings took his
place. There Collings worked to convince medical colleagues of the merits of developing
the department as a rehabilitation setting under the direction of the doctor in charged of the
department. He resigned due to ill health in 1970, without having succeeded, and died
some time later at the age of 53. RMH Archives/Medical Superintendent’s File/ N-P/ 1958
and 1960.
109
Petchey, op. cit.
101
suggests the existence of an undercurrent of medical ideas in Melbourne in
which social medicine exerted a significant influence.
Apart from his position as medical superintendent at the Royal Melbourne
Hospital, there is little else to connect John Lindell with this undercurrent
of opinion. However, the inclusion of features of social medicine in the
medical services he established in his position as first medical Chairman
of the Hospitals and Charities Commission, a position he was appointed to
in 1953, suggests that he was, at least, sympathetic to the social medicine
perspective.110 Lindell, himself, did not theorise about his approach to
developing the State’s hospital system and he certainly showed no sign of
subscribing to the critique of the reductionist model that is implicit in
social medicine. His career was almost entirely administrative in its focus.
Originally trained as a pharmacist, he completed medical training in 1940
and following his year of residency, was appointed deputy medical
superintendent at the Royal Melbourne in 1942, and medical
superintendent a year later. He qualified for Fellowship of the Australian
Institute of Hospital Administration with a thesis entitled, ‘A Regional
Plan for Hospital Development’ and his principal task as Chairman at the
Commission was to implement a regional hospital service in Victoria.111
However, in addressing this task Lindell did support the implementation of
medical services based on a socio-medical model of illness and disability,
and so he may be associated with the social medicine orientation. These
services were the geriatric services located in the benevolent homes,
specifically for elderly patients at risk of needing custodial care, and two
small rehabilitation centres for younger patients injured in motor car or
accidents, or adults disabled by chronic conditions, who were not eligible
110
Annual Report Mount Royal, 1954. The report suggests that it was Lindell who
initiated moves to establish a geriatric services as a cooperative venture between the Royal
Melbourne and Mount Royal Hospital; see also Uhl, op. cit. p.178. Lindell’s appointment
as Chairman, and that of the other two commissioners, occurred under controversial
circumstances. W. P. Barry, Minister for Health in the Cain Labor government was
dissatisfied with C. L. McVilly’s interpretation of his role as Chairman, and McVilly was,
in the end, obliged to resign. McVilly may have been too ready to share the views of
community representatives as to the need for hospitals in their localities and, consequently,
involve the State government in expenditure beyond its control and capacity. The episode
is described from the point of view of a community attempting to build a hospital by H. W.
Nunn, A Most Ingenious Hospital, A History of Sandringham and District Memorial
Hospital, 1940-1990, Sandringham and District Memorial Hospital, Sandringham,
Victoria, 1990, pp.75-85.
111
Australian Dictionary of Biography, vol 14, 1940-1980, Melbourne University Press,
Carlton South, Victoria, p.97-98.
102
for the services provided by the Commonwealth Rehabilitation Service.112
These services had the potential to provide the practical content of social
medicine. In referring to the candidate for custodial care as ‘neglected’
within existing hospital services Lindell clearly acknowledged the defects
of medical services based solely on the provision of curative services. In
proposing the establishment of rehabilitation services he implicitly
supported another model of hospital service and medical work, a model in
which social and medical factors were combined in the contributions of a
‘team’ of health professionals under medical leadership, and one in which
the objective was the restoration of social function, not merely
physiological function.113 In practical terms, the proposed combination of
medical,
para-medical
and
welfare
provisions
in
geriatric
and
rehabilitative services, services whose objective was similar to Collings’
medical centre, meant introducing features of social medicine into the
management of the State’s hospital services.
Nevertheless, the organisation and funding of medical work that was
established in the national health service introduced in the early 1950s
ensured that the services Lindell promoted were unlikely to impinge on
private medical practice. It was only the poor, infirm aged, who ‘blocked’
beds in the public hospitals because they had nowhere else to go, who
were likely to come to the attention of a geriatric service. As in the 1920s,
in Cumpston’s plans for the Commonwealth Department of Health, ‘social
medicine’ was given a local interpretation in the establishment of geriatric
services which did not contest the fundamental biomedical reductionism
112
The Commonwealth Rehabilitation Service was established in 1941 following the
recommendation of the Joint Parliamentary Committee on Social Security. It linked the
Invalid Pension with the provision of rehabilitation treatment, putting into effect one of the
recommendations Cumpston had made twenty years previously, J. Tipping, Back on Their
Feet, A History of the Commonwealth Rehabilitation Service, Commonwealth of Australia,
1992.
113
The influence of social medicine in Victoria became clearer in the 1960s when Thomas
McKeown’s notion of a ‘balanced hospital community’ informed the development of
services at the Alfred Hospital and the new Monash Medical Centre. See chapter five.
McKeown, Professor of Social Medicine at Birmingham University followed Ryle as
leader in the discipline of social medicine, introducing the organisation of hospital services
into the social medicine perspective. The ‘balanced hospital community’ was promoted as
a means of linking hospital and community and incorporating all types of afflictions within
the one system of care and medical training. Lindell presided over the Victorian
developments so it may be assumed that he was sympathetic to the ideas that stimulated
them. In 1968, at the Third Australasian Medical Congress, Lindell spoke in the ‘Section
of Preventive and Social Medicine: Community Medicine’ on the topic of ‘The Hospital
and the Community’, promoting the establishment of a relationship between local hospitals
and their communities by providing facilities for general practitioners to treat their patients
in hospital, MJA, vol 2, Supplement, 1968, p.87.
103
that underpinned medical understanding of disease and disability. It was
an interpretation which ensured that, in the context in which medical work
was organised and funded in Victoria, it was ‘social medicine’ for the
poor, located outside the mainstream of medical work and linked into to
the administrative requirements for the efficient management of public
hospital beds.
A comparison between the introduction of geriatric services in
Queensland, which also occurred in the late 1950s, and Victoria highlights
the isolation of such services from mainstream hospital and medical
services from the very beginning. In Brisbane geriatric services were
introduced as part of the redevelopment of a chronic hospital, the
Diamantina Hospital, renamed the Princess Alexandra Hospital, under the
direction of a government department responsible not only for funding
hospital services but also providing them. The insertion of socio-medical
services into acute hospital services in this instance was directly related to
the integration of social medicine in the 1930s (albeit also a local
interpretation), by Sir Raphael Cilento into the activities of the Department
of Public Health and the Queensland medical school. Geriatric services
were therefore a coherent element in the overall provision of hospital
services, not, as in Victoria, a measure to ensure the efficient use of
services for the infirm aged.114
Social Medicine and Old Age Infirmity in 1950s Victoria
Lindell’s appointment as first medical Chairman of the Hospitals and
Charities Commission and the innovations he attempted, may be
interpreted as an instance of what Kewley describes as the ‘new attitudes
114
The introduction of geriatric services as part of an acute hospital took place under the
direction of Abraham Fryberg (later Sir Abraham) who succeeded Cilento as DirectorGeneral of Health and Medical Services in Queensland, and who carried on the ‘social
medicine’ emphasis established by Cilento, R. Patrick, A History of Health & Medicine in
Queensland 1824-1960, University of Queensland Press, St Lucia, Queensland, 1987,
p.111-112; P.G. Livingstone who was appointed to develop the geriatric unit at the
Princess Alexandra described its activities at the Geriatrics Conference in Melbourne in
1962, Geriatrics Conference 1956-1966, Hospitals and Charities Commission, Spring St
Melbourne, nd, pp.78-87; see also Lefroy, 1988, op. cit. p.60. A brief history of the
Diamantina Hospital may be found in, R. Wood, ‘The Diamantina Hospital’, People,
Places & Pestilence, ed M.J. Thearle, University Department of Child Health, Mater
Children’s Hospital, South Brisbane Australia, 1986. The wards of this hospital must have
resembled the infirmary wards of Mount Royal Home and Hospital for the Aged in
Melbourne. They accommodated many long-term patients suffering from ‘rheumatoid and
other arthritis, strokes, heart disease, … chronic bronchitis, kidney disease and senility’,
p.49.
104
and habits of thought’ that characterised the approach of governments to
the task of postwar reconstruction.115
From this point of view the
provision of health and welfare services entailed an equitable distribution
of services, provided by trained workers, based on a rational estimation of
need.
The Hospitals and Charities Commission (HCC) replaced the
Charities Board in 1948, a change implemented by a Labor government in
Victoria, seeking to emulate its centralising, policy driven federal
counterpart. The three members of the Commission were full-time paid
officials, one of whom had to be qualified in medical administration, it had
its own staff and a more extensive range of responsibilities than the Board.
These included advising the Minister of Health, coordinating and
regulating the location and building of hospitals, developing common
management practices in them and standardised levels of staffing and staff
training.116
However, these apparently new habits of thought were not so pervasive
that politicians in Victoria were inclined to depart from customary
practices.
The adoption of the structure of a semi-autonomous
Commission, and not a policy-making ministerial department to
administer the development of hospital services, reflected a continuation
of government by the control of finances rather than the active
implementation of policy.
The voluntary element in the provision of
hospital services in the State was preserved in the lack of authority given
to the Commission to enforce any particular line of action on committees
of management, despite the increasing role of the State and Federal
government in funding their activities. The Commission’s coordinating
task was confined to advising, and to structuring the subsidies it provided
so they were put to uses the Commission agreed were necessary. The
preservation of local customs such as these led The Age newspaper to
115
Kewley, op. cit. p.173ff. The work of the Joint Parliamentary Committee on Social
Security is an example of this rationalised and expert driven approach, although, as Shaver
notes, it was initially a ‘pragmatic device of wartime politics’, Shaver, op. cit. pp.411-431.
The replacement of the Charities Board by the Hospitals and Charities Commission was
recommended by the State Development Committee in Victoria, to provide a coordinating
authority to ‘plan and organise an orderly and needed extension of modern hospital
facilities throughout the State,’ Inall, op. cit.
116
Inall, op. cit; Victoria Year Book, 1949-50.
105
commend legislators of all parties for preserving the ‘spheres of activity
and service’ within the new body. 117
Around the time he was appointed Chairman of the Commission, Lindell,
visited Britain where he met Marjory Warren and Lionel Cosin, and W. F.
Anderson (later Sir William), a leader in establishing geriatric medicine in
Scotland.118
All three physicians were later to play a part in the
development of geriatric medicine in Victoria. While there may have been
a personal element to Lindell’s interest in ‘the aged’, there was also an
administrative imperative. Throughout the decades from the twenties to
the fifties the State government had gradually assumed greater
responsibility for funding the care of those of the chronically ill and
disabled in the State who lacked the resources to provide for themselves.
Elderly people were always prominent amongst this group simply because,
as Sidney Sax noted, chronic illness and disability is more characteristic of
advancing age.119 Nonetheless it is worth asking why the focus on the
elderly persisted in the ‘new postwar order’ when the attention of
governments and some medical practitioners shifted towards the
chronically ill and disabled.
After all the benevolent home wards
accommodated younger adults afflicted by incurable disease or by
disabling injury from work and motor car accidents. In 1948 and again in
1950, anonymous editorials in the Medical Journal of Australia made the
point that from an administrative point of view there was no need to
distinguish the needs of the aged from the rest of the long term sick.
Overall this group required services that were not included in the curative
services provided in the acute hospitals.
H. O. Lancaster posed the
problem in terms of dependency, a problem that all societies faced to
greater or lesser extent.120
117
B. McCoppin, ‘The Hospital System of Victoria: Administration and Policy Making’,
MA Thesis, La Trobe University, 1974, Chapter 2; A.F. Davies, ‘The Government of
Victoria’ in The Government of the Australian States, ed, S.R. Davies, Longmans, London,
1960, pp. 182-186. The preservation of the ‘service’ element in the provision of health and
welfare services reflected a governmental approach whereby policy-making was situated
within semi-autonomous entities, the role of the minister being to overseeing the
distribution of funding.
118
Personal communication from Mrs Marion Shaw, March, 1997. Warren’s ideas were
readily adapted by Scottish doctors and, it appears, more quickly introduced into medical
teaching in Scotland, Sir William Ferguson Anderson, ‘Geriatrics’, Improving the Common
Weal, Aspects of Scottish Health Services 1900-1984, ed G. McLachlan, Published by
Edinburgh University Press for the Nuffield Provincial Hospitals Trust Edinburgh, 1987.
119
Sax, 1967, op. cit.
120
H. O. Lancaster, ‘Aging in the Australian Population’, MJA, vol 2, 1954, pp.548-553.
106
It needs to be clear, at this point in the early 1950s, that what is under
discussion here is the establishment of a form of civilian hospital service
directed towards the needs of the chronically ill and disabled who would
otherwise have been admitted to institutional care.
The Repatriation
Department hospitals had, since the First World War, provided services
directed towards returning injured service personnel back to civilian life at
whatever level of independence was possible. A number of voluntary
bodies had established rehabilitative services for individuals with specific
disabilities and in 1948 legislation was passed to establish the
Commonwealth Rehabilitation Service to provide similar services for
injured and disabled civilians of working age.121
Certain elements of a rehabilitation service were in fact provided at some
Melbourne Hospitals. The Repatriation General Hospital, first at Caulfield
and then at Heidelberg, had always combined medical treatment and
rehabilitation.122 When the Alfred Hospital took over convalescent wards
at
Caulfield
Hospital,
social
workers
and
occupational
and
physiotherapists provided treatment directed towards restoring disabled
patients to the community. The physiotherapy department at the Royal
Melbourne Hospital and no doubt at the other public hospitals also,
provided a range of treatments by therapists with the aim of restoring
function, under the direction of hospital consultants.123 At the Austin
hospital plans were underway for developing rehabilitation services for
patients paralysed as a result of spinal injury.124 The Children’s Hospital
121
Kewley, op. cit. p.326ff summarises rehabilitative services funded by the
Commonwealth for, in the beginning, applicants for the Invalid Pension and sickness and
unemployment benefits and sufferers from tuberculosis. For a survey of services provided
by voluntary groups in the late 1950s see, F.H. Rowe, ‘Rehabilitation in Australia’,
International Labour Review, vol LXXVII, no 5, 1958, pp.463; and for a longer account of
the Commonwealth Rehabilitation Services see Tipping, op. cit.
122
Ford, 1996, op. cit. and G. Hunter-Payne, Proper Care, Heidelberg Repatriation
Hospital, 1940s –1990s, Allen & Unwin, 1994.
123
Annual Reports, Alfred Hospital early 1950s. The development of occupational therapy
as a profession is described in B. Cameron, The Work of Our Hands, A History of the
Occupational Therapy School of Victoria, Gippsland Times Commercial Printing, Sale,
Victoria, nd, p.55-56; for social work see Laurence, op. cit.
124
G. G. Burniston, ‘Rehabilitation of the Disabled, with Particular reference to its Present
Progress in Australia’, MJA, vol 1, 1956, p.480. Dr Burniston gained his experience in
rehabilitation during war service in Britain. In 1956 he was Principal Medical Officer in
the Commonwealth Department of Social Services and in 1959, elected President of the
Australian Association of Physical Medicine and Rehabilitation. Howard Rusk, a
prominent American medical rehabilitationist, visited the Austin Hospital in 1956 to advise
on the development of rehabilitation services for spinal injuries, Gault & Lucas, op. cit.
p.139. See also footnote 131 in this Chapter.
107
had established an annexe, first at Hampton and then at Frankston, to
provide extensive services, including schooling, for children who spent
long periods in hospital.125
Had John Lindell been so disposed, he could have approached the
provision of specific hospital services for the chronically ill and disabled
in terms of an overall strategy to manage dependency. In New South
Wales, at the Royal Newcastle Hospital, the medical superintendent, C. M.
McCaffrey and Richard Gibson, a physician at the hospital, had
established what McCaffrey described as a second level of hospital
services in the provision of rehabilitative treatment and domiciliary
services. McCaffrey and Gibson aimed to reduce the need for custodial
care by providing services to support the chronically ill and disabled in
their own homes.126 Elsewhere in that state, a small group of medical
practitioners were in the early stages of promoting a medical role in the
provision
of
rehabilitative
services
to
hospital
patients,
whose
independence was limited by incurable conditions, immediately following
treatment during the acute phase of illness. In the mid 1940s doctors
interested in the field which became known as medical rehabilitation,
formed the Australian Association of Physical Medicine, five years later
‘Rehabilitation’ was added to the title.127 In 1955 Naomi Wing, convenor
of a committee commissioned to establish a rehabilitation centre at the
Royal South Sydney Hospital, addressed the New South Wales Branch of
the British Medical Association. The rehabilitationist’s field of work, she
125
For the Children’s Hospital see Yule, op. cit, Chapter 13.
McCaffrey, accompanied by Richard Gibson, described the service in these terms at the
Geriatrics Conference in 1961, making the point that he saw no need to distinguish
rehabilitation services according to the age of the patient. ‘Geriatric Care in the Newcastle
Hospital’, Geriatrics Conference 1956-1966, op. cit, pp.24-26. The service, established in
1954, was only given the title ‘Geriatric Service’ some years later. Grace Parbery, the
social worker who worked with Gibson from the beginning, said, some years later, ‘there
was no preconceived idea that they should work in Geriatrics. It was the result of natural
progress, ‘They looked at problems as they developed and developed a programme as they
went along’, M. Henry, ‘Pioneering in Geriatrics: The Newcastle Experience’, in Patients
& Practitioners & Techniques, Second National Conference on Medicine and Health in
Australia, 1984, eds A.H. Attwood & R.W. Home, Medical History Unit & Department of
History and Philosophy of Science, University of Melbourne, Parkville, Victoria, 1985,
p.56.
127
L. T. Wedlick, ‘Physical Medicine and its Place in the Rehabilitation Programme’,
MJA, vol 1, 1966, p.514. In the 1950s Australian doctors still had to travel to England to
complete a Diploma in Physical Medicine but in the 1960s the Australian Society
supervised its own Diploma program in cooperation with the Postgraduate Federation. For
the role of the Federation in promoting postgraduate medical training see, A.M. McIntosh,
‘The Development of Post-Graduate Training in Medicine in Australia’, MJA, vol 1, 1951,
pp28-32.
126
108
said, was found in the ‘increasing numbers of aged and permanently
disabled persons’ who had suffered illness or injury to the extent they
were unable to resume life in the community.128
Leigh Wedlick, the medical officer in charge of the physiotherapy
department at the Royal Melbourne Hospital was the principal spokesman
for medical rehabilitation in Melbourne.129 He had hoped initially, to
develop the department as a domain of physical medicine, with the
addition of rehabilitation treatment provided under special medical
supervision, but his ambition was frustrated by lack of support from his
colleagues. The department continued to function as provider of services
that were, principally, ordered by the consultants in charge of the units
where patients were admitted.130 In the early 1960s, after retiring from his
position at the Royal Melbourne he established one of the two small
rehabilitation hospitals that John Lindell promoted but, overall in Victoria,
medical interest in this aspect of the healing process was limited. The
impetus to establish a medical role in the provision of rehabilitative
services came principally from the Hospitals and Charities Commission
and the few doctors who were interested were, until the early 1970s, only
able to find part-time and honorary positions in these two small
rehabilitation hospitals.131
There was a degree of uncertainty in the early 1950s about the theoretical
justification for the role of the medical rehabilitationist. C. M. McCaffrey
believed that the only justification for separate rehabilitation units within a
hospital was the development of new ideas, otherwise restorative therapy
should be incorporated into routine hospital services.
Naomi Wing
concurred, citing Dr Howard Rusk, the American physician who promoted
rehabilitation as a natural extension of existing hospital services under
128
M. N. Wing, ‘Medical Rehabilitation’, MJA, vol 1, 1955, pp.705-714.
L. T. Wedlick, 1966, op. cit.
130
L. T. Wedlick, A Doctor’s Life (Odyssey), nd, held in RMH Archives.
131
The first steps towards establishing a rehabilitation hospital were taken in the mid 1940s
when the committee of management of the Melbourne Convalescent Home for Men
approached C.L. McVilly, then Chairman of the Hospitals and Charities Commission, to
inquire whether their property could be used for this purpose. A committee was formed to
consider the proposal. McVilly wanted to interest other parties in the project, such as the
Red Cross, and Colonel R. D. Galbraith had agreed to join the committee. VPRS
4523/P1/138/1341. Galbraith, a British physician who came to Australian in 1923, became
medical superintendent of the Frankston Orthopaedic Section of the Children’s Hospital in
1934. During the war he supervised the fitting out and operation of hospital ships and in
129
109
special medical control.132 Leigh Wedlick wrote in 1966 that there was
nothing new about rehabilitation, ‘it has been practised by every doctor
who sees his patient over a heart attack and supervises his convalescence
till he can be graded back to work’, thus transporting the general
practitioner’s role into the hospital environment.133 A similar point was
made by a West Australian advocate of medical rehabilitation when he
said, that the medical rehabilitationist was undertaking a duty to those
patients who lacked a general practitioner.134
G. G. Burniston, who
transferred his experience in medical rehabilitation in Air Force hospitals,
to the civilian field as Chief Medical Authority for the Commonwealth
Rehabilitation Service in Melbourne, provided a somewhat self-serving
justification for a medical role in rehabilitation. Therapists and nursing
staff were limited in their capacity to understand the ‘medical component
of disability’, and even though their knowledge of the social aspects of
disability exceeded that of medical practitioners, they could not be
expected to communicate as equals with consultants and general
practitioners.135
In the postwar shift of medical attention to conditions previously excluded
from the field of hospital work, the medical advocates of a socio-medical
model of hospital service directed towards the ‘social’ goal of returning
the sick and disabled to an active place in the community, were not
sophisticated in justifying a claim to specialist expertise.136 However in
answering the question of why John Lindell chose to introduce age-related
1945 was appointed Chief Rehabilitation Officer for the Australian Army, he then was
appointed Commonwealth Coordinator of Rehabilitation, Yule, op. cit. p.218.
132
Howard Rusk was one of the few American physicians who transferred their interest in
physical medicine and rehabilitation out of the armed forces hospitals, to the general
community, Gritzer & Arluke, op. cit. pp.91-94. Rehabilitation medicine was associated
with philanthropic institutions such as the Kabat-Kaiser Institute in California and the
Bellevue Hospital in New York. It was after her experience of rehabilitative treatment that
the Newcastle nurse suffering from multiple sclerosis, took the first steps that led
ultimately to the establishment of rehabilitative services at the Newcastle Hospital by Drs
C. McCaffrey and Richard Gibson, Henry op. cit.
133
Wedlick, op. cit. 1966, p.515.
134
C. Anderson, ‘The Scope of Rehabilitation in Australia, With a Suggestion for the
Future’, MJA, vol 1, 1955, p.161.
135
G. G. Burniston, ‘Rehabilitation in Australia’, Postgraduate Medicine, vol 25, no 1,
1959, pp.49-55.
136
Unlike the British orthopaedic surgeons who wanted to align their specialist skills with
the establishment of independent trauma/accident centres, ‘in the hope that (they) … might
improve (their) financial future and professional position’, and who consequently were
pushed to a degree of introspection they may not otherwise have attempted. ‘ “ Real
rehabilitation is getting into the mind of a man, finding out what his anxiety is and his
worry and fear, and removing them”’, Cooter, op. cit. p.210-211.
110
rehabilitation services rather than the general medical rehabilitation
proposed by members of the Association for Physical Medicine and
Rehabilitation, theoretical justification does not even enter the picture.
The specialist consultants who held sway over the services provided in the
public hospitals in Victoria, were simply not interested in the introduction
of a medical role in providing socio-medical services to supplement acute
care services. They were, it seems, satisfied to leave the provision of such
services to therapists and social workers who were ultimately answerable
to these specialist consultants.
Lindell’s decision, as Chairman of the HCC, to introduce age-related
rehabilitation services was formed in a context where attention was
directed by local circumstances towards the aged. Elderly patients were
prominent amongst those patients who were seen as ‘blocking’ acute
hospital beds, who could not be discharged because they had nowhere to
go.137 In addition, there was a focus on the infirm aged in the community
where there appears to have been a perception that accommodation for this
group was inadequate. General practitioners found it difficult to find
places for infirm elderly patients, ‘indigent, enfeebled old folk, some
bedridden, most of them dirty and frequently verminous, some receiving
charity with a grudging hand, others receiving none at all’.138 Others
watched their younger women patients attempt to provide care for an
infirm parent and a growing family in houses ill-suited to such diverse and
often conflicting needs.139
One woman in this position wrote to the
137
Early in the 1940s the annual reports of the medical superintendent of St Vincent’s
Hospital noted that the average length of stay of patients was increasing and that patients
‘appeared to be more elderly than before’, Egan, op. cit. p.178. The Annual Report for the
Royal Melbourne Hospital for 1949-50 noted that one in ten of the hospital’s patients could
not be discharged because of destitution and infirmity. While the number of claimants for
custodial care may have increased, the supply of beds for custodial care had diminished
according to Hutchinson who notes that hospital beds previously available for long-term
care had been taken over for acute care. The example of the changes introduced at the
Austin Hospital from the late 1920s indicates how this change may have come about. In
addition, the manager of Mount Royal Home and Hospital for the Aged was quoted in The
Age in the 1940s, to the effect that no infirmary beds had been added to Victoria’s stock in
60 years, VPRS 4523/P1/260/2242. Beds at the After Care Hospital may also have
reverted to their original purpose, for mothers and babies, during the rise in birthrates in
postwar Victoria, reducing those available for the infirm aged.
138
MJA, vol 2, 1952, p.490.
139
The problems experienced by families arose not only from the lack of accommodation
for the infirm aged but possibly also from an overall shortage of housing arising from low
levels of building during the Depression. Wilfred Prest questioned the degree of
overcrowding in Melbourne during wartime. He concluded his survey of housing in
Melbourne at this time, with the comment that while there was a degree of overcrowding,
especially in poorer suburbs, ‘popular ideas of dwellings being crammed to capacity with
111
Secretary of the Charities Board, Mr. McVilly, in 1944, asking for
assistance in finding a place for her 85 year-old father-in-law. His three
daughters were unable to care for him, she wrote, ‘one is in a delicate state
of health, one works in service and one is mental’. She herself had high
blood pressure and in addition to her father-in-law, who had to have
everything done for him, the household included her married daughter and
husband, with a baby on the way. She made her request on ‘doctor’s
orders’ because she simply had too much to do.140
Nurses in the
Melbourne District Nursing Society, set up originally to provide nursing
care for mothers and babies, found, by the early fifties, the focus of their
work had shifted to the care of infirm old people, who often lived in very
poor circumstances.141 The provision of hospital beds for the chronically
sick was noted as one of the most urgent needs by Hutchinson in the
recommendations made following his survey of ‘old people’ in Victoria.142
Many of the problems faced by Victorians in providing suitable care for
infirm old people arose from the restrictions imposed on the provision of
community facilities such as housing and hospitals while the country was
at war. Their plight became more noticeable by the early fifties when
higher levels of employment and new housing projects diminished signs of
poverty in other sections of the Victorian population. In the late 1940s,
the subsidies for housing introduced by the Chifley government promised
to alleviate the problem of housing the well aged. By rights, the State
government department most suited to take on the task of facilitating the
distribution of this funding would have been the Housing Commission.
However, the Chairman of the Hospitals and Charities Commission at the
time, C. L. McVilly, gained the approval of the Minister for Health, for the
HCC to undertake the role. In addition to supervising the provision of
infirmary accommodation in the benevolent institutions, the Commission
then had the responsibility of registering charities that wished to develop
housing for the ‘well’ aged.143 The separate matters of providing suitable
struggling humanity’ were exaggerated, W. Prest, ‘Housing, Income, and Saving in WarTime, A Local Survey’, Department of Economics, University of Melbourne, 1952, p.147.
140
VPRS 4523/P1/115/1120.
141
Rosenthal, op. cit. p.157.
142
Hutchinson, op. cit. p.157.
143
When the Chifley government promised subsidies for housing that could be used by
communities to erect accommodation for the elderly, Mr. McVilly, proposed that the
authority to supervise these subsidies should be given to the Hospitals and Charities
Commission instead of the Housing Commission, a more appropriate body. Possibly he
112
accommodation for elderly Victorians, and the provision of medical and
nursing care for the sick and infirm amongst them, were thus combined in
the activities of the Hospitals and Charities Commission.
The emphasis on ‘the aged’ in the operation of the Commission, combined
with the custom in Victoria, of the provision of hospital and welfare
services by charitable bodies, although heavily subsidised by the State
government, ensured that in Lindell’s view of the problems posed by
demands for infirmary accommodation, age occupied a prominent place.
An existing disposition in the Victorian community to focus on the aged in
charitable work was, in the late 1940s and early 1950s, reinforced by the
influx of literature from the United States and Britain where, in the 1940s,
the topic ‘the problem of the aged’ had emerged as a focus of concern for
policy makers and social scientists.144 In these societies the ageing of the
population was more marked than in Australia where it was obscured by
growing numbers of younger adults and children through immigration and
a rising birthrate.
Shortage of infirmary accommodation was only one aspect of a run-down
hospital system, impoverished during the Depression, neglected during
wartime and limited in capacity by the reliance on the voluntary sector to
provide services according to local perceptions of need.
As the
Commission confronted the situation it did so in conditions of financial
stringency particular to Victoria in the early 1950s.145
In these
circumstances the plans put forward by the Commission, while
highlighting
fresh
lines
of
development
in
regionalisation
and
rationalisation of services and staff training, also emphasised economies
through the use of existing institutions wherever possible. In his report to
the Parliament for the year 1953-54, Lindell noted two priorities in the
hoped these subsidies could be diverted to provide infirmary accommodation. It was in
this manner that the Commission became responsible for coordinating housing for the well
aged in addition to subsidising the care of the infirm. VPRS 4523/P2/947/72/1.
144
The establishment of the Old People’s Welfare Council in the early fifties, by the
National Council of Women, was a direct imitation of what had been done in Britain some
years earlier and the immediate objectives of the Council were also modelled on the British
experience, A. Norris, Champions of the Impossible, A History of the National Council of
Women, 1902-1977, The Hawthorne Press, Melbourne, 1978, pp.95-98.
145
Davies, 1960, op. cit. p. 235. When the states ceded their power to levy income tax to
the Commonwealth in the early 1940s, the level of reimbursement was based on existing
expenditure. Davies notes that the seven years of careful spending of the Dunstan Country
Party government meant that later, Victoria had to ‘pay dearly in lowered reimbursement
113
Commission’s forthcoming activities: the provision of more general
hospital beds and the provision of beds for patients excluded from those
institutions – the chronically ill and the convalescent.146
The phrase
‘within the limits of funds available’ set the scene for the implementation
of Lindell’s plans and ensured the existing emphasis on the special
provision for the aged would continue because it promised to provide the
cheapest alternative.147
Lindell announced his plans for tackling the ‘problem of the aged’ at a
meeting in 1954, with representatives of Mount Royal and the Queen
Elizabeth Home at Ballarat. He began with the announcement that a
special Geriatrics Division had been set up within the Commission with
the responsibility for supervising the organisation and provision of
services for the aged. Elizabeth Johnson, a nurse, had been appointed
divisional officer, and she had already begun her duties with a survey of
accommodation for the elderly in the metropolitan area.148 The centrepoint of these services was to be a Geriatric Unit located in each of the
benevolent homes throughout the State. From here, under the direction of
a medical practitioner appointed as geriatrician, patients from the general
hospitals and the community, who would otherwise be candidates for
custodial care, were to be classified according to their degree of
dependence.
The process of classification was to be linked to the
provision of restorative treatment to make the most of any individual’s
capacity for independence in the tasks of everyday living, followed by
discharge to whatever form of accommodation best suited his or her
needs.149 The objective Lindell said, was to set up a ‘chain of care’ for old
grants’ from the Commonwealth as it struggled to provide for a steadily increasing postwar
population.
146
Annual Report Hospitals and Charities Commission, also VPRS 6345/64/X1091/7.
147
Notes of a meeting between John Lindell when he was medical superintendent at the
Royal Melbourne Hospital, and the superintendent of Mount Royal, Colonel Robert Elliott,
give the cost of a bed in the proposed geriatric unit as between ten and fifteen pounds per
patient, per week. At the Royal Melbourne the bed cost was thirty pounds per week and in
the existing accommodation at Mount Royal, approximately five pounds per week,
16/6/53, JHL:IC, from Personal Papers Dr John Shepherd.
148
Marion Shaw, a registered nurse, who was appointed officer in the Geriatric Division in
1972, reported that one of the Division’s aims was to assist families seeking
accommodation for ‘people in need’ and that Division staff were chosen carefully for this
‘special role’, personal communication, M. Shaw, March, 1997.
149
VPRS 4523/P2/947/72/2. Annual Report Hospitals and Charities Commission 1955,
1956.
114
people throughout a specified region – a chain extending from the general
hospitals, through the geriatric unit, to hostels and homes in the
community, and into the homes of individuals through the provision of
domiciliary services:
From this central body there would be feelers extending out into
every home. It should be possible to docket every old person in the
region … to know their condition.150
Conclusion
When the medical ‘gaze’ in Victoria finally turned to the ‘unkempt’
garden of the infirmary wards of the benevolent institutions in the 1950s, it
was the ‘gaze’ of the medical administrator, not the clinician. In this
respect the introduction of geriatric services, and the role of the
geriatrician, differed from the hospital-based services in Britain that
otherwise provided the model for geriatric services in Victoria. In Britain,
physicians like Marjory Warren, Lionel Cosins and W.F. Anderson, had
taken a clinical view; that is, in addressing the needs of candidates for
custodial care, they focused on the medical activity of diagnosis in an
acute hospital setting as a means of imposing order on the demand for
custodial care. They were also concerned to make the most efficient use
of hospital beds, but their concern took the form of establishing a special
hospital department for the infirm aged. In Victoria the geriatric service
was to consist of the provision of restorative care and the supervision of
patients within a network of welfare services. It was benevolent care that
was to be transformed, not acute medical services.
When John Lindell spoke of addressing the neglect of this group of
patients he did not refer to neglect in the provision of acute medical
services, but neglect in the sense that an assumption was made that for
patients in whom the capacity for independent social life was diminished,
bed-care was the best provision. From this perspective the ‘unkemptness’
of the infirmary wards in the benevolent homes lay in the indiscriminate
use of long-term care. Indiscriminate in humanitarian terms so that the
lives of some individuals were thoughtlessly curtailed, and indiscriminate
in the use of scarce public funds.
150
Lindell, operating within a state
VPRS 4523/P2/947/72/2.
115
government authority that had limited power to determine what services
were provided in the acute hospitals it subsidised, and limited financial
resources, was in no position to ‘see’ the disorder in long-term care in the
same light as his English colleagues.
There is, however, no indication that he in fact did see the situation in
terms of deficient medical care. He proposed a socio-medical model of
service, not as a critique of the predominant biochemical model, but as an
appendage to enable it to function more efficiently. The advocates of
medical rehabilitation were no more sophisticated in theorising their role.
The word ‘social’ referred to provisions made for the poor through
publicly funded medical intervention, an intervention that was, as in the
case of Cumpston’s plans for the Commonwealth Department of Health,
based on an underlying biochemical reductionism.
Intellectually and
organisationally, social medicine in Victoria in the 1950s was confined to
a marginal area where the proximity to welfare, salaried medical work,
and the association with poverty and decrepitude, ensured its exclusion
from mainstream medical work.
116
CHAPTER 3
BUREAUCRACY, PHILANTHROPY AND MEDICAL
INNOVATION
Introduction
The previous chapter showed that in Victoria, ‘social medicine’ was
adapted to address the problems posed in the management of publicly
funded hospitals by a demand for custodial care. This chapter examines
how the introduction of this particularly local interpretation of social
medicine opened up the possibility for doctors to develop a role defined in
relation to old age infirmity. The provision of care for infirm old people in
the public institutions was transformed with the introduction of the role of
‘geriatrician’. It was however, a transformation that introduced a medical
dimension into the general activity of providing institutional care. The
charity model of care was not displaced by a medical model of service
based on specialist medical knowledge; on the contrary it was enhanced by
the addition of expertise in the provision of care and the management of
institutions and an extension of both state and federal government funding
of long-term care. Overall, the attempt to redefine the object of charitable
care as the recipient of special medical services was unsuccessful.
Nonetheless this narrative of frustration and disappointed does provide
insight into the processes underpinning the emergence of new medical
roles.
Not the least of these is that in a clash between medical and
community ideas about sickness, the medical perspective will not
inevitably dominate.
When Graeme Larkins, appointed as the first geriatrician in Victoria in the
late 1950s, gave his first public address on the topic of ‘geriatrics’, he
began by saying there was nothing new about the methods that were to be
used in the new geriatric unit at Mount Royal.1 The restorative treatment
provided in this novel hospital setting was new only in the sense that it
was to be used for old people whose disabling conditions had previously
been treated by putting the afflicted person to bed.
1
G. Larkins, ‘Modern Methods of Rehabilitation’, Geriatrics Conference, 1956, in
Geriatrics Conference, 1956-1966, op. cit, pp.23-26.
116
The introduction of ‘geriatric services’ into the benevolent institutions in
the late 1950s and early 1960s was a collaborative effort involving the
Hospitals and Charities Commission - the State government agency
responsible for overseeing the distribution of government funding for
hospital services - the voluntary committees of management of the
benevolent institutions, and a small number of medical practitioners who
were willing to take on a role removed from the mainstream of medical
practice. Unlike the English physicians who provided the model for the
geriatric service, Victorian doctors did not play a leading part in
developing geriatric services.
Their actions were secondary to the
initiatives taken by the Commission and the committees of management.
In introducing the position of ‘geriatrician’, the Hospitals and Charities
Commission took a more interventionist stance in the operations of the
benevolent institutions as they were transformed into Geriatric Hospitals.
This can be seen in the control the Commission exerted over the
reclassification of the institutions and the conditions of employment of
medical practitioners as ‘geriatricians’, a title introduced by the
Commission to describe the medical officers employed to develop
geriatric services in the benevolent homes. At the time, ‘geriatrician’ was
not in common use, even in England by the physicians who developed the
model used by the Commission.
However, in keeping with customary
practices in Victoria, whereby government funded hospital and welfare
services were provided by voluntary community based groups, the role of
geriatrician was shaped as much by community expectations of what
provision was suitable for infirm old people as by the medical view that
underpinned geriatric services.
Geriatric Services – A Community Enterprise
In November 1954, John Lindell outlined his plans for introducing special
hospital and medical services for the infirm aged and the chronically ill,
one of the most pressing problems he faced in developing a regional
system of hospital services throughout Victoria. The first step he took was
to establish a Geriatric Division within the Commission, to oversee and
coordinate activities in the provision of age-related services throughout the
117
state.2
The second step was to provide funding to the benevolent
institutions to assist them in establishing geriatric units where restorative
treatment for old people at risk of needing custodial care would be
provided. Geriatric services had a dual purpose. They combined an
humanitarian provision of rehabilitative services for old people whose
independence was compromised by increasing age or chronic illness, with
the administrative objective of limiting future demand for publicly funded
long-term care. The purpose of the geriatric units has been outlined in the
previous chapter; they were to be the headquarters of a medical officer,
classified according to qualifications and experience, as specialist
geriatrician or geriatric medical officer.3
The decision to establish geriatric services in the large benevolent homes
- Mount Royal, at Parkville, Queen Elizabeth at Ballarat, Bendigo
Benevolent Home, the Ovens and Murray Home at Beechworth, and
Cheltenham Old People’s Home – was supported by the voluntary
committees of management that ran the institutions. It was accompanied
by funding, badly needed for some years, to improve the facilities of the
institutions, and the addition of special medical services promised to
enlarge their already extensive work in providing care for the aged and
infirm. The role of the geriatrician was established in conditions where
the two principal sponsors – the Hospitals and Charities Commission and
the committees of management of the benevolent institutions – were
united in the aim of improving provisions for the infirm aged. The union
of state bureaucracy and community-based groups in this enterprise was in
keeping with the customary approach to the provision of hospital services
in Victoria. However, such unanimity and apparent clarity of purpose
disguised the complexity of the territory that these founding geriatricians
had to negotiate in order to establish a medical model of service in place
of the existing charity model of care. Their activities were enmeshed in
the ambiguities surrounding the operations of the Hospitals and Charities
Commission and entrenched community ideas about what constituted
2
Annual Report Hospitals and Charities Commission, 1953-54, VPRS 4523/P2/72/1/947.
The Commission, as a consequence of the ‘empire’ building of C. L. McVilly, who Lindell
replaced as Chairman, also had administrative responsibility for overseeing the provision
of services for the ‘well’ aged, see Chapter Two.
3
These proposals were outlined in the Annual Report of the Hospitals and Charities
Commission for 1956. The details of this classification of hospital medical officer are
118
appropriate provision for the infirm aged. Mainstream medicine was one
area quite free from ambiguity. Lack of interest in the project in this
quarter was clear from the beginning.
A preliminary survey of the complexities of the bureaucratic and
philanthropic environment that confronted the first ‘geriatricians’ in
Victoria will assist in clarifying the factors that finally shaped the role,
beginning with the establishment of the Geriatrics Division. The Division
was intended to oversee and coordinate all activities throughout the state
in the provision of services for the aged.4 In view of the central role the
geriatric service was to play in these services, and that it was to be
primarily a medical setting, it is curious that a nurse, Elizabeth Johnson,
was put in charge of the Division.5 Given the position of nurses in the
medical hierarchy it is difficult to understand how a nurse could provide
the administrative support for a medical service. In fact, her first task,
surveying the accommodation for the aged that was available around
Melbourne, suggests that Lindell did not envisage the Division playing a
direct role in relation to the work of geriatricians.
The other states also began to introduce a special medical role in relation
to the management of old age infirmity at this time. Victoria is notable in
these ventures, however, for the lack of any clearly demarcated medical
responsibility in the administrative structure overseeing the field in which
the ‘geriatrician’ was situated.
First in Queensland, then New South
Wales and Western Australia and later, South Australia, the position of
Director of Geriatrics was created within the relevant government
department, and a medical practitioner appointed.6
It may have been
outlined in the Hospitals and Charities Commission Circular No 22/1961, VPRS
4523/P2/961/183-1.
4
Annual Report Hospitals and Charities Commission, 1953-54.
5
Johnson was the first of a sequence of nurses appointed as officers in the Geriatrics
Division, VPRS 4523/P2/947/71/2. She completed general nursing training at the
Children’s Hospital, then additional certificates in midwifery and infant welfare, joining
the Hospitals and Charities Commission in 1951, Your Hospitals, vol 1, no 4. Her
successors over the period covered in this thesis, up to the late seventies, all registered
nurses, were, Doris Watkins, Rae Tabbner, and Marion Shaw. The early emphasis on
accommodation is confirmed in the report Doris Watkins made of an overseas study tour in
1969. Her principal recommendation was the provision of hostel accommodation for the
frail aged, distinguishing the needs of this group from those who needed long-term medical
and nursing care. There was no mention however, of a medical role in making this
distinction, an omission that highlights the separation between the Geriatrics Division and
the doctors who were establishing the role of geriatrician.
6
Queensland took this step in the late 1950s when P. G. Livingstone, the physician
appointed to establish a geriatric service at the Princess Alexandra Hospital, was also
119
Victoria’s straitened financial circumstances during the 1950s and 1960s
that accounted for the failure to appoint a medical practitioner in charge of
the Geriatrics Division.7
Certainly Lindell referred to the limits thus
imposed on his activities in his first report as Chairman of the Commission
in the comment that use would be made of existing facilities rather than
the erection of new buildings.8 It was cheaper to pay a nurse as Officer in
the Geriatrics Division because nurses’ salaries in these bureaucratic
positions continued to be paid under the trained nurses’ award.9
Even in relation to the institutions the Geriatric Division was to oversee,
Johnson had limited power.
This was made clear soon after her
appointment in an interview with a medical officer employed at Larundel
Mental Hospital.
He, hopeful perhaps that the establishment of the
Geriatrics Division augured a new era in the care of infirm old people, had
approached Johnson informally to enlist her aid in transferring those
elderly patients who did not need the services provided in a mental
hospital, to a benevolent home. The transfer of patients in this category
was a constant preoccupation of mental health authority doctors since, at
least, the 1920s.10 Her reply that she had no power to compel the homes to
admit any particular patient, and that she was unable to assist him, left no
doubt that little had changed in the ‘new’ order. It also conveys the
impression that the role of nurse as the follower of medical orders in the
hospital, had been transferred to this bureaucratic setting in the
appointed Director of Geriatrics within the Department of Health and Home Affairs,
Geriatrics Conference 1962, p.78-87, Geriatrics Conference 1956-1966, op. cit. In New
South Wales, following the recommendations of a committee set up to inquire into the
provision of hospital and welfare services for the infirm aged, a Director of Geriatrics was
appointed in the early 1960s. John Lindell was a member of the committee that made this
recommendation. The development of rehabilitation services took place in hospitals under
the control of the state government, Geriatrics Conference, 1962, Geriatrics Conference
1956-1966, op. cit.; ‘Care of the Aged and Chronically Ill’, MJA, vol 2, 1960, p.587-588.
Also, in the early to mid-sixties, R. B. Lefroy, a physician at the Royal Perth Hospital gave
up his position to take on the appointment of Director of Geriatrics and the commission to
develop a geriatric service at the Sir Charles Gairdner Hospital, Geriatrics Conference
1964, Geriatrics Conference 1956-1966, op. cit, pp.65-70. A reference in The Age 13/6/50
suggests a committee similar to that established in New South Wales may have also been
set up in Victoria. This brief note refers to a committee appointed by the state government
two years previously to investigate the problem of accommodating infirm old people, and
asks what has happened to this committee and its investigations.
7
A.F. Davies, 1960, op. cit. p.235.
8
Annual Report Hospitals and Charities Commission 1953-54.
9
McCoppin, 1974, op. cit. pp.50-52.
10
See Chapter Two.
120
relationship between the officer in the Division of Geriatrics and the
Chairman of the Commission, Dr John Lindell.11
Possibly it was considered that Lindell would provide the medical
leadership required to establish this new medical role. If so this would
have been in keeping with the conditions in which the Commission
operated. The work of the Commission was, fundamentally, to distribute
public funding for hospital services. It had no power to compel any of the
committees of management of the institutions it oversaw to take any
particular course of action, relying on advising, negotiation and the
structure of its subsidies to achieve any particular policy objective.12 The
establishment of geriatric services was then a collaborative venture in
which the funding body, the Commission, the public, in the form of
committees of management, and medical practitioners, the ‘experts’,
cooperated to provide a ‘community’ service.13
The Commission
prescribed conditions that had to be met as the benevolent institutions
developed restorative facilities, and they were subject to a process of
standardisation. Nonetheless the context in which such rationalisation
took place was also one in which the personal relationship between John
Lindell and medical practitioners on one hand, and committees of
management on the other, was an integral factor. The former individually
found Lindell most supportive, and the latter were likely to find that ‘a
lunch with Lindell’ would reliably result in his agreeing to whatever
project the committee was promoting.14
11
VPRS 4523/P1/422/3429.
The implementation of public policy through semi-autonomous entities such as the
Hospitals and Charities Commission was characteristic of the administration of the state of
Victoria, A.F. Davies, 1960, op. cit. pp. 190-196.
13
It is worth noting that the idea behind the implementation of policy by semi-autonomous
bodies such as the Hospitals and Charities Commission was initially intended to remove
the possibility of political influence on the provision of public services, Davies, 1960, op.
cit. pp.190-192. It was also a system whereby the Victorian community was able to
participate in decisions about the establishment of services through fund raising and
membership of committees of management. In the late 1970s when community
participation was a clear objective of policy, this approach to the development of
community services was criticised on the grounds that certain interest groups prevailed in
decisions about what kind of service was necessary and in management committees,
excluding others, J. Goode, ‘The Health Policy Process in Victoria’, Community Health
Studies, vol v, no 3, 1981, pp.206-215.
14
Personal communication from Drs John Shepherd 23/2/98 and M. Scott 18/12/97.
Interview with Dr David Quinn, a medical member of the committee of management in the
early 1970s, of the Kingston Centre (formerly Cheltenham Old People’s Home and
Melbourne Benevolent Asylum), Transcript Oral History of Kingston Centre, Ref 19/92.
When Lindell died in 1973, obituary writers noted his capacity to combine a personal
relationship such as has been noted in this paragraph, with the utmost integrity in his
actions, MJA, vol 2, 1973, p.984-985
12
121
This very personal approach to the implementation of policy regarding
hospital services had the potential for success, even in an environment
where service provision was as fragmented as it was in Victoria. The
potential was greater in areas where personal contact could be readily
established and maintained, and this was not always the case, particularly
outside the metropolitan area.
However success also depended on
unanimity in objective for any particular service, and in the case of
geriatric services, there were fundamental differences between the
committees of management in their approach to this project and the
medical practitioners who depended on their support.
The personal
relationship between Lindell and the committees of management on one
hand and the doctors who strove to establish medical services on the other,
combined with Lindell’s apparent even-handedness, created an ambiguous
atmosphere. This showed most clearly in relation to admission policy in
the institutions. The committees of management were reluctant to give up
any authority on this matter to their medical staff, and all the institutions
continued to maintain the policy of admission according to position on a
waiting list until the early 1970s.15 The doctors who attempted to establish
a geriatric service in which admission was entirely according to a medical
assessment of need, were effectively hamstrung by the continuation of
waiting-list based admission. It is not clear whether Lindell ‘advised’ on
this matter, but committees of management certainly did not take such
advice if it was given.
Ambiguity also characterised the position of the geriatrician in relation to
existing medical roles in the major teaching hospitals, a situation that
arose out of the autonomy enjoyed by the committees of management of
these institutions. This would not have mattered had the medical staff in
these hospitals taken an interest in the project of establishing geriatric
services because they did exert influence over lay members of committees.
The appointment of the first doctor to develop a geriatric unit at Mount
Royal Home and Hospital for the Aged appears to have set the pattern.
15
Committees of management supported their opposition to giving doctors more authority
by citing institutional by-laws that prohibited any employee of the institution being given a
position on the committee of management. .
122
Despite the innovatory nature of the role envisaged for the geriatrician – a
role situated at the intersection of acute hospital, long-term care and
community based welfare services – practitioners like Larkins were slotted
into a space already occupied by the convalescent medical officer in
outlying institutions attached to the public hospitals.
The role of convalescent medical officer was established in the 1920s
when the first wards at Caulfield Hospital were taken over from the
Repatriation Department by the State government.
As Caulfield was
established as a convalescent hospital, first under the control of the Royal
Melbourne Hospital, and then in the late 1940s, transferred to the Alfred
Hospital, patients treated there remained the responsibility of the
consultants in charge of the units where they were originally admitted.
The medical officers employed on the convalescent wards had
responsibility only for the day-to-day treatment of convalescent patients.16
Like the convalescent medical officer, the geriatrician had responsibility
for the day-to-day medical care of patients admitted to the geriatric setting,
while overall responsibility for that patient’s management remained with
the consultant in charge of the unit in the originating hospital where the
patient was treated during the acute period of illness. The geriatrician was
thus lodged in a confined and, given the existing pattern of medical work,
inconsequential space, bounded by that of the consultant specialist in the
acute hospital on one side, and by the general practitioner in the
community on the other. John Lindell’s insistence that the role be a
salaried position also set the geriatrician apart from the honorary
consultants in the teaching hospitals who occupied a position at the top of
the medical hierarchy, and from the fee-for-service, entrepreneurial
medical practice that prevailed in other areas of medical work. Salaried
medical work implied a close association between the medical profession
and the state and in the views of the majority of the medical profession,
something inimical to good practice.17
16
By the 1950s the Infectious Disease Hospital at Fairfield provided wards for
convalescent patients, as did the After Care Hospital in Collingwood. The geriatric unit at
Mount Royal was expected to have the same relationship with the Royal Melbourne
Hospital as the convalescent wards at Fairfield Hospital. RMH Archives/Committee of
Management Reports/vol 25; see footnote 50, chapter two.
17
RMH Archives/Committee of Management Minutes/vol 26; see Chapter One.
123
The ambiguities that surrounded the introduction of the medical role of
geriatrician arose from the traditional approach in Victoria to the
introduction of hospital and welfare services.
That is, the state
government was prepared to fund the development of services, but left it
to voluntary groups to provide them and, largely, to determine the form
they took and the needs they addressed.18 Other medical practitioners had
succeeded establishing the practice of medicine and surgery in the
voluntary institutions that developed as public hospitals by the 1930s,
wresting the requisite authority from their committees of management
through a process of negotiation.19 It appears geriatricians were expected
to do likewise.
However, nascent geriatricians, even in their relationship with their
committees of management, were in a more complex situation than were
their colleagues in the voluntary hospitals. There, a basis for common
interest existed between doctors and committee of management; first in
the desire to maintain a turnover of patients, and second in that, from the
1930s onwards, the benefits of medical advances were clear to both
parties. Although they often differed over the grounds for admission, a
medical assessment of need replaced the charitable assessment not long
after the institutions were established.20 The successful establishment of
the geriatrician’s role on the other hand depended on a complete shift in
the culture of the institutions, away from the provision of institutional
accommodation to the provision of services focused on keeping infirm old
people out of institutions. It was the geriatrician’s task to generate a
turnover of patients, but this threatened to undermine the need for a large
institution with hundreds of beds – the clearest possible evidence of a
community’s care for its infirm aged and the sign of a successful
committee of management. The proper operation of a geriatric service
18
In 1961 the Department of Social Studies at the University of Melbourne published a
study of the effectivness of the system of voluntary welfare provision in the State,
questioning whether the many public appeals on behalf of voluntary agencies were
necessary in light of the provision made by the State government for capital and
maintenance funding. The study concluded that while the voluntary effort was a valuable
expression of community concern, existing arrangements, particularly in reference to
health services meant that some areas of need were neglected and others over-supported, R.
Otto & L. J. Tierney, ‘Financing of Voluntary Welfare Agencies in Victoria, Social Studies
Department, University of Melbourne, 1961.
19
B. McCoppin, ‘The Government and Hospital Committees of Management in Victoria’,
Australian Journal of Public Administration, vol XLII, no 3, 1983, pp.376-379.
20
Walker, op. cit. pp.45-52, pp.128-113, p.138; see also McCoppin, 1974, op. cit. p.147ff.
124
meant limiting institution-based activities to the provision of short-term
accommodation to which patients could be admitted for treatment and
discharged, and some long-term accommodation for individuals whose
needs could not be met in the community.
There is no indication that as committees of management took up the task
of introducing the facilities for restorative treatment, they seriously
considered abandoning a culture of, in most cases, a century-long tradition
of providing institutional accommodation for both the infirm and well
aged. Any reluctance to diminish the importance of the institutions was
reinforced by the difficulties that did exist in finding long-term care for
people without resources who were not candidates for rehabilitation in the
early period, when restorative treatment was being introduced. It was in
these circumstances that the committee of management at Mount Royal
decided, in 1961, to continue to provide long-term care.21 The problem
faced by doctors in establishing geriatric services was that they were
located in institutions that had an interest in institutional care for both the
chronically ill and the ‘well’ aged. This interest was encouraged by the
inclusion of funding to improve accommodation facilities alongside the
introduction of a medical service, a step taken for reasons of economy, to
make the most of existing institutions, and because of the overall lack of
interest on the part of public hospital doctors, in the needs of the infirm
aged.
Each committee of management went about the process of introducing
restorative facilities according to its own ideas of what was fitting, within
the limits set by subsidies provided by the Commission. In 1955, When
the
Hospitals
and
Charities
Commission
took
over
hospital
accommodation that was no longer needed by the Department of Health
for tuberculosis patients, it was provided with an opportunity to develop
geriatric services without the impediment of an existing tradition in
providing institutional care.22 The Commission and the newly formed
committee of management did not, however, take this view.
21
22
Annual Report Mount Royal 1961.
Annual Report Hospitals and Charities Commission, 1955.
125
The admission of ambulant and infirm old people began while preliminary
discussions were underway with Prince Henry’s Hospital regarding the
involvement of that institution in establishing the geriatric unit, and well
before the appointment of a geriatrician and the appropriate facilities for
restorative treatment.23
No doubt it was the general pressure on the
Commission to provide accommodation immediately for old people whose
needs were urgent that led to this situation. Even so, the decision sits
oddly with John Lindell’s hope that Greenvale would become, ‘the most
modern institution in Australia for old people … and … pattern for future
establishments.’24 When a doctor was finally appointed to the position of
geriatrician, he was faced with an environment that had already taken on
the character of ‘old folks home’, despite the aspirations of the committee
and the Commission that the institution would develop as a showpiece of
the new era.
At Mount Royal the construction of the geriatric unit was a joint enterprise
between the benevolent home and the Royal Melbourne Hospital. It was
one of only two geriatric units that were successful in establishing formal
links with an acute hospital.25 This 76-bed unit was the first purpose-built
accommodation for the infirm aged in Victoria, and the planning process
was overseen by a consultative committee consisting of representatives of
both institutions, including doctors. The committee continued in existence
into the early 1970s.26
23
The proposed alliance between Greenvale and Prince Henry’s did not come about. There
is no reference to any representative of Prince Henry’s at the early meetings of the
committee of management, a point that suggests there was no interest on the part of that
institution. Greenvale Village, Board of Management Meeting Minutes.
24
Board of Management Meeting, Greenvale Village, 22/8/55.
25
As noted in Chapter Two, plans for this unit were first initiated when John Lindell was
medical superintendent of the Royal Melbourne Hospital. Notes of a discussion between
Lindell and Colonel R.L. Elliott, superintendent of Mount Royal on 16/6/1953, suggest that
the unit was to consist of three divisions, the first of which would accommodate patients
requiring ‘active’ medical or surgical treatment’. These beds were designated ‘acute’, but
it seems, not ‘acute’ in the sense that other beds in the Royal Melbourne were acute. They
were to cost less, that is between ten and fifteen pounds per week, whereas in RMH, bed
cost was approximately thirty pounds per patient per week, Dr John Shepherd’s Private
Papers. The committee of management at Mount Royal were willing partners, following
recommendations made by their manager, Colonel Robert Elliott when he returned from an
overseas tour, Uhl, op. cit. p.178. The Geriatric Unit at Mount Royal and the Marjory
Warren Geriatric Unit at the Princess Alexandra Hospital in Brisbane vie for the honour of
being the first purpose-built hospital settings for the infirm aged, see chapter two.
26
The existence of this committee cannot be taken to indicate great interest on the part of
Royal Melbourne doctors. It was most probably, principally an interest in organising a
process for the speedy ‘disposal’ of infirm elderly patients. The attitude of Royal
Melbourne medical staff in general, may be deduced from a letter written early in the
1950s, when the venture with Mount Royal was under discussion, by the medical staff to
126
At the Alfred Hospital the manager, at the direction of the committee of
management, sought advice from Elizabeth Johnson about developing a
geriatric unit in the infirmary section of Caulfield Hospital. The unit was
to consist of 280 beds, incorporating the infirmary wards already in the
hospital with the addition of a ward for short-term treatment. A doctor
was appointed in charge of the unit along with additional nursing staff, a
social worker and occupational and physiotherapists.27 The Caulfield unit
differed from the others in being situated in an existing hospital complex,
the Alfred Hospital having taken over all the wards of Caulfield
Convalescent Hospital in the late 1940s.
The medical practitioner in
charge of the geriatric unit, Cecil Ashley, may not have figured high in the
medical hierarchy but, unlike his colleagues in the benevolent institutions,
he did work in an environment where medical authority was taken for
granted.
There was no such close relationship between the other aged-care settings
and acute hospitals. At Greenvale Village, early hopes that an association
would be formed with Prince Henry’s hospital were not fulfilled. In 1956
the newly constituted committee of management was preparing to
interview six applicants for the position of geriatrician. One of these, a
physician at Prince Henry’s was offered the position of geriatrician but he
refused it and the committee prepared to start the process over again.28 At
the manager of the Royal Melbourne, asking that a long-term care unit be set up by the
Melbourne for its own patients. The virtue of such a unit would be that it was not under
the control of the Hospitals and Charities Commission. RMH Archives/Manager’s
Correspondence/Medical Matters 1/vol 15; Uhl, op. cit. p152, p.180. The Geriatric Unit
was named after Sir Herbert Olney, President of the committee of management, “‘that
staunch worker for the sick aged and better known as a philanthropist than as a
businessman’”, Uhl, ibid. p.180. Sir Herbert was also Chairman of the Charities Board
before it was replaced by the Hospitals and Charities Commission, and Member of the
Legislative Council, the Victorian Upper House, p164. Initially the Royal Melbourne was
represented on the consultative committee by Sir Victor Hurley, Dr Konrad Hillen and Dr
J. Lindell until his appointment as Chairman of the Hospitals and Charities Commission.
Mount Royal was represented by Colonel Robert Elliott, Superintendent, and Dr Alan
McCutcheon, Medical Officer. In August 1960, the members of this committee were Drs.
McCutcheon, Butterworth and Shepherd and Mr M.E Atkinson (Manager), from Mount
Royal, and Drs Sinclair and O’Donnell from RMH. RMH Archives/Committee of
Management Reports/ vol 25, and Medical Matters/ No 2/26; J. Uhl, op. cit. p.178,
27
Annual Report Alfred Hospital, 1956-57. At this time also the word convalescent was
dropped from the title of Caulfield Hospital, VPRS 4523 P2/822/9-3; VPRS 4523
P2/822/9-3.
28
Greenvale Village Minutes Board of Management Meeting, 22/8/55, 16/3/56. The
committee of management for this institution included two medical members, Dr Alan
McCutcheon, the medical officer at Mount Royal from around 1930 to the early 1960s, and
Sir William Upjohn, described by the most recent historian of the Royal Melbourne, as one
127
the Cheltenham Old People’s Home twenty beds had been set aside for
short–term rehabilitative treatment prior to the erection of a purpose-built
section that was opened in the early 1960s. There was already some
connection between this home and Prince Henry’s Hospital, as it provided
accommodation for diabetic patients from the hospital and for infirm old
people who could not be discharged. The relationship between Prince
Henry’s and Cheltenham continued as rehabilitative treatment was
introduced, but it was not managed through a consultative committee, as
was the relationship between Mount Royal and the Royal Melbourne.29 In
the late 1950s and early 1960s new buildings were being erected at the two
largest country institutions, the Queen Elizabeth Home at Ballarat and the
Benevolent Home at Bendigo. In addition, at Ballarat a home help service
was introduced to assist old people remain at home who may otherwise
have applied for admission.30 At both institutions medical practitioners
were appointed to the position of medical superintendent, replacing local
practitioners brought into to provide medical attention on a sessional basis.
Medical Practitioners
It is not accidental that the only mention so far, of the medical
practitioners who took on the task of establishing the role of ‘geriatrician’,
has been in passing. Unlike the introduction of other medical services such as those provided in the public hospitals - the practitioners who
undertook the task of establishing geriatric services came into the picture
only after the Commission and the committees of management had set the
project of developing geriatric services in motion.31 The extent to which,
of a remarkable group of physicians and surgeons who made their careers at the hospital.
Sir William’s relationship with the Royal Melbourne spanned 60 years, including
membership of the committee of management, A. Gregory, The Ever Open Door, Hyland
House, South Melbourne, Victoria, 1998, p.164. It can only be a matter for speculation but
possibly these two practitioners brought a conservative approach to their task that made it
unlikely that decisive and assertive action would be taken to emphasise the medical role of
geriatrician in providing services over the institutional focus already in existence by the
time a geriatrician was appointed. As will become clear later in this chapter, their presence
certainly does not appear to have fostered the role of geriatrician.
29
Annual Report Cheltenham Old People’s Home, 1959, 1961, 1963.
30
I.M. Dicker, ‘Home-Help Service’, Geriatrics Conference, 1958, p25-28, Geriatrics
Conference, 1956-1966, op. cit; C. Robjohn, My Several Lives, H. C. Robjohns,
Marrayatville, South Australia, 1988, p.88-95; Cusack op. cit. pp.195-7.
31
In introducing the role of geriatrician into the benevolent institutions, the Hospitals and
Charities Commission intervened to an extent not previously known in the employment of
medical staff by committees of management.
The Commission determined the
classification of the role of geriatrician, including terms and conditions of employment.
Previously these had been a matter for private negotiation between medical practitioner and
committee of management. Following the report of the committee led by J. V. Dillon in
128
in accepting positions as geriatricians, doctors were removing themselves
from the mainstream of medical work is illustrated by the travelling
scholarships that were awarded to three of the first geriatricians. The
scholarships were funded by three philanthropic businessmen associated
with Mount Royal and, as the Annual Report of the Hospitals and
Charities Commission for 1954 noted, they were intended to encourage
doctors to take on work far removed from other types of medical practice.
In due course the scholarships were awarded to Robert Butterworth at
Mount Royal, Cecil Ashley at Caulfield and David Wallace at Greenvale.
Each practitioner then spent a period of time travelling to the United
States, Europe and England to inspect provisions in these places for the
elderly, before taking up their position.32
The doctors who took on the task of developing an active medical role in
the care of infirm old people were a diverse group. The few young men
who were appointed were no doubt keen to integrate the role of
geriatrician into the general pattern of medical work in the state. Although
there were no women amongst the first appointments to the position of
geriatrician, the increased number of medical positions that accompanied
the introduction of geriatric services provided hospital positions that may
have been more difficult to obtain in mainstream medical work for
women.
They were soon prominent in the staffs of the geriatric
hospitals.33 Other doctors, many of them older men towards the end of
their careers, would take on the role of geriatrician for a variety of reasons,
none of which was necessarily concerned with establishing a specialist
field of medical work in relation to the aged.
1959, uniform conditions were introduced for all salaried medical officers in the State’s
hospitals.
32
Annual Report, Hospitals and Charities Commission, 1955. One of the donors was Sir
Edward Hallstrom, a businessman born in New South Wales and benefactor of Mount
Royal, Uhl, op. cit. p.230; another was Sir Herbert Olney, see above; the third donor was
Mr. James Ross, another member of the committee of management at Mount Royal, Uhl,
p.181.
33
Mount Royal in particular seems to have been attractive to women doctors as the
preponderance of female names listed amongst the medical practitioners in annual reports
suggests. For some, part-time positions may have been easier to fit in with family
responsibilities; for others the new role of geriatric medical officer may have offered an
opening into medical work that was not available in the public hospitals. However
positions in the institutions that were reclassified as Geriatric Hospitals were not the most
prestigious. In this respect the expansion of possibilities for women doctors was limited at
this time, being more a case of answering a demand for ‘pairs of hands’ in lower status
medical work, rather than career opportunities, as was the case in Britain in the 1960s,
M.A. Elston, ‘Women in the Medical Profession: Whose Problem?’, in Health and the
129
Graeme Larkins, a newly qualified physician, had returned to Melbourne
shortly before John Lindell made his announcement in 1954 that geriatric
services would be developed in the benevolent homes.34 Larkins appears
to have had a special interest in the medical care of old people because on
his way to England to complete his physician training, he stopped in San
Francisco
where
he
visited
the
Institute
of
Gerontology
and
Endocrinology, and the Maimonedes Hospital for the Aged. Larkins’
postgraduate training was undertaken in hospitals specifically for elderly
patients, including Marjory Warren’s base at the West Middlesex
Hospital.35 He was the only applicant when the position of geriatrician at
the geriatric unit at Mount Royal was advertised.
Larkins was appointed to the position after the Medical Advisory
Committee at the Royal Melbourne Hospital had agreed he was suitable,
and given the title Geriatric Research Officer and Clinical Assistant at the
Royal Melbourne – a title that suggests that in relation to the medical staff
of the acute hospital, his position was considered similar to that of a
general practitioner permitted to undertake limited duties in the acute
hospital.36 The first task that Larkins faced in his new appointment, was to
join the consultative committee overseeing preparation of plans for the
unit. The committee, as noted above, was made up of representatives of
the committees of management of both institutions and their respective
medical staffs. As Geriatric Research Officer his position was a full-time
salaried one, and he was responsible for the admission and discharge of
patients to the unit and for the supervision of their restorative treatment.
Also, he was allocated an Outpatient Clinic in the acute hospital in which
Division of Labour, eds M. Stacey, M. Reid, C. Heath & R. Dingwell, Croom Helm,
London, 1977, pp.123-125.
34
Larkins had gone to England for higher qualifications, as many Australian doctors did at
the time. He graduated during the war and spent the years immediately following
graduation (and one year as RMO at the Alfred Hospital) in general practice in an isolated
area of northeastern Victoria, details from Dr Larkins’ curriculum vitae submitted when he
applied for the position at Mount Royal Hospital, RMH Archives/Chairman’s
Correspondence no 1/Medical Matters/vol 15.
35
Ibid.
36
In England around 1950, the title Clinical Assistant was applied to general practitioners
who were allocated a part time position in the acute hospitals, Stevens, 1966, op. cit. p.104.
Larkins also had a part time position at the Alfred Hospital and what he described in his
CV as private geriatric practice.
130
to see prospective patients.37 Then in mid-1956, just as the geriatric unit
was almost ready to take the first patients, Larkins resigned from his
position.
The reasons for this decision can only be a matter for
speculation. It is likely they were related to the restrictions imposed on
developing a career as a consultant physician by the exclusion of acute
care from the work of the geriatrician, and by his full-time employment at
Mount Royal, separated as it was from the mainstream of medical work.38
In retrospect it seems clear that this would be the case from the outset, but
it is possible that when he was appointed he believed that there was some
room for flexibility.
Robert Butterworth, an English doctor with an MD qualification in
physiology, was appointed geriatrician when Larkins resigned. Coming
from the National Health Service in Britain, he may have been more
inclined to be satisfied with the salaried role he was offered in the unit
where he remained until his untimely death in the early 1970s.39 For S. J.
H. Shepherd, a general practitioner employed as medical officer at the
Repatriation General Hospital at Heidelberg, the new era beginning at
Mount Royal offered the opportunity for an hospital based career for
general practitioners that was rapidly disappearing in other hospitals in the
early 1960s.40 This opportunity arose when Larkins, who had maintained
37
RMH Archives/Minutes Committee of Management Meetings/vol 26.
During the preliminary discussions in relation to the unit, between Mount Royal and the
Royal Melbourne it appears that a more active medical role may have been envisaged. The
unit was to consist of three divisions, the first consisting of wards to accommodate
‘patients requiring active medical or surgical treatment’. The unit that was built contained
70 odd beds and patients were admitted following treatment during the acute stage of their
illness in the wards of RMH, Notes of Conference between Col. R. L. Elliott and Dr J. H.
Lindell, 16/6/53, Personal papers Dr John Shepherd. At this stage it was also planned that
the position of geriatrician would be honorary. The fact that it was salaried may be
attributed to either the failure to attract interest from doctors wishing to act in an honorary
position, or to the desire of the HCC to ensure stability of medical attendance in a unit
associated with the care of infirm old people, an association not highly regarded in medical
circles. As noted in chapter one, the early 1950s marked the final stages in the movement
to establish fee-for-service as the principal form of medical remuneration in Australia. In
the process the position of salaried medical officer was endowed with an opprobrium that
ensured its position at the bottom of the medical hierarchy, Gillespie, 1991 op. cit. chapter
11.
39
Butterworth had applied for the position of geriatrician at Greenvale when it was first
advertised but was passed over in favour of a physician from Prince Henry’s Hospital who
subsequently declined the position. Butterworth was a relatively young man when he died
in the early 1970s Uhl, op. cit. p.182.
40
The position at Mount Royal was unusual in that the position of specialist geriatrician
existed side by side with that of medical superintendent. Dr Shepherd came to Mount
Royal from the Repatriation General Hospital at Heidelberg at a time of change.
Previously staffed by full time general practitioner medical officers, with visiting
consultants providing specialist services, moves were underway in the hospital, to institute
medical staffing similar to that in the teaching hospitals where the everyday medical work
38
131
his connection with Mount Royal in a part-time position as Rehabilitation
Officer in the general wards of the institution, died suddenly. Shepherd,
who was familiar with the possibilities of rehabilitative treatment from his
work at the Repat, was appointed Rehabilitation Officer.41 Shortly after,
when Dr Alan McCutcheon, the most senior medical officer at Mount
Royal, resigned, he secured a new position in the institution as Medical
Superintendent.42 McCutcheon had spoken about the change in medical
role at Mount Royal a year or two before he retired after thirty years
service, noting ‘our role is steadily switching over from custodial care to
nursing and treatment care’. In his ‘conservative’ view, the introduction
of restorative treatment was most notable for the mental changes it
brought, the broadening of patients’ horizons from four walls and the three
meals each day.43
Like Graeme Larkins, David Wallace had also recently returned from
postgraduate study in England when he was appointed geriatrician at
Greenvale Village in 1957. In his case it had been undertaken at the
Postgraduate School at Hammersmith Hospital.44 He was a graduate of
was undertaken by trainee specialists. Shepherd had hoped for a career in general practice,
preferably in the country, but illness put this out of the question. From his point of view
the position at Mount Royal offered possibilities that were being eliminated from RGHH.
Shortly after his appointment as medical superintendent, he was awarded a scholarship by
the HCC and began the course in medical administration offered at the University of New
South Wales. Personal communication from Dr SJH Shepherd 23/2/98; also see HunterPayne, 1994, op. cit. p.81ff.
41
Malcolm Scott, who was appointed geriatrician at Greenvale Village in the 1960s, also
came from the Repatriation General Hospital at Heidelberg where he too was familiar with
the provision of rehabilitative treatment, Personal communication 18/12/1997.
42
In 1959, the committee chaired by J. V. Dillon, commissioned to report on the terms and
conditions of medical appointments in the state’s hospitals, noted the emergence of the
position of medical superintendent as a medical career associated with specific skills and
training. The Hospitals and Charities Commission responded by providing scholarships to
enable doctors to gain the qualification at the only institution that provided it at the time,
the University of New South Wales. This institution had been founded in 1950 and named
the New South Wales University of Technology, with the intention of providing the link
between university level training and industry and commerce, seen to be a necessary basis
for Australia’s developing role as an industrial nation. The medical administration course
was one of a number of specialised graduate courses. The institution was renamed in 1958,
possibly as part of an attempt to restore its image, having been subjected to criticism in
relation to its performance as a university. This criticism was part of a broader discussion
characteristic of postwar Australia in which the role of the universities was examined in
relation to the demands of national development, N. Brown, Governing Prosperity, Social
Change and Social Analysis in Australia in the 1950s, Cambridge University Press, 1995,
pp.222-227.
43
A. B. McCutcheon, ‘Retrospect’, MJA, vol 1, 1958, p.274.
44
A fitting background for a doctor to develop an interest in sickness in old age,
Hammersmith Hospital had itself evolved from a workhouse infirmary, Stevens, 1966, op.
cit. p.107.
132
the medical school at the University of Sydney and in contrast to most of
his colleagues, was an outsider in the parochial Melbourne medical world.
However, a family connection with Sir William Upjohn, whose medical
career at the Royal Melbourne spanned a period of 60 years, and a short
period as clinical assistant at the Royal Melbourne, may have led him to
believe he could make the necessary connections to carry out one of his
principal tasks - that of aligning the facilities he was to develop at
Greenvale with one of the acute hospitals.45
Wallace may also have been excited by the possibility of being associated
with the project so enthusiastically described by the Hospital and Charities
Commission, of developing Greenvale as the foremost institution of its
kind in Australia. Perhaps he foresaw the opportunity to develop the
institutional setting he was to advocate some years later, where doctors
tended to the ‘vegetable patch’ of chronic disease so disparagingly
regarded as clogging up the acute hospitals.
It was, he said, more
important for doctors to investigate these more mundane conditions rather
than ‘many of the acute conditions under investigation today’, so the
elderly would receive more effective care and doctors could be trained
more effectively and usefully. David Wallace formed his views at the
Hammersmith Hospital, where some of the patients were left over from
the institution’s Poor Law Infirmary days. Doctors began to investigate
the chronic respiratory disorders they found there and ‘completely altered
the understanding and management’ of them.46
If indeed this was
Wallace’s ambition, he was soon disillusioned by his dealings with the
Commission and his committee of management, and resigned three years
later.47
His successor, Eloise Lucas, was also a young doctor at the
45
Obituary, MJA, vol 1, 1980, p.40-41. Wallace did eventually succeed in establishing a
link with St Vincent’s Hospital and was given a position in Professor Hayden’s Unit
although not as a member of the medical staff of the hospital. Minutes Meeting Committee
of Management Greenvale Village, 25/7/58.
46
D. C. Wallace, ‘Changes in Educational and Living Standards (ii)’, in Medical Practice
and the Community, eds R. G. Brown & H. M. Whyte, Australian National University
Press, Canberra, 1970, p.131-132.
47
S. Wickham, ‘Greenvale From Isolation to Centre, A History of Greenvale Centre’,
unpublished manuscript held in the Library of Melbourne Extended Care and
Rehabilitation, (formerly Mount Royal Hospital). Possibly the position at Greenvale was
indeed a stage along the road to Wallace’s ultimate objective – physician in a provincial
city, D. Wallace, Joseph Coles: A Country Doctor, nd, no publisher, p91.
133
beginning of her career, who, after some years at Greenvale went on to
qualify in psychiatric medicine.48
Collin Robjohn was another who found the possibilities of establishing a
geriatric service exciting. He was appointed medical superintendent at the
Queen Elizabeth Home in Ballarat, and commissioned to introduce
rehabilitative treatment into the institution. Up to this point local medical
practitioners had provided medical care on a sessional basis for the 600
inmates. When he applied for the position, he had been in general practice
in South Australia after returning from China where he had worked with
the London Missionary Society. Life as a suburban GP failed to provide
the satisfaction he looked for in his work and he felt he had lost the sense
of vocation that had imbued his work in China.
The challenge of
developing rehabilitative facilities at Ballarat soon revived that sensation.
When he left Ballarat, to avoid appearing to condone a drive for
contributions for a building program, he continued his missionary role
providing rehabilitative services for infirm old people as Director of
Rehabilitation at Aldersgate Village, an institution for the aged run by
Wesley Central Mission in Adelaide.49
If younger doctors failed to find sufficient openings for developing a
medical career in establishing geriatric units, older men brought different
expectations and, it appears, were disposed to make the best of the
circumstances they found. Most of the other appointments made to the
positions of geriatrician and geriatric medical officer, in the period around
the late 1950s and early 1960s were usually older men, general
practitioners in the latter part of their careers. Cecil Ashley has already
been mentioned as the general practitioner appointed to develop the
geriatric unit at Caulfield Convalescent Hospital. At the Cheltenham Old
People’s Home, E. A. Eddy, another GP, was appointed medical
superintendent. Shortly after, he encouraged Horace Tucker, one of his
golfing partners to join him on the medical staff. Tucker was a local GP
who, due to the effects of war service, found it difficult to cope with a
busy practice. He found a new lease on life in taking on this work despite
48
The evidence for Lucas’ career is taken from entries in the Australian Medical Directory
in the years following her time at Greenvale.
49
C. Robjohn, My Several Lives, H. C. Robjohns, Marrayatville, South Australia, 1988,
p.88-95.
134
the disparaging remarks of his friends, and was later proud to be
associated with the early days of geriatrics as medical work in Victoria. In
time Tucker was also appointed medical superintendent.50
Reordering Old Age Infirmity
The doctors who took positions as geriatricians came into contact with a
range and depth of infirmity that few of their colleagues saw in everyday
work. This is not to suggest that the inmates of the benevolent homes
were exceptionally badly treated or accommodated.
Although the
institutions were drab and shabby, there is no reason to believe that, like
their counterpart in the Public Assistance Infirmary when Marjory Warren
first encountered them, they were not, in general well fed and clean.51
However, accepted practices whereby the poor and infirm aged had to be
grateful for what they were given, were challenged by the introduction of
an active medical role into the institutions, with specific techniques of
treatment and specified standards of accommodation and nursing care.52
Collin Robjohn was surely not alone in feeling a revived sense of vocation
as he confronted his task; old age infirmity on this scale would have stirred
the most phlegmatic of souls to ‘do something for these people’ as one
practitioner put it.
In all the homes, to varying degrees, new accommodation was added
(some of it for ambulant patients, some for long-term care), and old wards
were renovated.53 Wards, instead of being distinguished according to
whether the inmates were bedridden or ambulant, were reorganised
50
When he told friends of his change of direction they responded with remarks along the
lines , ‘What … are you doing out there? … getting mixed up with those dreadful old
people …’. Transcript of Oral History of Kingston Centre, Ref 3/93..
51
Warren, op. cit. 1946, p.841.
52
The difficulties in converting a custodial care mentality to a treatment oriented approach
may be discerned in the comment noted in the records of meeting of the consultative
committee overseeing the planning and building of the geriatric unit at Mount Royal, that
the plans submitted by the superintendent of Mount Royal, Colonel Elliott, indicated an
inadequate understanding of what was required in a treatment setting, RMH
Archives/Managers Correspondence/Medical Matters 1/vol 15. No details were given but
an indication of what the committee may have referred to may be found in notes by Elliott
of a conversation between him and the Hospitals and Charities Commission architect to the
effect that old people liked the large wards because there was plenty going on and, further,
that special rooms for the dying were not necessary. The old, he noted, were used to their
fellows dying amongst them, VPRS 4523/P1/260/2242.
53
While a certain amount of new building went on, possibly depending on the resources
individual institutions were able to call upon in addition to the subsidies provided by the
Hospitals and Charities Commission, new facilities existed amongst some very old and
dilapidated buildings. The Commission, in the interests of economy encouraged the use of
135
according to treatment regime; that is: geriatric units or rehabilitation
wards for patients undergoing straightforward restorative treatment with
the expectation of discharge; longer term rehabilitation wards; assessment
wards where newly admitted patients were examined prior to being
allocated to the appropriate section; and wards where long-term care was
provided. All the institutions continued to provide for ‘well’ old people in
the form of hostel or dormitory style accommodation. Day Hospitals were
established, often in converted local halls to provide restorative treatment
on an outpatient basis thus making it possible to treat without admission
and to maintain post-discharge supervision.54 Although there was room
for idiosyncrasy in how each committee of management approached the
project of expanding the facilities of its institution, changes were subject
to a degree of standardisation through the subsidies provided by the
Hospitals and Charities Commission. In the course of the 1960s, the
commonality imposed by these incentives led to a reclassification of the
benevolent homes as Special Hospitals for the Aged, or Geriatric Hospitals
as they were commonly known.
Requirements for change of status
included the provision of daily medical attention, and specialist geriatric
medical attention when required; the provision of trained senior nursing
staff who were to be available day and night; approved facilities for
nursing the sick; training programs for nurses aides and the appointment of
therapists and the provision of chiropody services.55
In the reconfigured ‘benevolent’ setting, medical practitioners had the
opportunity to develop a specific form of medical expertise related to the
management of old age infirmity.56 At the first public discussion of the
role of the geriatrician, Graeme Larkins pointed out that there was nothing
new about the methods used in treating disabled old people. The novelty
lay in providing this treatment with the aim of keeping them ‘active and
healthy functional members of the community instead of merely providing
existing buildings wherever possible, Annual Report Hospitals and Charities Commission
1953-54.
54
D. H. Blake, ‘A Day Hospital for Geriatric Patients: The First Twelve Months’, MJA, vol
2, 1968, pp.802-804.
55
VPRS 4523P1/382/3167. These conditions were noted in relation to the change in status
of the Bendigo Benevolent Home.
56
I have emphasised the association between the aged and these institutions because care
of the aged was the stated, formal objective of the institutions. Their wards did however,
also accommodate younger adults suffering from chronic disease and disability whose
needs were the same as their older companions.
136
them with comfortable custodial care’.57 It would have come as a shock to
the first set of patients admitted for rehabilitation treatment to find they
were the objects of such intense attention. All their experience would lead
them to expect that to have a stroke, to fracture a hip joint or have a leg
amputated, to be diagnosed with Parkinson’s Disease, or to be afflicted
with the crippling and debilitating pain of arthritic joints, would mean
spending the remainder of their days confined to bed or, at best, a
wheelchair. The prospect for those without any resources was grim.58
They faced the ignominy of going into ‘a home’, to see out their days in
the dreary routine of bed-care provided by overworked attendants, in
wards shared by forty or more of their peers, many of whom would have
already sunk wordlessly, others more raucously, into an indeterminate
condition between life and death.
In the geriatric unit at Mount Royal by contrast, infirm old people found
themselves, not in the long wards with forty or fifty others as they may
have expected, but in the hospital version of a domestic setting.59 Beds
were arranged in small units of four or six, with cupboards nearby for the
everyday clothes that patients were expected to wear during their stay in
the unit. Bathrooms were close by, where, depending on their disabilities,
57
Larkins, 1956, op. cit. p.23. Larkins was correct in saying there was nothing new about
the methods of rehabilitation – many of these techniques were developed during wartime to
enable maimed service personnel to make the most of their capacities. In relation to the
disabled aged, restorative methods had an even longer history as G. F. Adams notes in his
text Cerebrovascular Disability and the Ageing Brain, Churchill Livingstone, Edinburgh,
1974. Adams writes that Sir Richard Gowers, an English physician, described methods
similar to those publicised by Marjory Warren, in his textbook published in 1888, A
Manual of Diseases of the Nervous System. He continues with the point that Gower’s
principles of treatment and ‘profound first-hand knowledge’ were forgotten in the first half
of the twentieth century as ‘palliative treatment of the residual disabilities of
cerebrovascular disease became less important than the dramatic successes of curative
treatment …’. p.6.
58
This group did not necessarily include those who had been poor all their life. Others
with sufficient resources to manage while they were well, were not able to pay for the
degree of care they needed following a stroke for example. Lack of family to assist them
was also a factor in their need to call upon public assistance, Hutchinson, op. cit. p.143.
59
In emphasising Mount Royal in this brief account I am contributing to the situation,
often regretted by the other institutions, where their achievements may have been
overlooked because Mount Royal assumed and was usually granted precedence amongst
this group of state hospitals. In my account of the development of rehabilitative expertise,
Mount Royal is prominent simply because the doctors who developed the role of
geriatrician there were more inclined to document their work, thus making it accessible to
the historian. The reconfiguration of the benevolent home environment as a hospital
version of an appropriate domestic setting for the infirm aged is an extension of the process
Weindling discerns underlying the emergence of the ‘scientific’ hospital, in which
‘hospitals and sanitoria developed to provide an ideal type of domestic environment’ as an
antidote to mass urban poverty, P. Weindling, ‘From Infectious to Chronic Diseases”
Changing Patterns of sickness in the Nineteenth and Twentieth Centuries’, in Medicine in
Society, Historical Essays, Cambridge University Press, Cambridge, 1992, p.315.
137
they would relearn the art of bathing and dressing. In yet another section,
there was a dining room where patients were expected to take their meals
and engage in the sociable interaction that was so essential in maintaining
a mental orientation towards community life. In addition, there were
specified areas for occupational and physiotherapists to provide therapy
directed towards developing the necessary skills to negotiate these
activities despite disabilities.
For those whose lives had already been reduced to the confines of bed, the
dissection of every aspect of their disability must have been a confronting
experience, possibly a mixed blessing in view of the efforts they were
required to make if they wished to alter their bed-bound condition.60 On
admission to the Geriatric Unit at Mount Royal, each patient was the focus
of attention as physician, social worker, therapists and nurse attempted to
gain ‘full knowledge of the patient, his nutrition, his environment, his
aspirations and the foundation of residual capability’ on which to base
restorative treatment. Not surprisingly, it was often difficult to motivate
patients who ‘… when first seen are lacking hope: they feel that nothing
can be done for them and must be convinced that attempts at improvement
are worthwhile.’61 Group therapy was particularly helpful in assisting
such patients to see that what could be done for others may also be done
for them. It was, therefore, especially important to provide rehabilitative
treatment in an area well separated from the wards where long-term care
was provided, in order ‘to concentrate the thought of the patient on the
idea that they can and will get well’.62 The emphasis on the need to
separate the rehabilitation unit from the long-term care wards is an
indication of the extent to which the introduction of restorative treatment
for infirm old people contested prevailing ideas about what it meant to be
old and disabled. In managing the geriatric unit at Mount Royal, Robert
Butterworth adopted the policy of accepting any patient who was thought
to have ‘even a slender chance of benefiting from intensive rehabilitative
treatment’. In ‘borderline’ cases he sought the opinions of nursing staff,
therapists and almoner (social worker).63
60
L. Yapp, Physiotherapy in R.F. Butterworth, ‘The Geriatric Unit at Work’, Geriatrics
Conference 1958, Geriatrics Conference, op. cit. pp.13-24.
61
Butterworth, 1958, op. cit.
62
Larkins, op. cit. p.24.
63
Butterworth, 1958, op. cit.
138
There may indeed have been ‘nothing new’ about the character of the
rehabilitative techniques used in the geriatric units.
However, their
introduction did entail a complete reversal in the prevailing view that bedrest was the most appropriate response to old age sickness and disability.
Marjory Warren had described the debilitating the effects of bed-rest on
the aged body in terms of compounding existing infirmities, and providing
the conditions in which additional deformity and disease could develop.
Put to bed, she continued, the patient ‘rapidly loses morale and self–
respect’, it being clear that there is no hope of recovery and all
independence gone. The temperament becomes ‘apathetic or peevish’,
even aggressive, and laziness and faulty habits develop, perhaps even
incontinence.
Confined to bed the inactive aged body undergoes
detrimental physiological changes that are difficult to reverse – bed sores,
postural deformities, contractures, and ‘disuse atrophy of the lower
limbs’.64 Where the objective of rehabilitation treatment for other adults
was to restore the capacity to work and a stable level of independence, for
the infirm elderly, it was related to the capacity to participate in everyday
life: to get about, to feed oneself, to wash, dress, and be sociable. In
addition, restorative treatment was provided from a perspective that
recognised that this capacity for participation was likely to change from
time to time as new illnesses or injuries were superimposed upon existing
disease and infirmity. This recognition of the importance of activity in
maintaining well-being in infirm old people underpinned John Lindell’s
idealistic objective of ‘docketing’ each vulnerable individual in the region
served by a geriatric unit.65
Paralysed bodies, whether from stroke or some other degenerative disease,
were inspected closely by geriatrician and physiotherapist in order to
identify unimpaired muscles so they might be strengthened through
exercise in order to reinforce those affected by injury or disease.66 Bodies
long confined to bed, having lost strength and the capacity for balance,
had to learn anew how to move about, beginning by rolling from side to
side on the floor and crawling, until gradually reaching the point of being
64
Warren, 1950, op. cit.
VPRS 4523 p2/947/72/1.
66
L.T. Wedlick, ‘Physical Therapy in Geriatrics’, Geriatrics Conference, 1957, cit. p.1314, Yapp, op. cit.
65
139
able to remain upright with the assistance of technical aids.
When
individuals had been confined to bed or chair for a protracted period of
time and inactive limbs had contracted, it took time to distinguish damage
associated with neurological malfunction from that imposed by lack of
use, and even more time to strengthen long disused muscles. Time also
had to be allowed for patients’ lack of confidence to be gradually replaced
by the realisation that some independence was possible. Likewise, mental
confusion in a newly admitted patient could not immediately be attributed
to permanent changes; it was likely to clear given time, since ‘often
apparent poverty of intellect is due mainly to loss of hope and will
improve rapidly with active attempts to help.’67 Such tolerance of mental
confusion was based on a selective process through which patients whose
‘poor intellectual capacity, undue loquacity, inability to concentrate, (and)
spatial disorientation’ had already ensured they were considered unsuited
for restorative treatment.68
The foregoing comments must not be taken to mean that geriatricians saw
no role for themselves in providing services for the mentally disturbed. At
the 1961 Geriatrics Conference John Shepherd, medical superintendent of
Mount Royal said that 25 to 30 per cent of potential patients for the
services he offered at his hospital suffered from some degree of mental
deterioration. The problem he faced in providing services available to all
likely candidates for custodial care was that he could not admit patients
immediately as his institution continued the practice of admitting patients
on the basis of position on the waiting list.69 Psychiatrists in Victoria were
also beginning to develop services for this group of patients, and in
keeping with the division of medical labour between mental and physical
illness, this aspect of medical care for the elderly will be dealt with
separately in the following chapter. It was one of these psychiatrists, G.
V. Davies, who published a study in 1961 showing that old people were
badly done by in a hospital system based on this division. In acutely ill
elderly patients, mental and physical disorders could only be disentangled
67
Butterworth, 1958, op. cit.
Larkins, op. cit. 1956, p.24.
69
Geriatrics Conference, 1961, p97-98, Geriatrics Conference, 1958-1966, op. cit.
68
140
following prompt admission and investigation – it was this service that
Shepherd wanted to be able to offer.70
The Geriatric Community
The beginnings of a local body of clinical knowledge, techniques and aids
began to emerge as doctors, nurses, therapists and social workers focused
on a previously undifferentiated mass of old age infirmity. Some textual
material was already available. The doctors who developed the field of
geriatrics in Britain had, since the late 1940s, begun to publish on topic in
journals and medical texts.71
In the United States occupational and
physiotherapists developed aids and techniques in the rehabilitation
institutions established by philanthropic bodies as a means of dealing with
the problem of chronic illness in all age groups.72 Robert Butterworth,
geriatrician at Mount Royal, was notable amongst the small group of
medical practitioners who took on the role of ‘geriatrician’ in Victoria, for
disseminating his work in the form of journal articles.73
For most
Victorian practitioners the principal forum for disseminating their new
knowledge was the annual Geriatric Conference sponsored by the
Hospitals and Charities Commission. These conferences, organised in
turn by the Special Hospitals for the Aged, were meeting places not only
for the various groups involved in the ‘geriatric’ enterprise in Victoria but
70
G. V. Davies, ‘The Relation of Physical and Mental Disease in Later Life’, MJA, vol 2,
1961, pp.152-154.
71
Exton-Smith, 1955, op. cit. provided a handbook that combined all the facets developed
in the early work of the geriatric departments in British hospitals. The first edition of
Trevor Howell’s Old Age, Some Practical Points in Geriatrics, H. K. Lewis & Co. Ltd,
London, was published in 1944 but it was not reviewed in The Medical Journal of
Australia until the second edition appeared in 1950. As noted in chapter two, Marjory
Warren’s work was recognised in the 1940s in anonymous articles in The Medical Journal
of Australia, and J. S. Sheldon’s Social Medicine of Old Age, was reviewed in 1948 soon
after it was published.
72
In the early 1950s in the United States a number of professional bodies came together to
form a Commission on Chronic Illness - the American Hospital Assoc, American Medical
Assoc, American Public Health Assoc and American Public Welfare Assoc. Its findings
were published in four volumes in the course of the 1950s. In the US therapists played the
prominent part in developing aids and techniques. The manual published by the Institute of
Physical Medicine at the Bellevue Medical Centre at New York Hospital was used by
therapists at Mount Royal. With the exception of a small number of physicians, Dr
Howard Rush for example, doctors in the US showed little interest in civilian
rehabilitation, Gritzer & Arluke, op. cit.
73
R. F. Butterworth, ‘Localised Oesophagitis Due to Drugs’, MJA, vol 2, 1958, p.419-420
‘The Burning Skin Syndrome, Treatment with Hydroxychloroquin’, MJA, vol 2, 1960,
p.460-461. ‘ “Painful Leg” Following Strokes’, MJA, vol 2, 1963, pp.880-882, ‘Pneumatic
Device for Correcting Knee-Joint Contractures’, MJA, vol 1, 1965, pp.714-715. Annual
reports for Mount Royal in the years 1960-63 also list articles by Butterworth published in
General Practitioner of Australia and New Zealand, on the topic of knee joint deformity,
the management of stroke in general practice and incontinence in the elderly. Butterworth
141
also for those in the other states.74 In addition, they brought Australian
doctors together with the British practitioners whose work provided their
model. Marjory Warren visited Australia in 1958, Lionel Cosin followed
her in 1961, and W. F. Anderson in 1968.75
Even in the earliest attempts to develop geriatric services, it was made
clear that the restorative process entailed combining the skills of doctors,
nurses, therapists and social workers.
Medical knowledge of bodily
systems was combined with the skills of other health professions - in a
manner not usually seen in the general hospitals - to enable an elderly
amputee, often afflicted with multiple illnesses, to use an artificial limb, or
to restore independence in a stroke patient to whatever degree possible.76
Ideally
clinical
skills
combined
with
the
technical
skills
of
physiotherapists to strengthen muscles devise aides to mobility; with the
skills of occupational therapists to develop approaches to the tasks of
everyday life to encourage patients to persist through what was often a
slow process of bathing, dressing and eating; with the social worker’s
knowledge of a patient’s home conditions so he or she could be returned to
an environment where their hard-won independence would not be
undermined. In his first presentation at a Geriatrics Conference in 1958,
Robert Butterworth acknowledged the importance of his co-workers by
bringing them along to describe their contributions.77
In practice,
also contributed an article titled ‘Gerontology’ to Science Review, no 15, 1960, a
publication of Melbourne University Science Club.
74
Annual Report Hospitals and Charities Commission, 1955. John Lindell gave credit to
Elizabeth Johnson for the idea of the conferences and they continued from 1956 into the
1970s. The educative role of the Commission was fulfilled in a number of ways, these
conferences being only one of them. Others included awarding bursaries for various
categories of hospital staff to enable them to enter professional training with a higher level
of schooling, providing scholarships to enable managers and superintendents to gain
tertiary qualifications in this field, establishing the Mayfield Centre to provide training
courses for hospital staff, Inall, 1971, op. cit. p.49.
75
Collin Robjohn referred to Warren’s visit and how encouraging she was, Robjohn, op.
cit. p.89, see Geriatrics Conferences 1961 and 1968, Geriatrics Conference 1956-1966 op.
cit. and Geriatrics Conference 1967-1976, Hospitals and Charities Commission, Spring St
Melbourne, nd.
76
In the public hospitals doctors were inclined to assume that the poor peripheral
circulation that made amputation necessary would also ensure that it would be unlikely that
an artificial leg could be successfully attached to the stump. Consequently the operation
was not done with this in mind and there were further difficulties arising from the lapse in
time in these early days between amputation and the attempt at rehabilitation. The work
done in the geriatric units challenged the assumption that elderly amputees were not
candidates for artificial limbs. The doctors and technicians in the geriatric hospitals were
proud of their inventiveness in developing cheap, temporary prostheses that made it
possible to give patients the opportunity to regain mobility, see Geriatrics Conferences
1958, 1959, 1960, Geriatrics Conference 1956-1966, op. cit.
77
Butterworth, 1958, op. cit., p.13-14.
142
however, this ideal was achieved only patchily. Therapists were in short
supply, as were trained nurses and they were no more inclined to find the
work in these former benevolent institutions attractive than were medical
practitioners.78
The activity of nursing the infirm aged was transformed with the
introduction of the role of geriatrician. Graeme Larkins emphasised the
importance of the nursing role in his outline of rehabilitative treatment for
infirm old people. Where the measure of care provided by untrained
attendants was how much they did for their charges, in the environment of
restorative care the measure was how much the nurse was able to
encourage the patient to do for herself.79 The nurse needed to understand
the contributions of the different therapists to be able to reinforce them
outside treatment sessions. The relationship between patient and nursing
staff was fundamental to the success of restorative treatment because it
was continuous, whereas contact with therapists was intermittent.
In addition, the principle of encouraging activity in order to prevent illness
and disability was introduced into the nursing of patients who required
long-term care, giving the work of nurses in the long-term wards a
technical aspect. The avoidance of pressure sores through regular changes
of position and ‘pressure area treatment’; the treatment of incontinence by
means of routine measures; the recognition of the need for attention to
fluid intake and nutrition; all of these combined some degree of technical
understanding of the physiology of the aged body and a trained approach
to nursing care. There were special techniques to be learned but it was
also a matter of disposition.
The geriatric nurse, like the geriatric
physician described by Trevor Howell, needed to have a special
therapeutic interest in this group of old people. There was no place for the
nurse who took on the work as a matter of duty to a neglected group of
patients, or because it was considered less demanding than other types of
nursing.80
78
The Age, 24/4/71, quoted the Chairman elect of the Hospitals and Charities Commission,
as proposing establishing a ‘middle level’ of qualified therapists as a means of alleviating
the general shortage.
79
G. Larkins, 1956, op. cit. p.24.
80
R. Tabbner, ‘Geriatric Nursing’, Geriatrics Conference, 1960, Geriatrics Conference
1956-1966, op. cit. p.75ff.
143
The importance of the nursing role was acknowledged in the award of a
travelling scholarship, similar to those awarded to the first ‘geriatricians’,
to Ray Tabbner, registered nurse and Deputy Matron at Mount Royal.81
When the geriatric unit at Mount Royal was being planned, it was
proposed that nursing staff would come from the ranks of the trainee
nurses at the Royal Melbourne Hospital, as part of their general training
experience.82
This did not happen, possibly because of the general
shortage of both trained and trainee nurses in the early 1950s.
The
shortage was exacerbated by the overall expansion in the numbers of
hospital beds at the time, including the ‘hospitalisation’ of the benevolent
homes. In response to this situation the Commission established a system
of training at a lower level than the General Trained Nurse - that of the
Nurses Aide - and the Geriatric Hospitals thus became training schools for
their own staff.83 The question of equipping trained nurses to develop and
supervise this new nursing role was tackled by establishing a postgraduate
course of training at Mount Royal in the late 1960s.84
The Geriatric Patient
The ‘geriatric patient’ was defined at the annual Geriatrics Conferences
through the display of representative patients who demonstrated the
product of the combined activities of doctors, nurses, therapists and
institutional administrators.
Depending on the skills of the doctor
presenting these living examples, the appearance of rehabilitated patients
was both an illustration of the possibilities of restorative treatment and an
opportunity to teach the principles of an active approach to the medical
care of the elderly patient.
81
J. Uhl, op. cit. p.185-186. A report on this tour was presented at the 1959 Geriatrics
Conference, R. Tabbner, ‘Care of the Elderly Ambulatory People Overseas’, Geriatrics
Conference 1956-1966, op. cit. Up to this point it could not be taken for granted that the
Matron of Mount Royal would be a trained, registered nurse.
82
RMH Archives/Managers Correspondence/Medical Matters/1/ vol 15.
83
J. & B. Bessant, The Growth of a Profession, Nursing in Victoria, 1930s –1980s, La
Trobe University, Press, 1991, pp.71-73.
84
J. Uhl, historian of Mount Royal Hospital, dates the first postgraduate course in geriatric
nursing to the 1980s. However, Marion Shaw, the English nurse who arrived in Victoria in
the late 1960s, and went on to become an officer in the Geriatric Division of the Hospitals
and Charities Commission, says she participated in a postgraduate course at Mount Royal
in the geriatric unit, beginning in April 1969. Personal communication from M. Shaw,
March 1997. A reference to a post-basic nursing course in a talk given at the 1969
Geriatrics Conference by Kathleen Wilson, Principal Nurse Educator at Mount Royal,
confirms this, Geriatrics Conference 1967-1976, op. cit. p.74. A lecture published in the
MJA, in 1965, given by Sidney Sax to the second postgraduate nursing course at Concord
Repatriation General Hospital, suggests an earlier date for the introduction of postgraduate
144
Thus the account of restoring mobility in eighty-three years old Miss B,
whose leg had been removed because of arteriosclerotic gangrene, brought
out the need for vigilance in the prevention of bedsores.85 Having been
confined to bed for some time before her admission to Greenvale, a sore
had developed on the heel of her remaining foot and the noting of this
point was accompanied by a discussion of the methods of preventing and
healing such sores. When she was admitted she had lost all interest in life,
‘she was old, she’d lost her leg, attempts had been made to get her on her
feet, they’d been unpleasant to her and she’d given up hope.’ She was
prepared to spend what little time she had left sitting in bed waiting to die.
Had a rehabilitative approach been established practice in the public
hospitals, she may not have experienced this degree of despair.
At Greenvale the concerted efforts of therapists and nurses encouraged her
to make the effort required. An artificial limb was devised, - ‘nothing
much to look at’ - but she walked on it and ‘she’ll walk off with something
that’s well, quite passable for an artificial leg’.86 Once she had gained
some independence at Greenvale she was transferred to a halfway house,
where having got to the stage where she was looking after herself to a
certain extent in an institutional setting, she could then try herself out in a
more domestic environment.87 The hope was that she would return to her
little house in the inner Melbourne suburb of Richmond after it had been
checked to see what alterations were necessary to assist her to manage.
The rehabilitated patients exhibited at the Geriatrics Conferences were,
however, still a minority in the day to day work of geriatricians. On the
whole, the extent of deterioration in the patients referred to them ‘after
everyone else has had their go’ ensured that the patients who came into
training in this field in New South Wales, S. Sax, ‘Geriatrics: The Subject Defined’, MJA,
vol 1, 1965, pp.26-28.
85
Case presented by Dr David Wallace at the 1960 Geriatrics Conference, Geriatrics
Conference, 1956-1966, op. cit, p.97-98.
86
Wallace was, it seems, proud of what he, and his technician, were able to do cheaply and
effectively. They could make a light, temporary prosthesis for the cost of fifteen to twenty
pounds rather than the hundred or so needed for a conventional artificial leg. Other
solutions were even cheaper. Two or three pounds could provide a bucket and a peg leg,
also ‘rockers’ were devised for double amputees to provide a degree of mobility within
their home, with a wheelchair being used outdoors, Geriatrics Conference 1958-1959 for
examples, Geriatrics Conference 1956-1966, op. cit.
145
their care were, in the main, candidates for long-term care, with limited
prospects for effective rehabilitative treatment.88 Moreover, the continued
use of buildings erected in the nineteenth century, in the interests of
economy, to accommodate the unstemmed flow of infirm aged and the
chronically ill, ensured the persistence of aspects of the ‘benevolent
asylum’ era, particularly overcrowding and dilapidation. The foregoing
account of innovative techniques, the inventive fabrication of aids and the
air of optimistic cooperation amongst medical practitioners, nurses, social
workers and therapists thus provides a somewhat idealistic picture. At
best it was characteristic of the early years in the establishment of the
Geriatric Hospitals. After the mid-1960s the medical work of geriatrics
was defined in terms of the institutions in which it was located –
institutions which provided long-term care for individuals, most of them
elderly, with nowhere else to go. Despite the great hopes of the early
‘geriatricians’, the ‘geriatric patient’ in Victoria was still barely
distinguishable from the impoverished benevolent home inmate. David
Wallace made the association between geriatrics and poverty clear when
he defined it as the medical management of old people who, in addition to
physical and mental afflictions suffered from what he referred to as ‘social
infirmity’.
The combination of ‘lack of money, lack of friends and
relatives who can or will care for the patient … and general frailty which
makes it hard for an old person to continue to battle on leading an
independent existence.’89
Obstacles to Defining ‘Care of the Aged’ as Medical Work
One obstacle to the development of the geriatrician’s role as a provider of
medical services rather than the supervisor of institutional care, was the
condition under which doctors in the Geriatric Hospitals gained access to
87
Greenvale had a half-way house at Clayton. The importance of the half-way house in
restorative care was discussed by Graeme Larkins in his first contribution to the Geriatrics
Conference in 1956, ‘Modern Methods of Rehabilitation’, op. cit. p.25.
88
This telling phrase has been taken from notes for a lecture by Dr John Shepherd amongst
his personal papers. The lecture ‘A Total Geriatric Service’ was given in 1971. It is
substantially, a restatement of the aims John Lindell had identified when the first geriatric
units were established, an indication of the extent to which the original intentions had not
been realised.
89
D. Wallace, ‘Geriatrics Overseas’, MJA, vol 2, 1959, p.40-42. Wallace quoted Lord
Amulree in this definition. Amulree was an English physician and official in the National
Health Service, and author of the book Adding Life to Years, The National Council of
Social Services, Bannisdale Press, London, 1951. While encouraging the introduction of
geriatric departments into acute hospitals, Amulree opposed the creation of a new clinical
146
their patients. The majority of patients came from the public hospitals so
it was the relationship between the geriatrician and hospital medical
officers that was the source of greatest difficulty. It was noted above that
the ‘geriatrician’ occupied a place in the provision of hospital services
similar to that of the convalescent medical officer. In practice, however,
the geriatrician had the same difficulty in controlling the referral of
patients from the acute hospitals as did the earlier convalescent MO.90 As
a rule, patients in the public hospitals were brought to the attention of the
geriatrician after a period of treatment when it was clear that nothing more
could be done. Because geriatricians had no role in acute care, they had
no access to patients in the early days of their treatment, so it was more by
good luck than good management when they were referred patients who
were candidates for successful rehabilitation. The lack of a registrar to
establish an immediate connection between potential candidates for
custodial care and the geriatric service was an important factor in this
situation.91
Robert Butterworth hoped to circumvent some of the problems posed by
the lack of direct involvement in acute medical care by geriatricians by
setting aside a couple of beds in the geriatric unit for acute stroke cases, so
their restorative care could be integrated into their overall treatment. He
was unable to realise this ambition. His role as clinical assistant at the
Royal Melbourne did not encompass the provision of acute care and, in
addition, because of the pressure to take patients already waiting to be
discharged from the hospital, it would have been very difficult to maintain
the empty beds. In reality he was dependent on other hospital doctors to
refer patients to him and it was not very long after the geriatric unit was
established that he had cause to question their judgement of suitability. At
a meeting of the consultative committee soon after the geriatric unit
specialty as he believed the medical care of the elderly did not require any special approach
on the part of doctors other than an interest in this group of patients.
90
Ford, 1996, op. cit. pp.88-90.
91
Part of the initial agreement between Mount Royal and the Royal Melbourne Hospital
was that a registrar would be appointed to the geriatric unit. In fact a couple of doctors
were interested in the beginning but delay in opening the unit meant they had moved on to
other employment. Then RMH found it difficult to replace them, and the position of
registrar was not regularly filled. This is not surprising in view of the fact that such a
position had no point of connection with the training of physicians, RMH
Archives/Medical Matters/No 1/ 28, meeting of consultative committee 19/2/59. The lack
of a formal connection between the other Geriatric Hospitals and an acute hospital meant
147
opened, Butterworth cautiously noted ‘the slight tendency for RMOs to
dump patients on us’.92 He also feared the opening of a rehabilitation
hospital in the Royal Melbourne’s region would mean the patients referred
to the Geriatric Hospitals were likely to be very old and infirm.93
Butterworth’s sad observation that ‘we appear to be getting many decrepit
cases referred for admission … not all rehabilitation cases attend the
weekly Clinic’, illustrates the situation of the geriatricians within the
Victorian hospital system.94 His remark is the more telling since he was in
a better position to exert control over his work than any of his fellow
practitioners.
He was a member of the consultative committee that
oversaw the ‘cooperation’ between medical staff at Mount Royal and the
Royal Melbourne Hospital, he had an official position on RMH staff and
an outpatient clinic.95
Nonetheless he still appears to have had little
control over the referral of patients and there is no reason to think that the
experience of the other geriatricians was any better.
On the whole, general practitioners in the community were as ignorant as
their specialist colleagues in the public hospitals of the treatment offered
in the Geriatric Hospitals. Robert Butterworth played his part in educating
there was not even the possibility of a registrar to make a connection between the acute
wards and the geriatric service.
92
RMH Archives/Medical Matters/No 3/24.
93
See Chapter Two. Two small rehabilitation hospitals were established outside the acute
hospitals in the early 1960s, staffed by part-time medical officers. One was located at
Hampton, in a former annexe to the Childrens’ Hospital. L. Wedlick, formerly medical
officer in charge of the physiotherapy department at the Royal Melbourne Hospital, was
appointed honorary Director to establish the hospital, L.T. Wedlick, ‘Development of a
Rehabilitation Centre’, MJA, vol 1, 1961, pp.338-340. The other rehabilitation hospital,
the one Butterworth referred to, was located in the former colony for epileptics, the Royal
Talbot Centre, S. Steele, A Road to Rehabilitation, North Eastern Health Care Network,
Victoria, Australia, 1996, L.T. Wedlick, A Doctor’s Life (Odyssey) Leigh T. Wedlick, nd,
p.47.
94
RMH Archives/Managers Correspondence/Medical Matters/No 1/24/1969. Dr Eloise
Lucas who followed David Wallace as geriatrician at Greenvale, provided another view of
this situation when she remarked at a committee of management meeting that Greenvale
was in an unsatisfactory position taking patients from the Royal Melbourne because the
geriatrician at Mount Royal (Butterworth), being in charge of the clinic at RMH, ensured
that the ‘better type’ of case went to Mount Royal. Minutes Committee of Management,
Greenvale Village, 8/6/62.
95
The relationship between Mount Royal and the Royal Melbourne was an uneasy one. As
early as 1960, a meeting was called between representatives of both institutions and the
Hospitals and Charities Commission, to try to resolve the problems posed by the Royal
Melbourne regarding Mount Royal, even the Geriatric Unit, as a place to which chronic,
long-term patients could be cleared, and Mount Royal choosing to exercise its right to take
patients from any source. Note regarding meeting, 7/4/1960, by medical superintendent,
Mount Royal, from the personal papers Dr John Shepherd.
148
GPs by providing demonstrations and lectures in his unit.96 A special
interest group was formed in the very early 1960s within the Victorian
Branch of the British Medical Association but there is no record of any
promotional activities undertaken by this group.97 E. A. Eddy, medical
superintendent during the early sixties at Cheltenham Old People’s Home
(Kingston Centre), tackled the problem by placing a notice in one of the
Monthly Papers put out by the AMA, describing, for the benefit of local
GPs, the restorative treatment now available at his institution.
His
successors were also unsuccessful in attracting the interest of their local
colleagues, a situation Lloyd Jago accounted for by the tendency for
general practitioners to be excluded from the hospital system in general.98
While individual GPs may have been sufficiently interested to follow up
Butterworth’s demonstrations or to attend the occasional meetings and
lectures advertised in the AMA’s Monthly Papers, there was no formal
organisation providing an induction into the methods of restorative
treatment being developed in the Geriatric Hospitals. Also, if a GP, who
confronted with a patient who had suffered a stroke or whose arthritis was
making it increasingly difficult to get about, mentioned admission to a
Geriatric Hospital for rehabilitative treatment, the suggestion was likely to
be received unsympathetically. The view expressed by Horace Tucker’s
friends, when they asked why he was involving himself with those
dreadful old people, was most probably representative of the general
community perception of the Geriatric Hospitals.99 It highlights the point
that the people who did receive the benefit of restorative treatment were,
on the whole, those who had no choice, being in the public hospital with
nowhere else to go. There was a possibility of change when the hospital
insurance funds recognised rehabilitative treatment for the purposes of
claims by patients, but this could only influence the type of patient
96
An obituary for Butterworth in the Annual Report for Mount Royal, 1973, highlights his
educational activities and his inventiveness in developing devices to facilitate
rehabilitation.
97
Annual Reports Mount Royal, 1959-1963. This special interest group was formed while
the Australian medical profession was organised as state branches of the British Medical
Association. The Australian Association was registered in Canberra in 1961 and began
operation in January 1962 and the state branches then became branches of that association,
Pensabene, op. cit. p.168.
98
AMA (Victorian Branch) Monthly Paper No 76, May, 1969. Transcript of conversation
with Dr L. Jago, Oral History of Kingston Centre, 21/93.
99
See quote in footnote 32.
149
admitted for treatment once doctors and patients accepted such
practices.100
There is no doubt their medical colleagues were not disposed to take the
work of the geriatrician seriously. Had geriatricians been able to control
admission policy in their institutions, they might have been in a better
position to engage in negotiations with their colleagues in the public
hospitals - if for no other reason than to better expedite the transfer of
patients. However, even in their institutions geriatricians were not able to
gain control over the hospital environment.
Ten years after the
introduction of the expanded medical role into the benevolent institutions
and their reclassification as Special Hospitals for the Aged, the practice
continued of admitting patients according to position on the waiting list.
This in turn provided ammunition for demands for funds to provide
accommodation. The committee of management at the Kingston Centre,
despite the presence amongst them of a medical practitioner who could
have put the case for the provision of services rather than beds, hoped to
expand accommodation in the institution from around 600 beds to 1000.101
The Queen Elizabeth Home and Hospital at Ballarat was exceptional in
devoting resources to a domiciliary service designed to assist potential
patients to remain at home.102 Nevertheless the building virus lurked here
also. Collin Robjohn, appointed medical superintendent in the late 1950s,
resigned before his contract expired rather than remain and appear to
condone a fund raising drive by the committee to expand the institution, a
move he believed to be inimical to the provision of rehabilitation
services.103
Why were geriatricians in this awkward position? Why did they not, as a
group, bring pressure to bear on committees of management to change this
situation? It might have been expected that the Association of Geriatric
100
The annual report for Mount Royal, 1959 notes that the Director General of Health in
Canberra had given permission for patients admitted to the Geriatric Unit at the hospital, to
claim on their Hospital Insurance for the fees they were charged. This situation had
changed by the 1980s, see chapter seven.
101
Interview with Dr David Quinn, Transcript of Oral History of Kingston Centre, Ref
19/92.
102
Dicker, 1958, op. cit.
103
Robjohn, 1988, op. cit. p.94.
150
Medical Officers, formed in the early 1960s, would undertake this task.104
The Association, formed for the dual purpose of promoting the discussion
of common problems and representing the interests of these practitioners,
appears to have met for the former purpose only for a short period after its
formation. The only reference to the second aspect of its role appears in a
submission to the Hospitals and Charities Commission in the matter of
qualifications and the terms and conditions of employment of geriatric
medical officers.105 There is no indication that the Association played any
further part in advancing the role of geriatrician after these early years.
There is no doubt that geriatricians were not in the same favourable
position to establish professional associations as the doctors who were
cultivating the specialist fields that proliferated in the 1960s, in the
hospitals and research units around the city of Melbourne. Geriatricians
were, on the whole, isolated in institutions far distant from each other and,
in comparison, their numbers were few.106
Isolation and lack of numbers, however, do not entirely explain the lack of
action on the part of geriatricians to establish a more independent role as
providers of hospital services.
Just as influential was the absence from
the ranks of geriatricians of an individual who was prepared to take on the
undoubtedly difficult task of integrating the role of geriatrician into the
mainstream of medical work.
Instead it seems, the doctors who
persevered in working in the field of geriatrics throughout the 1960s were
those who, by virtue of age, gender and disposition, shared the same
conservative outlook as their mostly male committees of management.107
A conservatism that led them to be satisfied with a position of some
standing (such as medical superintendent), and significant, if limited,
104
A Special Interest Group was also formed within the Victorian branch of the British
Medical Association but apart from a brief reference to this by David Wallace, there is no
record of the section’s activities in The Medical Journal of Australia, see chapter six.
105
Personal papers Dr John Shepherd; VPRS 4523/P2/961/183-1.
106
Pensabene, op. cit. pp.163-166.
107
In the 1940s the Bendigo Branch of the National Council of Women made a direct
effort to seek the nomination of a woman for the next vacancy on the committee of
management of the Bendigo Benevolent Home, Cusack op. cit. p.193. There is no reason,
however, to believe that the inclusion of women in the committees of management would
have altered the inherent conservatism that seems to have imbued the ‘geriatric’
environment, an environment which reflected the broader society in the combination of a
respect for ‘science’ and ‘progress’ with suspicion of difference and a prejudice against
change, see S. Alomes, M. Dober & D. Hellier, ‘The Social Context of Postwar
Conservatism’, in Australia’s First Cold War, 1945-1953, eds A. Curthoys & J. Merritt,
Geroger Allen & Unwin, Sydney, 1984, pp.6-14.
151
power in the field of activity that was emerging around the provision of
care for the aged.
Those who were not so disposed, resigned – for enterprising medical
practitioners there were plenty of opportunities in other fields of medical
work at the time.108
The role of geriatrician did not offer sufficient
enticement to lure doctors into making the not insubstantial effort required
to bring this work into the mainstream. It could not compare with either
the technical advances that were taking place in the public hospitals, or
with the resurgence of general practice that had followed the introduction
of the national health scheme in the early 1950s.109 If George Rosen is
correct in nominating competition as an essential factor in the
development of medical specialisation, there was no competition to spur
the development of geriatric medicine.110
It is no accident that the
Geriatrics Conferences provide the best insight into the role of the
geriatrician in Victoria because the institution-based environment
displayed there, with its ethos of ‘care for the aged’ was the primary
influence shaping the medical work of geriatrics. It is entirely in keeping
with the direction taken by doctors in developing geriatrics in Victoria that
at a conference held at Lidcombe State Hospital in New South Wales in
1965, on the topic of ‘Clinical Problems Amongst Aged Patients’, the
Victorian contribution dealt with the provision of long-term care.111
108
The expansion of the hospital system in Victoria during the 1950s and 1960s provided
more positions within hospitals for doctors but these were absorbed into training positions
for the specialties that proliferated in the 1960s, R B. Scotton, Medical Care in Australia,
Sun Books Melbourne, 1974, p.76ff. In addition, the conditions of work for physicians, the
field where geriatric medicine would be located, were not so satisfactory as they were for
surgeons so the numbers of physician consultants did not grow at the same rate as the
numbers of surgeons.
109
Sir Earle Page, Minister for Health in the Menzies’ government and principal architect
of the national health system introduced in the early 1950s, included a quote in his
description of this system in which it is noted that the ‘Australian Medical Plan’ consisted
of two stages, both aimed at ‘restoring the position, prestige and fullest usefulness of the
general practitioner …’, Page, 1960, op. cit. p.47.
110
Pensabene, op. cit. pp.159-162. George Rosen notes that in the US and Britain, ‘the
organization of special ophthalmic institutions preceded the appearance of the
ophthalmologist’, it was competition amongst doctors in urban areas that was a significant
factor in the development of the specialty, Rosen, 1972, op. cit. p.33.
111
Newsletter of the Australian Association of Gerontology, vol 1, no 2, 1965, p.5. Dr
John Shepherd, medical superintendent of Mount Royal Hospital, gave a paper on the topic
of long-term care. The question arises of why Robert Butterworth did not speak about the
treatment of stroke, clearly a special interest of his. Possibly he did and the paper was not
included in the report on proceedings at the conference. Possibly the medical
superintendent took precedence over him. Lidcombe Hospital began as a reformatory for
recalcitrant boys, then during the 1890s depression, accommodated destitute old people and
the chronically sick. In 1914 it was renamed Rookwood State Hospital and Asylum and in
1943, Lidcombe Hospital. Its history was not unlike that of Mount Royal with a significant
152
If the failure of geriatricians to gain control over admission policy
suggests an absence of collegiality and initiative amongst these medical
practitioners, the question also arises of why the Hospitals and Charities
Commission did not intervene to ensure the efficient operation of geriatric
services by establishing medical control over admission policy.
The
Commission had, after all, been the principal sponsor of the geriatrician’s
role, and geriatric services were intended to play a part in the provision of
hospital services in Victoria. Why did the Commission not take whatever
steps were necessary to appoint geriatricians to positions where they could
influence policy?112 In the absence of any evidence on this matter it may
be speculated that first, the collaborative atmosphere in which geriatric
services were developed may have meant the possibility of achieving this
through negotiation was never closed off. However, the lowly position of
the Hospitals and Charities Commission in the bureaucratic hierarchy may
have contributed to the situation. Bridget McCoppin noted, in her early
1970s study of the Commission that the health portfolio ranked low
amongst ministerial offices. In the long reign of the Liberal Party (in
coalition with the Country Party), that began in the early 1950s, the
position of Minister for Health was a reward for loyal political service
rather than an indication of interest in the provision of health services.113
Assuming John Lindell may have wished to change admission policy in
the Geriatric Hospitals, he did not have a strong Minister to back him in
the face of protest from the committees of management of these
institutions. Individual members of these committees who were able to
gain the attention of the Minister, or better, the Premier could ensure any
measure they objected to was not pursued.
exception. That is Lidcombe was, from the period around 1914, under a medical model of
administration, not, as Mount Royal continued to be, a charitable model. In the period
1910-1914 a Labor government in New South Wales, unlike Victorian governments of any
complexion, included health services in its policy platform. At the time this meant the
direct provision of hospital services by the state alongside the large metropolitan voluntary
hospitals. The changes introduced then were part of a general move to upgrade the
facilities of asylums so they catered better for the needs of the chronically ill, G. Marcan &
J. Ballard, A Historical Tour of Lidcombe Hospital, Torch Publishing Co, Bankstown,
1995, Dickey, 1967, op. cit. pp.541-555.
112
In a submission to the inquiry into Victoria’s hospital services in the early 1970s, the
Geriatric Medical Officers Association noted the lack of medical representation in policy
making areas such as committees of management of the institutions and the Association of
Geriatric Centres, Personal papers Dr John Shepherd.
113
McCoppin, 1974, op. cit. p.95. McCoppin illustrates the point with the example of V.
O. Dickie, Minister of Health from 1965 to 1970, who had not, before his appointment
153
The isolation of geriatricians within Victoria’s general hospital system was
reinforced by a measure introduced by the Federal government, a measure
that effectively sidelined any attempt to introduce specialist medical
services for infirm old people. It was a measure that was very influential
in the provision of hospital services in the states, but one that was
introduced apparently without any reference to them. In an amendment to
the Hospital Benefits Act (1951) that came into effect in early 1963, the
federal government provided a subsidy for long-term care, thus entering a
field that had formerly been the responsibility of the states. This provision
derived from the operation of the system of voluntary hospital and medical
insurance introduced by the Liberal-Country Party coalition government.
From the inception of the Act in 1951, provisions were made for the
payment of subsidies by the federal government to enable insurance funds
to keep their rates at an affordable level while still providing cover for
patients who needed frequent admission to hospital (public or private) for
longstanding illnesses. Public hospitals also received a daily benefit for
the care of uninsured patients. The association between advancing age
and sickness or dependency ensured that old people were most prominent
amongst the beneficiaries of these subsidies.114
The subsidy introduced in early 1963 was directed towards the needs of
individuals who were not covered by hospital insurance and who were
deemed to require long-term care (there was already a benefit in existence
for those who were so covered).115 Like the other subsidies for hospital
care, this benefit, calculated on a daily basis, was paid directly to the
institution. As a consequence, a special category of hospital bed was
designated – the nursing home bed – out of a motley collection of
provisions for the long-term care of, in the main, dependent old people.
They included the infirmary wards in the Geriatric Hospitals, those in the
asked a single question or made any statement in the Legislative Council (the State Upper
House) relating to health matters.
114
Kewley, op. cit. pp.353-358. The effect of the introduction of the nursing home subsidy
in Victoria is documented in A. Howe, ‘Report of a Survey of Nursing Homes in
Melbourne’, Working Paper no 10, National Research Institute of Gerontology and
Geriatric Medicine, October, 1980, p.10-11.
115
Some insight into the system of benefits available then may be found in the
parliamentary debate on this matter. Allan Fraser, MHR for Eden-Monaro, pointed out that
patients already in ‘rest homes’ who had hospital insurance, received a benefit of one
pound per day. If that patient then was admitted to a public hospital that institution, with
154
voluntary agency homes, and the privately owned convalescent, rest
homes and small private hospitals scattered throughout the more affluent
suburbs of the capital cities. To be eligible for the benefit a provider of
long-term care had to be registered and formally recognised by the
Commonwealth.116
At the end of 1968 a supplementary subsidy was
introduced to pay for patients who were considered to need ‘intensive’
care; that is those who were substantially dependent on nursing care.117
Unlike all other subsidies for hospital care, eligibility for the nursing home
subsidy did not require a medical assessment of those requesting
admission. It was based on the unexamined view that the only possible
response to old age infirmity was the provision of bedcare. It resulted in a
proliferation of nursing home beds, many of them in Victoria in church
and voluntary agency homes but also in the private sector, and the
emergence of a powerful lobby group whose interests conflicted with the
advocates of rehabilitative geriatric services.118
Conclusion
The nursing home benefit did nothing to advance the cause of the
geriatrician, nor did it diminish the use of custodial care for infirm old
people. In Victoria (and indeed also in the other states) it undermined the
tentative beginnings of the geriatric service by adding to the possibilities
for discharging infirm old people from the public hospitals without using
the services of the geriatrician.
Hospital based medical staff were
reinforced in their predilection for dismissing infirm old people from the
field of active medical work, and the State government was relieved of
some of the burden of funding long-term care. The nursing home subsidy
also, incidentally, provided a source of funding for the Geriatric Hospitals
all its facilities and trained staff, would receive 8 shillings per day, Australia, House of
Representatives, 1962, Debates, vol HR37, p2791.
116
Private hospitals that provided care for the long-term sick as well as the acutely ill had
to chose which type of service they would continue with because of the conditions attached
to the subsidy.
117
This provision reinforced the tendency to accept that bed-care was the only response to
infirmity and with a financial benefit involved, moves to introduce rehabilitation treatment
which could minimise the need for care were unlikely.
118
In 1966 there were 23.4 beds per 1000 persons aged over 65 years, in 1976 there were
27.3 per 1000, an increase that was just ahead of the growth in aged population, Howe,
1980, op. cit. p19. In absolute numbers the total of beds available in State hospitals,
private and church nursing homes rose from 6665 in 1963 to 8321 in 1970, p.11. See also,
M. Coleman, ‘The Pattern of Permanent Care for the Aged’, Geriatrics Conference, 1969,
Geriatrics Conference 1966-1976, op. cit. pp.47-57. Coleman notes that in Victoria at this
time 71 per cent of nursing homes in private hands were managed by their proprietors, 30
155
in providing long–term care. The common perception in the Victorian
community that the provision of custodial care was the most appropriate
response to old age infirmity was reinforced financially, before the doctors
developing geriatric services in the former custodial care institution had a
chance to contest the practice.
The nursing home emerged as the
appropriate response to a generally perceived need, leaving the question of
appropriate medical services for old people at risk of being consigned to
the nursing home completely sidelined.
The Hospitals and Charities
Commission was helpless in the face of a process that undermined its
efforts, ambiguous as they were, to rationalise provisions for long-term
care and to provide treatment for a neglected group in the Victorian
community.
Nonetheless, within the small circle of Geriatric Hospitals and the larger
voluntary agency homes, geriatricians did exert an influence on the
provision of long-term care by establishing standards of service provision
and, to a limited extent, diminished the need for such care through the
provision of rehabilitation treatment. In a survey of hospital services
commissioned by the Victorian government in the early 1970s, it was
noted that the Geriatric Hospitals ‘appear to have a good record with
respect to rehabilitation and care of the elderly’. However the reservations
that accompanied this observation highlight the limitations of the
achievement of the doctors who persevered in developing the role of
geriatrician. It was noted that the institutions were very large, and while
size permitted economies of scale, it also produced an institutional and
impersonal atmosphere that was far from ideal. Outside the institutions,
however, this achievement paled into insignificance in comparison with
the proliferation of custodial care provision in the community, on the basis
of the nursing home subsidy.
In establishing a medical role defined in relation to old age, geriatricians
had aligned themselves with the community ethos of doing ‘something’
for the deprived and infirm aged. In time they settled into a role defined
by their committees of management on one hand, and by the total lack
interest on the part of their medical colleagues on the other. Employed in
per cent were managed on behalf of financiers of some kind. She also included details of
large financial enterprises that emerged at this time to provide nursing homes, p.53-54.
156
institutions closely associated with the Hospitals and Charities
Commission, geriatricians in Victoria in 1970 may be fruitfully compared
with the institutional psychiatrist in nineteenth-century Britain. There also
the number of doctors employed increased and the institutions became
more numerous.
While the barracks system of hospital care in the
Geriatrics Hospitals may have diminished, a similar atmosphere prevailed
in which the principal medical career was that of medical superintendent.
The geriatric medical officers who filled positions lower down the career
ladder, had limited prospects, their role being confined to easing the
burden on the superintendent.119
119
A. Scull, C. Mackenzie & N. Hervey, Masters of Bedlam, The Transformation of the
Mad-Doctoring Trade, Princeton University Press, Princeton, New Jersey, 1996, p.269.
157
CHAPTER 4
PSYCHIATRY AND OLD AGE
Introduction
In the early 1950s, Victoria’s mental health services were subject to an
extensive process of reform under the direction of an English psychiatrist,
E. C. Dax, who was appointed Chairman of the new Mental Hygiene
Authority. The sort of geriatric service that John Lindell, Chairman of the
Hospitals and Charities Commission, had tried to establish in the
benevolent homes was also introduced into mental health services as part
of this process. Although G.V. Davies, one of the few psychiatrists who
were interested in health and illness in old age, showed in an early 1960s
study that the patient for whom geriatric services were intended, was badly
served within the existing organisation of hospital services, psychiatrists
and geriatricians had to pursue their attempts to develop geriatric services
separately because of the division between services related to physical
illness and services related to mental illness.
This chapter traces the
development of a medical role in the provision of age-specific services in
the mental hospitals. Themes prominent in the previous chapter emerge
here also, the funding of hospital services and state/federal relations, and
the relationship between the community and the medical profession in the
provision of services.
The difference is that the more advanced
development of a theoretical model in relation to the geriatric service in
the psychiatric system, makes it possible to examine the situation in
Victoria up to the early 1970s, in relation to a body of sociological
literature in which the claim is made that as psychiatry developed as a
specialist field of practice, it became implicated in the maintenance of
social order.
Within the psychiatric system the ‘geriatric service’ was one element in a
broader process aimed at shifting the focus in treating mental illness, away
from institutional provision into local, community-based mental health
services. Psychiatrists were encouraged to develop an age-specific field of
practice as part of a general development of the professional setting for
psychiatry, a development that led to the revival of the role of public
institution psychiatrist. Overall, by the early 1970s, they had not achieved
this aim and their failure can be attributed to factors similar to those that
157
limited the development of geriatric services in general medical services.
Factors such as the inability or unwillingness of the State government to
provide adequate funding for the plans it encouraged its bureaucrats to
implement, its reluctance to upset existing interests to facilitate these
changes, and the effect of the subsidy provided by the Federal government
for nursing home care.
There was, however another dimension to the failure of psychiatrists to
establish either an age-specific form of hospital and medical service or a
cognitive model for a psychiatry of old age, a dimension that was related
to the professional environment in which they were situated.
Local
psychiatrists were in an ambiguous position because, first, although they
were encouraged to develop a model of mental health and illness in old
age, the biographical model that appeared to be most suited for this
purpose was out of kilter with their colleagues’ preoccupation with a
biological model of mental disease. Furthermore the overall shift away
from institutional care that underpinned the development of psychiatric
services in the 1950s and 1960s was limited in relation to elderly patients.
The adverse circumstances in which these psychiatrists worked accounted
largely for this failure.
However, at the same time their limited
achievements were also related to reluctance on the part of E.C. Dax to
engage with the community-based groups who provided care for the
infirm aged because he could not do so under the conditions he believed
were necessary.
These ‘internal’ limitations on the development of age-specific psychiatric
services offer some insights into aspects of the critical literature around the
practice of psychiatry that began to appear in the 1970s. Theorists have
sought, in different ways, to establish the claim that the emergence of
psychiatry as an established specialty entailed collaboration between
psychiatrists and dominant social forces with the effect that the operation
of political power was extended into the realm of everyday life. The
discipline of psychiatry became an instrument in the maintenance of social
order by contributing, in the examples noted in this chapter, to the
construction of femininity and the conditions necessary for a capitalist
158
economic order.1
There is no scope in this chapter for an extensive
engagement with this literature but the early concern amongst Victorian
psychiatrists with mental health in old age does provide some insights into
the ‘disciplinary’ role of psychiatrists.
They did engage in
‘problematising’ aspects of everyday life in relation to old age, but there
were self-imposed limitations on the extent to which psychiatrists were
prepared to be involved in dealing with this ‘problem’. These limitations
were associated with the cognitive model psychiatrists sought to establish
in the postwar period, and with their unwillingness to compromise their
model of service, even at the cost of the continued neglect of infirm old
people.
States of Confusion
The psychiatrists who were interested in the care of elderly patients and
the doctors in the Geriatric Hospitals were aware that they shared a
common interest in focusing on elderly people who were at risk of needing
custodial care. In the 1960s the only arena in which this common interest
could be addressed was the annual Geriatrics Conferences sponsored by
the Hospitals and Charities Commission, and, after 1965, the meetings of
the Australian Association of Gerontology.2
The 1961 Geriatrics
Conference was the first time this psychiatric dimension of the ‘geriatric
patient’ appeared, at a session titled ‘Confusion – A Problem of Old Age’.
A brief review of this session provides a useful introduction to the issues
surrounding the efforts of psychiatrists to develop a specialist field of
practice in the treatment of elderly patients during the 1960s.
The question of how the provision of medical services for the ‘geriatric’
patient was to be divided between psychiatrists and the nascent
geriatricians in the Geriatric Hospitals had yet to be decided. While the
medical practitioners involved in this work may have been able to
1
P. Miller, ‘Critical Sociologies of Madness’, in The Power of Psychiatry, P. Miller & N.
Rose, eds, Polity Press, Cambridge, 1986, p.29ff. The texts referred to in this chapter are;
J. J. Matthews, Good and Mad Women, The Historical Construction of Feminity in
Twentieth-Century Australia, George Allen & Unwin, Sydney; A. Scull, Decarceration,
Community Treatment and the Deviant – A Radical View, 2nd edn, Polity Press, Cambridge,
1984; N. Rose, Governing the Soul, The Shaping of the Private Self, Routledge, London,
1990.
2
For the Australian Association of Gerontology see Chapter Five.
159
negotiate an arrangement between them, a substantial obstacle lay in the
administration of psychiatric services and physical illness services by
separate, semi-autonomous bodies linked to the Department of Health.
Another fundamental problem that faced psychiatrists, and geriatricians,
was the question of how the approach to old people at risk of needing
custodial care was to be shifted away from the provision of long-term care,
towards episodic treatment supported by a range of welfare provisions. In
Victoria the fragmentation of responsibility for the provision of
community-based services, and the complete separation of such services
from hospitals made the necessary coordination virtually impossible. In
addition, doctors in the psychiatric service and the Geriatric Hospitals
confronted a situation in which many individuals in the group of patients
for which they were claiming responsibility did in fact need custodial care.
To focus on the provision of acute hospital services in the face of this
existing and unalterable demand was to run the risk of excluding these
individuals from the medical sphere altogether - the only source of
attention at this time for mentally disturbed old people.
The principal speaker in this Conference session was Lionel Cosin, the
physician in charge of the Geriatric Unit at the Cowley Rd Hospital,
Oxford, England.3 Earlier in the conference Cosin had described how his
unit operated within a local hospital service, admitting all old people who
were considered in need of hospitalisation and specialist medical services,
including those patients whose mental state gave cause for concern.4
When Cosin referred to ‘all’ old people, he was referring to those who
depended on publicly funded services. Anyone who could afford to pay
for medical attendance, and chose to do so, would not be categorised in
this manner.
It was the unified approach to sickness in old people
promoted by Cosin, that ensured the topic of mental disturbance was
3
‘Confusion – A Problem of Old Age’, Geriatrics Conference, 1961, Geriatrics Conference
1956-1966, op. cit. pp.89-106. Cosin was one of the small group of English doctors who
established the Geriatric Service to provide appropriate hospital and medical services for
old people at risk of needing custodial care, see Chapters Two and Three. Cosin’s
association with the efforts of Victorian doctors to establish similar services began early in
the 1950s when John Lindell, visited England. It continued into the late 1970s when the
Hospitals and Charities Commission brought him out to Victoria to advise on the
development of a Geriatric Service in the eastern suburbs, see, Dr L.Z. Cosin, ‘Report on
Eastern Suburbs of Melbourne Geriatric Services Development & Manvantara Hospital,
June, 1979.
4
Ibid. p.20-21.
160
presented on this occasion as ‘confusion’.5
The term indicates the
existence of a condition requiring investigation, with the possibility that it
is treatable or at least manageable, by a physician or psychiatrist. The
approach promoted during this conference session contrasted with the
more common response that saw mental disturbance in the elderly as a
form of insanity, an irremediable and hopeless condition which, until the
category of voluntary admission was established in the State mental
hospital, required certification as insane.6
The contributions to the discussion from a local geriatrician and a
psychiatrist made it clear there were significant obstacles to overcome
before they too could present the condition of mental disturbance as
generic ‘confusion’.
John Shepherd, recently appointed medical
superintendent of Mount Royal Geriatric Hospital, made the point that
while he was aware of the need for immediate and appropriate diagnosis
of mental disturbance, and he believed he had the facilities to provide such
a service, his lack of authority in regard to his institution’s admission
policy limited the scope of his activities.7 The Hospital continued to admit
patients according to position on a waiting list and it was impossible to
provide the immediate attention these patients required.
Shepherd’s
remarks revealed the shortcomings of the services provided in the
Geriatric Hospitals. He may also be interpreted as staking a claim to
territory that belonged, in as much as it was anyone’s, to the psychiatrists.
His comments foreshadow a dispute that was to arise in the future between
geriatricians and psychiatrists.8
5
The term ‘mental disturbance’ will be used in this chapter to refer to conditions that
brought elderly patients into the psychiatric service. Use of the term ‘confusion’ as
recommended by Lionel Cosins, did not become common in Australia until the late 1970s
and this chapter deals with the period from the mid to late 1950s, to the early 1970s. Anna
Howe notes that the term ‘confusion’ did not enter everyday use until the late 1970s when
psychogeriatrics was first included as a topic for discussion at the annual conference of the
Australian Association for Gerontology, A.L. Howe, ‘From States of Confusion to a
National Action Plan for Dementia care: The Development of Policies for Dementia Care
in Australia’, International Journal of Geriatric Psychiatry, vol 12, 1997, p.166. Professor
Tom Arie from Nottingham used the term ‘confused elderly’ at this meeting and it was
taken up generally from there. Arie’s influence would have been reinforced when local
psychiatrists were sent to his unit for postgraduate training in psycho-geriatrics in the early
1980s, when renewed efforts were made to develop psycho-geriatric services, Personal
Communication from Assoc Prof. E. Chiu 27/9/2000.
6
See Chapter Two.
7
Geriatrics Conference, 1961, op. cit. p.97-98. For admission policy in the geriatric
hospitals see Chapter Three.
8
An indication of the extent of the differences between ‘geriatricians’ and
‘psychogeriatricians’ may be found in the response of psychiatrists to the establishment of
a psychogeriatric unit at Mount Royal. The unit was opened in the mid-1980s under the
161
The other local contribution to the session was made by E. C. Dax,
Chairman of the Victorian Mental Health Authority and consultant
psychiatrist. Dax chose to speak about an aspect of the problem presented
by ‘confused’ old people, that was important because it highlighted a
neglect that should have been easily rectified. It was, however, not one of
the most pressing problems faced by the psychiatrists he encouraged to
develop specialist medical services for elderly patients.9 Cunningham Dax
was appointed Chairman of the newly constituted Mental Hygiene
Authority in the early 1950s, with a commission to reform public mental
health services in Victoria.10 It is not clear that the use of the term
‘hygiene’ by Victorian legislators indicated any special understanding of
the scope of activity of the new authority as being concerned with the ‘art
of healthy living’ as well as the treatment of disease. In any case hygiene
was soon replaced, informally, in the title of the Authority by the word
‘health’. When he spoke at the Geriatrics Conference Dax was at the end
of his first decade as Chairman and it was almost four years since he had
instigated moves to establish special geriatric services within the mental
health system.
Dax began by acknowledging that mental disturbance in some elderly
patients was a sign of serious and, often, irremediable disease, soon
followed by death. He chose, however, to emphasise the point that in
many elderly patients mental disturbance was just as likely to be an
indication of inappropriate medical care, as of the mental state of the
patient. He gave the example of an elderly man he had been called to
direction of J. Tulloch, one of the first locally trained physician geriatricians. A memo to
the Chairman of the Victorian Health Commission from the Directors of the Hospitals
Division and Mental Health, calling for a formulation of policy guidelines relating to a
rational development of services, notes that the proposal to establish the unit at Mount
Royal was ‘not necessarily desirable’. This memo followed a meeting in 1979, between
the medical administrators at the Geriatric Centres in the metropolitan area and the
psychiatric hospitals, at which the recurring topic of co-ordination of services between the
two sections of hospital services was discussed. VPRS 4523/P2/1064/1979-45. A personal
communication from Dr Herbert Bower, psycho-geriatrician, 17/7/2000, suggests that the
differences between psychiatrists and physician geriatricians in Victoria were resolved
amicably during the 1980s.
9
Geriatrics Conference 1961, op. cit. p.89-91.
10
R. Inall, State Health Services in Victoria, Occasional Monograph No 4, Department of
Government and Public Administration, University of Sydney, 1971, p64.ff; B. Robson,
‘An English Psychiatrist in Australia: Memories of Eric Cunningham Dax and the
Victorian Mental Hygiene Authority, 1951-1969’, History of Psychiatry, 13, 2002, pp.6987.
162
assess because of the man’s response to admission to hospital for a
procedure.
The man had refused to cooperate in what he viewed as an assault on his
person, and the medical staff had interpreted his reaction as requiring a
psychiatric opinion. Dax pointed out that the man’s response arose not so
much from his own mental state, as from the approach taken by medical
and nursing staff.
They had failed to provide an explanation of the
situation so he could understand it; had failed to take account of the
possibility that the hyoscine they gave him might not have been
appropriate, or that his history of heavy drinking may also affect his
reaction to it. Confusion in this case was not so much related to the
patient’s condition - he could have been ‘nursed’ through that, Dax said as to failure on the part of medical and nursing staff to perceive his
particular needs.11
Lionel Cosin amplified the point that confused thinking in old people did
not necessarily indicate an irretrievable breakdown in an individual’s
capacity to continue to live in the community. He referred to surveys of
the area served by his hospital showing that many elderly people lived
well and happily in familiar localities with the support of families and
neighbours, despite some degree of mental confusion. It was only when a
crisis fractured their social competence that their mental state became a
matter for concern: a crisis that might arise from changes in physical
condition, social situation or a combination of both. By focusing on these
elements, through medical treatment and support in the domestic
environment, the patient’s competence could be restored.12 But it was not
only access to immediate hospital admission that made it possible to
regard mental confusion in the elderly as a treatable condition. This group
of elderly patients needed also to be lodged within a network of
observation and support, extending from the geriatric unit into the
domestic environment, and this included a promise by hospital authorities
to carers that should it be necessary, immediate readmission would be
available. Social and medical support was provided to reinforce, what
11
12
Geriatrics Conference, 1961, op. cit. p.89-91.
Ibid. p.92-94.
163
Cosin believed to be, the most important factor in maintaining competence
in everyday life. That is ‘how one feels about one’s ability to cope’.13
Dr C.J. Cummins, Director General of the Department of Public Health in
New South Wales and responsible for overseeing the State-run hospitals,
proposed another ‘community’ view. He also advocated the provision of
the appropriate acute facilities to ensure sick old people were properly
investigated.
At the same time he referred to the special provision
necessary for those who were ‘completely out of touch with reality’, so
that they could ‘exist in an atmosphere of tranquillity removed entirely
from any conflicting influences with which (they) … find it hard to cope’.
14
Around the time of the conference, a Royal Commission into one of the
large mental hospitals in New South Wales, had brought to light the
appalling conditions in which old people were cared for there. Following
the recommendations of the Commission, Cummins’ department had
removed these patients en masse into unused district hospitals, that were
then given over to the management of church groups.15 This move was
certainly a matter of expediency – the removal of these patients was not
associated with the provision of any special form of care at the time.
Force of circumstances may have meant that in this case Cummins
presided over a response to the needs of infirm old people that he knew
was inadequate. At the same time, however, under his direction, steps
were being taken to establish specific services in New South Wales, for
old people at risk of needing custodial care, and these did include special
medical services. Cummins’ acknowledgment that the provision of agespecific hospital services also needed to take account of the needs of those
who required long-term care meant that it was more likely that appropriate
provision would be made.16
13
Ibid. p.2-21.
Geriatrics Conference, 1961, p.96.
15
Following the Royal Commission a Division of Establishments was set up within the
Department of Health, and separated into three sections of which Geriatrics was one.
Under the first Director, Sidney Sax, this Division focused on development of community
based services to minimise the need for institutionalisation. Cummins hoped to encourage
church and other voluntary groups to provide the facilities for those old people who needed
long-term care. Presumably this is what he referred to in his talk at the 1961 Geriatrics
Conference, when he spoke about another ‘community view’, Personal communication
from Dr S. Sax, 13/4/2000; ‘Care of the Aged and Chronically Ill’, Editorial, MJA, vol 2,
1960, p.587-588.
16
MJA, ibid.
14
164
The emphasis Cosins put on acute medical services raised the possibility
that those patients whose needs could not be met in this fashion would be
neglected.17
In view of the problems Cunningham Dax faced when he took on the task
of reforming the State’s mental health services, it might have been
expected that he, like Cummins, would have referred to the need to make
suitable provision for old people whose immediate needs could only be
met through the provision of long-term care. The extent of the difficulties
in relation to elderly patients that confronted Dax when he first took on the
position of Chairman of the Mental Hygiene Authority, was made very
clear in a survey of the country’s mental hospitals in the mid-1950s.18
Alan Stoller another English psychiatrist who came to Australia in the late
1940s, was commissioned to undertake this project by Earle Page, then
Commonwealth Minister for Health.19
In Victoria, Stoller found a
situation that, he said, was roughly the same in all states:
The problem of the senile has been a severe burden to all Mental
Hygiene Departments, ... It is interesting to note that, although the
number of seniles had increased from 1948-53, the proportion in the
population had remained constant.
Senile admissions were
appreciably higher in 1951-52-53 than in 1947-48-49, and the
17
In fact the plight of old people in England who had nowhere else to go other than the
publicly funded institutions, received much publicity in the early 1960s and this included
those who were admitted to mental hospitals because there was, apparently, nowhere else
for them, B. Robb, Sans everything, A Case to Answer, Nelson, London, 1967. Peter
Townsend’s study published in 1962, found old people in local authority accommodation
well below the standard of the public assistance infirmaries where they may have been
accommodated before physicians such as Cosin and Marjory Warren established the more
rigorous standards of illness that saw these people put back into the community, P.
Townsend, The Last Refuge: A Survey of Residential Institutions and Homes for the Aged
in England and Wales, Routledge & Kegan Paul, London, 1962, p.27ff, pp.34-36. Pat
Thane notes that the effects of Geriatric Services were slow to spread amongst hospital
services in general because the success of the Service depended upon the commitment of
the person in charge of it, Thane, 2000, op. cit. pp.451-453; see also C. Webster, ‘The
Elderly and the Early National Health Service’, in Life, Death and the Elderly, eds, M.
Pelling & R.M. Smith, Routledge, London, 1991.
18
Report on Mental Health Facilities and Needs of Australia, presented to the
Commonwealth Minister for Health, by A. Stoller with K. W. Arscott, 1955, pp.56-94.
19
Stoller was appointed Chief Clinical Officer in the Mental Hygiene Authority under Dax,
but could not take up the position until 1955 because he was occupied with this survey.
165
proportion under care in mental hospitals was twice that of the
proportion in the community. Roughly a third of all admissions
were over the age of 60. Many of these were obviously sent in to
die, as 40 per cent of the deaths which took place were within a year
of admission.20
Psychiatrists not only had to deal with a rising number of admissions, they
also had responsibility to provide proper care for patients who had been
admitted when younger and grown old in the mental hospital.21 Many in
this group no longer needed to be in a hospital environment, but there was
nowhere else for them go. There had always been some exchange of
patients between the psychiatric hospitals and the benevolent institutions
(now Geriatric Hospitals) and this continued. However such patients also
had to take their place in the queue for admission.
Why did Dax not join Cummins in calling for the proper provision of
long–term care?
The Geriatrics Conference was a suitable venue for
highlighting the needs of a neglected group of old people because the
conferences were attended by representatives of the church and voluntary
groups that, from the 1950s when the Commonwealth began to provide
subsidies for age-specific accommodation, had begun to establish an
extensive field of activity in providing special forms of accommodation
for the aged.
In choosing to follow Cosins and emphasise the provision of appropriate
medical services in an acute setting, Dax was, no doubt, trying to avoid
encouraging what he clearly believed to be a too-ready resort to the
provision of institutional care in Victoria.22 In his view, institutional care
20
Stoller, 1955 op. cit. p.169.
In his Beattie-Smith Lecture, J.F.J. Cade noted that the mental hospitals accepted patients
unwanted anywhere else although they did not necessarily need psychiatric treatment,
‘Beattie-Smith Lecture’, MJA, vol 2, 1951, p.218.
22
E. C. Dax, ‘The Accommodation and Treatment for Mentally Disturbed Geriatric
Patients’, in Growing Old, Problems of Old Age in the Australian Community, ed A.
Stoller, F. W. Cheshire, Melbourne, 1960, pp.40-45, Second Australian Medical Congress,
Plenary Session on “The Problems of the Aged in Society’, MJA, vol 2, 1965, p.565, and,
‘The Problem of the Aged in Society’, MJA, vol 2, 1966, pp.201-203. It is open to
question whether the demand for institutional care arose from a general disinclination on
the part of Australians to take care of their infirm old people at home. The doctors who
had regular contact with families in this position were inclined to dispute this and many
applicants for institutional care did not have families, A. Howe, ‘Family Support of the
Aged: Some Evidence and Interpretation’, Australian Journal of Social Issues, vol 14, no
4, 1979, p.266. Richard Gibson, the physician who established a Geriatric Service at the
21
166
should be aligned with a system of acute services, such as those Cosins
had described, to ensure that only those who needed long-term care were
admitted to institutions. However in view of the lack of facilities for old
people whose mental state had led to their rejection by family, neighbours
and other institutions, it seems short sighted to emphasise the provision of
acute services from which patients would be discharged.
Dax’s insistence that the provision of acute medical services should
precede the provision of institutional care certainly reflected a response to
the local situation in which the needs of infirm old people were interpreted
wholly in terms of custodial care.
It also reflected I believe, Dax’s
objective in reforming the mental hospital system; that was to establish a
system of acute medical services backed by rehabilitative facilities,
underpinned by research based on a biological interpretation of mental
disease.23 In a professional context shaped by this intellectual orientation
the provision of age-specific psychiatric services was a means of dealing
with that remnant of patients for whom this approach was unsuccessful.
Psychiatrists were limited in what they could achieve in terms of a
cognitive model to mental health in old age by the overall model
governing the interpretation of mental disease, and were limited to
establishing services to support patients for whom this model had nothing
to offer. Their efforts to do this were dogged by the need to accommodate
those old people who could not be returned to the community, a problem
that was not confronted, partly because of Dax’s insistence on the priority
of acute medical services. At the same time, while psychiatrists were
encouraged to develop a psychiatry of old age, the uselessness of the
biological model in this venture meant that doctors were not attracted to
the field.
Royal Newcastle Hospital, said in 1970, that families were willing to care for their old
people ‘and they will do so if presented with a properly assessed and secure proposition’,
quoted in S. Sax, A Strife of Interests, Politics and Policies in Australian Health Services,
George Allen & Unwin, Sydney, 1984, p.213. Herbert Bower, on the other hand, the
Victorian psychiatrist who played a prominent part in laying the foundations for psychogeriatrics, said in his Beattie-Smith Lecture in 1964, ‘The younger generation is quite
prepared to go to considerable lengths in relief of intolerable living conditions experienced
by the aged, but it must be on their terms, and must not involve them personally.’ MJA,
vol 2, 1964, p.287.
23
B. Robson, ‘The Making of a Distinguished English Psychiatrist: Eric Cunningham Dax
and the Mythology of Heroics’, PhD Thesis, University of Melbourne, 2000, p.137ff.
167
Bringing Old Age to Light in the Mental Hospitals
The ‘severe burden’ of providing appropriate care for old people in the
mental hospitals, highlighted by Stoller in his survey, was but one aspect
of the complex task that confronted Cunningham Dax in the reform of the
State’s mental health services. It was a task commissioned by a State
government unwilling to give the first Director of the newly constituted
Mental Health Authority control over the finances at his disposal and
unwilling, possibly even unable, to match its demand for reform with the
appropriate level of funding.24 When Dax spoke at the 1961 Geriatrics
Conference he had already taken steps to develop special psychiatric
services for all patients over the age of 65.25
Herbert Bower, medical superintendent of the Beechworth Mental
Hospital was appointed medical superintendent of Willsmere Hospital at
Kew, and the institution was given over almost entirely to the care of
elderly patients.26 Bower, ‘young, ambitious and confident’, a newcomer
himself to Australia, was one of Dax’s supporters amongst Victorian
psychiatrists, not all of who approved of the approach he took to reforming
the public mental health institutions.27
At Mont Park Hospital, G.V.
Davies was allocated wards designated for the treatment of elderly
24
As early as 1952 the annual report of the new Mental Hygiene Authority noted the
inadequacy of the funds available to it. This was compounded by the necessity for the
Chairman of the Authority to receive authorisation for expenditure from the Public Works
Board, a process that led to lengthy delays in executing plans for building and
refurbishment. The problems Cunningham Dax faced arose from the administrative setting
in which he had to work. The Mental Health Authority was one of the semi-autonomous
bodies that oversaw the provision of the State’s infrastructure – power, roads, hospitals etc.
In this administrative system ministerial control was exerted principally by control over
finances, control separated from policy for which the head of the relevant authority was
responsible, A. F. Davies, 1960, op. cit. pp.184-186. For the state of Victoria’s finances in
the 1950s and 1960s, see Chapter Two. The Federal government had, since 1948, made
some contribution to the States for the upkeep of patients and capital works in mental
hospitals. Payment of the Age Pension for old people who were pensioners, ceased when
they entered a mental hospital. In 1948 legislation was introduced to enable the payment
by the Commonwealth to the States to cover the loss of revenue involved, and patients in
State mental hospitals were not required to pay hospital fees. This situation continued until
1966 when amendments were introduced to ensure payment of the Age Pension continued
following admission to a mental hospital in the same way that pensioners continued to
receive payments during admission to a general hospital. Kewley, op. cit. p.249, p.305,
pp.422-423.
25
Age of eligibility for the Age Pension had, since 1909, defined the starting point of old
age in Australia and the category of the ‘elderly’.
26
E.C. Dax, Asylum to Community, The Development of the Mental Hygiene Service in
Victoria, F.W. Cheshire, Melbourne, 1961, p.100ff.
27
Bower joined the Mental Health Department in 1949 as an emigrant from Europe and
responded readily to Dax’s enthusiasm, Robson, op. cit. 2000, pp.38-40.
168
patients. Davies, a physician who took up psychiatry late in his career,
exemplified the trend, noted by Humphrey Rolleston in the 1920s,
whereby doctors most interested in the topic of illness in old age were
those at that stage of life themselves.28 Davies believed the similarity in
age between himself and his patients made for a degree of empathy not
common in doctor-patient interactions.29
The prominence of just two
psychiatrists, Davies and Bower, in this account of the early days of agespecific psychiatric services suggests that another problem Dax faced was
a lack of interest on the part of other psychiatrists in this field of work.
There was little difference in the services geriatricians were commissioned
to establish in the benevolent institutions in the late 1950s and those
proposed for the psychiatric system. Both services were based on an
English model in which hospital and community based services were
combined in the objective of limiting the need for institutional care for
elderly people. Had there been any possibility of cooperation between the
Mental Health Authority and the Hospitals and Charities Commission (the
body responsible for overseeing the provision of general hospital
services), the one type of service would have served the interests of both
authorities. There was, however, a significant difference between the two
ventures, one that had the potential to promise a more favourable outcome
in the psychiatric institutions. In the mental hospital system, the move to
develop age-related services was part of an overarching model of medical
service where curative, preventive and restorative services were combined.
The internal coherence of the service model within which psychiatrists
worked did not diminish the effects arising from the isolation of mental
hospitals from general hospitals on one hand, and welfare provisions in the
community on the other. Nevertheless psychiatrists did have an advantage
in this respect that was not available to the doctors in the Geriatric
Hospitals.30 There the introduction of geriatric services was isolated from
the general organisation of medical services, and the incongruity of the
socio-medical model underpinning them with the disease-based model that
informed other forms of medical work highlighted this isolation.
28
H. Rolleston, Some Medical Aspects of Old Age, Macmillan and Co. Ltd. London, 1922,
p.7.
29
G. V. Davies, ‘Family Structure and Family Attitudes of Elderly Mental Hospital
Patients’, PhD Thesis, University of Melbourne, 1967, Introduction.
30
Dax, 1961, op. cit. p.100ff.
169
In his description of the ideal ward setting for the treatment of elderly
patients, G. V. Davies echoes the requirements Graeme Larkins listed for
the effective operation of the rehabilitation unit in the Geriatric Hospital.31
Davies noted that even an old ward could be made welcoming with
pictures on the walls, flowers, music and television – a comment that
indicated psychiatrists, like their colleagues in the Geriatric Hospitals, also
had to make do with settings that were often far from salubrious. A
cooperative atmosphere amongst the various health professionals working
in the unit reinforced this welcome, making patients and families
comfortable in the mental hospital environment, one that often aroused
apprehension. Davies also echoes Larkins in emphasising the necessity of
separating the treatment setting from the long-term wards to ensure
patients took a positive view of their condition.
The more ‘sombre’
picture of mental disorder in the long-term wards could be discouraging.32
A geriatric service was planned for the mental hospital at Kew, which,
after Dax renamed it, was known as Willsmere Hospital. It was to include
an admission unit, early treatment facilities, long-term care and a visiting
psychiatric service to local old people’s homes.33 The first Day Hospital
in the psychiatric service was opened there in 1965.
Like the Day
Hospitals established at the Geriatric Hospitals, this innovative outpatient
service served a number of purposes, all aimed at limiting the need to
admit patients to hospital or, if admitted, to keep them there for shorter
periods of time. Patients whose condition improved with treatment could
be monitored after discharge, as could others whose living conditions
increased the risk of breaking down. Day Hospital care provided some
respite during the day for the carers of for mentally disturbed old people
living at home, thus deferring, or perhaps even avoiding the need for
admission to long-term care. Attendance at the day hospital was also a
means of bridging the gap between hospital and what could be an isolated
existence in the community for discharged patients.34
31
G. Larkins, ‘Modern Methods of Rehabilitation’, Geriatrics Conference, 1956, p.24,
Geriatrics Conference, op. cit.
32
Davies, ‘Clinical Advances in Geriatric Psychiatry’, MJA, vol 2, 1959, p.45.
33
Dax op. cit. pp.135-137; Robson, 2002, op. cit. p.78.
34
H. M. Bower, ‘The First Psychogeriatric Day-Centre in Victoria’, MJA, vol 1, 1965,
pp.1047-1050.
170
The development of a geriatric service was the lesser aspect of the task
that faced Herbert Bower when he took up his post at Willsmere in the
mid-1950s. He faced the problem of providing a satisfactory level of
general accommodation and treatment services in a building that had been
completed in the late 1880s, condemned as unfit for patients just prior to
the beginning of the Second World War, but remaining in use without any
upkeep.
In his survey, Stoller described its physical condition as so
appalling that he wondered if the renovations then in progress were
worthwhile since the process would be so lengthy and maintenance so
costly. In light of the condition of the buildings, it is almost insignificant
that they were also overcrowded.35 It was also the case that most of these
people would remain the responsibility of the hospital because there was
nowhere else for them to go. In their institutional setting and in the
practical problems they faced, psychiatrists were in a similar position to
the geriatricians in the benevolent institutions, although conditions at
Willsmere Hospital were even worse. Bower described early efforts to
examine patients, ‘There’s an enormous amount of noise going on and …
no privacy. The patient is lying in a bed, the pillows… are black with dirt,
the linen hasn’t been changed, the patient hasn’t had a bath … there
wasn’t enough staff’. 36
Cunningham Dax included the professional development of psychiatrists
in his reform of mental health services.
A postgraduate Diploma in
Psychiatry was already available at the University of Melbourne and in
1955 the Mental Health Research Institute was established.37
The
Department of Psychiatry and the Institute were affiliated when the Cato
Chair of Psychiatry was established in 1965. Despite its small staff and
limited facilities in the early years, there was a commitment at the Institute
to research in a number of fields: clinical, epidemiological, biological and
sociological. Dax was ready to support his medical staff in developing
35
Stoller 1955, op. cit. p.65-66. By January 1958 the institution housed 1,126 patients,
Annual Report Mental Hygiene Authority, 1957.
36
Robson, 2002, op. cit. p.37-38.
37
The founding of the Institute and its first twenty-five years of work are described in J.
Krupinski, A. Mackenzie, R. Banchevska, eds. Psychiatric Research in Victoria, Mental
Health Research Institute & Health Commission of Victoria, Special Publication No 9,
Melbourne, 1981.
171
their special interests and encouraged them to acquire postgraduate
qualification in these fields.38
The changes in institutional psychiatric practice in Victoria took place
alongside developments in the professional organisation of psychiatrists.
The Australian Society of Psychiatrists, founded in 1946, became a
College in 1964. In 1967 a scientific journal, the Australian and New
Zealand Journal of Psychiatry, replaced the newsletter produced by the
Society since its inception, the Australian Psychiatric Bulletin. Access to
a broader potential patient base was ensured when, in the late 1960s, an
agreement was reached between the College, the Australian Medical
Association and the federal government, on a common fee for psychiatric
services within the national system of hospital and medical insurance.39
This last development meant that psychiatric treatment became available
to that section of the population who could not afford to pay fees outright,
but whose means were sufficient to prevent them being classified as public
patients. Psychiatrists in private practice may have benefited most from
this measure but, together with the slow acceptance of voluntary
admission in the public institutions, it would have broadened the patient
base for state hospital psychiatrists also. Under Dax’s leadership, the
reorganisation of psychiatric services in the State led to the rejuvenation of
the role of the public institution psychiatrist. For psychiatrists interested
in the topic of mental health and illness in old age, the situation offered
both advantages and disadvantages. Their professional environment was
conducive to disciplinary development but their institutional setting was
dominated by the necessity to manage large numbers of individuals
unwanted anywhere else.
The Geriatrics Conferences, run by the Hospitals and Charities
Commission to promote the education of a range of groups involved in
providing ‘care for the aged’, were the principal arena for disseminating
the professional knowledge and techniques developed by the medical
practitioners in the Geriatric Hospitals.
The psychiatrists in the state
mental hospitals joined them there occasionally but this arena was
38
Dax, 1961, op. cit. p.31.
W. D. & H. L. Rubinstein, Menders of the Mind, A History of the Royal Australian &
New Zealand College of Psychiatrists, 1946-1996, Oxford University Press, Australia,
1996, p20, p.48.
39
172
secondary to publication in a professional journal. G. V. Davies’ work can
be traced through articles published in The Medical Journal of Australia in
the years before the Journal of Psychiatry appeared. Davies was also able
to use the new structure in the organisation of the mental hospitals and the
links with a university department, to develop a research program for a
PhD thesis on the topic of mental illness in old age.40 An indication of the
difference in professional standing of the psychiatrists cultivating the field
of mental health in old age, compared to the geriatricians in Victoria, is
that Herbert Bower delivered the prestigious Beattie Smith lectures in
1963. This gave the topic of mental health and illness in old age an airing
in circles to which the doctors in the geriatric hospitals could never aspire.
The lectures, generally an annual event, were held in memory of one of
Victoria’s early and prominent practitioners in the field of mental illness,
Dr W. Beattie–Smith.41 Bower shared the distinction with colleagues
notable in other fields of psychiatry, including J. F. J. Cade, who
developed the drug lithium for use in treating mental illness.42
A Local Psychiatry of Old Age
Psychiatrists and the doctors situated in the Geriatric Hospitals were able
to draw upon the work of British physicians and psychiatrists in
developing their role of providing age-related medical services.
Psychiatrists, however, were in a better position because they had access
to patients who were acutely ill, whereas their colleagues in the Geriatric
Hospitals were limited to supervising the provision of restorative treatment
for a small proportion of their patients and long-term care for the
remainder.
Both groups of doctors were in the same position of
cultivating a field of medical practice in an area where medical interest
was, on the whole, conspicuous by its absence. Despite the difficulties
faced by Herbert Bower and G. V. Davies, the two psychiatrists
disseminated imported knowledge and Davies in particular, established the
beginnings of a local contribution to be added to the newly emerging body
of knowledge in the psychiatry of old age produced by British
psychiatrists.43
40
Davies, 1967, op. cit.
C. R. D. Brothers, Early Victorian Psychiatry, 1835-1905, nd, no publisher, p.176-77.
42
‘Beattie Smith Lectures’, MJA, vol 2, 1951, pp.213-219 and pp.245-250.
43
Herbert Bower named Martin Roth and Felix Post as the most influential of the English
psychiatrists in his work. In 1965 the former was Professor of Psychological Medicine at
41
173
In 1962, Herbert Bower spoke at the Geriatrics Conference on the topic of
psychiatric disorders in the elderly.
He expanded the more general
discussion on mental confusion in the previous year by outlining the
process of classification that underpinned the diagnostic process advocated
by Drs Dax and Cosins.44 The first two categories of mentally disturbed
old people he described had long been recognised by doctors. They were
those old people whose disordered thinking, associated with organic
disease of the brain, gradually and inexorably developed to the point
where the individual in question did not know how old he or she was,
where they lived or recognise their relatives. He classified this group of
patients as the senile dementias associated with organic disease of the
brain, caused in some cases by faulty circulation.45
Bower’s point in emphasising the importance of diagnosis was that
although about half of the cases of dementia admitted to psychiatric
hospitals died within two years of admission, the other half remained
alive. In view of the impossibility of altering the condition there was little
to offer other than long-term care. In these cases, however, Bower
believed some improvement could be achieved through expert care. The
provision of a stimulating environment slowed the rate of deterioration to
the extent that ‘they may still be reasonably alert people’ who find
the University of Newcastle (UK) and Clinical Director, Psychiatry Unit, Newcastle
General Hospital, and the latter, physician at Bethlem Royal and Maudsley Hospitals.
Personal communication from Dr Bower, 17/7/2000.
44
H. M. Bower, ‘Psychiatric Disorders in the Elderly’, Geriatrics Conference, 1962, pp.9098, Geriatrics Conference, op. cit.
45
G. E. Berrios, ‘Dementia, Clinical Section’, R. Porter, ‘Dementia, Social Section, Part 1’,
T. Kitwood, ‘Dementia, Social Section, Part 2’, in A History of Clinical Psychiatry, The
Origin and History of Psychiatric Disorders, eds G. E. Berrios & R. Porter, Athlone Press,
London, 1995. As was the case with many other conditions associated with old age,
mental disturbance was also explored and classified by French physicians, beginning in
mid nineteenth century. The use of the term dementia to describe mental disturbance in old
age seems to have emerged as other forms of mental excitement (dementia) were classified
in specific organic or functional terms, for example the establishment of a relationship
between syphilis and General Paralysis of the Insane. The distinction made by Pick,
Binswanger and Alzheimer, between dementia associated with cerebral arteriosclerosis,
that arising from lobar atrophy and senile dementia was a further step in this process.
Around the time Herbert Bower gave his lecture, despite the histological delineation of
these processes ‘there was still no general agreement about the nature of the relationship
between cerebral degeneration and dementia’. Dementia continued to be ‘one of those
words, freely but loosely used, and difficult to define accurately in useful clinical terms’,
‘The Evolution of Geriatric Psychiatry’, a paper read at a meeting of the Scottish Society of
the History of Medicine, Medical History, vol 16, no 2, 1972, pp.184-193.
174
something to enjoy in life and who were thereby easier to manage in
hospital or at home.46
A remark by John Cade in the course of his Beattie-Smith lecture, that
more was to be gained by investigating the changes in the brain associated
with the dementing process, than classifying forms of dementia, suggests
that Bower’s interest in classification may not have been shared by his
colleagues. It did however, at least offer the possibility of ameliorating
the effects of a condition that could not be altered, a response to the
immediate need of patients as opposed to doing nothing. More important,
Bower’s stance highlighted the focus on diagnosis characteristic of the
specialist skills in treating elderly patients. The emphasis on diagnosis
indicated openness to the possibility that conditions could be alleviated,
even if only at the level of day to day management, thus discouraging any
tendency to view the condition of elderly people as hopeless.47
In addition to classifying the dementias, other distinctions in mental
disturbance could now be made and they were associated with the
development of therapeutic techniques in both general medicine and in
psychiatry. Confusion related to identifiable organic conditions would
clear as treatment was given for the condition that precipitated it. Or, as E.
C. Dax had gone into some detail to say at the 1961 Geriatrics Conference,
the patient could be nursed through such an episode if medical and nursing
staff paid sufficient attention to that person’s needs. The other major
change was that depression was now recognised as the basis of change in
46
H. Bower, ‘Sensory Stimulation in the Treatment of Senile Dementia’, Report on the
Third Annual Conference, Australian Association of Gerontology, MJA, vol 1, 1967,
p.1057.
47
Cade, op. cit. and Bower, 1964, op. cit. p.327-8; see also H.M. Bower, ‘The Differential
Diagnosis of Dementia’, MJA, vol 2, 1971, pp.623-626.
175
mental state in elderly people and this was also associated with the
development of pharmaceutical, surgical and electrical treatments in the
postwar period.48
A discerning medical practitioner prepared to
investigate his elderly patients would find that, in a majority of them, the
condition could be alleviated. Pharmaceutical therapy also alleviated the
effects of disordered thinking, ‘the so-called late paraphrenias’, conditions
in which otherwise quite normal elderly individuals suffer from delusions
related to persecution or sexual conduct.49
In psychiatry, just as had happened in general medicine and surgery,
advances in therapeutic techniques had the effect of bringing elderly
patients, who might otherwise have joined the ranks of the infirm aged,
back into the realm of everyday life in the community. G. V. Davies
provided a summary of such developments in an article published in 1959.
He noted, that at this point, towards the end of the first decade of the new
era in the mental health services in Victoria, one third of all patients over
sixty, admitted for the first time to mental hospitals, were eventually well
enough to be discharged.50 He gave the example of a man of seventy,
suffering from melancholia referred by a psychiatrist who had been
satisfied to interpret his mental state as being related to the patient’s
realisation that his life was drawing to a close. This man was admitted to
Mont Park Hospital and discharged two months later, following a
leucotomy, going off ‘enthusiastically’ to ‘embark on a new avenue of
work’. Davies suggests he may have been an exception in being treated in
this fashion, leucotomy being resorted to only in selective cases that did
not respond to electroconvulsive therapy or pharmaceutical agents.51 Not
all problems of mental disturbance were so resolutely dealt with. Families
often had to continue to care for relatives whose condition posed
substantial difficulties despite the more optimistic medical approach to
48
A distinction between depression or melancholy, and dementia had been made much
earlier. Kraepelin for example disputed that depression was an invariable symptom of
dementia and that it inevitably degenerated into dementia, R. Porter, op. cit. p.60. The
development of pharmaceutical treatments for depression made the distinction more telling.
49
Bower, op. cit. p.90-93.
50
(G) V. Davies, ‘Clinical Advances in Geriatric Psychiatry’, MJA, vol 2, 1959, p.43-46.
51
Davies, ibid. p.45-46. In a talk given at a seminar organised by the Victorian Council for
Mental Hygiene, Cunningham Dax expressed the opinion that more attention should be
given to the use of leucotomy in cases of depression in old people ‘because often enough
their time is running out and they can’t afford to have a long illness at this age.’ E. C. Dax,
‘The Accommodation and Treatment for Mentally Disturbed Geriatric Patients’, in
Growing Old, ed A. Stoller, F. W. Cheshire, Melbourne, 1960, p.44.
176
these patients. Davies hints at this when he writes that the news that
admission of an old person to a mental hospital was just as likely to be
followed by discharge, ‘ … cheers up some (relatives) and lets others
know that, even if they thought so, their responsibility is not at an end.’52
Framing Old Age
Davies, in common with British geriatricians in the early 1960s, identified
the characteristic patient as female.53 At Mont Park Hospital, the number
of females admitted in the early 1960s was two and a half times the
number of men.54 Women between the ages of 70 and 80 were more
numerous in this group than those in their sixties or over 90. Those who
were widowed were more numerous than the married or single.55 In an
earlier paper Davies noted that the typical elderly patient had lived through
hard times. The depression of the 1890s may have caused hardship for
their parents, blighting their childhood. In the 1930s Depression they
themselves suffered similar hardship, perhaps compounded by the loss of
husbands, brothers or sons in either of the two world wars. In the post-war
period when prosperity brought good times for younger generations, these
elderly women (and men too) often found themselves excluded by
inadequate pensions or inflation eroded savings. Accumulated hardships,
diminishing strength and perhaps sensory loss, made the changes brought
by ageing intolerable.
52
Davies, 1959, op. cit. p.45.
J. Agate, The Practice of Geriatrics, William Heinemann Medical Books, Ltd, London,
1963, p.6-8.
54
G. V. Davies, ‘Female Geriatric Admissions to a Mental Hospital’, MJA, vol 2, 1965,
p.309.
55
Davies points out that the preponderance of widows amongst mental hospital patients in
Victoria contrasted to the situation in England where 54% of admissions of women over
the age of 60 to mental hospitals were women who had never married. He wondered if
‘The Australian spinster … who over the last generation has so often carved out a
rewarding career for herself and achieved a sturdy independence, may have a few secrets of
successful aging that would help us all’, p.310. The overall preponderance of women over
the age of sixty in the psychiatric hospitals arose partly from the admission of greater
numbers of women than men in this age group, but also because of the women admitted
when younger and grown old in the institution. G. V. Davies, ‘The Geriatric Population of
a Mental Hospital’, MJA, vol 1, 1965, p.182. In his social history of medicine and madness
in New South Wales between 1880 and 1940, Stephen Garton notes that by the 1930s
patients admitted to the State Mental Hospital were more likely to be female and older than
those admitted in the 1880s. However he also notes that although the proportion of
married women amongst female patients was slightly higher than single women, there was
no sharp differences in the rate of committal between these two groups and this situation
did not alter greatly between 1880 and 1940, S. Garton, Medicine and Madness: A Social
History of Insanity in New South Wales, 1880-1940, New South Wales University Press,
Kensington, NSW, Australia, 1988, p.104 and p.147.
53
177
Women, Davies concluded, ‘having more restricted interests'’ were also
more ‘emotionally affected by non-cerebral illnesses’ than men.56 They
were, however, less likely to be affected by a life-time of heavy drinking,
a working class male response to the difficulties they faced in life.57 Men,
who may have had the stamina to withstand the effects of alcohol on their
bodies while they were younger, finally subsided into mental breakdown
when senescence weakened their capacity to deal with the effect of longterm intoxication.58 In keeping with his linkage between mental health in
old age and social conditions, Davies also noted in a later paper that using
the age of 60 to designate the onset of old age in women was no longer
appropriate in postwar society.
In contrast to their sisters in earlier
generations, 60-year-old women in the 1960s lived longer than their male
counterparts and, ‘with wider interests, cosmetics and hair tints, look and
feel younger.’59
There may have been other factors in addition to lifelong hardship,
underlying the restricted interests Davies noted in his elderly patients. The
experience of John Lack’s mother suggests as much although she was not
as old as Davies’ patients.60 Just as she reached the point in her life where
she could see something for all her hard work in rearing four sons and
keeping up a home for them and her husband in the working-class suburb
of Footscray, she had what the family referred to as a ‘nervous
breakdown’. Certainly her interests may have been restricted. She’d had
to take all responsibility for three sons and another on the way, when her
husband enlisted for war service. When he returned his ‘one day at a time’
attitude, a natural element in his character reinforced by his experience as
a prisoner of war, exasperated her because she was inclined to save and to
56
Davies, 1959, op. cit. p.43.
The association between excessive consumption of alcohol and mental disturbance is a
recurrent theme in Garton’s chapter on the topic of madness and men. Garton, 1988, op.
cit. Chapter 6.
58
Davies, 1959, op. cit. p.43. The characterisation of the effects of a difficult life on
women in terms of their constitution as females, and in men in terms of what was just
beginning to be described as a disease (alcoholism) was, even when it was made not
accepted uncritically by psychiatrists. J.F.J. Cade found that combining total admission
rates of depressed women and alcoholic women on one hand, and those of depressed men
and alcoholic men on the other, showed that male and female admissions were of the same
order of magnitude, Krupinski, Mackenzie, Banchevska, 1981, op. cit, p.82.
59
G. V. Davies, MJA, 1965, op. cit, p.309-310.
60
J. Lack, ‘Melbourne: In and Out of My Class’, in ‘The Forgotten Fifties’, a special
edition of Australian Historical Studies, vol 28, no 109, 1997, pp.159-164. Mrs Lack was
somewhat younger than the patients Davies describes, nonetheless her case does serve to
illustrate the multiple dimensions of the condition he describes as ‘restricted interests.’
57
178
plan. Paradoxically, he had been strengthened by his experience in war
but the family had ‘been drained by four years of separation and anxiety’.
When she had the opportunity and wished to go out to work, he forbade
her, thus eliminating any outlet for her obvious capacity to manage life
and in a sense putting to nought her achievements during his years of
absence. Although he was an affectionate father and husband, and his
actions were most likely prompted by the desire to spare his wife extra
work, his misguided concern for her well-being contributed to a situation
that, in time, sapped her vitality.
Davies’ characterisation of the ‘geriatric’ patient as the ‘feeble’ old
woman exemplifies the gendered psychiatric diagnoses Jill Julius
Matthews identified in her study twenty years later.61 Davies’ description
of the condition of the typical patient in terms of her ‘restricted interests’
and ‘emotional response to non-cerebral illness’ seems to anticipate the
judgements about womanhood masquerading as psychiatric diagnoses,
that Matthews found in her study of women admitted to a South Australian
mental hospital.
Matthews concludes that to maintain any degree of
mental equilibrium, women, in addition to coping with the vicissitudes of
everyday life, have the added burden of negotiating the ‘maze’ of feminine
existence. The goal in this process, of being a ‘good woman’, is one that
is fundamentally unachievable and it is in finding a way to live with
‘failure’ that women face a double burden in maintaining a satisfactory
degree of well-being. Mrs Lack’s case illustrates the combined obstacles
posed by gender, class, and the anxieties of daily life in time of war.62
It may be, however, that the experience of the Depression marked elderly
women in ways that over-rode influences relating to gender.
The
comments of women who reflected on their lives in Janet McCalman’s
study of life in working-class Richmond, some of whom could have been
contemporaries of Davies’ patients, with similar life experiences, suggest
that the Depression marked their lives indelibly.63 These women also
mention the obstacles they confronted as women. However such
61
J. J. Matthews, Good and Mad Women in Twentieth Century Australia, 3rd ed, George
Allen & Unwin, North Sydney, NSW, 1987.
62
Ibid. p.200-201.
63
McCalman, 1984, op. cit. Chapter10.
179
difficulties pall besides the affront to their emotional security they
experienced in the realisation that respectability was not the bulwark
against ‘destitution and disgrace’ that many of them had grown up to
believe.
No doubt men were also shaken by this realisation, but for
women, who overall had less power in the organisation of social life, and,
as a consequence, may have put greater reliance on social forms,
respectability could provide an emotional defence on the passage through
the ‘maze’ of feminine existence. The loss of trust in life manifested by
many survivors of the Depression, including Davies’ patients, was
fundamental to their experience of growing old. The mental dis-ease
Davies diagnosed in his patients in the 1960s, was related it seems, not
simply to their experience as women but also to general social and
economic conditions.
They may have been, in Matthews words,
‘survivors of ‘a bygone generation’ without the status of mother,
economically dependent on the government instead of a husband and often
living in poverty, with ‘(their) only feminine function being occasional
babysitter to … grandchildren’.64
However, for many elderly women
poverty may have been life-long, and a government pension may have
provided a degree of security not previously experienced. What made it
difficult for them to share the exuberance of postwar prosperity was their
loss of trust in life itself, a loss that blighted the remainder of their lives,
and their relations with children and grandchildren.65
Herbert Bower joined Davies in emphasising the part played in mental
disease by factors well outside the psychiatrist’s purview. Paradoxically,
while a reductionist approach to understanding disease made the
identification of depression in elderly patients such a worthwhile process,
and the distinction between organic and psychogenic mental changes made
for theoretical clarity, as Bower pointed out, it was, nonetheless, an
artificial distinction because:
Anatomical changes can never completely explain the symptoms of
the senile psychoses; personal and environmental factors contribute
towards the patient’s ability to withstand the cerebral insult … In
64
65
Matthews, op. cit. p.195.
Ibid. p.293.
180
short, any psychiatric illness must be regarded as one link in the
causal chain of an individual’s life experience.66
In this situation a biographical approach to diagnosis was necessary,
geriatric psychiatry being often concerned with sickness where ‘emotional
stress and psychological mechanisms have fired off a mental disorder
which has bodily repercussions.’
It was also necessary for the
development of preventive health measures. G. V. Davies, in what may
well have been the first local identification of the condition, notes that
geriatric psychiatry required contributions from psychology, sociology and
economics to fully comprehend the disorder of ‘unsuccessful ageing’.67
The dimensions of this project were foreshadowed in Marjory Warren’s
conclusion to her outline of the ‘untreated case’ of old age infirmity, when
she described those ‘… human forms who are not only heavy nursing
cases in the ward and a drag on society but also are no pleasure to
themselves and a source of acute distress to their friends.68 However,
while these psychiatrists were ready to play a part in ‘problematising’ old
age, it was by no means clear that they were also going to be involved in
‘disciplining’ old age.
Herbert Bower proposed a standard of normal senescence by which
success or failure in the project of ageing could be measured, ‘mental and
physical changes, normal for the age period, providing the essential
prerequisites for good adjustment’.69 During the session on the medical
care of the aged at the Australasian Medical Congress in Melbourne in
1952, A. T. Edwards, a psychiatrist from Sydney, listed some of the
adjustments that may be required of the elderly adult. They included
getting along with the spouse, adjusting to loss of employment and
reduced income, living with physical infirmity, and finding satisfactory
accommodation.70 The problem of establishing a norm of adjustment had
been illustrated in J. S. Sheldon’s survey of a random sample of elderly
66
H. Bower, ‘Old Age in Western Society, Lecture 2, Psychiatric Aspects’, MJA, vol 2,
1964, p.328.
67
Davies, 1961, op. cit. p.153.
68
Warren, 1946, op. cit. p.841-842. Warren’s description displays a characteristic Haber
notes is common to many advocates of geriatric medicine from Nascher onwards. While
promoting attention to this neglected group, they also tended to emphasise the
unpleasantness of decrepit old age, Haber, 1986, op. cit. p.67. The use of the term
‘unsuccessful’ in relation to old age decrepitude by Davies seems to continue the tradition.
69
Bower, 1964, op. cit. p.328.
70
‘The Medical Care of the Aged’, MJA, vol 2, 1952, p.491.
181
people in the English city of Wolverhampton.71
As he went about
interviewing people in their homes, he was constantly perplexed as to how
to classify individuals along a scale of normal, normal plus and subnormal because of the range of variability he noted. He found individuals
who maintained an active life, contributing to the life of their community
or family, despite significant physical handicaps and clearly identifiable
disease conditions.
Others, apparently free of such restrictions, had
responded to the changes in their lives in old age by withdrawing from
social interaction. For Sheldon, the people he surveyed illustrated the
statement made by J. S. Ryle, the advocate of social medicine, that there
was no normal versus abnormal in states of health but only a range of
variability related to environmental conditions.72
The attempt to establish a norm of old age was a very different matter
from establishing physiological norms in laboratories isolated from the
ambiguities of everyday life.73 In contrast to the demonstrable differences
of quantity that underlay definitions of organic disease, the norm of
adjustment in old age, (if Dr Edward’s list is any guide) tends to reflect
what may be required for the maintenance of social order. Wealthy old
people were not required to deal with these matters while they had the
resources to shield them from public scrutiny. Even living with physical
infirmity was a very different matter for those with sufficient resources.74
Elizabeth Hunter, the central character of Patrick White’s Eye of the
Storm, continued to rule the lives of her adult children and hired help as
she subsided into decrepitude. She had the financial resources, which her
children were not brave enough to alienate, to sustain her accustomed
manner of living to the end and to pay for a housekeeper and private
nurses. One of these nurses, Elizabeth took comfort from knowing, was
able to perceive that ‘the splinters of mind make a whole piece’, and to
71
Sheldon, op. cit, p21, pp.86-180.
‘For Ryle, biological normality was the quantifiable range of physiological variability
which resulted from adaptation necessary for survival in a given environment’, Porter,
1993, op. cit. p.253.
73
Canguilhem, 1989, op. cit. p.35ff.
74
After she left Cheltenham Old People’s Home Fleur Finnie was employed to care for an
elderly man who had suffered a stroke, at home. Finnie, and another untrained nurse,
attended to this man’s every need, providing 24 hour attention, and his daily routine was a
stark contrast to that of the old men in her first ward, Finnie, op. cit. p.39-40.
72
182
sustain her in her journey towards the realisation that she was but ‘a detail
of the greater splintering’.75
The disorder inherent in increasing numbers of infirm old people requiring
publicly funded care may not have constituted a threat to public order of
the same magnitude as the adolescent delinquents who were the subject of
psychological investigations into the experience of childhood in the
1930s.76 Nevertheless, although psychiatrists in Victoria did join other
professionals in publicising the ‘problem of old age’, on the whole, local
formulations of the problem lurking in the future of the western
democracies – the relentless increase in numbers of dependent old people
– emphasised managing the financial resources of the state, not the
conduct of elderly individuals.77 The overall lack of interest amongst
psychiatrists, in the problems of mental health in old age, and indeed
amongst doctors in general, combined with the continuing emphasis on the
provision of custodial care by community-based groups, meant that any
disciplinary potential in Davies’ contribution to framing old age remained
unrealised. As was the case in general medicine, psychiatry did become
more involved in problems of mental disease in old age, but only in so far
as elderly people were treated in the same manner as other adults. The
response on the part of the knowledge makers in the Victorian psychiatric
community, to the possibility of establishing a body of knowledge based
on the social medicine approach to interpreting ill-health, suggests that it
may also be the case that the fundamental interest in a reductionist model
of mental health limited the possibilities for intervention by psychiatrists
into the social world inhabited by ageing Victorians.
The emphasis Bower and Davies laid on a biographical approach to mental
illness was not altogether at odds with trends in mainstream psychiatric
research in Victoria in the 1960s. Soon after the Mental Health Research
Institute was formally opened in May 1956, it gained recognition for
epidemiological and social research, an area of study that was promoted
by Alan Stoller, Chief Clinical Officer in the Mental Health Authority.
75
P. White, The Eye of the Storm, Penguin Books, Middlesex, England, 1982, p.89-90.
N. Rose, Governing the Soul, The Shaping of the Private Self, Routledge, London, 1989,
p.121ff.
77
Current Affairs Bulletin, vol 5, no 8, 1950; N.G. Francis, ‘A Problem that Grows with
the Years’, The Australian Quarterly, vol xxxvi, no 2, pp.50-56.
76
183
This reputation was reinforced in 1960, following the appointment of Dr
Jerzy Krupinski, who described himself as ‘a medical administrator with a
special interest in epidemiology and social medicine’.78 The commitment
of researchers to investigating social influences on mental disorders would
appear to have provided an ideal environment for studies similar to that
conducted by Sheldon and, no doubt, others more sophisticated because of
the range of statistical skills that were available.79
The emphasis on
statistical methods and the appointment of a social worker early in the life
of the Institute – Stoller’s interpretation of ‘sociological input’, one shared
by Ian Wood at the Clinical Research Unit located at the Royal Melbourne
Hospital - suggests that John Ryle’s model of social medicine influenced
the approach to developing a research program in mental health.80
In the late sixties and early seventies, three social surveys were carried out
within the Victorian community in country Heyfield, inner suburban
Prahran and the north-west region of Melbourne.81 These opened up the
possibility of establishing a focus on old age in the psychiatric field as Eric
Saint had attempted to do in general medicine in his work, in the 1950s, at
the Clinical Research Unit at the Royal Melbourne Hospital and Walter
and Eliza Hall Institute.82 However, although older adults were included
in these surveys there was no specific focus on them as a group. Research
listed under the heading ‘epidemiology and social psychiatry’ in the
history of the Institute suggests that the interests of researchers simply did
not lie in this direction. Instead they were shaped by the most prominent
features of the Victorian population at the time, that is growing numbers of
adolescents and younger adults, the effects of an increased birthrate in the
postwar period and high levels of immigration.83
78
Krupinski, Mackenzie, Banchevska, 1981. op. cit. Introduction. For ‘social medicine’
see Chapter Two.
79
A. Westmore, ‘Mind, Mania and Science: Psychiatry and the Culture of Experiment in
Mid-Twentieth Century Victoria’, PhD Thesis, University of Melbourne, 2002, p.186.
80
See Chapter Two.
81
J. Krupinski, A. Stoller, A. G. Baikie, J. E. Graves, A Community Health Survey of the
Rural Town of Heyfield, Victoria, Australia, Mental Health Authority, Special Publications,
No 1, Melbourne, 1970 and J. Krupinski & A. Stoller, eds, The Health of a Metropolis,
Findings of the Melbourne Metropolitan Health and Social Survey, Heinemann
Educational Australia, South Yarra, Victoria, 1971, J. Krupinski, & A. Mackenzie, The
Health and Social Survey of the North-West Region of Melbourne, Special Publication No
7, Mental Health Division, Health Commission of Victoria, Melbourne, 1979; Porter, 1992,
op. cit, p.145-146.
82
Saint, MJA, 1953, op. cit; MJA, 1955, op. cit. p.161-165.
83
J. Krupinski, ‘Epidemiology and Social Psychiatric Research’ in Krupinski, Mackenzie,
Banchevska, 1981, op. cit. p.17ff.
184
The numbers of people categorised as old – that is of pensionable age –
had also increased, but as a group, the elderly, remained a small proportion
of the whole population.84 It was left to G. V. Davies, who in 1969 was a
Research Fellow in the Department of Psychiatry, to investigate the sociopsychological elements in senile dementia in different groups of elderly
hospital patients.85
Neglect of the topic of ‘ageing’ in the Institute’s research during the 1960s
is difficult to reconcile with Alan Stoller’s call, in the late 1950s, for
research to develop the preventive measures necessary to ensure
‘successful ageing’. Stoller was a prominent participant in a two-day
seminar on old age in Melbourne in 1958. The seminar was organised by
the Victorian Council for Mental Hygiene and it brought together the
small number of ‘experts’ on ageing in the Victorian community with the
intention of promoting the prevention of ill health and maladjustment
through education.86 The Council, consisting of both lay members and
mental health professionals, including psychiatrists, was first formed in the
1930s as part of a world-wide mental hygiene movement that began, early
in the twentieth century in the United States. It was one of a number of
state-based Councils in Australia. In the 1930s the Council promoted the
same type of project in relation to childhood and adolescence that it was
84
While there appears to have been no association between increasing numbers of adults
classified as ‘old’ in the Australian population and the growth of a psychiatry of old age,
there was also no association between rising numbers of children and child psychiatry.
This speciality attracted only between five and ten per cent of psychiatrists in the late
1970s, M. Lewis, Managing Madness: Psychiatry and Society in Australia, 1788-1980,
Australian Government Publishing Service, Canberra, 1988, p.139.
85
G. V. Davies, B Teltscher, & B. Davies, ‘Senile and Arteriosclerotic Dementia – a Study
of Personal, Social and Family Data’, Australian and New Zealand Journal of Psychiatry,
vol 3, 1969, pp.398-400.
86
The proceedings at this seminar were later published as, Growing Old, Problems of Old
Age in the Australian Community, ed, A. Stoller, F.W. Cheshire, Melbourne, 1960. The list
of participants included psychiatrists, E. C. Dax, G. V. Davies, and A. Stoller (Herbert
Bower had only just taken up his position as medical superintendent at Willsmere
Hospital); the first doctors appointed as geriatricians at Mount Royal, G. Larkins and R.
Butterworth; Elizabeth Johnson, nurse and first officer in the Geriatrics Division of the
Hospitals and Charities Commission, R. I. Downing, Ritchie Professor of Economics at the
University of Melbourne who had recently taken on the project of investigating the means
of restructuring the Age Pension to address the poverty experienced by some pensioners ; I.
K. Waterhouse, lecturer in the Department of Psychology at the University; representatives
of the Trades Hall Council, the Over 50s Association, the Old People’s Welfare Council
and the voluntary agencies.
185
now promoting in relation to the ‘problem of old age’.87 However, the
interest in old age was short-lived.
Following publication of the
proceedings of the seminar, the Council moved to other ‘social problems’
such as child abuse, drug and alcohol abuse, and suicide.88 In Stoller’s
conclusion to the seminar he noted the importance of the early detection of
mental ill-health in elderly people, calling for research into the multiple
factors involved in ‘mental breakdown’. Interestingly, he did not refer to
the possibility of this research occurring at the Mental Health Institute but
called upon Victorian universities to cultivate research in the social
sciences.89
In the early 1970s, although Stoller and Krupinski had ‘wrested significant
initiative in mental health research away from the biologically-oriented
groups within the mental hospitals and the university’, population studies
at the Institute were abandoned.90 Researchers concluded that, in general,
while health and disease ‘are the result of continuous interaction with the
environment’, the problems of separating physical and psychological
components limited the usefulness of examining them in their social
environment.
‘Hard’ social data, they concluded, were less useful in
understanding mental illness than they had previously thought.91 This
truncated attempt to establish the discipline of social medicine in relation
to mental health cannot be attributed to the limited development of social
research in Victoria at the time.92 Rather, the conclusion that ‘hard’ social
87
Lewis, op. cit. pp.135-139. The Victorian Council played an active part in supporting
the foundation of the first Chair of Psychiatry at the University of Melbourne by
contributing funds for the purpose.
88
Ibid, p.140.
89
Stoller, 1960, op. cit. p.198.
90
Westmore, op. cit. p.189.
91
Krupinski, Mackenzie, Banchevska, 1981, op. cit. p.26.
92
The establishment of the discipline of economics at the University of Melbourne, under
the direction of L.F. Giblin, first Ritchie Professor of Economics, led to the development of
statistical skills and social surveys similar to those pioneered in England by Charles Booth.
This disciplinary formation brought together a moral imperative to achieve a just
distribution of resources and increasing technical skill, N. Brown, Richard Downing,
Economics, Advocacy and Social Reform in Australia, Melbourne University Press, Carlton
South, Victoria, 2001, pp.45-48. In the Department of Psychology at the University of
Melbourne, under the leadership of O.A. Oeser, Professor of Psychology, social surveys
were undertaken to ‘assess the interaction between ‘social structure and personality’ in
rural and urban Australia’, N. Brown, Governing Prosperity, Cambridge University Press,
Cambridge, 1995, p.194-195. These surveys were published in two volumes, Social
Structure and Personality in a City, and Social Structure and Personality in a Rural
Community, Department of Psychology, University of Melbourne, 1949-1950. Economics
did contribute to the discussion of the ‘problem’ of old age in the 1950s through a study of
pension rates, see Brown, 2001, op. cit. p.185ff, but there was, it appears no interest in old
age in the Department of Psychology, Brown, 1995, op. cit. p194-195. In the Department
186
data was not so useful in understanding mental illness suggests a
somewhat narrow understanding of what was entailed in such research.
The limitations of the conception of the ‘social’ at the Institute, can be
seen in the appointment of a social worker as a means of including the
‘social’ element in research, and the failure to attempt its development as a
specific form of research expertise.
In following the model set by Ryle in the Oxford Institute, the founders of
the Mental Health Research Institute thus also imported the deficiencies of
this model in its conception of the ‘social’. George Rosen noted this
aspect of British efforts to establish the discipline of social medicine in the
1940s and 1950s. Ann Oakley reinforces the point in her essay on the
relationship between the work of Richard Titmuss, statistician turned
‘sociographer’, and the wider project of social medicine in Britain in this
period. Oakley characterises it as a failure to ‘theorize and practise the
study of the social relations of health as an activity which does not in some
direct or indirect way feed off that of medicine itself’.93
A paper read by Cunningham Dax at the Second Australian Medical
Congress in Perth in 1965 exemplifies the point made by Rosen and
Oakley.94 Dax began by noting the need for ‘modifications in our society’
to diminish the difficulties experienced by elderly people, difficulties that
played a part in the increasing incidence of mental disorder amongst this
group. Following an examination of three problem areas, he concluded by
of Social Studies, although social workers began to extend their expertise into care of the
aged in the 1950s, there was, it seems, no interest in developing a body of theory about life
in old age. This may have been part of the general lack of interest in developing a critical
tradition in the Department noted by R.J. Lawrence, author of the first history of the
Australian social work profession, Laurence, op. cit. pp.205-208. Even a decade after
Laurence made these comments, the situation had, it appears, not changed, B. Healy,
‘Social Work Research: Emergent Methods and Models for the Evaluation of Everyday
Casework Practice’, in Social Work in Australia, Responses to a Changing Context, eds
P.J. Boas & J. Crawley, Australia International Press and Publications Pty. Ltd, p.172. The
survey conducted by Bertram Hutchinson with the assistance of the Department of Social
Studies at the University of Melbourne, and published under the title, Old Age in a Modern
Australian Community, in 1954 was a lone example of an investigation in which the
experience of ageing adults was linked to their social status. However, it was instigated,
not by academic researchers, but by charitably minded citizens, members of the Rotary
Club of Melbourne. Hutchinson’s survey was later criticised by M. J. Jones, as lacking in
systematic empirical material, M.A. Jones, The Australian Welfare State, Growth, Crisis
and Change, George Allen & Unwin, Sydney, 1983, p.57. Jones was also critical of the
methodology of the statistical surveys of the 1960s which identified poverty amongst old
people, p.58.
93
Rosen, 1974, op. cit, pp.110-111; A. Oakley, ‘Making Medicine Social: The Case of the
Two Dogs with Bent Legs’ in Porter, 1997, op. cit. pp. 92-94.
94
E. C. Dax, ‘The Problem of the Aged in Society’, MJA, vol 2, 1966, pp.201-203.
187
noting the interdependence of physical, mental and social aspects of
ageing and that the integration of the three was vital to the maintenance of
good health.95 In his view the ‘social component’ was the ‘weakest’ and
to rectify this he advocated an Australia-wide survey of old people in
institutions to identify what needed to be done to ‘get them out again, in to
a community better organized and subsidized to receive them’.96
He
illustrated the type of survey he had in mind by citing the few local
surveys that were done in the 1960s. In Melbourne, M. Dewdney, the
social worker attached to J.S. Collings practice in Richmond, alongside
Collings himself, surveyed elderly people in Richmond to ascertain what
their needs were, and similar local surveys were done in Sydney and
Brisbane.97 It is a view in which ‘social’ aspects appear as undisputable
and quantifiable, and it suggests that the ‘social’ may be integrated with
the ‘physical and mental’ through the work of the social worker.
Dax conveys an impression of social study that contrasts with Stoller’s call
for sociological and psychological research to provide insight into the
complex interactions that he, together with psychiatrists Bower and
Davies, saw underlying mental illness in elderly patients.
However,
despite advocating research into the experience of ageing, Stoller, it
seems, did nothing to promote it. Herbert Bower, who appears to have
had a genuine interest in opening up the topic of dementia for
investigation in ways that were not dependent on biological investigations,
has, as his most noted contribution to the body of gerontological
knowledge that began to emerge in the 1960s, the idea for the ‘granny
flat’. This publicly subsidised accommodation built adjoining the family
home was intended to provide a way of acceding to the desire Bower
discerned in elderly people to remain close to their family.98
95
The three areas were the family, retirement and legislation relating to pension
entitlements, ibid. p.202-203.
96
Ibid, p.203.
97
It is interesting to note that Hutchinson’s survey, based on the notion that the status of
the aged in society needed to be changed was not listed in Dax’s references. Dewdney and
Collings’ survey was on a smaller scale than Hutchinson’s and free of ideas about social
change, Living on the Old Age Pension, Hospitals and Charities Commission, Melbourne,
1965. The other two referred to by Dax were, ‘A Survey of the Needs of the Aged in
Marrickville, N.S.W. by W.L. Robb, and K. Rivett, 1964, and in 1967, ‘A Survey of the
Aged in Brisbane’, A.E. Hartshorn, Dax, 1966, op. cit. p.203.
98
H. Bower, ‘Aged Families and Their Problems’ in The Family in Australia, eds J.
Krupinski & A. Stoller, 2nd ed, Pergamon Press, Australia, p.172-173.
188
Investigation of the experience of old age in the Australian community
was, with the occasional exception, neglected in favour of a focus on
service provision.
The Psychology Department at the University of
Melbourne was, it appears just as uninterested in researching the
experience of ageing as was the Department of Psychiatry.99 Although
there was some interest in the topic of old age in the Department of Social
Studies at the University of Melbourne and in the sociology department at
the newly established La Trobe University, in neither place was it part of a
research program.100 The interest in old age was confined to those health
professionals employed in the Geriatric Hospitals and the voluntary
agencies, and the psychiatric service. Consequently the knowledge they
produced was characterised by a concern with old people who needed
assistance and with an orientation to service provision.
Institutional Stagnation
Davies’ characterisation of the typical ‘geriatric’ patient as the ‘feeble old
woman’ may have had the potential to nourish a distorted view of older
females in general. However, any possibility of a psychiatry of old age
exerting any degree disciplinary power in Victoria during the 1960s and
early 1970s, was stifled by the continuing emphasis on institutional care in
relation to infirm old people. Other psychiatrists may have been able to
use the revival of the role of the state institution psychiatrist to cultivate
their specialist fields, but practitioners interested in old age were unable to
develop their role much beyond the point of improving institutional
management.
As had happened in general medicine and surgery,
increasing technical competence and the greater availability of chemical
99
The most sustained and extensive research into the experience of old age began in 1965,
in the Department of Psychology at the University of Queensland by Dr E. Harwood,
Senior Lecturer and Dr G.F.K. Naylor, Reader. They began a longitudinal study, of 300
individuals aged between 65 and 95 years, focussing on the intellectual and emotional
changes experienced by this group. Their research was presented at meetings of the
Australian Association of Gerontology; E. Harwood, ‘Anxiety Levels in Old and Young –
A Comparative Study’, pp.15-18, G.F.K. Naylor, ‘Some Aspects of Memory in the Aged’,
p.19-20, Proceedings of the Australian Association of Gerontology, vol 1-2, 1969-1976.
100
At the 1965 Geriatrics Conference, L.J. Tierney, Reader in the Department of Social
Studies at the University of Melbourne, spoke on the topic of the social relationships of old
people. In 1967, Professor J. Martin, from the Department of Sociology at La Trobe
University, addressed the topic, ‘The Place of the Aged in Society Today’. Martin’s
contribution may have given G.V. Davies grounds for thinking that his wish would be
fulfilled, that the close proximity of La Trobe University and Mont Park Hospital would
provide the basis for ‘the first Australian Institute of Gerontology’, Davies, 1965, op. cit.
p.312. Davies wish was ultimately fulfilled some twenty years later when a Gerontology
Centre was established at the university. Tierney’s and Martin’s papers can be found as
189
therapies, meant that elderly adults were initially treated in a similar
manner to younger adults. The psychiatry of old age was thus oriented
towards the management of a remnant of patients for whom such treatment
was not successful.
Even in respect to this patient group, in whom, with the exception of the
geriatricians in the Geriatric Hospitals, no other medical practitioners were
interested, psychiatrists were unable to establish the geriatric service as the
principal form of hospital and medical provision for them. A survey by
hospital social workers in 1967 highlighted the problems they faced in
finding suitable care for infirm old people whose mental state caused them
to be rejected by most providers of custodial care.101 Anna Howe’s study
of long-term care provisions in Melbourne in the late 1970s, showed a
diagnosis of ‘confusional state/senility’ in forty-three per cent of
admissions. The relevance of this statistic to the period at the beginning of
the 1970s may be disputed because, as Jan Carter notes in relation to such
statistics, an assessment of ‘brain failure’ reflected the biases of the
observer as much as the behaviour of the observed. Nonetheless it is at
least an indication that confused thinking played a significant part in
ensuring an elderly patient’s admission to long-term care, illustrating a
need for the services psychiatrists advocated.102
The essence of the reforms Cunningham Dax introduced in the early 1950s
was a shift in the approach to treating mental illness, away from
institutional care to community. In the 1950s and 1960s he achieved some
success in achieving this objective for other groups of patients, but in
relation to old people there was absolutely no move away from
institutional care.103 Lack of resources was one element in the failure of
follows; Geriatrics Conference 1965, Geriatrics Conference 1956-1966, op. cit, Geriatrics
Conference 1967, Geriatrics Conference 1967-1976, op. cit.
101
J.S. Lawson, Australian Hospital Services, A Critical Review, Gardner Printing &
Publishing Pty. Ltd, Hawthorn, Victoria, 1968, p.21.
102
Howe, 1980, op. cit, p.82. A survey of provisions and the needs of old people suffering
from ‘brain failure’, published in 1981, drew on a range of material published throughout
the 1960s and 1970s, to estimate that between twenty and fifty per cent of places for care
for the elderly were taken up by persons in this category, a number equivalent to the
population of a city the size of Ballarat, for example, J. Carter, States of Confusion,
Australian Policies and the Elderly Confused, Social Welfare Research Centre, University
of New South Wales, No 4, 1981, p.10-11.
103
Robson, op. cit. p.243ff, deals with the question of what happened to the parts of the
system that were not amenable to Dax’s ordering, for example, the lack of community
back-up to de-institutionalization, p.257ff. Lack of ministerial support may also have been
a factor as well as Dax’s refusal to ‘curry favour’ with politicians.
190
the development of psychiatric geriatric services. Seventeen years after
Herbert Bower set about the monumental task of developing acute psychogeriatric services in the antiquated Willsmere Hospital, C.G. Burt, then
medical superintendent, included a terse note in the annual report of the
Mental Health Authority recording the absence of ‘any reasonable
facilities for an acute psychiatry of old age’.104 In the directory of services
published by the Mental Health Authority in 1975 the facilities at
Willsmere, inpatient, outpatient and day hospital were the only
psychogeriatric services listed for the whole State.105
In addition to inadequate resources, psychiatrists were hamstrung in
developing a practice in regard to mental disturbance in old age by the
lack of awareness in the general community about their services. Even
general practitioners were unaware of the services offered by psychiatrists,
and ignorance was compounded in some cases by a persisting suspicion of
psychiatric treatment on the part of both medical practitioners and their
patients. The limitations on the use of psychiatric services were identified
in a small study of the attitudes of general practitioners, to referring their
patients for psychiatric treatment.106 A minority shared their patients’
view that such a referral was not acceptable either because mental
disturbance in the elderly was not considered an appropriate matter for
medical treatment or because of shame at having to make such matters
public. Those who were prepared to consider this option were likely to be
frustrated by the lack of general information, even within the medical
profession, about the process of referral and the services that were
available.107
104
Annual Report, Mental Health Authority, 1973, p.78. Under the Mental Health
Institutions Act (1948) the Commonwealth contributed to the maintenance of patients.
This provision expired in 1954, and was replaced the following year by a measure under
the State Grants (Mental Institutions) Act whereby the Commonwealth matched
expenditure made by the State government up to a maximum set by the Commonwealth.
These subsidies were for capital purposes only and Victoria had exhausted its entitlement
by 1960-61, Otto &Tierney, op. cit. p.17-18.
105
Mental Health Services in Victoria, 1975, Mental Health Authority, William St
Melbourne, p.17-18.
106
B. Teltscher, ‘Misreferral of Patients to a Geriatric Hospital’, MJA, vol 1, 1968, p.218219.
107
A general practitioner would need to be particularly interested in the matter to take note
of a small notice in the Australian Medical Association (Victorian Branch) Monthy Paper,
January, 1973, to the effect that a summary of facilities provided by regional psychiatric
services, was available, on application, from the Mental Health Authority.
191
Fundamentally, the division of hospital services between physical and
mental disease did not serve the interests of an old person at risk of being
committed to custodial care – the patient for whom services in both the
Geriatric Hospitals and the psychiatric hospitals were intended. Davies
illustrated this situation in a study he made of admissions to the mental
hospital and to one of the geriatric units. Of 50 consecutive admissions to
the mental hospital, 28 had major physical disabilities, and of 50
consecutive admissions to the Geriatric Unit at Caulfield Hospital, 23
patients had problems that called for admission to a mental hospital. To
back up his claim for special hospital and medical services for this group
of patients Davies quoted a recommendation of the World Health
Organization that the provision of effective treatment for this group
required a setting in which geriatrics (care of the aged) medicine and
psychiatry were combined.108
The complete lack of interest amongst
hospital doctors in providing appropriate hospital services for this group,
or even acknowledging the need to do so, was clear in the report on
hospital services in Victoria published in the mid-1970s. This inquiry was
conducted by Sir Colin Syme and Sir Lance Townsend, both prominent
members of the Melbourne medical world and the only reference they
made to the needs of infirm old people, was an acknowledgment of the
rehabilitation services provided in the Geriatric Hospitals. There was no
mention of the failure of existing general and psychiatric hospitals services
to address the needs of this group of patients.109
The provision of institutional care for infirm old men and women, whose
capacity for independent living was impeded by confused thinking, did not
diminish during the 1960s. The mental hospitals continued to take in
elderly people who were unwelcome in other institutions.
Medical
administrators in this service, like their predecessors since at least the
1920s, continued to call upon administrators in these other sectors to
develop a unified approach to the care of these people.110
The only
alternative form of accommodation that had emerged since the early 1960s
108
‘Points of View’, G. V. Davies, ‘The Relation of Physical and Mental Disease in Later
Life’, MJA, vol 2, 1961, pp.152-154. Davies’ conclusion was reiterated in a survey
conducted by the Planning and Research Branch of the Health Commission of
Metropolitan Melbourne psychiatric hospitals in 1979, Carter, op. cit. p.10.
109
Commission of Inquiry Report, July, 1975, Hospitals and Health Services in Victoria,
(Sir Colin Syme & Professor Sir Lance Townsend) Melbourne, p.73.
110
VPRS 4523/P2/1064/1979-45.
192
were the private nursing homes that sprang up around the suburbs
following the introduction of a subsidy for long-term care by the Federal
government in the early 1960s.111 This bureaucratic measure, an extension
of the system of publicly subsidised voluntary hospital insurance, offered
an alternative to mental hospital admission for some mentally disturbed
old people and an avenue for discharging others.112
The removal of
mentally disturbed old people from the mental hospitals was something to
be applauded. However, their incarceration in smaller institutions without
the benefit of any of the expertise that was available in the psychiatric
hospitals by the late 1960s, was yet another indication of the reluctance of
administrators and medical practitioners to address the specific needs of
this group of elderly patients.
In the 1960s, admission to the nursing home did not require a medical
certification of need. Where a medical practitioner was involved, it was
the general practitioner.
The State institution psychiatrists may have
provided consultative services for those nursing home patients who had
private medical insurance and whose GP was inclined to seek assistance in
providing appropriate medical care for them, but the provision of specialist
care was left to the discretion of the general practitioner.
Until the
introduction of a publicly funded, universal system of hospital and medical
insurance by the Whitlam Labor government in the mid 1970s, old people
who could not afford private medical insurance were only able to get
specialist medical services in a public hospital.
111
By the time Carter published her survey in 1981, she was able to note that ‘in every
state besides South Australia and Tasmania … the largest resource (for mentally disturbed
old people) appears to be the private nursing home.’ Carter, op. cit. p.7.
112
The process of deinstitutionalisation that was inherent in the plans E. C. Dax had for
reforming Victoria’s psychiatric services, was common to psychiatric services in Britain
and America. It seems that the situation in Victoria, in relation to old people, fell
somewhere between the experience in these two countries, both of which moved towards a
similar provision of psychiatric care in the community rather than through
institutionalisation, in the 1960s. On the whole, in England the over 65 year olds ‘did not
constitute a disproportionate fraction of those discharged from mental hospitals’, possibly
because there was nowhere else for them to go. In America the provision of publicly
subsidised, unregulated, private nursing homes made it possible to almost completely
eliminate old people from the State mental hospitals, A. Scull, Social Order/Mental
Disorder, Anglo-American Psychiatry in Historical Perspective, University of California
Press, Berkeley, 1989, p.312 and p.320; for conditions in Australia see Kewley, op. cit.
pp.357-358.
193
The pressure on the publicly funded psychiatric services was such that
only the most severe cases were admitted there.113 The deficiencies of the
nursing home were made evident in Ellen Newton’s account of her time as
a patient in a number of nursing homes in the eastern suburbs of
Melbourne in the mid to late 1970s.114 Her description of nights ‘jagged
with hideous sounds’, and the dismay, sometimes terror, invoked by the
uninvited visitors wandering into her room, day and night, are a telling
indictment of the failure of psychiatrists or the relevant state hospital
authorities to make anything of the medical model developed in the
psychiatric hospitals.
There can be no doubt that the provision of a subsidy for long-term care,
introduced without reference to the State governments or to the medical
practitioners who had a professional interest in the care of the infirm aged,
prolonged the period during which this group was denied appropriate
hospital and medical services. The needs of this group were overlaid by
the interest of the State government in minimising its own expenditure in
relation to the infirm aged by making the most of the Federal subsidy for
nursing home care. The point made in the previous chapter, that this
subsidy meant the Federal government shared an expense that would
otherwise have been borne entirely by the State government, was even
more the case in relation to mentally disturbed old people. The State
government bore sole responsibility for the cost of psychiatric services
whereas the Federal government contributed to the cost of general
hospitals.115 However, in participating in a process whereby the infirm
aged were decanted out of the mental hospitals, and into private nursing
113
The Pensioner Medical Service introduced in the early 1950s by the Liberal-Country
Party government, provided free general practitioner services for eligible pensioners (Age
and Invalid) but these people had to attend the outpatients department of a public hospital
for the services of a specialist consultant. This arrangement led to the situation where old
people were at risk of not receiving treatment they needed because of the difficulties
involved in getting to one of these hospitals. Carter found it hard to discern any particular
pattern as to whether a patient suffering from ‘brain failure’, the term she uses, was more
likely to be placed in a Geriatric Hospital, private nursing home or mental hospital,
although she concluded that patients were likely to be transferred to mental hospitals from
private nursing homes when they became difficult to manage, Carter, op. cit. p.10.
114
E. Newton, This Bed My Centre, McPhee Gribble, Melbourne, 1979, p.146-148, p.184.
115
A representative of the Commonwealth Department of Health which administered the
nursing home subsidy described the response on the part of State governments; there was
‘concerted action by some States to move busloads of people out of their mental
institutions and into big boarding houses. They immediately approved these as nursing
homes before we got into the act …’ House of Representatives Standing Committee on
Expenditure, In a Home or at Home, (Chairman L. McLeay) Australian Government
Publishing Service, Canberra, 1982, p.13.
194
homes, were psychiatrists collaborating with ‘the state’ as it sought to
minimise its costs, and manage a ‘problem’ population to maintain a social
order conducive to the capitalist mode of production?116
In Andrew Scull’s view it was the administrative techniques developed to
manage a ‘community-oriented’ psychiatric service, techniques that were
part and parcel of the emergence of psychiatry as a developed specialty,
that formed the basis of psychiatry’s involvement in maintaining social
order.117
In Victoria however, well into the 1980s, the scope for
psychiatrists exerting their administrative capacity in relation to provisions
for old people, was limited by the fragmented system of service provision,
the reluctance of the state bureaucracy to recognise psychiatric expertise,
and the subordination of psychiatry to general medicine and surgery in the
organisation of hospital services. Psychiatrists might have been able to
exert some influence in the provision of long-term care by setting up an
alliance with the voluntary agencies. However, E.C. Dax’s insistence on
addressing issues relating to the provision of long-term care in terms
consistent with his professional view; that is, only after acute medical
services had been established, and in relation to the need that was thereby
identified, meant that even this limited form of cooperation in managing
the ‘problem of the aged’ was eliminated. The infirm aged, ‘social junk’
in Scull’s terms were, in the course of the 1960s, transformed into a
commodity from which entrepreneurs profited but psychiatrists did not.
The exercise, contrary to Scull’s formulation was not an inexpensive one,
but it was an expense that did not fall on the State government.118
116
Scull, op. cit. p.135.
Scull, ibid. p.31.
118
Scull, ibid. p.150.
117
195
Conclusion
The failure of the Mental Health Authority, in the period between the late
1950s and early 1970s, to establish appropriate psychiatric services for old
people whose needs could not be met through services for younger adults
is understandable in light of the difficulties faced by E.C. Dax in
implementing reform in the psychiatric hospitals. Confused old people
were neglected because the combined effects of an overall lack of
resources available to the Mental Health Authority, lack of central
coordination to ensure prompt access to patients who did not fit into the
organisation of hospital services around the division between mental and
physical disease, and the introduction of the Federal government subsidy
for nursing home care. In many respects the conditions necessary for the
successful operation of geriatric services were beyond the control of
psychiatrists. The revolution in psychiatric care that was set in motion in
the early 1950s certainly did not bring the benefits to old people at risk of
needing custodial care, that it may have done for other members of the
community. It is also likely that the trend towards developing a biological
model of mental illness ensured that the attempts of the few psychiatrists
who were interested in mental deterioration in old age from a biographical
perspective were sidelined.
Nevertheless there are aspects of the failure of psychiatrists to promote the
cause of elderly patients that are not explained by outside elements. The
doctors who promoted attention to the needs of elderly patients occupied
influential positions – E. C. Dax was Chairman of the Mental Health
Authority and Alan Stoller his Chief Clinical Officer. It might have been
expected that the latter would have used his position to advance research
into ageing in some fashion other than simply referring it to the social
sciences. If the mental condition of migrants was regarded as a suitable
subject for study at the Mental Health Institute, why not the mental
condition of elderly Victorians? In relation to E.C. Dax, the question has
to be asked as to why he did not encourage the voluntary agencies to
develop special facilities for those old people who needed long-term care
but who were unwelcome everywhere else. He did not hesitate to bring
voluntary agencies into the work of providing special facilities for children
with particular needs and Robson’s study of his tenure as Chairman of the
Mental Health Authority stresses his ‘capacity to represent the interests of
196
the profession of psychiatry within the government and to use the media to
communicate the vision of reform to the public’.119 It is unlikely there was
no interest at all amongst the agencies.120 The conclusion can only be
drawn that Dax’s insistence on linking institutional provision with the
development of acute care facilities and community based welfare
provisions, led to his taking a stand against the encouraging institutional
provision by voluntary agencies.
The result was, however, that the
expansion in institutional care, unregulated and unsupervised, in the
private nursing homes, left the recipients of such care bereft of what
expertise there was in the community. Psychiatric expertise remained
confined to the psychiatric institutions, not exerting even the minimal
influence that the geriatricians had through their interactions with the
voluntary agencies.
119
Robson, 2002, op. cit. p.70.
In the early 1980s the Uniting Church, one of the voluntary groups involved in
providing age-specific services, did take steps towards assessing the needs of mentally
confused old people by sponsoring research into the incidence of dementia, VPRS
4523/524/8670; VPRS 4523/407/8087; see also Howe, 1997, op. cit.
120
197
CHAPTER 5
GERIATRICS AS MEDICAL WORK
Introduction
The focus in this chapter shifts away from Victoria to the national arena.
The reason is that when, in the early 1970s, Victorian ‘geriatricians’ had
the opportunity to develop their institutional role as a field of special
interest, defined in terms of a specific body of knowledge and training, it
was because of changes at the national level, changes in which the
Victorians were onlookers, not active participants. This chapter surveys
an extensive area of activity in relation to health and welfare services in
the Commonwealth and the States. Activities that include the provision
and funding of age-specific welfare services; the meaning of ‘geriatrics’ in
the different state environments; relations between federal and state
governments; and the efforts made by a segment of the medical profession
to address the deficiencies they perceived in the existing organisation of
medical services. Among such deficiencies were the failure of medical
training to equip general practitioners to deal with the chronic illness and
disability that constituted much of their workload; and the failure to
develop an organisation of health services in the Australian context that
would facilitate the treatment of such conditions. My over-riding aim here
is to show how the providers of geriatric services in their various statebound locations sought to establish geriatric medicine as a field of practice
or specialty defined in terms of specific training, and then to identify the
possibilities for doing this that appeared in the changing professional and
political environment of the early 1970s .
The Victorian doctors who supervised the transformation of Benevolent
Homes into Special Hospitals for the Aged were part of a small, nationwide community of medical practitioners who provided services for the
infirm aged in their respective states. The defining characteristics of this
community were: salaried employment in state funded institutions; local
adaptations of the British geriatric service; isolation from the mainstream
of medical work; and, in some cases, positions in the state’s Public Health
bureaucracy as Directors of Geriatrics. In their role of providing services
for the infirm aged, services based on a socio-medical model of service,
these medical practitioners found more in common with an emerging field
198
of care of the aged than with their medical colleagues providing personal,
curative medical services.
In this field medical practitioners held positions of importance, were
prominent
participants
at
‘field’
gatherings
like
the
Geriatrics
Conferences, and took the lead in establishing the Australian Association
of Gerontology. But they did not succeeded in diminishing the emphasis
on institutional provision for the infirm aged. The growth of the private
nursing home industry throughout the 1960s, on the basis of subsidies
provided by the Federal government, was graphic testimony to the failure
of these medical practitioners to establish the ‘geriatric service’ in their
respective states, as the principal means of managing the needs of
candidates for custodial care. Their failure was not so much at the state
level; the appointment of doctors as Directors of Geriatrics in some state
health bureaucracies suggested state governments were not altogether deaf
to the advocates of geriatric services. It was more a failure in gaining a
foothold in mainstream medicine and in policy formation in the Federal
government.
In the early 1970s this situation changed as a segment of the medical
profession, concerned to address problems of ill-health they believed were
neglected in the existing emphasis on individualised, curative medical
services, gained a foothold in making health policy at the Federal level.
Once again social medicine provided a model for the implementation of
socio-medical services, through the work of Thomas McKeown.
McKeown, who had replaced John Ryle as leader in the discipline of
social medicine in Britain, visited Australia in the late 1960s. His ideas
were particularly influential in the work of Sidney Sax, who led the revival
of social medicine in Australian through his work in the health
bureaucracies of New South Wales and the Federal government. The
revival of social medicine certainly provided conditions essential to
establishing the field of geriatric medicine as a medical specialty.
However, the emphasis in this revival on the rational management of
national resources – human and technical – through community-based
organisations, did not always work to the advantage of doctors who sought
to establish age-specific, hospital-based services.
199
The Australian Scene
The following survey of developments in the other states is intended to
provide a brief outline of the field of ‘geriatrics’, as it emerged during the
1960s. A point that needs to be made at the outset, one that is equally
applicable to all the states, is that these activities took place on the margins
of ‘mainstream’ health services everywhere in Australia. The ‘problem of
the aged’ featured prominently in public discussion and, by the early
1970s, a sizeable amount of public funds was spent on the provision of
services for the infirm aged. However, despite the rhetoric and financial
commitment, the provision of special hospital and medical services for old
people at risk of becoming dependent was not prominent in policy related
to the overall provision of hospital and medical services in the states.
The record of the annual Geriatrics Conferences, sponsored by the
Hospitals and Charities Commission in Victoria, is useful for charting the
emergence of the field of geriatrics in that state. It also offers an insight
into similar activities in the other states as their representatives were
invited to participate in the Conferences.
By and large these
representatives were medical practitioners but, as noted in chapter three,
they were only one group amongst a number of potential experts in
relation to services for the infirm aged.
The others included social
workers, nurses, and institutional managers, all of who were in the process
of establishing a professional role in this emerging field.1 Nevertheless,
medical practitioners played a leading role in presenting a new form of
expertise at the conferences where they appear as hosts, speakers and
leaders of discussion groups. A constant theme in all these activities was
the ‘Geriatric Service’ as the most appropriate form of hospital and
medical service for infirm old people, and in this respect, the model
promoted in the growing field of activity around the care of the aged was a
medical one. It was questionable however, whether this would necessarily
entail the development of the geriatrician as a specialist practitioner in the
field of health and sickness in old age.
1
See Appendix 1.
200
Richard Gibson, in keeping with his work in establishing the first form of
geriatric service in Australia at the Royal Newcastle Hospital in New
South Wales, was a frequent visitor to the Victorian conferences from the
first one in 1956.2 By 1964 various ventures were underway in all the
states, to replicate his model, and representatives of the states attended the
Geriatrics Conference of that year to describe their efforts. The 1964
Geriatrics Conference thus provides a convenient introduction to the range
of activities throughout the country that were encompassed within the term
‘geriatrics’.
The marginal status of the Victorian ‘geriatricians’, was
especially clear on this occasion.
Elizabeth Johnson, officer in the
Geriatrics Division of the Hospitals and Charities Commission represented
Victoria and the medical services provided in the Geriatric Hospitals were
listed as just one aspect of a varied and fragmented range of activities
included in the category ‘care of the aged’.3
Tasmania and South Australia were represented in 1964 by the Secretary
of the Launceston General Hospital and the honorary secretary of the
Central Methodist Mission in Adelaide respectively. Both described the
development of institutional settings in which different types of
accommodation were provided, ranging from independent living to longterm care. In both states, some restorative treatment was offered, and in
Launceston, domiciliary services were also provided. The main difference
between them was that the latter was attached to the Launceston General
Hospital, whereas the Adelaide project was an independent, church run
enterprise which, although it provided restorative treatment, was not
connected to a hospital. In both states there were prominent medical
spokesmen – Dr A. M. Forster in Tasmania, and Dr Collin Robjohns in
South Australia.4 Neither of these practitioners referred to the nature of
the medical role in the provision of the services they were involved in.
This suggests that their main preoccupation was the provision of services
2
Geriatrics Conference, 1956-1966, op. cit.
Geriatrics Conference 1964, pp.77-80, Geriatrics Conference, 1956-1966, op. cit; see also
Chapter Three.
4
After leaving the Queen Elizabeth Centre at Ballarat, where, as medical superintendent he
had established rehabilitative treatment, Robjohns went to Aldersgate Village, the
institution run by the Methodist Central Mission in Adelaide.
3
201
for infirm old people, services that certainly had a medical component but
were not specialist medical services.5
Queensland and Western Australia were exceptional because the
introduction of geriatric units into acute hospital settings was associated
with a clearly defined medical orientation to sickness, albeit one that was
dominated by an overall emphasis on curative medical services. The
Marjory Warren Geriatric Unit at the Princess Alexandra Hospital in
Brisbane, a purpose-built unit, was but one aspect of the conversion of an
old chronic diseases hospital into a modern general hospital.6 The unit
was in the charge of P. G. Livingstone who had undertaken his
postgraduate training with Marjory Warren at the West Middlesex
Hospital, and it was staffed by doctors and nurses as part of their rotation
through all hospital departments.7 This development took place within a
system of hospital services funded and provided by the state government
and administered by the Department of Health and Medical Services
established by Sir Raphael Cilento in the 1930s.8 Cilento, worked from a
perspective in which medical services combined preventive and clinical
elements and hospitals were organised to provide services rather than
beds.9 The Geriatric Unit, instigated by Cilento’s successor, Sir Abraham
Fryberg, demonstrated all these attributes.10
Livingstone was also
5
Dr Forster’s views may be discerned in his opening address at the 1976 meeting of the
Australian Association of Gerontology. He emphasised the needs of the elderly, including
medical care, rather than the specific character of that medical work, Proceedings
Australian Association of Gerontology, vol 2, no 4, 1976, p.199-200. Collin Robjohn
stressed that ‘care of the aged, especially the frail aged is a medical matter, not something
to be handed over to either the Nursing Profession or to lay administration’ but did not
define the character of that medical role, ‘Care of the Aged’, Newsletter of the Australian
Association of Gerontology, vol 1, no 5, 1967, p.36-37.
6
See Chapter Two.
7
Livingstone himself described these developments at the 1962 Geriatrics Conference,
Geriatrics Conference, 1956-1966, pp.78-87.
8
See Chapter Two. In Queensland, although hospitals were initially established along the
lines of the voluntary model provided by the English system, problems in funding and
management, combined with a Labor government inclined to favour the provision of
hospital services by the state, led to the situation where, in 1944, a Labor administration
finally achieved its aim of controlling the public hospital system. J. Bell, ‘Queensland’s
Public Hospital System: Some Aspects of Finance and Control’, in J. Roe, Social Policy in
Australia, Some Perspectives, 1901-1975, Cassell, Australia, 1976.
9
Gould-Fisher, op. cit. p.103-4. See Chapter Two.
10
Fryberg was appointed Director-General of Health and Medical Services in 1947, having
worked with Cilento in the 1930s, R. Patrick, A History of Health & Medicine in
Queensland 1824-1960, University of Queensland Press, St Lucia, Queensland, 1987,
p.112. The Division of Geriatrics was created in 1961, ‘for the express purpose of
improving the health and welfare services for senior citizens across the whole range of
needs including the provision of hospital care, accommodation in nursing homes’, S.D.
Tooth, ‘Progress in Geriatric Care in Queensland’, Proceedings Australian Association of
Gerontology, vol 2, no 1, 1973, p.3.
202
appointed Director of Geriatrics in the Department of Health and Medical
Services with responsibility for developing similar services in other
hospitals.11 His success in doing so was limited by a lack of domiciliary
services in the state so this process was patchy.12
In 1964, developments were also at an early stage in Western Australia
when R. B. Lefroy described them to the Conference. Lefroy, a physician,
relinquished a position at the Royal Perth Hospital and in the Department
of Medicine at the University of Western Australia, to take an appointment
as Director of Geriatrics in the Department of Public Health.13
His
promotion of geriatrics was influenced by the approach Eric Saint,
foundation Professor of Medicine at the University of Western Australia,
brought to his teaching role in the newly established medical school at the
University.
Saint, as a medical educator, sought to establish ‘social
medicine’ as part of the intellectual orientation of students by cultivating
in them ‘an attitude of mind which views the pattern of disease in a
population as a reflection of the cultural structure of society and the
occupational pursuits of its members’.14 From this perspective, the neglect
of infirm old people in the acute hospital reflected a ‘cultural’ disposition
amongst doctors to view infirmity in old age as inevitable and the
provision of custodial care as the principal response. The introduction of
an age-related service into the acute hospital as Lefroy planned, was
11
In 1964 Livingstone’s contribution to the conference was read by a representative, H. N.
Acklom, Geriatrics Conference 1964, Geriatrics Conference 1956-1966, op. cit, p63.
12
R. B. Lefroy, 1988, op. cit, p 60-61. Livingstone himself may have provided this
assessment to Lefroy.
13
Geriatrics Conference 1964, pp 65-70, Geriatrics Conference, 1956-1966, op. cit.
Lefroy had joined Eric Saint who had been appointed to establish a medical school at the
university in 1957, as Associate Professor. In the history of the medical school Lefroy is
described as a ‘superlative clinical teacher’, N. Stanley, ed. Faculty of Medicine, The
University of Western Australia, The First Quarter Century (1957-1982), Faculty of
Medicine, University of Western Australia, 1982, p59; Lefroy, 1988, op. cit. p.65.
14
See Chapter Two for an outline of social medicine; R. B. Lefroy, 1998, op. cit.
Introduction, also E. G. Saint, 1955, op. cit. pp.161-165. Saint later noted the
‘development of style in the teaching hospital’ as one of three achievements of the early
years of the medical school, ‘A Coming of Age’, Lefroy, 1998, op. cit. p.127. Saint went
from Western Australia to the inaugural position of full-time Dean in the Faculty of
Medicine at the University of Queensland.
203
simply a case of recognising the needs of this group of patients by
providing them with a hospital environment in which they could be treated
and recover at a pace dictated by their needs, not those related to the
management of the hospital.15
It was not until the 1972 conference that Lefroy was able to describe the
opening of a purpose built geriatric unit with 120 beds at the Sir Charles
Gairdner Hospital in that year.16 Lefroy also faced difficulties in aligning
hospital and domiciliary services. He decided it would be unrealistic to
introduce separate domiciliary services operating out of the hospital when
an efficient organisation already existed (providing nursing care, home
help and physiotherapy), in part because he believed doing so would
disturb the relationship between the general practitioner and the patient.
The other side of this arrangement was that he then had to develop a
relationship with the agency that provided domestic and nursing services
in private homes (Silver Chain), and with the general practitioners in the
area, so the services they provided could be aligned with those provided
by the hospital.
Bruce Ford attended the 1964 Geriatrics Conference and described the
service he had developed at the Canberra Community Hospital. While
working as a general practitioner in Canberra, Ford also held a position as
medical officer at this newly built hospital where he was commissioned to
develop a Department of Physical Rehabilitation.
As he told the
conference, this step was taken to deal with the problems posed in the
management of the hospital by the occupation of 12 per cent of its beds by
15
Geriatrics Conference, 1964, pp.65-70. Soon after Saint arrived in Perth he published a
study showing how unsatisfactory it was to provide treatment for disease that focused
solely on services provided in hospital without attention to other conditions that affected
the health and well-being of patients. The study looked at discharged patients and found a
significant number of cases where the treatment provided in hospital was undone as a
consequence of the conditions in which these people lived, E.G. Saint, ‘Medical Morbidity
in a General Hospital’, MJA, vol 2, 1960, pp.601-608.
16
Geriatrics Conference, 1972, Geriatrics Conference 1966-1976, op. cit. The Sir Charles
Gairdner Hospital was, in the mid 1960s, ‘still struggling to emerge as a general hospital’
from its previous existence as a tuberculosis hospital, and Lefroy hoped it would ‘be the
first to achieve a geriatric hospital service in its fullest meaning’ because it had not been
fully committed to specialised medicine, Geriatrics Conference 1964 op. cit.
204
a group, as he described them, of ‘neglected’, or, he corrected himself, ‘…
not … neglected – inadequately occupied elderly people’. In the 1960s the
first residents of the capital city were beginning to age and in response
community groups and voluntary agencies began to build accommodation
to provide for their needs. In addition there was a District Nursing Service
administered by the federal Department of Health and a Housekeeping
Service administered by the National Council of Women.
Perhaps
because of the lack of long established interests in both the provision of
hospital and welfare services, and the smaller population, Ford was able to
establish a department that acted as a ‘bridge’ from hospital to community
in a fashion not so easily achieved in Melbourne and Sydney.17
The success of the services offered at the Royal Newcastle and the
Canberra Community Hospitals showed what could be achieved in
establishing a geriatric service in a community of moderate size. The
situation was more complex in the large capital cities where it was not so
easy to establish personal relations between institutions and communitybased domiciliary services, nor between the various medical practitioners
who may be involved. In addition demand was greater.18 It also suggests
that the provision of such a service did not necessarily entail the
development of the role of physician geriatrician.
The medical
superintendent of the hospital in Newcastle, Dr C.J. McCaffrey, made it
clear, when he accompanied Richard Gibson to the 1961 Geriatric
Conference, that the provision of medical rehabilitation services was
simply another level of general hospital care that, as it happened, treated
mostly elderly people.19
17
B. Ford, Geriatrics Conference, 1964, pp.41-46.
When John Shepherd, medical superintendent of Mount Royal, and the manager of the
hospital, M.E. Atkinson, visited Richard Gibson’s geriatric unit at the Royal Newcastle
Hospital, in 1963, they both concluded that while his achievements were to be admired, it
would be difficult to reproduce such a service in Melbourne where patients were admitted
from widely scattered areas and demand was greater. Personal Papers, Dr John Shepherd.
19
Geriatrics Conference 1961, op. cit. pp.24-26. See also Chapter Two.
18
205
Bruce Ford also worked within the framework of medical rehabilitation.
Possibly his interest in this type of work was aroused in the early 1960s
when he worked as a medical officer at the Prince Henry Hospital in
Sydney, where plans were underway to introduce rehabilitation services
for stroke and poliomyelitis patients.20 It is likely that by then he had
established contact with the small group of doctors described in chapter
two, who lay the groundwork in New South Wales for developing medical
rehabilitation facilities in the 1950s.21
At the same time in New South Wales in the late 1950s, the DirectorGeneral of Public Health, Dr C.J. Cummins, had begun to establish special
hospitals for the aged in several hospitals under the control of the State
government.
John Lindell, Chairman of the Hospitals and Charities
Commission in Victoria, was a member of the Health Advisory Council of
New South Wales, which had recommended this.22 Unlike the Geriatric
Hospitals in Victoria, the State hospitals in New South Wales were under
medical control and there appears to have been more generous funding
available for the development of age-specific services. When Geoffrey
Hughes, deputy superintendent of Lidcombe Hospital attended the 1960
Geriatrics Conference he commiserated with Collin Robjohn, then the
medical superintendent at the Queen Elizabeth Centre at Ballarat, who had
20
Bruce Ford was medical officer at Prince Henry Hospital before his move to Canberra.
At Prince Henry, it appears from the final pages of the history of the hospital, that in the
early 1960s there were plans to establish rehabilitation services, G. Caigen, ed, A Coast
Chronicle, The History of the Prince Henry Hospital, The Board of Prince Henry Hospital,
Sydney, 1963; B. Ford, The Wounded Warrior and Rehabilitation, The Alfred Healthcare
Group, Caulfield General Medical Centre, Melbourne, Australia, 1996, p.137.
21
Leigh Wedlick, medical officer in charge of the physiotherapy department at the Royal
Melbourne Hospital noted in an article published in 1957 that the Association of Physical
Medicine, formed in the mid 1940s, had added ‘Rehabilitation’ to its title, L. Wedlick, ‘The
Physical Medicine Department in Hospital Service’, MJA, vol 2, 1957, p.718, see also
Chapter Two.
22
An early indication of the intention to introduce geriatric services in New South Wales
may be found in a report compiled by G. Procopis, a medical officer at Lidcombe Hospital,
based on what he had seen in the services developed by Marjory Warren and her colleagues
in England, cited by S. Sax, ‘Perspectives on the Development of Gerontology in
Australia’, Proceedings 20th Annual Conference Australian Association of Gerontology,
1985, p.7. Procopis’ report was followed by the report of the Advisory Committee which
is outlined in an editorial, ‘Care of the Aged and Chronically Ill’, MJA, vol 2, 1960, p.587588; Dr Cummins attended the 1962 Geriatrics Conference and gave a personal account of
the proposed changes in which he noted John Lindell’s presence on the Advisory
Committee. A note in The Age newspaper, 13/6/50, suggests that a similar committee may
have been established in Victoria as it refers to a committee formed two years previously
and asks what has been done. There is no mention of such a committee in the files of the
Hospitals and Charities Commission, VPRS4523/P1/260/2242.
206
lamented the poor facilities at his disposal.23
Hughes reported that
Lidcombe had the medical equipment ‘of a standard comparable with that
of a first-class hospital’, and facilities that included a Department of
Physical Medicine where the ‘rehabilitation potential’ of every applicant
for admission could be investigated, and an Institute of Clinical Pathology
and Medical Research to foster clinical expertise in the diseases of old
age.24
It is likely, however, that despite its greater facilities, Lidcombe Hospital
functioned in much the same fashion as the Geriatric Hospitals in Victoria.
When Hughes stressed the investigation of every applicant for admission
and their classification and placement according to their needs, he did not
broach the question of how potential patients came to be referred for
admission. The lack of any organised link with the acute hospitals, and
Lidcombe’s established role as a chronic disease hospital providing longterm care, meant that its function was limited to providing rehabilitation
treatment for patients who could not be discharged. In this context also,
the term ‘geriatrics’ referred to the provision of institutional care.
When Sidney Sax addressed the Geriatrics Conference in 1964, it became
clear that the meaning of geriatrics in New South Wales was beginning to
shift.
25
Sax, a South Africa-trained doctor had arrived in Australia in
1960. His qualifications included membership of the Royal College of
Physicians of Edinburgh and a Diploma of Public Health. Having decided
against making a home in Melbourne, his first port of call, he joined the
Department of Public Health in New South Wales and after a stint as a
hospital based doctor, he was appointed Director of Geriatrics when that
position was created in the early 1960s. This marked the beginning of a
distinguished career in health administration in both state and federal
spheres of government.
23
G. C. Hughes, ‘Medical Aspects of Longer Living’, Geriatrics Conference 1960, p.106,
Geriatrics Conference 1956-1966, op. cit. A brief outline of the history of Lidcombe
Hospital may be found in footnotes to Chapter Three.
24
It was these facilities that made it possible to host a conference at Lidcombe in 1965 on
‘The Clinical Disorders of Old Age’, Newsletter of the Australian Association of
Gerontology, vol 1, no 2, 1965, p.5.
25
S. Sax, Geriatrics Conference 1964, p.60-62, Geriatrics Conference 1956-1966, op. cit.
207
Sax spoke about a range of measures introduced in New South Wales,
many of them similar to those in Victoria. The Old People’s Welfare
Council, like its Victorian counterpart, was active in encouraging the
establishment of local social clubs for elderly people with the aim of
alleviating problems of loneliness, isolation and poor nutrition. The state
government and the voluntary agencies were establishing a range of
purpose-built accommodation for old people who were well and the
number of nursing home beds in the state had expanded to around 12,000,
for those who needed permanent care. The drawback was, that, with the
exception of the service at Newcastle, all the innovations were limited in
their effectiveness by lack of coordination.
Sax did not refer to the
changes Hughes had so proudly spoken of a few years earlier, apart from a
passing remark to the effect that unfortunately the infectiousness of ideas
about the special needs of old people did not show any signs of developing
into an ‘epidemic’ of services.
This comment implies that the state
hospitals had not become essential transit points for candidates for
custodial care, and that the idea of classification according to degree of
infirmity and potential for rehabilitation had not been taken up by the
church and voluntary agencies.26
As Director of Geriatrics within the Department of Public Health, Sax
went on to outline to the conference the approach he intended taking. He
stressed the lack of coordination between the various hospital and welfare
services provided in the state. In response to this situation, he had formed
a consultative committee for ‘the care of the aged’ comprising those
groups whose interest in this matter arose from their activities in the
community – representatives of the Australian Medical Association, local
government, the New South Wales Old People’s Welfare Council and the
state government. This approach implies that ‘geriatrics’ was principally a
matter of coordinated community-based welfare services related to the
needs of the elderly.
26
One exception was the Church of England Nursing Home, ‘Chesalon’. The
rehabilitation services provided there were described by E. Biven (Physiotherapist) and A.
Fallon, (Medical Officer) in ‘Geriatric Rehabilitation’, MJA, vol 1, 1966, pp.1081-1088.
These services were most probably limited to those admitted to the home, they were not
part of a classifying and treating, hospital-based medical service.
208
Sax clarified this interpretation in an address to a meeting of the New
South Wales Gerontological Society, not long after speaking at the
Geriatrics Conference. He began by defining geriatrics in a manner that,
he said, went beyond the standard understanding of it ‘as a branch of
medical science dealing with old age and its diseases’. Geriatrics, was
‘concerned as much with ability or its loss as with the diseases that are
related to disability, and as much with the effect on the individual of the
social and political sciences as with the effect of the medical spectrum’.27
These comments on the nature of geriatrics reflect ideas similar to those
found in John Ryle’s description of social medicine as the ‘ ‘third epoch of
prevention’, the previous two having been first the sanitary era and
second, the attack on chronic diseases such as tuberculosis and venereal
disease’. The concern in the third era is to ‘identify the social causes of
health and to construct it through socio-medical reforms’.28 The sociomedical reform in Sax’s proposals was the coordinated provision of
welfare services within a regional area so the medical care of elderly
people at risk of needing custodial care could be linked into specific
welfare services.
The connection between Sax and Ryle may be traced in the influence
exerted by the advocates of social medicine on the training program for
medical officers of health in Britain, in the late 1950s. Through the
courses taught in the Public Health Diploma they sought to redefine the
meaning of administration in public health to include ‘strategies for the
health services as a whole’, instead of the everyday administration of the
services for which the medical officer of health was responsible.29 Sax’s
Diploma in Public Health was gained in South Africa, but his subsequent
career as medical bureaucrat in both state and federal spheres of Australian
government, clearly shows the influence of British ideas of public health
administration, especially in his promotion of forms of hospital and
medical services based on a socio-medical definition of health. Not that
this precluded a definition of geriatrics as a specific form of medical work:
Sax himself published an article defining geriatrics in these terms in
27
S. Sax, ‘Modern Horizons in Geriatrics’, Newsletter of the Australian Association of
Gerontology, vol 1, no 3, 1966, p.1.
28
Porter, 1993, op. cit. p.252.
29
J. Lewis, What Price Community Medicine? The Philosophy, Practice and Politics of
Public Health Since 1919, Wheatsheaf Books, Brighton, Sussex, 1986, p.58.
209
1965.30 However, from his point of view as health services administrator,
geriatrics referred to community care for the elderly – it was left up to
other advocates of geriatrics as medical work to establish the conditions
for their definition to prevail.
Lefroy also defined geriatric medicine in an article published in the midsixties.31 The typical patient that he and Sax described, had already been
discussed by the Victorian psychiatrist, G. V. Davies, in his 1961 study, as
one who was ill-served by the division between mental and physical
illness in hospital and medical services.32 Sax and Lefroy also described
this patient as not fitting easily into existing hospital services, being ‘often
confused, they misunderstand and are misunderstood, they may lack
normal means of communication, and their rate of recovery is slow. … (in
the general hospital ward) … Though they share the high standards of
technical care (given to younger adults), they may not receive the almost
continuous, always time-consuming close personal supervision that they
need to be restored to independence.’33 Sax and Lefroy agreed this group
ought to be treated within the general hospital, in a department devoted to
the purpose and consisting of beds for assessment, rehabilitation and
permanent care, outpatient clinic and day hospital.34
Lefroy’s and Sax’s definitions, however, differ in one significant respect.
Sax made a distinction between this unit and those sections of the hospital
where treatment was provided during episodes of acute illness.35 Lefroy
on the other hand, advocated the provision of acute treatment within the
geriatric unit. Old people, he wrote, ‘differ not so much in what they need
during this assessment stage, as in the extent and the rate to which they
respond to “acute” treatment’. It is because these patients do not fit into
the ‘normal’ response to treatment during the acute phase of illness – their
30
Sax, 1965, op. cit.
Sax, ibid, and R. B. Lefroy, ‘The Medical Care of the Elderly’, MJA, vol2, 1966, pp.204210.
32
G. V. Davies, 1961, op. cit. pp.152-154.
33
Sax, 1965, op. cit. p.27, Lefroy, 1966, op. cit. p.205. The ‘close personal attention’ these
old people needed to ensure their recovery from illness was in fact the norm of nursing care
in the late nineteenth and early twentieth century when it was the most effective response
to serious illness, J. McCalman, 1998, op. cit. p.73ff.
34
The term assessment was used to describe a process of diagnosis which combined a
delineation of an elderly person’s physical, mental and social condition and it implied that
the restoration to independence was the aim of medical treatment in addition to rectifying
physiological abnormalities, Lefroy, 1966, op. cit. p.204-205.
35
Sax, 1965, op. cit. p.27.
31
210
response is slower, cure less likely – that they are at a disadvantage in this
setting. The restorative phase cannot be so readily distinguished from the
acute phase and ‘it should be continued by the same doctors and social
workers as attended him in the acute phase ….’36 In a later article Lefroy
also outlined the need for the geriatrician to be involved in supervising the
provision of long-term, or as he preferred to call it, ‘permanent’ care, and
the necessity for such facilities to be attached to a general hospital so that
elderly patients who could not be restored to any degree of independence
would be cared for in an environment where high standards of medical and
nursing care were the norm. The point was that this group of patients
would then receive attention on the basis of their needs, not the need of the
acute hospital to empty its beds as quickly as possible.37
The Field of Geriatrics
The various medical activities that came under the heading of ‘geriatrics’
in Australia in the 1960s show no definite and clear line of development,
rather they reveal a number of possibilities as yet unrealised.
The
uncertainty of the nature of geriatrics as medical work, and the isolation of
these practitioners from mainstream medicine, contrasts with the strong
growth of the field of care of the aged in general, the field in which these
doctors sought to establish their authority. In promoting the geriatric
service as a means of providing appropriate support for dependent old
people, medical practitioners found common cause with the many
community groups, which, from the 1950s on, began to direct their
activities towards the needs of the elderly.
However, despite the
prominence of medical practitioners in certain aspects of the field of care
of the aged, they failed to secure the support they needed to minimise
institutional care.
The plight of infirm old people in the early 1950s has already been
described.38 Other elderly people also experienced problems that brought
them to public attention. Those who perhaps had always lived in some
degree of poverty found it increasingly difficult to maintain an adequate
diet, cleanliness and warmth on the Age Pension if they did not have
36
Lefroy, 1966, op. cit. p.205.
R.B. Lefroy, ‘Permanent Care of Elderly People in Institutions’, MJA, vol 2, 1969,
pp.707-712.
38
See Chapter Two.
37
211
family or friends to assist them. The overall postwar shortage of housing
in the capital cities and an inflationary economy led to the situation where
even those who were better off found it hard to manage on a fixed income.
Possibly also the rise in living standards that came with postwar prosperity
made the conditions in which some old people lived conspicuous in a way
they hadn’t been previously. While old people had their strength, were
able to see and hear clearly and to get about easily, changing social and
economic conditions could be accommodated. However, when they lost
the capacity to struggle in crowded shops, to hunt around for bargains, to
keep up a supply of fuel for cooking, washing and keeping warm, their
overall wellbeing suffered.39
The basis for a common interest between the medical advocates of the
geriatric service, and groups such as the state Old People’s Welfare
Councils that took on the task of promoting the interests of the elderly in
postwar Australian society, lay in their joint concern to promote the
integration of elderly people into the society around them.
Medical
practitioners aimed to diminish the use of institutional care by fostering
the ideal of a ‘productive old age’ through the rehabilitation of old people
who already experienced a degree of dependence, and the prevention of
disability in those who were fit, by emphasising the value of activity and
engagement. The voluntary agencies had as their objective the aim of
showing ageing people in general ‘how to preserve their integration in
society’.40 In each state, the medical advocates of the geriatric service
were aligned with State government departments to varying degrees.
Victoria was at one end of the spectrum in that the state government
subsidised but did not provide hospital services directly and Queensland at
the other, with its publicly funded hospital service. New South Wales fell
in between. However in relation to the community-based welfare services
that were necessary for a geriatric service to function, doctors everywhere
39
Current Affairs Bulletin, 1950, op. cit, 119; Garton, op. cit. p146; The Current Affairs
Bulletin was issued fortnightly. It was developed by the Australian Army Education
Service as it took on the task of converting fighting men into citizens with a sense of
communal responsibility, able to ‘think intelligently’ about postwar reconstruction. The
Bulletin continued to be published after the war by the Commonwealth. Many educators
urged sn extension of the Army Education Service into the civilian population to equip
adults as a whole to participate as responsible citizens in the reconstruction of postwar
Australian society, a venture that also saw the establishment of the Council of Adult
Education in Victoria in 1946, Brown, 1995, op. cit. pp.168-173.
40
Larkins, 1956, op. cit. p.23 and the introductory remarks by Archdeacon G. T. Sambell,
Geriatrics Conference, 1957, p.27, Geriatrics Conference 1956-1966, op. cit.
212
were obliged to cultivate a common interest with voluntary agencies and
community based groups. It was these autonomous bodies that emerged
as providers of many of the services and forms of accommodation
necessary for the effective operation of such a service.
The provision of welfare services by voluntary groups was a long
established custom in all the states. Even where state governments were
more disposed to play an active role in the provision of services, voluntary
groups were encouraged to extend their role, as a result of two apparently
ad hoc decisions by the federal Menzies’ government. The first was the
introduction of a subsidy for providing purpose-built accommodation for
well old people through the Aged Persons Homes Act (1954), and the
second was the subsidy for the provision of long-term care - the Nursing
Home Benefit - which became available in early 1963. Both forms of
subsidy provided the means for extensive institutional development by
church and voluntary agencies and a burgeoning private enterprise in the
provision of long-term care. State governments, to a greater or lesser
extent, also assisted local groups to develop services through special
funding measures. The effect was that a not insignificant stream of public
funding began to be absorbed into a range of fragmented communitybased activities as individual groups responded to their particular
perception of need without reference to existing services, nor indeed to
how potential recipients may have construed their needs.41 It was the
41
In Victoria, for example, where the State government assisted Local Government
agencies and community groups to provide services, there were around 100 organisation
registered with the Hospitals and Charities Commission as recognised recipients of
government aid in 1960. By the early 1970s the number had grown to around 500,
Geriatrics Conference 1960, p.47 and Geriatrics Conference 1973, p.24, Geriatrics
Conference 1956-1966, op. cit. and Geriatrics Conference 1967-1976, op. cit. Subsidies
provided through the Aged Persons Homes Act, from its introduction in 1954 to the end of
the financial year 1970-71, amounted to around $148 million, allocated throughout
Australia to voluntary agencies, Kewley, op. cit. p.476. By 1972, the nursing home
subsidy introduced by the Commonwealth in 1963, accounted for ‘almost three times as
much as the expenditure … on Commonwealth hospital benefits for insured patients.’,
Kewley, p.536. In relation to the provision of services without reference to how potential
recipients may have perceived their needs, in Victoria, Elderly Citizens Clubs were
established following a decision made by the Old People’s Welfare Council in Victoria,
following their English counterpart, not a demand from the elderly people in the local
government areas where they were built. Where elderly people did organise themselves it
was in order to protect any erosion of pension benefits, B. Gilsenan, ‘The Involvement of
Older Adult Organisations in the Policy Making Process in Australia’, Hons. Thesis,
Department of Political Science, University of Melbourne, 1999. Provisions for the aged
in the form of pensions and subsidies for long-term care and purpose-built housing stood
out in a period when overall welfare spending was low, even if it was insufficient to keep
some old people out of poverty, G. Gray, ‘Social Policy, in The Menzies’ Era, A
reappraisal of Government, Politics and Policy, eds S. Prosser, J.R. Nethercote, & J.
213
fragmentation and proliferation of such services that led Sidney Sax to
tackle the problem of coordination as one of the principal initiatives in his
role as Director of Geriatrics in New South Wales.
The multifarious enterprises that began to appear in all the states,
beginning in the 1950s, were identified by their providers as being
responses to problems experienced by old people. However apart from the
association with age – always defined as age of eligibility for the Age
Pension – the common factor amongst these providers was their individual
association with the federal government; an association that increased as
the Commonwealth became more involved in a field previously entirely
the responsibility of the states. In the 1950s and 1960s this involvement
was motivated by the belief that the role of government was to organise
the conditions in which individuals could act responsibly by developing
the virtues of thrift and self-help, while at the same time providing
assistance for the permanently poor, especially ‘the aged’.42 As Jill Roe
notes, the relatively easy prosperity that characterised the postwar
economy in Australia, gave no cause for the mindset that underpinned the
greater involvement of the federal government, one that rejected state
intervention into social life, to acknowledge these cumulative changes as
such.43 At the same time the extent of the financial commitment provided
visible proof of ‘the aged’ as an inexorably increasing financial burden on
the community.
What role did medical practitioners play in the emergence of this field of
activity related to old age?
On occasions such as the Geriatrics
Warnhurst, Hale & Iremonger, Sydney, 1995. The existence of poverty amongst age
pensioners, despite these measures, was demonstrated in the 1960s survey conducted by
researchers at the Institute of Applied Economic and Social Research at the University of
Melbourne, R.F. Henderson, A. Harcourt, R.J.A. Harper, People in Poverty: A Melbourne
Survey with Supplement, Reprint 3, Cheshire, Melbourne, 1975.
42
The proposal to grant subsidies for purpose built housing for elderly people was first
mentioned in a policy speech by Robert Menzies, leader of the Liberal Party, at the 1954
election. There was no clear constitutional basis for the measure, Kewley, op. cit. p.315316. The subsidy was intended to enable old people to preserve a domestic environment at
a time when age or depleted resources imposed obstacles to their capacity to do so. It was
a measure that was consistent with the ‘ “home-centred independent individualism”’
characteristic of much of the legislation in the 1950s, J. Murphy, Imaging the Fifties,
Private Sentiment & Political Culture in Menzies’ Australia, Pluto Press, University of
New South Wales, Sydney, 2000, p.14. Few impoverished old people benefited from the
measure because the voluntary bodies that made use of the subsidies provided through the
Old Persons Homes Act, required residents to make an ingoing payment, Kewley, op. cit.
p.323.
43
J. Roe, ‘Perspectives on the Present Day: A Postscript’, in Roe, 1976, op. cit. p.314-315.
214
Conferences when many of the participants in this field gathered together,
medical practitioners were prominent in every respect.
They were a
majority amongst the speakers and the constant reiteration of the theme of
the ‘Geriatric Service’, by both local and visiting speakers, reinforced the
emphasis on a medical model in the provision of services for old people
whose independence was diminished. However, when account is taken of
the failure of the geriatric service to be accepted as the principal means of
providing hospital and medical services for this group, the apparent
prominence of these practitioners takes on a different complexion.
Constant repetition of the theme of the ‘Geriatric Service’ at the geriatrics
conferences throughout the 1960s, in the face of its very limited
development, can only be viewed as a lesson that went unheard by the
various parties who sat and listened to it - the voluntary agencies and
community associations that were busy expanding institutions, and even
the government departments in charge of overseeing the provision of
hospital and welfare services in the state. The absence of the private
nursing home industry at these conferences testifies to the peripheral
position of the medical advocates of the geriatric service in relation to the
overall provision of services for elderly people.
Even in promoting the provision of community-based services to minimise
the need for institutional care, the advocates of the geriatric service were
in danger of being sidelined. The expansion and multiplication of welfare
organisations throughout the 1960s expanded the field of work for social
workers.
From the 1950s, whether in voluntary agencies, local
government or state government departments, social workers began to
establish their expertise in relation to the elderly in addition to their
existing work with children, adolescents and other adults.44
Social
workers appear to have taken a lead in itemising and publicising the
deficiencies in nursing home provision for infirm old people.
In the
44
In Melbourne the Citizens’ Welfare Service appointed Shirley Ramsay, as the first social
worker to be given special responsibility for aged people. Her next position was with the
Victorian Old People’s Welfare Council, and after that, she took a position with
Nunawading Council, also with responsibility for elderly citizens, Personal communication
from S. Ramsay, 30/9/97. See also, E.P. Dobbyn, ‘The Contribution of the Social Worker
to Care of the Aged in General Practice’, Annals of General Practice, xvii, part 4, pp.169171. At the time Dobbyn held the position of Senior Social Worker in the Division of
Geriatrics, Queensland Department of Public Health, see Jones, 1980, op. cit. for an
interpretation of why social workers, despite the more favourable funding environment of
the 1970s, were unable to establish a role in the provision of personal services, p289ff,
215
Geriatrics Conferences it was a social worker, Marie Coleman, who took
on this task in a paper read at the 1969 Conference. In Victoria, hospital
social workers conducted surveys, first in the mid 1960s, and then ten
years later, to illustrate the problems of an unregulated provision of
nursing home beds.45
There was common ground between the social workers and nascent
rehabilitationists and geriatricians, in that both wanted to minimise the
provision of institutional care, to give elderly people some choice in the
matter of where they lived once their independence was compromised.
However, in their focus on the community, social workers were more
closely aligned to the shift that occurred in the 1960s towards the
provision of community services. It was a shift that Maureen Bowman
describes as the ‘mood of the sixties’ – a ‘generalised reaction against
large centralised systems, in favour of small units and community-based
services.’46
To the extent that this reaction was also against the
medicalisation of social problems, social workers were more in tune with
this climate of thought than the medical practitioners who wanted to
establish
geriatric
component.47
services
that
included
a
domiciliary
service
The problems posed by this change in the culture of
‘welfare’ for doctors wishing to promote geriatric medicine, became
clearer in the 1970s when the shift to non-medical ‘community care’ in
both health and welfare services, was underpinned by federal government
funding.
If the Australian Geriatrics Society promoted the hospital
component of geriatric services, it risked isolating geriatrics by appearing
45
M. Coleman, ‘The Pattern of Permanent Care for the Aged’, Geriatrics Conference,
1969, pp.47-57, Geriatrics Conference, 1966-76, op. cit.; E. Marshall, ‘The Chronically IllA Survey’, a Report from the Nursing Homes Group of the Victorian Association of Social
Workers, August, 1975.
46
In Britain the promotion of a role for social workers in providing personal services,
working towards establishing an environment conducive to ‘social’ well-being, occurred
within the same development that promoted the role of ‘community physician’ and that
provided inspiration for a revival of social medicine in Australian medicine, Lewis, op. cit.
p.105.
47
M. Bowman, ‘The Welfare Officer For the Aged : A Study of the Implementation of a
Commonwealth Program’, Occasional Paper in Gerontology, No 8, National Research
Institute of Gerontology and Geriatric Medicine, 1985. One obstacle faced by social
workers interested in ‘demedicalising’ welfare, was that in Victoria, community based
welfare services for the elderly were administered by the Department of Health and a
doctor’s (general practitioner’s) certification of need was required before they could be
authorised. In these circumstances nascent geriatricians were at as much of a disadvantage
as social workers. Not only were the needs of the elderly medicalised without reference to
specialist expertise, other potential recipients did not even qualify because a doctor could
not attest to the social deprivation that underpinned their needs, Coleman, 1969, op. cit.
p.47ff.
216
too much of the ‘medical establishment’ and insufficiently ‘community’oriented.48
The peripheral standing of the medical advocates of geriatric services was
not simply a matter of reluctance on the part of state governments to heed
their message. The creation of positions such as Director of Geriatrics in
some of the states indicates some preparedness within state bureaucracies
to respond. Evidence can also be found in the record of the meeting of
state ministers of health in Sydney in 1966. The previous year these
ministers passed a resolution that showed the influence of the medical
advocates of geriatric services. They called for the provision of services
for old people to be based upon an organised body of research in which
needs were identified objectively, and for an emphasis on providing
services directed towards retaining elderly people at home rather than in
institutions.
This resolution was discussed again in 1966 and each
minister reaffirmed his state’s support. However it was clear that each
was wary of committing his government to any course of action,
especially one that involved greater expenditure, until it was clear how the
federal government would respond. Over the past twelve months there
had been no indication from that quarter as to whether the resolution had
been accepted or rejected.49
The reluctance of state ministers of health to take any steps without clear
direction from the federal government is understandable. On one hand the
nursing home subsidy had brought the Commonwealth into an area of
expenditure that had previously been left to the states. On the other hand,
it was provided as a cash benefit, a form that represented minimal
interference in the organisation of services in the states although it went
against the spirit of the resolution supported by the health ministers.
When the ears of the federal government were finally opened to proposals
for the provision of domiciliary services - a result of concern at the
increasing expenditure on nursing home subsidies - the effectiveness of
48
Archives Australian Society for Geriatric Medicine, letter dated 5/4/79 from E. Erlich to
R. B. Lefroy.
49
Conference of State Health Ministers, Held in Sydney, 19th to 21st April, 1966,
Government Printer, Sydney, pp.125-128. Participants in this discussion all stressed the
enormity of the ‘problem’, stressing its social and economic and psychological dimensions.
This formulation may not have helped the cause of geriatric medicine or geriatric services
because it implied the need for action on an extensive front and large expense.
217
the domiciliary and paramedical services promised in legislation
introduced by the Gorton government, was diminished in some states by
antagonism to such overt intervention in state affairs.50 This legislation,
enacted in the States Grants (Home Care) Bill in 1969 was the first
indication that Sidney Sax’s definition of geriatrics as a system of
‘community care’ had begun to exert some influence in the construction of
the ‘field’ of care for the aged in the federal arena. The extent of this
influence was not so great, however, that this form of provision overcame
the problems posed by the fragmentation of services.51
Professional Organization
Despite their relative isolation and small numbers, the medical
practitioners involved in providing or organising services for the infirm
aged did establish professional bodies during the 1960s and early 1970s.
They did so in such a manner that the differences in ideas about the nature
of geriatrics as medical work were accommodated rather than narrowed
down. To some extent this was inevitable in view of their low numbers
and insecure foothold within the profession as a whole. The overall effect,
however, was that the advocates of geriatric medicine were not in a strong
enough position to exert any control over the conditions in which the
specialty was to develop.
50
States Grants (Home Care) Bill, 1969, Kewley, op. cit. p.484-485. John Gorton, Prime
Minister and leader of the Liberal-Country Party Coalition at this time, set up a committee
to review social welfare provisions with the aim of ensuring those in need would be helped
without discouraging self-reliance, and fostering coordination amongst the various
departments involved in providing these services, Kewley, op. cit. p.390. The Victorian
government, in this case, was reluctant to take advantage of the funding provided through
this legislation, not because of matters related to the actual legislation, but because of
concerns regarding state-commonwealth relations, Bowman, op. cit. p.24. Bowman’s
study looks at this legislation and how it was implemented by the different states.
51
Bowman, op. cit. p.6-9. The Consultative Committee for the Care of the Aged
established by Sax in the early sixties, presented a report to the minister for health in New
South Wales outlining the necessary components of community based services to relieve
the demand for institutional care. The connection between the 1969 legislation and Sax’s
plans is clear from his address to the New South Wales Gerontological Society, Sax 1966,
op. cit. He listed a range of ‘domiciliary and supportive services’, noting their relation to
social welfare rather than hospital services, then continues, ‘There should be some
operational focus within local communities designed to ensure that existing services are
accessible … Thought will have to be given to the appointment of executive welfare
officers and to the administration and cost of the services’, p.3. While the legislation may
have been influenced by Sax’s ideas in one respect at least, as he himself points out it, was
quite contrary to his notion of a comprehensive, state-wide program. Funding was made
available to local voluntary agencies, thus ensuring a continuation of fragmented services
dominated by local interpretations of need, S. Sax, Ageing and Public Policy in Australia,
Allen & Unwin, St Leonards, NSW, 1993, p.87.
218
The first association formed by the advocates of the geriatric service was
the Australian Association of Gerontology, founded in the mid-1960s.
The Association took over from the Victorian Geriatrics Conferences as a
meeting place for the various professionals and groups involved in the
growing field of ‘care of the aged’, again with the exception of
representatives of the private nursing home industry. As my concern is
with the emergence of a medical role in relation to old age infirmity, the
Association will be considered only from that point of view. None of the
possibilities for the role of geriatrician - that is, provider of age-related
rehabilitation services or age-related acute care and rehabilitation services,
or investigator of common degenerative disease - were uppermost in the
mind of David Wallace when he took the first steps to establish an
Australian association to be affiliated with the International Association of
Gerontology. At the time, in the late 1950s, Wallace had just returned to
Greenvale Village to take up his appointment as geriatrician and to
develop a geriatric service there. While he was overseas on a study tour
he attended the Fourth Congress of the International Association of
Gerontology and the President of the Association suggested he set up an
Australian branch.
Wallace’s ideas about the form the association should take were clear
when, on his return to Melbourne, he wrote to the Vice Chancellors of the
Universities of Melbourne and Sydney.52
He wanted to develop the
science of gerontology in Australia along lines similar to the British
Society for Research on Ageing, rather than the International Association
of Gerontology, which, he believed, focused on welfare rather than
science.53 His letter to the Vice Chancellor of the University of Sydney
led him into correspondence with Arthur Everitt, a physiologist already
engaged in studying the ageing process in rats.54 Everitt was out of the
52
Details of Wallace’s efforts are taken from letters written by him to the universities, to
Arthur Everitt and to the National Old People’s Welfare Council over a period from mid
1959 to the end of 1960. The letters are held in the archives of the Australian Association
of Gerontology, Box File A.
53
The British Society for Research on Ageing was established in 1947 with funding from
the Nuffield Foundation, the biological interests cultivated by this group contrasted with
the clinical and service oriented interests of the doctors such as Marjory Warren, Trevor
Howell, Lionel Cosins and Eric Brooke, who established the British Geriatrics Society in
the same year.
54
Everitt’s interest in this matter may have developed under the influence of his associates
in the Department of Physiology at the University of Sydney. Professor Frank Cotton had
established a gerontological group affiliated with the British Society for Research on
219
country at the time but replied suggesting likely contacts for Wallace.
Everitt also enclosed a letter for Wallace to circulate outlining a definition
of gerontology. It was a definition which included ‘not only the study of
natural age changes in various body functions, metabolism, enzyme
activities, histology, response to drugs etc., but also the study of the
diseases of old age … and then there is the biology of ageing’.55
Wallace’s own work in the following years was to demonstrate his interest
in diseases common in old age and in theories of ageing.56
He had little response from the contacts Everitt had suggested. The only
expressions of interest came from the staff of the research laboratory that
had been established at Lidcombe Hospital in New South Wales in the
early 1960s, and the Department of Psychology at the University of
Western Australia.57 His letter to the University of Melbourne led him in a
different, and not altogether welcome, direction.
It brought him into
contact with Professor R. D. Wright, Professor of Physiology and Dean of
the Faculty of Medicine. Wright expressed interest in the idea and advised
Wallace to make a list of all the charitable organisations interested in old
age and then consult him as to the next step.
The influence of
developments in Britain in relation to Victorian responses to the ‘problem
of old age’ has been a recurring theme throughout this study, and it is
likely that Wright’s reaction was another, more subtle manifestation of this
influence. In 1959 Wright had been back in Melbourne for a couple of
years after some time spent in England.
In referring Wallace to the
Ageing in 1949. It was disbanded after a few years. ‘Gerontological Activity in
Australia’, Newsletter of the Australian Association of Gerontology, vol 1, no 1, 1965, p.2.
55
In a paper calling for the development of experimental gerontology in biological and
medical research, at a symposium on gerontology in Melbourne in February 1976, Everitt
cited the work of Brailsford Robertson as the first Australian investigation into the ageing
process, Multidisciplinary Gerontology: A Structure for Research in Gerontology in a
Developed Country, ed I.R. Mackay, S. Karger, Basel, 1977, pp.8-16. Robertson was
Professor of Physiology at the University of Adelaide from around 1919 to 1930, his work
investigating processes of growth was commemorated in a special edition of The
Australian Journal of Experimental Biology and Medical Science, (which he founded)
published in 1932, MJA, vol 1, 1919, p.323, vol 1, 1930, p.269, vol 1, 1932, p.691.
56
After leaving Greenvale Wallace worked as a physician in a group practice in
Goulbourn, New South Wales where he published an epidemiological study of cerebrovascular disease in the area, ‘A Study of the Natural History of Cerebral Vascular Disease’
MJA, vol 1, 1967, pp.90-95. He was awarded the Doctorate of Medicine in 1968 at the
University of Sydney, for a thesis on the topic, ‘Hereditary Sensory Radicular Neuropathy:
A Family Study’, and published ‘The Inevitability of Growing Old’, Journal of Chronic
Disease, vol 20, 1967, pp.475-486.
57
The establishment of research facilities at Lidcombe has already been noted above in the
outline of developments in New South Wales. Geoffrey Hughes, deputy superintendent at
Lidcombe in the early sixties, and Arthur Everitt formed the Gerontological Association of
New South Wales in 1962, preceding the national association by three years.
220
charitable organisations he may have been expressing ideas already
formed about what gerontology entailed, ideas in which welfare
predominated, as a consequence of his second wife’s association with the
Nuffield Association in England where she had worked as a research
assistant in the mid 1950s.58
The Victorian Old People’s Welfare Council responded with enthusiasm
to Wallace’s letter. At the time the Council, together with the New South
Wales Council, was in the process of setting up a national body. Their
aim was to establish a more straightforward communication with the
federal government, and to ensure the coordination of age-related
activities, and the promotion of research into the problems of old age on a
national scale. The formation of the national body coincided perfectly
with the appearance of a task so suited to the Council’s ambition to play a
leading role in encouraging the development of interest in ageing at all
levels.
But Wallace had misgivings about this line of development.
Writing to Everitt he cautioned against allowing a ‘non-scientific’ body to
play a prominent part in the early development of a scientific organisation.
The organisation would be suffocated before it ‘could take a breath’. It
should be, from the start, ‘a body capable of furthering in a concrete
manner the conduct of basic research into the ageing process. … if it
seemed to be tending towards the welfare association pattern I should want
no part of it.’59
In the event, his misgivings about the leading role taken by the National
Old People’s Welfare Council must have been set aside. At the inaugural
meeting of the Australian Association of Gerontology on the 10th June
1964, at the John Curtin School of Medical Research, at the Australian
National University, Wallace was elected to the position of honorary
secretary/treasurer. Perhaps the preponderance of medical men in the
Council of the new association, and the absence of a representative of the
National Old People’s Welfare Council, allayed his apprehensions.
58
P. McPhee, ‘Pansy’, A Life of Roy Douglas Wright, Melbourne University Press, Carlton
South, Victoria, 1999, p.109. Meriel Wilmot’s association with the cause of the aged
continued after her return to Melbourne. In 1983 the Australian Council on the Ageing
established a library in its Victorian headquarters, named the Meriel Wilmot Library in
recognition of her 21 years of service to the needs of old people as secretary to the Myer
Foundation, Victoria.
59
Letter from Wallace to Everitt, 26/11/60.
221
However none of the medical representatives, with the exception of
Wallace and Everitt, had, in their public discussion of the topic of old age,
nominated the scientific study of the ageing process as a priority. In time
branch associations were formed in the states; New South Wales had
already formed a Gerontological Society in 1962 and it affiliated with the
national body.
The National Old People’s Welfare Council, having
carried out its self-appointed task of sponsoring the formation of the
Association, retired from the limelight having provided sufficient funds to
meet initial expenses and the early operating costs of the Association.60
The composition of the governing body of the Association reflected the
leading role taken in this field by medical practitioners – eight out of the
ten members of the first Council were medical men and two were female
social workers.61
The Association’s objectives included the promotion of gerontological
research, encouragement of cooperation between organisations and
individuals interested in gerontology and the promotion of training for
persons in all fields of gerontology.62 A glance at the programs of the
annual conferences that began in 1965 shows that many of the individuals
who participated in the Geriatrics Conferences in Victoria adopted the
Australian Association of Gerontology as a professional body. Similar
themes may also be noted: the geriatric service as the model of hospital
and medical services for infirm old people, discussions of the ‘needs’ of
the aged, the organisation and management of institutions and, a perennial
focus of interest in relation to old age, retirement.63
David Wallace’s hope that the Association would encourage a form of
gerontology that did not focus on welfare was partially realised in the
presentation of papers on the topics relating to degenerative disease and
the scientific understanding of the ageing process.
These occasional
60
Minutes of Inaugural Meeting of the Australian Association of Gerontology, 10/6/1964.
Mr James Ross, benefactor of Mount Royal, whose contribution made possible one of the
travelling scholarships awarded to three of the first doctors appointed as geriatricians in
Victoria, once again contributed to the cause of ‘old age’ by donating to these funds.
61
For a list of members of first Council see Appendix 2. The second issue of the
Association’s Newsletter listed 68 individual members of whom around 40 were members
of the medical profession in private and hospital practice and the state bureaucracies.
62
Proceedings of the Australian Association of Gerontology, vol 2, no 1, Contents page.
63
See C. Russell, ‘Aging as a Feminist Issue’, Gender Studies International Forum, vol 10,
no 2, pp.125-132 on the topic of retirement as an ‘andro-centrist’ concern which represents
the ‘real’ issues of ageing as those that concern men.
222
papers did not, however, represent any institutional developments based
on a study of ageing or indeed a clearly identified clinical concern with
health and sickness in old people. It was rather, that amongst the general
run of work of these individuals, there was some aspect related to old age.
The AAG conferences were not the principal forum for the dissemination
of studies in the fields of endocrinology, general medicine or biological
research.64 The form of gerontology that was fostered by the Australian
Association of Gerontology may be discerned in the collection of papers
given at a symposium organised by the New South Wales Division of
ANZAAS. Introducing this collection Sidney Sax, as inaugural president
of the Australian Association of Gerontology, noted that one of the
functions of ANZAAS was to bring to public attention current needs for
research. The papers published in support of the need for research relating
to old age suggest that research would take the form of an analysis of
dependency amongst the aged, its demographic representation and
significance in the economy of the nation and the provision of services.
The purpose of such studies was, hopefully, to inform government
policy.65
While the Australian Association of Gerontology provided a national
forum for doctors interested in matters relating to health and illness in old
age, its potential for supporting the development of any particular
organisation of medical work around this topic was limited for a number
of reasons. First, it was not entirely a medical association despite the
predominance of medical practitioners amongst its members, nor is there
any indication that it was ever intended to be one. Second, as is already
clear from the foregoing survey of the medical roles that were emerging in
relation to old age infirmity throughout the country, the practitioners
involved had different objectives within the larger project of ensuring the
provision of appropriate hospital, medical and welfare for a neglected
segment of the population. Bruce Ford, promoted this objective within the
broader framework of medical rehabilitation. Sidney Sax’s concern, as
public health administrator, was with the coordinated provision of
64
For example the programs of the 1972 and 1974 conferences, Proceedings of the
Australian Association of Gerontology, vol 1-2, 1969-1976.
65
S. Sax, ‘Editorial Preface’, in The Aged in Australian Society, ed S. Sax, Angus and
Robertson, 1970, p.1.
223
community based welfare services.66 David Wallace supported research
into the process of ageing on one hand, and the ordinary ailments of
ageing individuals on the other. R. B. Lefroy envisaged the geriatrician’s
role as provider of medical services including care during acute episodes
of sickness and advice and assistance to the general practitioner in the
community, as the community physician.67 In the late 1960s another voice
entered the discussion, Gary Andrews, Medical Superintendent at
Lidcombe State Hospital in New South Wales, saw the role of the
consultant physician in geriatric medicine as supervising a hospital unit
within a regional system of services which provided ‘comprehensive and
modern facilities for medical investigation and treatment modified to be
appropriate to the needs of elderly and disabled patients’, in addition to
‘retraining’ facilities.68 Although all, in one way or another, supported the
introduction of the geriatric service as the most appropriate form of
hospital service for old people at risk of needing custodial care, their
diversity of views meant that the AAG could not work to promote a
specific field of medical expertise in the same way that similar groups had
supported other medical specialties.
The common denominator of
interests within the AAG was the provision of particular age-specific
services – not a specific medical field of expertise.
A further impediment to the AAG acting as a basis for establishing a
specialist field of medical work, or indeed work in any of the fields
represented in its membership, was its complete separation from any
research, teaching or accreditation body. The professional interests that
were found in the Association developed through the relevant professional
bodies, not the Association. By the early 1970s the medical advocates of
the geriatric service had formed their own more narrowly focused
66
S. Sax, ‘Chronic Disabilities as a Public Health Problem’, MJA, vol 2, 1968,
Supplement, Report of Australasian Medical Congress.
67
Lefroy’s use of this term is discussed below.
68
G. Andrews, ‘Planning a Geriatric Service’, Proceedings Australian Association of
Gerontology, vol 1, 1971, pp.149-154. Andrews had gone to Glasgow to do his physician
training with W. F. Anderson (Sir William) following a visit by Anderson to Australia in
1968. He returned to Lidcombe to the position of medical superintendent. During this
1968 visit Anderson attended the Geriatrics Conference and a seminar at Lidcombe
Hospital where he spoke on the topic of training the geriatrician physician, Newsletter of
the Australian Association of Gerontology, vol 1, no 8, 1969, p.67. Andrews, with D. H.
Blake, an English physician and medical superintendent at Bendigo Home and Hospital for
the Aged in 1968, were, it appears, the first physician geriatricians in Australia who trained
with Anderson, see Chapter Six, Personal communication from D. H. Blake; The
Australian Medical Directory; Sir William Ferguson Anderson, ‘Geriatrics’, op. cit.
224
professional groups.
The Society for Physical Medicine and
Rehabilitation, formed in the 1940s with Rehabilitation added to its name
in the 1950s, was, by then, in the process of seeking approval of their
training program from the Royal Australasian College of Physicians. Up
to this point the Diploma program developed by the Association, had been
supervised by the Australian Postgraduate Federation in Medicine.69 In
October, 1972 in Melbourne - a surprising location in view of the apparent
lack of medical interest there, in geriatrics as a specific form of medical
work - the Australian Geriatrics Society was formed, despite some debate
as to whether such a society was necessary.70 In keeping with the second
objective of the Society, ‘to promote, improve and encourage training to
the highest possible level’, one of the earliest tasks was to seek recognition
from the Royal Australasian College of Physicians that special training
was needed for physicians to practice geriatric medicine.71
Potential
problems arising from differences about what constituted geriatric
medicine and where it could be practised, were circumvented by the
structure of the core component of the training program that was
eventually accepted by the College in 1975.72
The following month an editorial in the Medical Journal of Australia
provided a formal definition of the geriatrician’s work. The anonymous
author described the existing situation in Australia where ‘without proper
assessment and without any attempt having been made at rehabilitation’,
patients are admitted directly to permanent institutional care. This was
compared with the situation found by Marjory Warren when she first
encountered the inmates of the Poor Law Infirmary attached to the West
Middlesex Hospital in London in the late 1930s. The geriatrician’s role
69
Wedlick, 1957, op. cit. p.718. The specialty was slow to develop in England in the
interwar years, but gained some impetus from the wartime emphasis on rehabilitation,
Stevens, 1966, op. cit. p.47; Cooter, op. cit. p.227.
70
Gary Andrews, medical superintendent of Lidcombe Hospital was the first president of
the Society. Not all of the medical practitioners involved in providing geriatric services
were in favour of a special medical society, believing that the Australian Association of
Gerontology provided sufficient forum for doctors interested in geriatric medicine, R.B.
Lefroy, 1988, op. cit. p.69.
71
Ibid.
72
The need to accommodate variation arose from the differences in organisation in the
various states, and in the training and experience of practitioners – not all of who would
qualify, or even wish to qualify for College Membership. In view of their relatively small
numbers, the promoters of geriatric medicine could not afford to be too restrictive.
Material sent by the Australian Geriatrics Society to the National Specialist Qualification
Advisory Committee indicates that core training consisted of twelve months ‘in an
225
was to introduce a form of medical care aimed at preserving
independence, not to encourage dependence. The author combined
the various possibilities for geriatric medicine, describing the special skills
of the geriatrician physician in relation to, ‘… the clinical, social,
preventive and remedial aspects of illness in the elderly’.73
The
jurisdiction envisaged for this role was regional, with the geriatrician’s
responsibilities extended from the provision of services within a hospital
setting, to long-term care, and community based services. Curiously, in
view of the use of population statistics showing growing numbers of
elderly Australians that substantiated the need for an age-related medical
specialty, the advocates of geriatric medicine also claimed responsibility
for all the disabled, a claim that brought them into conflict with medical
rehabilitationists.74
A further sign of an emerging community of ‘geriatricians’, and its rather
fragile condition, was the appearance of the Journal of Geriatrics in
1970.75
Affiliated with other world-wide publications and, if the
advertisements are any indication, funded by commercial interests, it was
described as a journal devoted ‘to the science and practice of geriatric
medicine’. At first there were six issues annually, later ten. The editorial
board included most of the names that have been prominent in the chapters
of this study, with the addition of others, many of them associated with
state government posts. The volumes published between 1970 and 1972
contained local and international material but by April 1973, the Editor
was calling for more local articles, a ‘greater scientific expression of local
experience and expertise’. The call went unheeded it appears, as a year
later the material in the Journal was entirely foreign and the last edition
appeared in 1975.
approved post which provides experience in Geriatric Medicine, Rehabilitation, General
Medicine, Community Care …’, Archives Australian Society for Geriatric Medicine.
73
‘Geriatric Medicine’, MJA, vol 2, 1972, p.1041-1042.
74
Undated draft of the statement sent by the Australian Geriatrics Society to the National
Specialist Qualification Advisory Committee in support of its call for recognition as a field
of specialist medical work, Archives of the Australian Society for Geriatric Medicine;
‘Medical Rehabilitation’, MJA, vol 1, 1974, p.907-908.
75
Published by the Geriatrics Publishing Company of North Sydney between 1970 and
1975, in 6 volumes. Affiliated publications included Modern Medicine of Australia,
Modern Medicine USA, Modern Medicine Great Britain, etc.
226
Professional Integration
By early 1973, only months after the Australian Geriatrics Society was
established, the question of what form geriatric medicine would take was
still open.
Many of the first members of the Society were general
practitioners working in state hospitals, and like most Victorian
‘geriatricians’, satisfied with their standing as such. Only a few of these
early members qualified for membership of the Royal Australasian
College of Physicians or one of the British Colleges. The early move to
gain acceptance of geriatric medicine by the RACP, suggests that at least
there was the intention that, in future geriatric medicine would be
practised by College-accredited physicians.
However, the broad definition of the role of the geriatrician and the
inclusion of administrative, social and clinical elements ensured that it was
a role that lay outside the usual conception of the physician’s work.
Geriatric medicine was further differentiated from the work of physicians
in that the relationship between geriatric medicine and the state was more
explicit than it was in the case of those physicians whose work was
confined to hospitals and private practice. Medical rehabilitationists were
also in this position. By defining geriatric medicine as a form of practice
linked to regional hospital services and dependent upon the activities of
other health professionals, such as social workers and therapists, nascent
geriatricians made their close alliance with the state much clearer than did
their other physician colleagues. The dependence of the latter upon the
state was concealed in the emphasis in the existing organisation of medical
work, on fee-for-service, personal curative medical services that supported
by public funds in the form of research grants, subsidies for hospital
services and private hospital and medical insurance.
By the late 1960s the shortcomings of the organisation and funding of
hospital and medical services in Australia had become the focus of critical
attention which, for the first time, was formulated in terms the Federal
government could not easily ignore.
Academic researchers provided
material for a well-informed critique of the existing system for providing
and organising hospital and medical services, and in 1968 the Gorton
government responded by establishing an independent enquiry into the
227
hospital and medical insurance scheme.76 The provision of welfare was
also subjected to a similarly well informed critique.77 Within the medical
profession a range of matters were discussed.
Once again general
practitioners expressed concerns about their exclusion from hospitals and
the expansion of specialist services, concerns that were aggravated when
the government implemented one of the recommendations of the Nimmo
committee that differential insurance benefits be paid for specialist
services.78
Others – general practitioners and medical educators – were
concerned about the capacity of medical education and the organisation of
services to equip doctors to meet the demands posed by the forms of
disease and disability that were prominent in the Australian community. In
1965 the Royal Australian College of General Practitioners commissioned
one of its members to undertake a survey of general practice to clarify
these problems and in 1968 medical educators, researchers and
practitioners gathered in Canberra at the John Curtin School of Medical
Research to discuss matters relating to medical training and the
organisation of medical services.79 At this conference it was clear that,
76
Kewley, op. cit. p.391. At this time the Senate began to play a part in policy
development and assessment through a range of Select Committee enquiries, including one
on the cost of hospital and medical care. The Committee of Enquiry commissioned in
1968, was chaired by Mr Justice J.A. Nimmo and it presented its report in March, 1969,
Ibid. pp.503-505.
77
Public discussion at this time was stimulated by publication of the survey of people
living in poverty in Melbourne, Henderson et al, 1975, op. cit. Other (unpublished)
contributions to the discussion were made by the Senate Standing Committee on Social
Welfare which existed for a short time between 1968 and 1969, and expert representations
were made by the Australian Association of Social Workers, the Victorian Council of
Social Service and the Australian Council of Social Service, Kewley, op. cit. p.502-503,
and p.377ff. The Institute of Applied Economic and Social Research at the University of
Melbourne played a prominent role in providing the research base for discussions of both
health and welfare in the 1960s and 1970s. It was founded in the early to mid-1960s by R.I
Downing, Ritchie Professor of Economics at the University of Melbourne, Brown, 2001,
op. cit. pp.227-231.
78
Provision was made for the payment of differential insurance benefits for specialist
medical services to be structured so that the net cost to the patient was nearly identical
whether specialist or general practitioner services were involved. National registration of
specialists was required with the associated stipulation of training requirements, thus
obliging general practitioners to identify themselves as either GPs or specialists. The
formalisation of specialist practice further eroded the possibilities for GPs to perform
procedures in hospitals and a GP whose income depended mainly on surgical procedures
would be particularly hard hit because they were more highly reimbursed than ordinary
attendance, R.B. Scotton, Medical Care in Australia, An Economic Diagnosis, Sun Books,
Melbourne, 1974, p.83, p.8. This amendment to an insurance scheme that was, initially,
intended to protect the position of the general practitioner, raised a storm of protest from a
sizeable group of GPs who believed the Australian Medical Association had advanced the
interests of specialists above theirs, and the subsequent formation of a small but vocal,
break-away group, T. Hunter, ‘Medical Politics: Decline in the Hegemony of the
Australian Medical Association?’ Social Science and Medicine, vol 18, no 11, p.974-975.
79
C. Jungfer, ‘General Practice in Australia; A Report on a Survey’, Annals of General
Practice, vol x, part 1, 1965, pp.4-48; the proceedings of the 1968 conference were
published in Brown & Whyte, 1970, op. cit.
228
once again, Australian medical administrators and educators were looking
to social medicine for inspiration in addressing issues related to the
funding, organisation and content of medical services.80
In contrast to the earlier period, when Australian doctors had gone to
England to imbibe the lessons of social medicine, in the late 1960s social
medicine came directly to Australia.
Thomas McKeown, who had
succeeded John Ryle as the dominant figure in the discipline, came to
Australia in 1967-68 and was a principal speaker at the Canberra
conference.81 In addition to emphasising the social components of disease,
McKeown also devoted attention to the organisational aspects of medical
services. He used the concept of a ‘balanced hospital community’ to
describe the integration of all forms of hospital and welfare services in the
one institution, and directly related to the needs of a specific local
population, rather than those of medical research and ‘other ephemeral
interests’.82
This aspect of his influence was already evident in the
approaches to defining geriatric medicine displayed by Sidney Sax and
R.B. Lefroy.83
McKeown’s influence, and that of social medicine in general, was clearly
evident the book Sax published in 1972, in which he proposed a form of
organisation of health services in Australian conditions so they could
better address prominent problems of ill-health in the Australian
population.84 The emphasis in this text was on the organisation of medical
services outside the hospital, services that, in the Australian setting, were
provided principally through general practice.85 The ideas in Sax’s book
were given practical form in the Community Health Program, one of the
80
See Chapter Two.
Porter, 1977, op. cit. p.102; Brown & Whyte op. cit. Introduction. Rene Dubos was the
other notable guest at the conference. McKeown came to be known principally for
proposing that changes in social and economic conditions played a greater part in
combating disease than advances in medical science see, The Modern Rise of Population,
was published, Edward Arnold, London, 1976.
82
T. McKeown, Medicine in Modern Society, George Allen & Unwin Ltd, London, 1965,
p.121ff.
83
Both Sax and Lefroy included references to McKeown and Ryle in their mid 1960s
attempts to define geriatric medicine, Sax, 1965, op. cit, Lefroy, 1966, op. cit.
84
S. Sax, Medical Care in the Melting Pot, An Australian Review, Angus and Robertson,
Sydney, 1972.
85
The influence of McKeown has been noted because of the personal contact between him
and doctors like Sidney Sax, who attempted to develop a local form of social medicine.
However Sax’s work also makes as much reference to J.N. Morris, a prominent figure in
the development of policy in England, relating to ‘community medicine’ in the late 1960s’,
Lewis, op. cit. p.102ff.
81
229
first of a number of publicly funded health service initiatives introduced
by the Whitlam Labor government when it came to power in late 1972.
The appearance of the word ‘community’ in the language of social
medicine was associated with changes noted above whereby academics in
the discipline of social medicine in Britain, sought to reform the practice
of Public Health medicine as ‘community medicine’ and the Public Health
medical officer as the ‘community physician’.86 R.B. Lefroy’s description
of the physician geriatrician as ‘community physician’ in his 1966 article,
may also have been influenced by these developments because he
emphasised management of hospital and community resources in
maintaining the health of elderly people and supporting the general
practitioner in caring for elderly patients.87 In the English context both
academics and ‘community physicians’ had difficulty in defining and
integrating this new role with its emphasis on epidemiology and the
management and planning of health services, with mainstream medicine.
Lewis notes that ‘the specialty was born largely of administrative fiat’,
more closely bound to a reorganised health service than to the providers of
personal, medical services.88
In the Australian context ‘community
medicine’ was adapted to provide an intellectual and organisational
orientation for re-building general practice (this was also the goal of J.H.L.
Cumpston when he became first Director-General of the Commonwealth
Department of Health).
In this case the problem of integration was
compounded by the long-standing reluctance of the medical profession to
be involved in any activity that entailed an open association with
government.
McKeown’s ideas were influential in the first attempt to incorporate the
geriatric service into mainstream hospital services in Victoria, but the
service would not be under the direction of a geriatrician. At the Alfred
Hospital, the medical superintendent, Ian Howard, seeking to develop the
institution along the lines of McKeown’s ‘balanced hospital community’,
appointed Bruce Ford to develop rehabilitation services at Caulfield
Hospital, and this included the geriatric unit that had been established in
86
Lewis, op. cit. p.100-101. These changes were also associated with the promotion of the
role of the social worker in providing personal care services that was noted above.
87
Lefroy, 1966, op. cit. p.206, and Lewis, op. cit. pp.102-104.
88
Lewis, op. cit. p.101-102.
230
the hospital by Cecil Ashley in the mid 1950s.89 Ford later recorded that it
was his sociology degree – a Master’s degree gained through a study of
the dependent aged in Canberra - together with his experience in
establishing a rehabilitation department at the Canberra hospital that
ensured his selection for the task at Caulfield.90 A balanced hospital
community was, ideally, one in which, services were organised to respond
to patients’ needs rather than the requirements of medical research and
other ‘ephemeral interests’. This meant that on one hand hospital services
were based on the needs of populations and that hospital services were
aligned with community based services in a manner similar to that
proposed for the geriatric service. On the other hand, it meant that the one
hospital complex included all the subsidiary institutions that had grown up
around the acute hospital – chronic hospitals, psychiatric services, and
maternity and children’s hospitals, and each area was staffed by the same
doctors and nurses.
The balanced hospital community provided the
organisational setting to enable doctors to ‘know’ about illness in all its
complexity, as a social as well as a biological phenonomen.91
To the extent that the ‘balanced hospital community’ provided an
organisational basis for including a geriatric service within the acute
hospital, the adoption of this approach opened up the possibility for
doctors in Victoria to link their activities in the Special Hospitals for the
Aged into general hospital services. It may well have been the more
advanced organisation of the medical rehabilitationists, and the direction
chosen by Bruce Ford in developing his career within this organisation,
89
In May 1972, Dr G.I. Howard, medical superintendent at the Alfred Hospital in
Melbourne, addressed the annual general meeting of the Victorian Branch of the Australian
Association of Gerontology, describing the introduction at the Alfred, of McKeown’s
‘balanced hospital community’, Personal Papers of Dr John Shepherd.
90
B. Ford, 1996, op. cit. p.112; S. Sax, 1985, op. cit. p.8.
91
McKeown, 1965, op. cit. p.121ff.
231
that led to medical rehabilitation (which included the care of infirm old
people) being introduced into the ‘balanced hospital community’ at the
Alfred. 92
The Monash Medical Centre, a new outer-suburban complex established
in the early 1970s was, it appears, also intended to function along the lines
recommended by McKeown.93
The establishment of Monash as a
‘balanced hospital community’ might be expected to provide an
opportunity for the doctors who provided geriatric services at the nearby
Kingston Centre to incorporate their work with that of the acute hospital.
However, not only was there no medical practitioner with the higher
qualification necessary for appointment to a hospital position, it may also
have been the case that the doctors at Kingston actively resisted taking any
such opportunity, being content to remain secluded in their own isolated
realm.94
The interest in social medicine amongst a minority in the Victorian
medical profession persisted through the 1960s.
However, the
fragmentation of hospital and welfare provision and the lack of a central
controlling body - elements essential to the functioning of a ‘balanced
hospital community’ - ensured that the prospects for inserting the role of
92
D.H. Blake, the Glasgow trained physician geriatrician and medical superintendent at
Bendigo Home and Hospital for the Aged, was qualified to take on the role given to Bruce
Ford. He was appointed by Ford to take charge of the Geriatric Division in Caulfield
Rehabilitation Hospital, where he remained for four years. The possibilities for developing
the role of the geriatrician in relation to acute care in these circumstances were just as
limited as they were at Bendigo because the whole idea of rehabilitation medicine was that
it was a post-acute form of medical care. In a rehabilitation hospital there was no scope for
Blake to practise as a physician geriatrician providing acute care as he would have been
prepared to do by his training, Personal communication, 10/4/2001.
93
A remark made by a participant at the 1968 conference in Canberra indicates that the
Monash Medical Centre was established with this model in mind, Brown & Whyte, op. cit.
p.222; see also Report to Government of Victoria by Hospitals and Charities Commission
and Monash University, 1970 which notes that the hospital was intended to provide
comprehensive services, including obstetrics, paediatrics, geriatrics and mental health, in
addition to medicine and surgery. It was also intended that general practitioners would be
included in the hospital medical staff.
94
This inference is drawn from a comment made by Lloyd Jago in the course of an
interview for an oral history of the Kingston Centre. Jago was appointed medical officer at
Kingston in 1973 and medical superintendent in 1981, and he is noted as saying, ‘For many
years we all thought that being a separate isolated identity was a good idea’, Transcript
Oral History of Kingston Centre, Ref 21/93.
232
the geriatrician into the acute hospital system remained poor. Even in
relation to the Alfred Hospital, the establishment of a rehabilitation service
at the Caulfield Hospital, an outlying section of the Alfred did not
constitute a balanced hospital community in McKeown’s terms as
Caulfield had its own management, and its own medical and nursing staff.
And yet it would be because of Sidney Sax’s influence and his promotion
of social medicine in the form of ‘community medicine’ that Victorian
‘geriatricians’ were able to shift the focus of their work from the
supervision of institutions to the provision of services. How this was done
will be addressed in the following chapter. The concern here is to clarify
just what form this influence took, and to identify the implications of the
association with community medicine for the development of geriatric
medicine.
Sax’s influence was pivotal. His capacity for leadership included the
ability to present ideas originally developed to suit other countries, so they
were more suited to local conditions. This quality was amply illustrated in
Medical Care in the Melting Pot.95
His work brought a degree of
sophistication to the formulation of proposals relating to health services
that had not previously been apparent in Australia. However his personal
qualities would probably not have flourished in the way they did under the
circumstances in which hospital and medical services were organised in
Victoria. It was the recognition in the New South Wales government that
health services warranted significant attention in terms of both policy and
funding that permitted Sax to implement his ideas.96
Sax and the other advocates of community medicine received a
sympathetic reception from the federal Labor government that came to
power at the end of 1972, after twenty-three years in opposition. The
change of government brought about a shift in thinking in relation to the
role of the federal government in the provision of health services and an
explicit commitment to expand the role of the public sector in funding and
95
Sax, 1972, op. cit.
For example the paper Sax read at the Australian Medical Congress in Perth in 1968,
‘Chronic “Disabilities as a Public Health Problem’ was based on a survey of chronic illness
and injuries conducted by the Council of Social Service of New South Wales. The
legislation introduced by the Gorton government noted earlier in this chapter, was also
based on recommendations by the Consultative Committee for Care of the Aged in NSW
and supported by the Minister for Health at the time.
96
233
providing such services.97 The establishment of the National Hospitals
and Health Services Commission, with Sidney Sax as Chairman, for the
purpose of developing and implementing health policy, and the Health
Insurance Commission to administer a universal health insurance program
(Medibank), provided conditions long sought after by Sax’s predecessors,
the national hygienists who established the Commonwealth Department of
Health in 1921.98
The administrative measures introduced by the Whitlam government
opened up the possibility, for the first time at a national level, of
establishing a model of health services focused on needs objectively
determined in the community rather than the narrowly defined notions of
sickness found in hospitals and medical research institutes.99
These
measures included funding, not only for comprehensive community based
health services but also for the research necessary to identify these needs
and to evaluate the effectiveness of services, research not promoted by the
National Health and Medical Research Council since the period
immediately following its establishment.100
Further, they measures
promoted publicly funded health services that combined the contributions
of a number of health professionals operating outside the hospital, with an
emphasis on prevention and rehabilitation.
What did these changes mean for the small group of doctors who wanted
to develop geriatric medicine as a specialist field? Most importantly they
opened up avenues of funding health services that were appropriate for the
geriatric service, thus providing the opportunity to shift the provision of
services out of the field of ‘care of the aged’ into the realm of ‘medical
services’. However, even as these opportunities were opened up, they
were also restricted. First, the antagonistic reception given the changes
97
R. B. Scotton & H. Ferber, eds, Public Expenditures and Social Policy in Australia, Vol
1, The Whitlam years, 1972-1975, Longman Cheshire for the Institute of Applied
Economic and Social Research, University of Melbourne, 1978, p.98ff.
98
Cumpston, 1978, op. cit. p.46-47, p.68.
99
The continuing emphasis on the provision of hospitals diminished the innovative
character of these reforms. For another Labor view on the topic of health services see
M.H. Cass, A National health Scheme for Labour, Victorian Fabian Society Pamphlet, 9,
1964.
100
The Community Health Program had two major policy objectives ‘(i) to emphasise the
neglected aspects of prevention, health maintenance, rehabilitation and primary care; and
(ii) to improve the availability and accessibility of health services outside of hospitals and
nursing homes’, S. Sax, ‘Australian Health Services – Development and Problems’, Public
Administration, vol xxxiv, no 3, 1975, p.222, p.224.
234
introduced under the Whitlam government by the mainstream medical
profession ensured that any field of medicine that was promoted within
these changes would remain on the margins of medical practice, at least
for the short term.
Second, even the changes in health service funding that made possible the
development of the geriatrician’s field of practice, also limited them, a
situation that may be read as a sign of the peripheral position of the
advocates of geriatric medicine within the new order. The first limitation
arose out of the location of support for geriatric services within the
Community Medicine Program – a program principally directed towards
reviving the role of the general practitioner. To the extent that the role of
geriatrician had been promoted in the 1960s as adviser to the general
practitioner this was a rational arrangement.
It certainly fostered the
development of ‘skilled full-time assessment and rehabilitation services,
and of the well-organised, reliable and comprehensive supportive services
….in every locality’, so vital to the efficient operation of a geriatric
service.101 However it did nothing to address the desire of would-be
geriatricians to establish hospital-based services to provide appropriate
clinical care for acutely sick old people. The limitations of this approach
in developing the clinical skills appropriate for the care of elderly people
at risk of needing custodial care were highlighted by Eric Saint in his
subsequent review of the Departments of Community Health that were
established to educate medical students in the field of general practice.102
To the extent that any of the components of geriatric medicine were
aligned with hospital-based work, they were included as a sub-section of
the broader activity of ‘medical rehabilitation’. In the report submitted by
the Interim Committee of the Hospitals and Health Services Commission
in November 1973, the word ‘geriatrics’ was used to describe a special
group of problems that would be addressed through the provision of
hospital-based medical rehabilitation services.103 In its Report on Hospital
101
Ibid. p.225.
E.G. Saint, ‘Evaluative Studies Program, Community Practice in Australian Medical
Schools’, Australian Government Publishing Services, Canberra, 1981, p.74.
103
Report from the Hospitals and Health Services Commission: Interim Committee, A
Medical Rehabilitation Program for Australia, Government Printer of Australia,
November, 1973, p.3. Medical rehabilitation was represented on the Interim Committee by
Bruce Ford, there was no representative of geriatric medicine.
102
235
services throughout Australia the Commission reinforced the identification
between geriatrics and rehabilitation in its section on nursing homes,
recommending the provision of a ‘geriatric assessment and rehabilitation
unit’ in every region.104
This subsidiary relationship with medical
rehabilitation was also made clear in the Report submitted to the
Universities Commission by the Working Party on Rehabilitation
Medicine and Geriatrics in 1976. Although the objective of this group was
to specify how doctors should be trained to work in the rehabilitation
services that the Hospitals and Health Services Commission promoted,
there was no representative of the Australian Geriatric Society amongst
them.
Geriatrics appeared as a small sub-section of medical
rehabilitation.105
Conclusion
While many opportunities opened up for medical practitioners to develop
the practice of geriatric medicine in the early 1970s, they were
opportunities lodged within agendas set by others. Most importantly the
agenda of the acute hospital remained untouched by the establishment of a
‘post-acute’ field of medical practice to deal with the problems of illness
that were not satisfactorily dealt with in the acute field. To the extent that
the advocates of geriatric medicine identified problems in the provision of
acute medical care for old people at risk of needing custodial care, they
gained no advantage under this new regime. The introduction of social
medicine into Australian medical practice did not lead to a publicly
recognised voice for geriatric medicine.
The position of the advocates of geriatric medicine was not improved in
relation to the overall activity in ‘care of the aged’. Not only did the new
emphasis on ‘community’ work against extending a medical role into
supervising the provision of domiciliary services but the Hospitals and
Health Services Commission could not take any action to implement the
104
Report on Hospitals in Australia, Hospitals and Health Services Commission, Australian
Government Publishing Service, 1974, p.44.
105
Report of the Working Party on Rehabilitation Medicine and Geriatrics to the
Universities Commission, ‘Rehabilitation Medicine and Geriatrics’, Australian
Government Publishing Service, Canberra, February, 1976, p.12-13. Members of this
committee were, Professor E.O. Hall, consultant to the Universities Commission, Dr G.G.
Miller, from the Repatriation General Hospital in Brisbane and Dr. I.W. Webster, formerly
of the Department of Repatriation and Compensation and appointed Professor of
Community Medicine at the University of New South Wales, in January 1976.
236
regulatory practices it recommended in relation to nursing homes.106
Neither the Commission, nor the federal government, could exert any
meaningful control over what was ultimately a matter for state regulation
in the same manner that private hospitals were regulated in their
activities.107 General practitioners also resented any moves that might
promote a specialist medical role in relation to the infirm aged. The
uncompromising response to the system introduced prior to the change of
government in 1972, indicates little sympathy for the notion that specialist
expertise was required in the care of the infirm aged.108 As a means of
controlling admissions and costs, a system was introduced whereby
Commonwealth Health Department medical officers had to approve the
admission of any patient into a nursing home if that patient was to be
eligible for Commonwealth subsidies.109
This move, unrelated to the
promotion of the role of physician geriatrician, was greeted as ‘a threat to
the civil liberties of patients because it could lead to bureaucratic
infringement of (their) … rights … to receive the treatment their doctor
recommends.’110 The defensive stridency of this response, and indeed of
other AMA responses to the innovations introduced in the Community
Health Program, silenced the calmer tones of the promoters of geriatric
medicine as they reasonably pointed out the need for expert medical
assessment before admission to a nursing home.111
106
Report of the Hospital and Health Services Commission, 1974, op. cit. Chapter 4.
Kewley, op. cit. summarises the problems facing any attempt at regulation, pp.536-546.
The Labor government sought to deal with the problem of an apparent shortage of nursing
home beds, and the need to monitor costs, by introducing the deficit funding of nursing
homes operated by non-profit bodies, in 1974, Scotton & Ferber, op. cit. p.248
108
Journal of Geriatrics, vol 4, April, 1973.
109
Report from the House of Representatives Standing Committee on Expenditure, In a
Home or At Home, (Chairman L. McLeay) October, 1982, p.16.
110
A.M.A. (Victorian Branch) Monthly Paper, No 116, 1973.
111
Editorial, The Journal of Geriatrics, April, 1973.
107
237
CHAPTER 6
PERCEIVING THE ‘SICK MAN’ IN THE OLD PERSON IN
TROUBLE1
Introduction
This chapter examines how, in a new climate of federal funding for
hospital services, doctors in Victoria were able to shift the focus of their
work, away from the management of institutions, towards the provision of
services. In doing so it draws together themes that have been present in
earlier chapters. These include; state/federal relations, the development of
a medical model for dealing with sicknesses that did not respond to
individualised, curative medical services, relations between the medical
profession and government at all levels and the emergence of a field of
welfare provision related to old age.
The funding for innovative health services introduced by the Whitlam
Labor government between 1972 and 1975, facilitated the development of
the role of ‘geriatrician’ in Victoria. For analysts of federal government
policy this brief period stands out as one in which, for the first time,
spending on social welfare was not subordinated to that aimed at fostering
economic development. This shift in policy brought a change in the fiscal
balance between the states and the federal government as the latter played
a larger role in funding health and education.2 For analysts of the politics
of health provision, this period saw the relative decline of ‘medical
monopolists’ and the rise of the ‘equal health advocates’ and ‘corporate
rationalisers’.3
The advocates of geriatric medicine sat somewhat uneasily in this
company. In promoting the needs of a neglected group of old people they
1
This chapter heading is taken from a lecture given by Derek Prinsley shortly after he
arrived in Melbourne in mid-1976, to take up his position as Foundation Professor of
Geriatric Medicine and Gerontology and Director of the Mount Royal National Research
Institute for Gerontology and Geriatric Medicine.
2
R.B. Scotton, ‘Public Expenditures and Social Policy’, in Scotton & Ferber, 1978, op.
cit.p.15ff.
3
H. Gardner, ‘Interest Groups and the Political Process’, in The Politics of Health, The
Australian Experience, 2nd edn, ed, H. Gardner, Churchill Livingstone, Melbourne, 1995,
p.203-4.
238
had common interests with the equal health advocates.
However in
emphasising the provision of hospital-based services and an extension of
medical practice, the Australian Geriatrics Society was out of step with the
trend to promote community-based health centres and non-medical
providers of health services. Furthermore, the neglect of old people in
existing hospital provisions could not be demonstrated so readily as the
neglect of Aborigines or migrants, and it was obscured by the extensive
expenditure on nursing home care and other forms of accommodation. In
relation to the ‘corporate rationalisers’, a group that must include the
advocates of medical rehabilitation because of their promotion of a ‘total
service organization’ to meet the needs of the ‘handicapped population’,
the promoters of geriatric medicine were in a subordinate position,
providing services for a sub-section of this population.4 Finally, despite
the universalist emphasis in policies promoted by the Whitlam
government, the politics of implementation ensured that the ‘ageing
enterprise’ in existence when it came to power remained untouched.
Programs inherited from Coalition governments continued unabated.5
The Hospitals and Charities Commission in Victoria took advantage of
funding provided through the Community Health Program to develop
geriatric services. As was the case in the 1950s, when it was introduced,
the role of ‘geriatrician’ was revived because the Hospitals and Charities
Commission played a leading part in this process, in cooperation with the
committees of management of the geriatric hospitals. Once again the
medical practitioners involved were dependent upon the support of these
two groups. For the first time in Victoria the provision of medical services
was justified in the language of social medicine. No doubt social medicine
became more respectable in Victorian medical circles because of the rise
to prominence in the federal arena of individuals such as Sidney Sax, who
promoted this orientation in the provision of health services. However in
relation to the revival of the role of geriatrician in Victoria, social
medicine referred not to the ‘social biology’ of old age, nor to a specific
4
B. Ford, ‘Rehabilitation, The Analysis of a Concept’, MJA, vol 1, 1973, p.909-910.
H. Kendig, ‘Ageing, Polities and Politics’ in Grey Polity, Australian Policies for An
Ageing Society, eds H.L. Kendig & J. McCallum, Allen & Unwin, Sydney, 1990, p.9-10;
C. Estes, The Aging Enterprise, Jossey-Bass Publishers, San Francisco, 1981, Estes uses
the term ‘aging enterprise’ to call attention to her argument that the implementation of
public policy regarding ‘the aged’ leads to the development of entrenched interests that are
5
239
medical interpretation of disease in old age, but to the development of
services to maintain dependent, elderly patients as functioning members of
the Victorian community.
Call for the Geriatrician
The second attempt on the part of the Hospitals and Charities Commission
(HCC) to introduce age-related medical services took place in the early
1970s in a context that had changed significantly since the first attempt in
the 1950s, although not in the way that John Lindell had hoped in 1954
when he announced the introduction of geriatric services.
Then the
introduction of the role of ‘geriatrician’ and the provision of rehabilitation
treatment in ‘geriatric services’ attached to the benevolent institutions, was
one aspect of a two-pronged response to the demand in the Victorian
community for accommodation for the chronically ill and the infirm aged.
The other aspect was the provision of funding by the State government to
establish such accommodation in the benevolent institutions, demand for
which it was hoped, would be minimised by the provision of rehabilitation
treatment. By the early 1970s it was clear that this latter aim had not been
realised. Instead hospital accommodation had expanded, largely on the
basis of the subsidy for long-term care provided by the Federal
government; the ‘nursing home’ had emerged as the accepted form of
‘hospital’ care for infirm old people. This provision was found in the
Geriatric Hospitals supervised by ‘geriatrician’ medical superintendents, in
the voluntary homes and in the converted family homes run as private
businesses that proliferated throughout the suburbs following the
introduction of the subsidy. The addition of supplementary benefits in the
late 1960s, to compensate for the greater needs of some patients, spurred
the expansion of the private sector even further.6
At the 1969 Geriatrics Conference, Marie Coleman, described an
entrenched response to old age infirmity, centred upon the nursing home. 7
more concerned with maintaining their positions than critically assessing the programs and
services they provide, p.2-3.
6
Kewley, op. cit. p.357, ‘intensive care’ was defined as ‘the degree of nursing care or
paramedical treatment that the patient needed and received’, and this usually referred to
patients who were bed-bound and substantially dependent on nursing care, p.536-537. The
addition of the supplementary benefit had the effect of increasing an already significant
number of nursing home beds, by 1971 the national number was 3.7 per thousand of
population over 65, from 2.3 per thousand in 1963.
7
Coleman, op. cit. 1969, p.49-50.
240
Until the early 1970s, when the Federal government made Health
Department authorisation necessary for the purposes of claiming the
subsidy, it was the only form of hospital accommodation for no medical
opinion of any sort was necessary to secure admission. With the exception
of the Geriatric Hospitals and some of the larger voluntary agency
institutions that adopted the restorative approach, no consideration was
given to the provision of any specific treatment for these patients.8 The
common use of the term ‘geriatric’ to describe anything old and decrepit –
in particular the nursing home and its inhabitants - was the only indication
that community thinking about old age had been influenced by the
introduction of the role of ‘geriatrician’ into the benevolent homes, and
their subsequent transformation into Special Hospitals for the Aged.9
The ‘nursing home culture’ that had emerged over the preceding decade
was associated with the provision of accommodation, and standard of care,
of a quality no other sick person was expected to tolerate.10 It engendered
an attitude of mind that saw Ellen Newton, a mentally alert woman with
limited, but adequate, resources, and susceptible to severe attacks of
angina, confined to seeing out her days in a nursing home. Her general
practitioner may have taken into account the stress it would have placed on
her sister had she returned home, but at the same time there was no
consideration of any alternative approach to meeting her needs and she
was never consulted. The manner in which the subject was broached by
her doctor exemplified the prevailing attitude, ‘“We’ve decided it will be
8
Large voluntary agency homes such as the Royal Freemasons Homes and the Montefiore
Homes, adopted the restorative principles developed in the Geriatric Hospitals to the extent
that when a training program was introduced for medical staff, these voluntary agency
homes were accredited as training institutions, see below this chapter. The introduction of
deficit funding for voluntary agency institutions, by the Whitlam government made it
possible for them to develop a restorative approach to providing care, A.L. Howe, ‘Report
of a Survey of Nursing Homes in Melbourne’, Working Paper no 10, Mount Royal
National Research Institute for Gerontology and Geriatric Medicine, 1980, p.25.
9
The term ‘geriatric’ does not appear to have been used generally before the Hospitals and
Charities Commission used it to refer to the age-specific services it introduced into the
benevolent homes in the late 1950s and early 1960s.
10
Quality of accommodation varied – it included new buildings erected by the voluntary
agencies, converted private houses in the private sector, and, in the Geriatric Hospitals,
some very old buildings alongside newer ones. In the mid-1970s the Australian
Government Social Welfare Commission conducted an inquiry into welfare provisions for
old people. Although nursing homes were funded under the National Health Act, the
committee did comment on them, concluding that nursing homes were the ‘most
unsuccessful as well as the most financially unsatisfactory of the various areas in which the
government has provided assistance’ for the aged. It recommended that the nursing home
should be part of ‘an integrated system of progressive patient care’, ‘Care of the Aged’,
Report of the Australian Government Social Welfare Commission, Chairman, M. Coleman,
1975, Australian Government Publishing Service, pp.127-132.
241
best for you to live in a nursing home ...”’. He continued, as Newton
reports:
“It will be better if you do not go home,” he says, just like a clerk at
a tourist bureau saying you’ll do better travelling in the Aurora, than
in the Daylight Express. Home is your particular treasure. For your
G.P. it is just another address. You are no longer an average human
being, alive with joys and doubts and fears. Hope is not for you
either. From today you are a Patient.11
As a ‘patient’ Ellen Newton was a bystander in a process that was to affect
the remainder of her life. Her acquiescence illustrates the extent to which
those who promoted an alternative approach had failed to penetrate the
enclave of the private hospital, personal medical services and the nursing
home, which as Sidney Sax observed, was, under the circumstances,
assured of patronage.12
Newton was aware also that she was just not any patient, but a ‘geriatric’.
She had crossed the boundary separating the twilight world of the
‘geriatric’ from the everyday world. Here the inhabitants no longer played
an active part in their own existence and, unless endowed with a
robustness of personality that enabled them to resist, the characteristics
that had defined them as individuals all their adult lives were obliterated in
a deadening institutional regime.
Newton’s response betrays some
uneasiness in herself at being classified with the inhabitants of this nether
world, which itself suggests an aversion similar to that expressed by
Horace Tucker’s friends when he went to work at the Cheltenham Old
People’s Home in 1965.13 Newton felt sympathy for her fellows in the
private nursing home and wondered why they had to be shut up without
anything to pass the time, and to accept conditions that, despite the genteel
trimmings, made it clear that the enterprise was, above all, a profit making
one. At the same time she seems to have taken pains in her account of this
period of her life, to emphasise that she could not possibly be regarded as
one of them. Her private room, and her efforts to maintain the decencies
of a cultivated middle-class existence marked her out as different.
Newton’s reaction was not so blunt as that of Tucker’s friends when they
11
E. Newton, This Bed My Centre, McPhee Gribble, Melbourne, 1979, pp.4-11.
Sax, 1993, op. cit. p.88.
13
Transcript of interview with H. Tucker, Oral History of Kingston, Ref. 3/93.
12
242
exclaimed, ‘How could you get mixed up with those dreadful old people?’
but a similar distaste underlies her sympathy – a great repugnance at being
a ‘geriatric’.
Despite the age-specific welfare measures that were introduced during the
1950s and 1960s, some of which may have supported Ellen Newton in
another form of accommodation, doctors in the public hospitals continued
to voice complaints, heard since the late forties, about their problems in
discharging infirm old people.14 A medical officer at the Royal Melbourne
wrote directly to the Minister for Health, Alan Scanlan, saying that one
quarter of the hospital’s beds were occupied by old people who had
nowhere else to go, one of whom had been in the hospital for 16 months.15
Social workers took a more positive line, requesting the Hospitals and
Charities Commission (HCC) to create the position of placement officer to
facilitate the discharge process (a request that, in itself, shows how little
the work of geriatricians had penetrated the general hospitals). They also
conducted a survey to make the point that it was not simply the absence of
nursing home beds that was the cause of these difficulties, but the lack of
coordination in their provision and use.16 Pressure on the Commission did
not only come from the public hospitals but also from the community,
from the families and neighbours who took responsibility for the care of
infirm old people. In some of these cases the strain this put on all parties
was relieved by intermittent admissions to hospital. Old people who had
hospital insurance were in a somewhat better position than those who did
not. Admission of an insured patient to a private hospital was much a
much easier process than that of the uninsured patient to a public hospital
when it was clear to the admissions officer that there could be difficulties
in discharging that person. However, private hospital admissions were
also interspersed with periods at home to accommodate the requirements
of hospital insurance fund regulations relating to length of stay. None of
these hospital admissions was for specific treatment: the needs of this
group were seen entirely in terms of bed-care.
14
Miss Newton may have been more comfortably accommodated in one of the church run
nursing homes, however while they provided extensive accommodation, the nursing home
beds were often used only for individuals who were already in the institution, in
ambulatory accommodation, a practice that contributed to the apparent shortage of nursing
home beds in the 1970s.
15
VPRS 4523/P2/848/9-135.
16
VPRS 4523/P2/848/9-135, and Marshall, 1975, op. cit.
243
It might have been expected that the Geriatrics Division, established in the
Commission in the mid 1950s, would have been able to sort out some of
these problems, which Divisional officers agreed, arose out of a lack of
coordination in the location and provision of services. The Geriatrics
Division had been established to develop a coordinating role in advising
the voluntary groups that both State and Federal governments encouraged
to provide services.17 However, the potential for developing this role was
limited first, by the appointment of nurses as divisional officers - nurses
having no authority in medically dominated health services.
Second,
although one of its principal functions was to encourage collaboration
between the voluntary groups that provided services, the Division in fact
had no power to compel any of them to take any particular course of
action, relying solely on advice and negotiation to achieve its objectives.
In this situation services were provided according to how the church and
community groups viewed ‘need’ from their own particular perspectives,
with the result that while there was a significant increase in services
available for the infirm aged, they were fragmented and uncoordinated.18
Following her interview with Divisional officers in the early 1970s, Brigid
McCoppin concluded that they had developed a role in which they
responded to the demands of a varied clientele. There was little room for
implementing policy as they balanced the often-conflicting requirements
of a disparate collection of organisations in a series of ad hoc responses.
The provision of a subsidy to pay for patients to be cared for in private
hospitals while they awaited admission to a Geriatric Hospital, illustrates
the confusion amidst which Geriatric Division Officers functioned. It was
a step totally at odds with the objective underpinning geriatric services.19
The HCC faced other problems apart from its lack of power in relation to
the institutions and community groups that came within its jurisdiction.
Since its inception in 1948, the Commission’s activities had been
constrained by the apparently poor financial position of the Victorian
17
Annual Report Hospitals and Charities Commission, 1955. The Old People’s Welfare
Council, established in the early 1950s, and by the end of the 1960 known as the Victorian
Council on the Ageing, also aimed to develop a coordinating role but there are no
indications that it succeeded.
18
See Appendix 3 for a summary of these provisions.
19
McCoppin notes the annual cost of this measure was $250,000, McCoppin, 1974, op. cit.
p.48.
244
government.
The complaint that Victoria was disadvantaged in the
allocation of funds by the Federal government was a persistent theme with
all Victorian governments since 1942 (when the states had handed over the
principal taxing powers to the Federal government).20 Financial strictures
were compounded by the apparently lowly status of the Commission
within the State bureaucracy. The Health portfolio, as was noted above,
was more a reward for party service than a particular focus of policy.21
By the late 1960s, in addition to the expensive muddle in relation to
services for infirm old people, the Commission faced a growing demand
on the State’s hospital services from a population expanding from
immigration and a rising birth rate.22 Its capacity to respond to these was,
by then, limited by the openly adversarial relations between the State
government and its Federal counterpart as the former reacted to what it
viewed as the increasing encroachment into State affairs by the latter. The
funding measures introduced by the Gorton Government in 1969 through
the States Grants (Home Care) legislation, provided funding for the
domiciliary services that could support the type of geriatric service that
had been planned in the 1950s.23 However, despite the cost to the State,
the Bolte Government in Victoria at first refused this funding, a decision,
McCoppin notes, that was quietly reversed a year or so later.24 Hostility
between the two levels of government increased when the Whitlam Labor
Government came to power in the Federal arena at the end of 1972. It was
further aggravated by the strategy this government adopted to avoid
having its program of social reform blocked by unsympathetic state
20
J. Holmes, The Government of Victoria, University of Queensland Press, St Lucia,
Queensland, 1976,p.180ff.
21
McCoppin, 1974, op. cit.p.95, also see chapter three.
22
Holmes, op. cit. p.163. Between the censuses of 1947 and 1971 the overall population
increase had been 70 per cent, Holmes notes that the rate of increase was expected to slow
during the seventies.
23
Kewley, op. cit. p.484ff, see chapter five.
24
McCoppin, 1974, op. cit. p.96-97.
245
governments. It made grants directly to local councils and community
groups on the basis of submissions from them to the funding body, these
were then assessed according to a needs formula determined by that
authority.25
The first steps in the revival of the geriatrician’s role, a revival that was
given added impetus by Community Health Program funding introduced
by the Whitlam administration, were taken in the months before the Labor
Party came to power.26 Once again the H.C.C. was the principal instigator
of this process as it encouraged the doctors employed in the Geriatric
Hospitals to develop plans for establishing geriatric services and a training
program to equip medical practitioners to provide such services. Once
again, the Commission had the same twofold objective – to provide
appropriate hospital and medical services for infirm old people and to
make the most efficient use of the State’s hospital beds.
The
inconsequential position of the Geriatrics Division and its nurse-officers,
may be inferred from the fact that the revival of the geriatrician’s role was
set in motion by David Race, recently appointed Chief Medical Officer in
the Commission, when he chaired the first of what were intended to be
regular
meetings
between
the
Commission
and
superintendents and managers of the Geriatric Hospitals.
27
the
medical
The agenda for
the first meeting included the planning and decentralisation of geriatric
services; domiciliary care programs: the relations between this type of
service and the voluntary agencies, local government and local general
practitioners; and the relations between State and Commonwealth
25
It was not so much the extent of Federal funding of health services that changed when
the Whitlam Government came to power as the way it was provided. Instead of, as in the
past, subsidies being made for private expenditure, they were now provided in the form of
public expenditure and were thus more visible, Scotton & Ferber, 1978, op. cit. p.97ff.
26
No doubt following the informal decision to make use of the funding for communitybased services funded by the States Grants (Home Care) legislation in 1969.
27
VPRS 4523/P2/1010/1973-170. This first meeting took place 25/7/72. Notes in this file
suggest similar meetings had occurred at some time in the past but there is no record of
them here. Possibly this accounts for the scepticism with which the participants greeted
David Race’s remark that he hoped the meetings would provide a source of advice for the
Commission in developing policy. The medical superintendents who attended included, H.
Tucker (Kingston Centre), John Shepherd (Mount Royal), J. G. Wijeyesekera (Greenvale
Village), Bruce Ford, Caulfield Rehabilitation Hospital (which included a Geriatric
Division). David Race was appointed to the Commission in 1973, as Chief Medical
Officer, following the retirement of John Lindell, due to illness, in 1972. Lindell died the
following year. Race was previously a biophysicist in the Clinical Research Unit at the
Alfred Hospital, which he followed by several years as Director of the Computer Study
Group in the Hospitals and Charities Commission. In 1970 he qualified as a Fellow in the
Royal Australian College of Medical Administration, Australian Medical Directory.
246
agencies.
The principal concern at this stage, however, was the
development of a training scheme for geriatricians to make the work more
attractive to doctors at a time when medical work was increasingly being
defined in terms of specific skills and knowledge and accredited training
programs.28
It was David Race who took the lead in suggesting the Association of
Geriatric Medical Officers (AGMOs) assumed responsibility for
developing and supervising a training program, with the administrative
assistance of the Melbourne Postgraduate Committee.29 Possibly Race’s
suggestion followed informal discussions with the medical practitioners
involved. Nevertheless, in comparison with the introduction of training
programs by other medical specialties, it is notable that the record of this
decision is found in the minutes of a meeting sponsored by the
Commission, not a meeting of a professional association.30 In the case of
geriatric medicine in Victoria, the introduction of the training program was
the occasion of the revival of an Association that appears to have lapsed
after a few years of activity following its formation in the early 1960s. 31
The introduction of a training program under these circumstances
illustrates the dependent nature of the relationship between this group of
medical practitioners and the Commission - a relationship that most
medical practitioners sought to avoid.32
This is not to suggest that
individual practitioners had not given thought to developing their role as
geriatricians. In 1967 John Shepherd, medical superintendent of Mount
28
VPRS 4523/P2/1010/1973-170. The trend towards specialisation in medical work in
Australia, while slow to begin, accelerated in the 1960s when special interest medical
societies, ‘mutual interest groups’, shifted towards the status of ‘qualifying associations’
with ‘formal control over the training and qualifications required of entrants to the subprofession’. In the course of this process distinctions between the general practitioner and
the specialist consultant became more marked and were reinforced by the introduction of
differential fees for specialist medical attendance in the system of voluntary medical
insurance at the time. Separate registers of specialists were established in each state.
Scotton, 1974, op. cit. p.77ff.
29
VPRS 4523/P2/1010/1973-170.
30
For example, the medical practitioners who promoted medical rehabilitation as a
specialist field of work worked from an association that had been formed in the mid-1940s
as an entity quite separate from the state bureaucracies responsible for the hospitals where
these doctors were employed, see Footnote 21, chapter five.
31
Personal Papers Dr John Shepherd.
32
It was not just the closeness of the relationship with a state instrumentality that made
geriatricians in Victoria conspicuous. It was their dependence in the relationship and its
visibility. Other hospital based doctors were also highly dependent on State and Federal
funding to develop their work but this close relationship was masked by, for example, the
autonomy of hospital committees of management and by the provision of federal subsidies
directly to the providers – the hospitals.
247
Royal hospital had presented plans for a Geriatric Service to the
Commission. He did this however, as representative of his institution, not
his professional association. Such dependence on the Commission rather
than their own professional organisation was typical of the approach
Victorian practitioners had taken to their work as geriatricians and while
their attitude was understandable in view of their isolation from the
mainstream of medical practice, it also reinforced that isolation.
Patient demand for geriatric services has not been mentioned as a stimulus
to the revival of the geriatrician’s role. On one hand lack of demand
reflects a situation where elderly people simply had no say whatsoever in
any arrangements that were made for them. On the other hand it also
reflects a situation in which the elderly responded to the possibility of
being in a position of needing assistance and not being able to get it, by
‘putting their name down’ for institutional care. From their point of view,
responsible provision for one’s old age included taking the necessary steps
to ensure such a catastrophe was avoided. Up to the late 1940s and early
1950s, when the Federal government first provided subsidies for agespecific accommodation, it was mostly the poor who took the step of
putting their name on the waiting list of one of the benevolent homes.
They did so even if it meant accepting a place when it was offered while
they were fit, to ensure that if they needed assistance, it would be
available. The attitude underlying this practice is illustrated in a short film
made by the Kingston Centre (formerly the Cheltenham Old People’s
Home) to advertise its facilities.33 The film begins with a view of an
elderly, but fit, man, walking through the gates and down the drive,
dressed in his best and carrying a small suitcase. The accompanying
commentary gives his name and a brief history. After a life-time of hard
work, being alone in the world, he is, says the narrator, although still well
and able to work, approaching the time when he may not be. It is in
preparation for this that he has taken the wise step of applying for
admission and now it is his turn to be offered a place where he can see out
his days in the security of the institution.
33
Archives Kingston Centre, Cheltenham.
248
When the Federal government began to subsidise, first, age-specific
housing in 1954, and then, in 1963, long-term care, the voluntary agencies
found a source of funding that enabled them to establish extensive
complexes consisting of different levels of accommodation ranging from
self-contained flats to long-term care beds. The middle classes were thus
able to make responsible provision for their old age by going to live in one
of these protected environments, secure in the knowledge that whatever
their needs were in the uncertain future, they would be met. The report by
the Committee of Inquiry into Aged Persons Housing noted that the
provision of funding for institutional care through the Aged Persons
Homes Act, 1954, fostered a demand for institutional care.34 In turn this
demand would also have fed upon reports of the difficulties faced by many
infirm old people in getting ‘a bed’ when they did need permanent care, in
the uncoordinated system that existed in the early 1970s.
In these
circumstances the demand for ‘community services’ came entirely from
the doctors who promoted geriatric services and the social workers who
promoted the replacement of institutional care by ‘community care’.
From Institution to Community – Re-Situating the Geriatrician
The introduction of a training program for geriatricians in the mid-1970s
was a major step towards shifting the focus of ‘geriatrics’ from
institutional supervision to service provision, but funding provided by the
Federal government from the late 1960s, had already begun to change the
environment in which geriatricians worked. The first changes came with
the funding for domiciliary services provided by the Gorton LiberalCountry Party coalition, but when the Whitlam Labor government was
elected in late 1972, they were accelerated and extended. Not only did the
physical conditions in which geriatricians work shift outwards from their
institutions to the surrounding communities, but for the first time, the
cognitive orientation of the geriatric service found a place within the
broader medical profession.
Victorian geriatricians found fresh
opportunities in the early 1970s, to develop their role although their close
34
Report to the Social Welfare Commission by the Committee of Inquiry into Aged
Persons Housing, (Chairman) Mr. K. Seaman, AGPS, p.41.
249
alliance with the HCC continued to impede their integration with other
medical services and the new medical environment in which they found
themselves did not necessarily work in their interest.
Even as the AGMOs was reactivated in October 1972 for the purpose of
developing a training program for geriatricians, the conditions in which
some of these doctors practised had begun to change.
Bruce Ford,
Director of Rehabilitation Services at Caulfield, and a member of the
training program sub-committee, had appointed D. H. Blake, a physician
trained under W. F. Anderson (later Sir William) at Glasgow, to take
charge of the Geriatric Division in his hospital.
Blake had come to
Caulfield from the position of medical superintendent at the Bendigo
Home and Hospital for the Aged.35 Blake took over the unit established
by Cecil Ashley in the infirmary wards of Caulfield in the 1950s and
continued his work with the improved resources that Ford had at his
disposal to develop Caulfield as a Rehabilitation Hospital. Blake did so,
however, within a hospital organisation focused on the provision of
rehabilitation treatment, which he regarded as only one aspect of the
practice of geriatric medicine. The other aspect being the provision of
‘adequate … hospital services for geriatric patients’, adequate meaning the
facilities of a general hospital.36
Malcolm Scott, formerly geriatrician at Greenvale, had taken on the task
of establishing a Geriatric Service at Mt Eliza in 1971, in buildings
previously used as an annexe to the Royal Children’s Hospital.37 At the
time the Mornington Peninsula, the area served by Mt Eliza, was being
transformed from farming and seaside communities to suburban housing
35
See Chapter Five.
D.H. Blake, ‘The Planning of Geriatric Medical Services’, Newsletter of the Australian
Association of Gerontology, vol 1, no 7, 1968, pp.54-56. While Blake would have been
able to develop a service similar to that described in this article in that he may have been
able to admit patients from the community to an assessment ward, and he certainly had the
facilities of the Alfred Hospital within a short drive by car or ambulance. However,
located in a Rehabilitation Hospital, he could not provide care during acute illness as did
his physician colleagues at the Alfred.
37
VPRS 6345/512/1867. Mount Eliza had been used as an orthopaedic section by the
Children’s, with a special school for children with disabilities, which continued to operate
on the site until 1973.
36
250
estates with industrial production providing work for a growing
population.38 Scott’s experience at Greenvale gave him an advantage over
his committee of management and he used this to good effect to develop
the facilities at Mount Eliza as a rehabilitation centre through which
patients passed rather than as a community monument to ‘the aged’.39 He
was assisted in this by having only a hundred or so beds at his disposal so
there was little scope for providing long-term care at the Centre and
building up the waiting list.
Scott turned the situation to good advantage by making the best use of the
nursing home beds and domiciliary services that became available in the
late 1960s and early 1970s, in combination with the rehabilitative
treatment provided at the Centre. Local church halls and community
centres were included as makeshift Day Hospitals.40 The innovative use of
existing facilities was enhanced by the imaginative deployment of the
occupational and physiotherapists allocated to the service.
In these
circumstances an energetic and pragmatic practitioner, disinclined to be
constrained by administrative rules, was able to turn the shortcomings of
his institutional setting to advantage. In 1974, three years after taking on
this task, he was able to report that the Mount Eliza Centre operated with a
turnover of patients exceeding that of any other Geriatric Centre.41
It was Scott’s personal enterprise that contributed to the successful
operation of a service that, in its emphasis on restorative treatment, was
exactly what the Hospitals and Charities Commission aimed for. This
success, however, was achieved at the cost of friction with the committee
38
At the end of 1971 the population of Victoria amounted to three and a half million, much
of this increase coming from migrants. The growth in population was accompanied by an
extension of suburban development to the outskirts of the metropolitan area. It was in
response to this change in the population that the move was made to introduce a Geriatric
Service on the Peninsula. Holmes, op. cit. p.163ff, p.175ff, also Victoria Year Book, 1972,
p272-273.
39
VPRS 4523/P2/359/7834Pt2, Scott submitted his plans for developing a Domiciliary
Care Program in October 1971.
40
A letter from John Lindell in November 1971, in reply to Sir Laurence Hartnett
(Committee of Management for Mount Eliza) who had made proposals regarding the
Centre following a visit to Geriatric Centres in England, suggests the Commission
continued to be short of funds. Lindell wrote that the Commission had, when Day
Hospitals were first advocated, spent too much on construction and costs escalated
‘alarmingly’. He went on to suggest the use of Church and Public Halls ‘which can be
converted for modest sums and are usually conveniently situated’.
VPRS
4523/P2/359/7834Pt2.
41
Minutes Meetings of Hospitals and Charities Commission Officers and Medical
Superintendents and managers of the Geriatric Hospitals, 11/9/74.
251
of management, which, in turn, may have disposed the committee
unfavourably to accepting the specialist role of the geriatrician.42 Nor it
appears, were local general practitioners appreciative of the expertise
provided by the geriatrician. In June 1972 Scott described the services
provided in the Geriatric Centres, in the Monthly Paper issued by the
Victorian Branch of the Australian Medical Association. The emphasis in
this short note, on the importance of the role of the general practitioner in
providing medical services to ‘the elderly and chronically ill’, suggests
that on the whole general practitioners did not welcome the geriatrician’
expertise.43
It is not altogether clear how Community Health Program (CHP) funding
came to be used to develop geriatric services in Victoria although there
can be no doubt that it was used for this purpose.44 Perhaps in light of the
vehement opposition of the State government to most of the reforms
introduced by the Whitlam Labor government in the Federal arena there
was an element of subterfuge in the manner of doing so.45 It would not be
42
Shortly after Malcolm Scott retired from a full time position at Mt Eliza in 1980, the first
locally trained physician geriatricians completed their training and it might have been
expected that one of them would take Scott’s position. However a local general
practitioner was appointed, Dr David Phillips, FRACGP.
43
AMA (Victorian Branch) Monthly Paper, no 110, 1972, p.4.
44
The introduction to the report on the pilot geriatric service established at Mount Royal in
1973 records that it was Community Health Program funding that made the service
possible. Hospital and Charities Commission files record the purchase of a private
hospital, Manvantara Hospital, with CHP funding, for the purpose of establishing a
geriatric service in the eastern suburbs of Melbourne. VPRS 6345/540/2164; see also Sax,
1993, op. cit. p.97, Sax notes especially that in Victoria, Community Health Program
funding was used for geriatric services. The Australian Assistance Plan, also introduced in
1973 by the Whitlam government, promised funding for the regionally-based coordinated
community services that would complement geriatric services, Scotton & Ferber, op. cit.
p.218.
45
Scotton and Ferber note that the Victorian government was the most antagonistic of all
the states to the innovations introduced by this government. They refer to special
legislation to prevent public or private organisations in the state from receiving federal
grants, the Hospitals and Charities (Institutions and Benevolent Societies) Act 1973, p.103.
On the other hand, in an article assessing the achievements of the Community Health
Program, which the federal government ceased to fund in 1981, Elizabeth Furler and
Michael Howard noted that the Victorian Hospitals and Charities Act was a ‘Trojan Horse’
which allowed local groups to register or incorporate in order to receive funding from the
federal government despite the opposition of the state government to such measures. E.
Furler & M. Howard, ‘Commentary Sequels to the Community Health program’,
Community Health Studies, vol vi, no 3, 1982, p.294. The Victorian government refused to
permit the public and private hospitals in the State to take part in the first attempt by the
Hospitals and Health Services Commission to amass an organised body of information
about the country’s hospitals. However while the State might not have been represented in
the statistical material the Commission gathered, information relating to the State’s
hospitals did come from written submissions. Appendix V lists authors of written
submissions, includes the Department of Health and the Hospitals and Charities
Commission as well as public hospitals, Hospitals and Health Services Commission,
Report on Hospitals in Australia, AGPS, Canberra, 1974, Appendix V.
252
the first time that a state government used federal government funding
without acknowledging its origins. From the point of view of the HCC
and that of the institution-bound geriatricians in Victoria, the Community
Health Program offered possibilities, on the one hand, for implementing
the form of service the Commission believed was the most appropriate
response to managing long-term illness and disability, and on the other, for
integrating the work of geriatricians into a new model of medical practice.
The CHP was intended to fund health services aimed at addressing
problems neglected within existing medical services, particularly the needs
of patients whose ailments could not be cured, but whose disabilities could
be limited or even prevented by the services of a team of health
professionals under medical direction. While the geriatric service as the
HCC envisaged it, was hospital based, it was aimed at establishing and
supporting ‘social competence’ rather than cure, in order to diminish the
need for institutional care, and in this respect, was an ideal expression of
the values inherent in the CHP.46 From the perspective of the institutionbound geriatricians, the CHP promised to integrate the medical work of
‘geriatrics’ within a broader model of medical knowledge and service. In
addition to promoting the provision of medical services for the chronically
ill and disabled, CHP funding was available to establish a knowledge base
derived from epidemiological and sociological studies of health and illness
in their ‘natural’ environment to complement that produced in hospitals
and biochemical research.47
In another respect however the geriatric services planned by the
Commission highlighted an ambiguity in the Community Health Program
which is worth mentioning, because it illustrates the complexity of the
environment in which the geriatric service, and the role of the geriatrician,
finally emerged. The list of objectives of this Program contained reference
to the need for health professionals and individuals in the community to
46
See Chapter Five, and Scotton & Ferber, op. cit. p.102-103, p.105-106.
Report from the National Hospital and Health Services Commission, ‘A Community
Health Program for Australia’, Interim Committee, 1973, p.1.
47
253
come into a ‘dynamic’ relationship in ‘seeking to solve the local
community’s health and related problems’. This objective implies some
agreement between medical practitioners and ‘the community’ about the
nature of those problems. In relation to the geriatric services there was no
such coincidence of opinion about the needs of infirm old people. The
experts - the Commission and the geriatricians - thought in terms of the
provision of services. The community thought in terms of the provision of
beds. In view of there being no change in the longstanding practice on the
part of the Victorian government of encouraging voluntary groups to take
on the task of providing services, this difference of opinion promised to
pose some difficulty in the process of developing geriatric services. It was
the failure of the medical view of managing old age infirmity to dominate
over the community view that contributed to the retarded development of
the first attempt to establish geriatric services.
Two committees were in existence in the early 1970s, drawn from
members of the community, with the objective of developing provisions
for infirm old people in the northern and eastern suburban areas. Both
local committees focused on establishing large institutions with several
hundred beds. In both cases the Geriatrics Division intervened in the only
way available to it, indirectly and cajolingly, to divert the committees’
attention towards what expert opinion believed was the preferable
solution. This approach was successful but time-consuming and probably
expensive. Certainly this was the case in relation to the Peter James
Centre in the eastern suburbs, because Dr Lionel Cosins, one of the
English pioneers in geriatric services, was brought out to conduct a survey
of the resources in the area around the proposed centre, with the aim of
redirecting the committee’s attention to the ‘correct’ decisions.48
48
Personal communication from Mrs Marion Shaw, March, 1997, Mrs Shaw, as noted in
chapters two and three, was appointed officer in the Geriatrics Division in the Hospitals
and Charities Commission after John Lindell died in the early 1970s. Concerned at the
plans she was aware the two local committees had for establishing institutions with large
numbers of beds, she took the only steps open to Divisional officers, to gently redirect
attention towards the provision of services. She encouraged the committee planning the
north-eastern suburbs project to invite doctors from Mount Royal to join them, Dr John
Shepherd and Dr Boyne Russell. In regard to the eastern suburbs project, she advised
bringing Lionel Cosin to Victoria to report on the requirements necessary to develop a
geriatric service, see L. Cosin, ‘Report on Report on Eastern Suburbs of Melbourne
Geriatric Services Development & Manvantara Hospital, 1979, Hospitals and Charities
Commission, Melbourne.
254
Despite their reliance on the HCC for the impetus to develop their role,
Victorian geriatricians did make their own contribution to this effort.
Malcolm Scott’s work in establishing a geriatric service at Mt Eliza is but
one example. Although Scott’s work was important in demonstrating the
role of the geriatrician through the implementation of services, it was John
Shepherd who provided a formal definition of the work in a lecture in
1971 where he outlined his plans for a ‘Total Geriatric Service’.
In
addition to describing the structure of this service he also defined the
patient for whom the service was intended. The geriatrician, he said, dealt
with those patients, who were, by and large, over the age of 75, although
age was not the principal factor identifying the geriatrician’s patient. Such
patients presented a clinical picture not easily interpreted according to the
approach cultivated in the acute hospitals and general practice, because of
the multiplicity of pathological conditions and because the physical and
mental
components
of a
patient’s
condition
were
not
readily
distinguished.49 The term Shepherd used to describe the geriatrician’s
approach to this patient was ‘assessment’, a process that encompassed the
whole spectrum of factors that contributed to the complex clinical picture
presented by these patients – physiological, social, psychological and
sensory.50 Shepherd’s definition implies a role for the geriatrician in the
diagnosis and treatment of acute conditions. However, it was clear from
when the Hospitals and Charities Commission first introduced the role of
geriatrician in the fifties, that treatment during acute phase of illness was
not likely to be included.
In 1974, a year after the pilot program in the service proposed by John
Shepherd, had been established, David Race addressed the representatives
of the local communities that would be served by the geriatric service
planned for the Ovens and Murray Home for the Aged at Beechworth.51
His explanation of the service made it clear the Commission’s view of the
49
SJH Shepherd, ‘A Total Geriatric Service’, Appendix 1 in B. Russell & R. Dargaville, A
Geriatric Community Care Service in Brunswick, Mount Royal, June, 1976.
50
Ibid.
51
The Beechworth institution was one of the last benevolent homes to be transformed into
a Special Hospital for the Aged, John Lindell opened a new nursing home ward there in
1965, that was named in his honour. In the early 1970s Dr D. McDonald, an emigrant from
Scotland, (one of a number of English doctors appointed to develop geriatric services in
Victoria) was appointed ‘geriatrician’, I. Hyndman, Out of the Goldfields, A History of the
Ovens and Murray Hospital for the Aged, Beechworth Hospital, Beechworth, Victoria,
1993, p.178ff. McDonald was one of the first candidates when the Diploma of Geriatric
Medicine was introduced in 1975.
255
geriatrician’s role had not changed since John Lindell first introduced it in
the late 1950s.52 Certainly the Commission wanted to shift the focus of
the geriatrician’s work away from the supervision of institutional care.
However, rather than emphasising the complexity of the clinical
presentation of sickness in the elderly, Race focused on the need to
develop the social provisions to support infirm old people to remain at
home. The acute hospitals already provided adequate medical services, he
said: what was necessary were the community services to complement
these for elderly people whose conditions could not be altered by medical
science. The geriatrician would coordinate medical and welfare services
from a base in the geriatric hospitals, a base that was linked into the acute
services in the public hospitals and to domiciliary services in the
community. There was no difference between this outline of the role of
the geriatrician in the early 1970s and that given by John Lindell in 1955.53
In justifying the need for the geriatric service David Race made explicit
reference to one of the principles of social medicine, a rare occurrence in
discussions of health services in Victoria.54
Perhaps the rise to
prominence of the advocates of social medicine in the Federal bureaucracy
had conferred a degree of respectability on this view of health and
sickness. Race related improvements in health and longevity to social
provisions rather than medical science. Most of these changes, he said,
‘have been due to improvements in housing, hygiene and other sanitary
measures, with improvement in food, (and) industrial safety’. It was thus
social measures that would deal most satisfactorily with the new needs
associated with such changes. His promotion of social medicine was
somewhat diminished by his subsequent remarks to the effect that the
development of geriatric services was less costly than providing special
hospitals for this type of patient. There was a need for a continuing
medical role in the management of old age infirmity but, ‘like all these
services, they are very expensive and … we are starting to price ourselves
out of the market’.55
The Commission’s promotion of the role of
52
The Victorian Hospitals Sector No 2, in conjunction with the Hospitals and Charities
Commission, Integrated Geriatric Care – The Need for Co-ordination, Proceedings of a
One Day Seminar, November, 1974, p.7-8.
53
Hospitals and Charities Commission Annual Report, 1956.
54
For social medicine see Chapters Two and Five.
55
Integrated Geriatric Care, op. cit. p.7.
256
geriatrician, and social medicine, was inextricably linked to the need to
make the most efficient use of the state’s health and welfare resources.56
From the early 1970s the geriatric hospitals began, very slowly, to
reorganise their facilities to provide services in the form described by
David Race.
At Mount Royal, for example, the success of the pilot
geriatric service set up in 1973 led to the reorganisation of the hospital’s
facilities into a divisional structure with each division providing a geriatric
service to a specific locality.57 The older establishments continued to
provide long-term care (although to a diminishing extent through the
1980s) and to maintain their hostels and other forms of accommodation,
but the working environment gradually began to resemble the model
promoted throughout the sixties at almost every annual Geriatric
Conference.58 The role of the geriatrician began to change but it was a
slow, gradual and uneven shift, barely perceptible amidst the enduring
elements of fragmented service provision, committees of management
reluctant to relinquish their authority, and a very slow process of
recognition from other fields of medical work. The introduction of the
role of the geriatrician as service provider and the characteristic hospital
setting for this work, took place, as it did in the 1950s, in circumstances of
urgency and expediency, dominated by the Commission’s need to respond
to the problem of managing hospital resources overtaxed by an expanding
population, uncoordinated in planning and development, amidst disputes
over funding allocations between State and Federal governments.
The Brunswick Community Care Program described by John Shepherd in
his 1971 lecture was introduced at Mount Royal in 1973, under the
direction of a physician - Boyne Russell. Russell had joined the medical
staff at the hospital in the previous year after her return from England
where she worked with Tom Wilson, one of the first consultant
56
David Race may have been influenced by the ideas disseminated by Thomas McKeown
in his 1968 visit to Australia, or at least his text, The Balanced Hospital Community,
published a few years previously. McKeown expressed sentiments similar to Race’s more
elegantly in a later text, when he defined quality of care to mean ‘(a) the standard of care
(how well we do what we do), (b) effectiveness of care (whether what we do is worth
doing), and (c) efficiency of care (whether what we do makes better use of resources than
the available alternatives’, he made it clear he was not concerned with ‘… the cost/benefit
issues which arise in relation to efficiency’, T. McKeown, The Role of Medicine, Dream,
Mirage, or Nemesis? 4th reprint, Basil Blackwell, Oxford, 1989, p.138.
57
Annual Report, 1977.
58
Geriatrics Conference, 1956-1966, Geriatrics Conference, 1967-1976, op. cit.
257
geriatricians, in the service he established at Barncoose Hospital in
Cornwall.59 The Mount Royal geriatric service was only one of a number
of developments along these lines that began in the early seventies.
Reference has already been made to Mount Eliza and similar changes were
introduced at the Cheltenham Old People’s Home. The shift in emphasis
at the latter was marked by replacing the name ‘Cheltenham Old People’s
Home’ by ‘Kingston Centre’. None of the changes, however, was so
innovative that it provided a service in which psychiatric and general
medical services were integrated. It wasn’t until the early 1980s that an
integrated service was established at Mount Royal.
In view of the developments that took place in country and metropolitan
areas, the question could arise as to why I have given prominence to
events at Mount Royal. It was Mount Royal, with its link to the Royal
Melbourne Hospital, at the intellectual centre of medical work in Victoria,
and its committee of management which included influential businessmen,
that provided additional opportunities for geriatricians in Victoria to
develop their role. These circumstances did not exist to the same extent in
the other institutions, isolated as they were from the centre of the State’s
political, medical and business communities in the city area, with
committees of management made up from local suburban or country town
communities.60 The difference in standing between Mount Royal and the
other Centres was marked at the end of the 1970s when the institution was
given permission to change its title to ‘Mount Royal Hospital’ in view of
the services it provided to the chronically ill and disabled in general.61
59
Personal communication from B. Russell 12/12/97. Wilson’s career is described in
‘Comment’, Age and Ageing, vol 3, 1974, pp.69-72. He was, it appears, the first physician
geriatrician to make a special study of incontinence. Russell carried on this tradition,
establishing the first continence service at Mount Royal. An early study of this topic at the
Queen Elizabeth Centre at Ballarat was reported on at the Geriatrics Conference in 1968,
Geriatrics Conference, 1966-1976, op. cit.
60
The qualities brought to their task by the members of committees of management of
hospitals in Victoria were vital elements in the successful operation of a hospital where,
although the State government provided a substantial proportion of funding, responsibility
for administration lay with the committees of management. The importance of the
committee of management – its competence and social and political clout - in the
development of any type of hospital in Victoria is shown in McCoppin, 1974, op. cit. and
two more recent theses on the topic of Victoria’s hospital system, C. Walker, ‘The
Emergence of the Hospital System in Melbourne: 1846-1975’, PhD Thesis, La Trobe
University, 1994, and Collins, 1999, op. cit.; for a briefer account see, McCoppin, 1983,
op. cit. pp.376-377.
61
VPRS 4523/P2/8283.
258
Essentially, the service developed to address the needs of elderly people in
Brunswick, consisted of one ward in Mount Royal Hospital, reclassified
from nursing home to acute care so that patients could be admitted
directly, some short term beds for rehabilitation treatment, and others to be
used to admit old people cared for at home to provide some respite for
their carers. When a longer period for rehabilitation was necessary, the
hospital’s rehabilitation unit was used and, when necessary long-term care
beds in the other wards of the hospital. These existing and refurbished
facilities were linked to a Day Hospital and a Day Centre in the
community and the whole service was limited to the population of the
municipality of Brunswick. The aim was to provide a service that could
respond to urgent need on the day of referral, and to the less urgent within
48 hours.62 This mode of operating was in complete contrast to previous
arrangements for admission to Mount Royal, in which medical opinion
regarding need for admission ran second to management of the waiting
list. The establishment of geriatric services at the geriatric hospitals in the
early seventies provided the long-awaited opportunity for medical staff to
gain authority regarding admissions.
The Brunswick Community Care Program had its own staff – physician in
charge, social worker, nurses, therapists, clerk and carpenter (the provision
of assistance in removing impediments to independence in patients’ homes
was part of the service).
Junior medical staff came from the Austin
Hospital, either because the Royal Melbourne was unable to supply them,
or because Russell was able to arrange this more easily with the Austin.
As in the past, the incorporation of time at Mount Royal into the duty
roster of trainee doctors was not accompanied by any theoretical
component. If Boyne Russell’s teaching struck a spark of interest in any
of these students, it was quite likely to be squashed by their supervisors in
the acute hospital.63 Nor, during the period of the pilot program, did she
have a Registrar appointed to the service, which made communication
with the acute hospital more complex.
Referral to the service was
accepted from families, neighbours or professional health workers in the
62
63
Russell & Dargaville, op. cit.
Personal communication from B. Russell, 12/12/97.
259
community, and leaflets describing the service were distributed in the
languages spoken by the various migrant groups in Brunswick. Russell’s
flexible attitude to referral was essential if the benefits of the service were
to be disseminated amongst both lay and medical communities in the area.
The combination of factors that often underpinned the collapse of an old
man or woman already meant they were neglected within existing medical
services, oriented, as they were, towards identifying a single cause of
disease and divided along the lines of physical and mental disease. To rely
only on a medical interpretation of this group, by either the general
practitioner or the hospital medical officer, would be to miss the very
group the service was intended to assist.64
Nevertheless, establishing
personal contact with these medical practitioners was an important
component of Russell’s work. A professional relationship could be the
basis for inserting the geriatric service into existing hospital and medical
services available to Brunswick residents.
Slowly, and unevenly, over the years from the early to mid-1970s in
Victoria, as the geriatric service gradually shifted the focus of geriatric
medicine away from institutional supervision, the geriatric patient defined
by David Wallace in 1959 began to fade from view.65 This patient, the
institutional inmate whose general frailty, compounded by social infirmity
– the lack of money, friends or relatives - brought him or her, into the
Geriatric Hospitals, was replaced by the patient G.V. Davies, the Victorian
psychiatrist, had identified a decade earlier; one described by the British
geriatrician, John Agate, as most likely to be female, and in the eighth
decade of life.
It was around this point that long-term degenerative
conditions began to take a toll that was reflected in mental changes and
difficulties in going about the business of everyday life.66 In Victoria
however there were two views of this patient, views that were not
completely dissimilar, but whose differences had implications for the
development of geriatric medicine.
At a Symposium on the Medical and Social Problems of Ageing, in
Melbourne in 1976, Russell described the geriatric patient in terms similar
64
Russell & Dargaville, op. cit. p.11-12.
Wallace, 1959, op. cit. p.40.
66
Davies, 1961, op. cit. pp.152-154; J. Agate, The Practice of Geriatrics, William
Heinemann Medical Books, Ltd, London, 1963, p.6-7.
65
260
to those used by John Shepherd in his initial outline of the service. Mostly
over 70 years, mostly female, and, in general, the typical patient’s multiple
problems of ill health were aggravated by an inability to adapt to changes
in her social circumstances, changes that included a diminishing capacity
to participate in the social life of her neighbourhood, family or friends.
The isolation that resulted compounded her physical and mental
problems.67 The majority of people treated by the BCCP spoke English as
their native language and the number of non-English speakers was small in
relation to their proportion in the Brunswick population. These figures
suggested that in future, the widowed, 70 plus, women – the characteristic
patient of the geriatrician – would also experience difficulties arising from
cultural differences.
It was in moving the service out into the community, building on the
contacts she made with local GPs, private hospitals, nursing homes and
rest homes, that Russell came into contact with the patient that British
geriatricians had established as typical.
Poverty continued to be a
characteristic of many of the patients treated in the service simply because
of its location in a working-class area. The old men who had always been
prominent in the wards of Mount Royal were still there, as were the old
women refused admission by the public hospitals when they suffered a
stroke or fractured femur because of the problems anticipated in
discharging them. A promise that they could be admitted to the acute
ward of the Geriatric Service following treatment in the public hospital
soon changed an admitting officer’s point of view.68 At the same time,
however, in going out into the community, Russell came into contact with
potential patients who would never cross the threshold of a public hospital.
In establishing contacts with general practitioners and the proprietors of
the private hospitals, nursing homes and rest homes in the Brunswick area,
67
B. Russell, ‘Geriatric Service Monitoring’, in Multidisciplinary Gerontology: A
Structure for Research in Gerontology in a Developed Country, ed I.R. Mackay, S. Karger,
Basel, 1977, p.111.
68
Russell & Dargaville, op. cit.
261
Russell opened up the field of practice of the geriatrician in a manner that
had not been achieved previously at Mount Royal.
69
The patient Boyne Russell identified, as was noted above, was not
unknown to the advocates of geriatric medicine in Victoria.
The
significance of Russell’s definition was that it was made by a physician
geriatrician within an organisational setting specifically established to
cater for the needs of this group of patients. The distinctive character of
the geriatrician’s patient may be discerned by comparison between
Russell’s definition in her report, and that of Bruce Ford, medical
rehabilitationist at Caulfield Hospital, in a text he published in the early
1970s.70 Ford described the group of patients for whom the geriatric
service was provided, as, ‘the group of dependent adults who must be
provided with services and facilities to compensate for what they can no
longer do for themselves because of physical dependency, intellectual
deterioration or sickness’.71 He also noted that women predominated in
this group and that the factors that precipitated individuals into this group
combined elements that were medical and social.
Ford’s definition differed however, in that he characterised the condition
of this group as dependency - a condition related to the individual’s social
situation so that she was obliged to call upon publicly funded services.
The disorders which undermine the capacity to ‘get about and think
clearly’ were only given a formal interpretation of dependency when the
person in question has insufficient resources to compensate for
diminishing physical and mental competence. As Ford elaborated the
physical and mental disorders that were the basis of dependency, he
covered a range of disorders similar to those described by Russell. The
69
It was noted in Chapter Three that the introduction of rehabilitative treatment into the
benevolent institutions and the subsequent recognition of this type of hospital care for the
purposes of claims upon hospital insurance, opened up the possibility of a more affluent
clientele for the Geriatric Hospitals. Possibilities, however, were limited by the lack of
access geriatricians had to treatable patients and those treated in the private hospitals or the
private sections of the public hospitals. When the restorative methods promoted in the
geriatric hospitals were taken up by the voluntary agencies in their institutions, ‘geriatrics’
was also extended into the middle classes. In 1979 Boyne Russell addressed the Private
Geriatric Hospitals Association of Victoria on the topic of integrating public and private
sections. The president of this new group was Dr Michael Nissen described as
‘geriatrician’ to Montefiore Homes, VPRS 4523/P2/1002/1973-53. Malcolm Scott would
also have achieved a similar broadening of the patient base for geriatricians in his work at
Mount Eliza.
70
B. Ford, The Elderly Australian, Penguin Books, Ringwood, Australia, 1979.
71
Ibid. p.6.
262
difference was that he focused on the condition of dependency and its
management, while Russell emphasised the medical expertise required to
manage illness in this group of patients. They require, Russell said, a
service which ‘is different in pace, concept and range of facilities’.72
Russell’s view of the matter appears to coincide with John Shepherd’s
remarks relating to the complexity of the clinical picture presented by
these patients. Russell’s view provides a local example of that publicised
by the West Australian physician, R. B. Lefroy, in his mid-1960s article
when he defined geriatric medicine as ‘the practice of medicine among the
elderly, so arranged that their care is based on an understanding of the
physical, social and mental factors responsible for their disabilities’.73
Ford, on the other hand, reflected the ideas underlying the specialty of
medical rehabilitation.
His notion of dependency was derived from
understanding this form of medical practice as the medical supervision of
a process of retraining of a disabled individual and his or her management
within a coordinated range of welfare services, medical work quite
separate to the diagnosis and treatment of disease. The special skill of the
medical rehabilitationist lay in the capacity to combine an understanding
of the requirements of the medical management of chronic conditions with
an understanding of the psychosocial and vocational problems experienced
by this group of patients, in addition to skills of management and
leadership.74 The rehabilitation of an old person certainly provided a
different set of problems from those of a younger person, ‘having restored
an old lady or gentleman to the optimum level of independence, they (the
medical rehabilitation specialist) had a customer for life’.75
The
association between the rehabilitationist and this ‘customer’, however, was
a matter quite separate from that patient’s treatment for acute illness. In
this focus on ‘post-acute’ health care, medical rehabilitation fitted more
readily into the Community Medicine Program than did geriatric medicine
when it included an acute care component. It was in this respect that D.H.
Blake, the physician Bruce Ford appointed in charge of the Geriatrics
Division at Caulfield Hospital, felt he was only doing half of what he
72
Russell, 1977, op. cit. p.109.
Lefroy, 1966, op. cit. p.206.
74
Ford, 1996, op. cit. pp.117-119, also, ‘Medical Rehabilitation’, Editorial, MJA, vol 1,
1974, p.908.
75
Ford, 1979, op. cit. pp.100-103.
73
263
believed constituted geriatric medicine. However, as has been made clear
throughout this section, the emphasis on rehabilitation and dependency
coincided exactly with the aims of the Hospitals and Charities
Commission in establishing geriatric services.
Making Geriatricians
The development and implementation of a training program highlighted
some of the ambiguities surrounding the development of geriatric
medicine in Victoria.
These were, first, the question of whether the
provision of acute care would be included, and second whether geriatric
medicine would be a ‘special interest’ field of general practice, or a
specialist consultant field of practice associated with accreditation by the
Royal Australasian College of Physicians. The Hospitals and Charities
Commission was consistent in the view that geriatrics would be associated
with age-specific rehabilitation services, but there was sufficient
ambiguity in the Commission’s approach to leave open the possibility that
acute care could be included. The Commission’s stance in promoting
‘post-acute’ rehabilitation services was, however, reinforced by the form
of funding provided by the Federal government. It was expressly intended
to cultivate a field of medical practice outside the acute hospitals to
provide services for conditions related to chronic illness and disability,
that were neglected there. A further source of ambiguity arose from the
desire of local medical practitioners to preserve their identity as service
providers, an identity that was both bolstered and, at the same time,
threatened by moves to establish geriatric medicine as a sub-specialty of
general medicine.
Overall, the tendency in Victoria was to establish the role of the
geriatrician as a special interest in general practice. From the point of
view of the Hospitals and Charities Commission the principal interest in
funding a training program was to provide medical staff for the geriatric
services it wished to promote. In a medical profession where work was
increasingly defined in terms of specific skills and training, a training
program promised to encourage doctors to take on work that John
264
Shepherd described as the ‘ugly duckling’ of medicine:
… the geriatrician receives patients after everyone else has had their
‘go’. The patients have gross deterioration … and the geriatrician is
expected to put them back into circulation by active rehabilitation.
Very few like this work … [it’s] difficult to interest doctors in gross
deterioration.76
Shepherd, a general practitioner who had made a career as medical
superintendent/geriatrician, had himself, in the late 1960s, begun to
explore the possibility of linking training in geriatric medicine with the
postgraduate training supervised by the Victorian Faculty of the Royal
Australian College of General Practitioners. With the psychiatrist, Herbert
Bower, and Horace Tucker, medical superintendent of the Kingston
Centre, Shepherd had formed a Geriatric Study Group within the Victorian
Faculty of the College, with the objective of inserting education in
geriatrics into the experience of general practitioners. This group had, to
this point, shown no interest in joining the Victorian branch of the
Australian
Association
of
Gerontology,
formed
following
the
establishment of the national Association in 1965. The minutes of an early
meeting of the Study Group indicate that it hoped to assist the College
with a geriatrics component in training courses and continuing education.77
When David Race announced, in July 1972, that the Commission was
prepared to support the development of a training program for
geriatricians, the project to educate GPs shifted to a revived Association of
Geriatric Medical Officers.78 There is no evidence of further activity on
the part of the Study Group, but John Shepherd continued to cultivate his
association with the Victorian Faculty of the Royal Australian College of
General Practitioners. In time, when the Diploma of Geriatric Medicine
became available, parts of this training program were incorporated into the
continuing education courses and postgraduate training organised by the
76
Personal papers, Dr John Shepherd.
Ibid.
78
At the meeting in July, David Race noted that the constitution of the Association
permitted this course of action and suggested that the Melbourne Postgraduate Federation
be asked to assist with the administration of the program. Minutes Meeting Medical
Superintendents and Managers of the Geriatric Hospitals, 22/2/74. For postgraduate
medical training in Australian see McIntosh, op. cit, also, K. F. Russell, The Melbourne
Medical School 1882-1962, Melbourne University Press, Carlton, Victoria, 1967, p.162,
p.185.
77
265
Victorian Faculty.79 There was no conflict in this association between
geriatric medicine and general practice. The ideas the Commission had
regarding the role of the geriatrician did not preclude a close association
between the two areas of practice. In fact the introduction of the Diploma
program opened up the possibility for general practitioners to develop a
special interest in geriatrics, an interest that fitted with the Commission’s
desire to staff its services. This became clear in the course of discussions
relating to the training program. Bruce Ford, Director of Rehabilitation at
Caulfield Hospital, questioned why any doctor would undertake the
Diploma course, which, incidentally, meant paying a fee that in the early
stages was set at $300. David Race said in reply that the Commission
would recognise graduates of the program as specialists and pay them
accordingly.80
The retention of these specialists within the Victorian
health service system, and within the ranks of general practitioners, would
be assured because this ‘specialist’ qualification would not be recognised
by the national Specialist Qualifications Advisory Committee, nor by the
Health Insurance Funds.81
The Hospitals and Charities Commission’s conception of the role of the
geriatrician coincided with the broader aims of the national movement to
define and cultivate a field of non-acute medical practice through the
reports and funding programs of the Hospitals and Health Services
79
The Family Medicine Program, funded by the National Hospitals and Health Services
Commission as part of the Community Health Program, was intended to assist general
practitioners to develop their own specialist skills. The term ‘family medicine’ appears to
have been adopted by GPs to indicate the particular form of community setting for these
doctors who provided personal medical services. A letter from Dr M. O. Kent-Hughes to
John Shepherd dated 3/3/1970 suggests that the term ‘Family Medicine’ was already used
by GPs to define the scope of general practice as a specialty in which ‘the whole person
and the whole family is treated’, before the term was associated with the program funded
by the Whitlam Government, Personal Papers Dr Shepherd. Kent-Hughes had long been
an advocate of postgraduate qualifications for general practice. He had been involved in
the decision that, from 1965, future candidates for membership of the Royal Australian
College of General Practitioners should pass an examination. He was President of the
College in 1968 when the College Vocational Training Program was announced, Wilde,
1998, op. cit. pp.4-10.
80
Minutes Meeting Medical Superintendents and Managers of the Geriatric Hospitals,
22/2/74. The Hospitals and Charities Commission also contributed $7000 in the form of an
annual grant towards the expenses of running the course.
81
Scotton, 1974, op. cit. p.83, see also chapter five. The specialist geriatricians recognised
by the Hospitals and Charities Commission would not be recognised by the National
Specialist Recognition Qualifications Advisory Committee.
266
Commission.82 This was particularly the case in relation to the promotion
of the role of general practitioner by the Hospitals and Health Services
Commission (H&HSC) through the Family Medicine Program and the
training programs initiated by the Universities Commission.
The
introduction of the Diploma in Geriatric Medicine fits into this emphasis
on the role of general practitioner.
At the same time, however, the
Association of Physical Medicine and Rehabilitation, and the Australian
Geriatrics Society, both sought to take advantage of the shift in orientation
in funding for medical services at the Federal level, to promote their
respective fields of work by applying to the Royal Australasian College of
Physicians for recognition of their training programs as part of physician
training.83
Doctors who qualified under these schemes would receive
national accreditation, including recognition as specialists by the national
committee and the health insurance funds, so the possibilities for the
general practitioner geriatrician were limited even before they were
established.
John Shepherd may have had thoughts of aligning geriatric medicine with
general practice, but Malcolm Scott, who drafted a proposal for the
Diploma program, clearly expected that, in time, it would be absorbed into
the training programs then being developed by the Association for
Physical Medicine and Rehabilitation and the Australian Geriatrics
Society. Bruce Ford commended Scott’s draft as being an improvement
on the existing Diploma of Rehabilitation Medicine.
Scott himself
emphasised the benefits of developing a Diploma program with content
that could be absorbed into either of the above training programs – if only
to save the College from getting mental indigestion as it considered claims
for recognition from both specialist societies.84
Bruce Ford, also a
member of the sub-committee responsible for developing the program, did
not see any need for an age-related rehabilitation training program. The
emphasis on age, he said, reiterating the argument he made in an article
82
The Community Health Program Report was the first of these, it was followed by the
Report of the National Committee of Inquiry led by Mr. Justice W. O. Woodhouse,
‘Compensation and Rehabilitation in Australia’, AGPS, Canberra, 1974 and Report of the
Working Party on Rehabilitation Medicine and Geriatrics, ‘Rehabilitation Medicine and
Geriatrics’, AGPS, Canberra, 1976.
83
‘Medical Rehabilitation’, MJA, vol 1, 1974, p.907-908; ‘Miscellanea’, MJA, vol 2, 1972,
p.1154.
84
Minutes Meeting Medical Superintendents and Managers and Representatives of HCC,
12/12/73.
267
published in 1973, led to ‘boxing’ people in a manner that narrowed the
field of effectiveness of any services.85
Ford’s views on education in the medical care of the elderly had been
conveyed in a letter to the Hospitals and Charities Commission in October
1973. As a member of one of the committees assisting the H&HSC, he
suggested the Commission encourage the incorporation of some aspects of
geriatric medicine into the Family Medicine Program then being
developed by the Royal Australian College of General Practitioners.86
Scott and Shepherd both affirmed that age could not be separated from
disability, the former concluding that, in the short term, the value of the
Diploma program was that it would get things started. The discussion was
brought back to ground with the remark by the manager of Mount Royal
Hospital that the point of the training program was to provide geriatricians
– giving other concerns too much play could defeat this object.87
Why did the Australian Geriatrics Society not take on the project of
developing the Victorian diploma? The obvious answer to this question is
that the Society focused its attention on establishing training in geriatric
medicine at the level of physician training.88 This did not suit the aim of
the HCC in developing a workforce to staff its geriatric services - as David
Race’s reply to Bruce Ford makes clear. Even if Race had been open to
the Society being involved, it was by no means certain that it would be
successful in gaining the College’s approval of its training program and
the introduction of a training program to encourage doctors to take
positions as geriatricians would have been further delayed. It was not until
the second half of 1975 that the College finally agreed to recognise
geriatric medicine, and by then, the first candidates in the Diploma
program were halfway through their first year.
85
Ford, 1973, op. cit.
VPRS 4523/P2/1010/1973-170, letter dated 22/10/73 to the Secretary of the Hospitals
and Charities Commission from Bruce Ford.
87
Minutes Meeting Medical Superintendents and Managers and Commission officers,
13/3/74.
88
Lefroy, 1988, op. cit. p.70. In the early 1970s the Royal Australasian College of
Physicians took steps to phase out the Membership examination and to replace it with a
system of physician training that was more specific in its content and linked to the
accreditation of suitable training positions. The Membership examination was replaced
with the Fellowship, Part 1 examination and eligible candidates had to have completed an
approved Basic Physician Training program in an approved institutions, W. J. Benson,
‘The History of the College Examination’, in Wiseman, 1988, op. cit. p.4.
86
268
Other interests were also involved. Although the Australian Geriatrics
Society held its inaugural meeting in Melbourne, a Victorian branch was
not formed until the 1980s and Victorians were not listed amongst the
early office holders. These details suggest that interest in the national
society was not strong amongst Victorian geriatricians. The revival of the
Association of Geriatric Medical Officers only days after the Australian
Geriatrics Society was formed in late 1972, gives the appearance of
asserting local interests to support a local project – the development of the
Diploma program. No doubt the Hospitals and Charities Commission did
insist on the Association taking on the task of developing the training
program but at the same time, some Victorian geriatricians may have had
their own reasons for supporting a State based project, as opposed to a
profession oriented one.
Many of these doctors did not have the higher qualifications that would
make them eligible for the College qualification.
Once the Society
succeeded in establishing geriatric medicine at the highest level of
qualification in the medical profession, the general practitioners would be
relegated to an inferior position. However if the Diploma program were
established and supervised by the State based Association of Geriatric
Medical Officers, these practitioners would be able to maintain their own
position as specialists. The re-activation of the Association was a means
of maintaining the position of general practitioners in providing specialist
services. These comments should not be taken to suggest that Victorian
geriatricians were against the development of a role for the specialist
physician in geriatric medicine: just that they were acting to protect their
own bailiwick.
The first candidates for the Diploma of Geriatric Medicine began their
training in February 1975.89 All nine met the requirement of a minimum
89
In a letter thanking the Acting Chairman of the HCC for attending the inauguration of the
course, John Shepherd listed: L. C. Jago (whose appointment to the position of medical
superintendent of the Kingston Centre depended upon completing the course), D. S.
McDonald, (Ovens and Murray Home for the Aged at Beechworth), K. W. Shannon from
Warracknabeal, J. F. O’Callaghan from Warrnambool (one of these already had an
association with the Grace McKellar Centre at Geelong), Dr Hill, Ballarat (possibly already
employed at the Queen Elizabeth Centre there), and E. Morrison, P. Gladwell, G. Bearham
and D. Rodda, all of whom were employed at Mount Royal Hospital.VPRS 4523/P2/381/7105. The association between nearly all these doctors and institutions subsidised by the
Commission, confirms the purpose of the Diploma as a means ensuring a qualified staff for
the Geriatric Hospitals.
269
of three years postgraduate experience, and they embarked upon a twoyear program of 30 weeks attendance per year. In the first year they met
for one day each week for lectures, discussion groups, visits to institutions,
and case presentations. The second year was devoted to practical work in
an accredited institution under the supervision of two experienced doctors
selected by the committee established to supervise the course.90
In
addition one full training day was held weekly at Mount Royal.
Candidates were assessed through examinations and the submission of
written work. In view of the aim of the course, that is to equip doctors
with the skills and knowledge to undertake the process of assessment and
the supervision of ‘total care’, the training program was wide-ranging. It
covered the topic of gerontology – by which was meant the biology,
physiology and psychology of the ageing process; and ‘social’ gerontology
in the form of services for the infirm aged, geriatric medicine, geriatric
therapeutics, epidemiology and demography and administration of
services.
By the mid seventies, when the course was introduced, there was a wide
range of material on ageing to draw upon, much of it from overseas, but
some also from local sources.91 The local material reflected developments
in biology, in MacFarlane Burnet’s work, and that of Arthur Everitt,
whose studies of ageing rats were one of the earliest Australian
90
Minutes of the first meeting of the Victorian Postgraduate Geriatric Medical Training
Program, in January 1975, lists members as follows; Drs Shepherd, Russell and Barratt
from Mount Royal (Barratt, a doctor without any specific qualification in relation to this
work, replaced Robert Butterworth, physician in charge of the Geriatric Unit at Mount
Royal, when he died prematurely in July, 1973), R. H. Aldous (Bendigo Home and
Hospital for the Aged), H. Tucker and D. H. Blake (Kingston Centre), C. G. Burt
(Willsmere Psychiatric Hospital), J. G. Wijeyesekara (Greenvale Village), M. Scott (Mt
Eliza), P. J. White (Department of Health), M. Nissen (medical superintendent Montefiore
Homes). Bruce Ford represented Caulfield Hospital where the Geriatrics Division
provided training posts in geriatrics as an aspect of medical rehabilitation. His comments
during discussions regarding the development of the course made it clear he did not see
much point in it. By 1981 his repeated absence from meetings led the Committee to inform
him that representation from Caulfield was not required, Minutes Meeting Training
Committee, 6/7/81.
91
SJH Shepherd, ‘The Evaluation of a Postgraduate Medical Training Programme Leading
to a Diploma in Geriatric Medicine’, paper presented at the 1978 meeting of the
International Association of Gerontology. The texts noted in this section are taken from a
Reading List for candidates which is undated but the publication date of some texts was
1976, so it was prepared after that year. Personal Papers Dr John Shepherd.
270
contributions to the study of the ageing process.92 On a more mundane
level the gradual development of the field of ‘care of the aged’ over the
previous twenty years had produced some reports and local texts, in
particular, The Aged in Australian Society, a compilation of papers
published in 1970, and Growing Old, Problems of Old Age in Australian
Society.93 The latter was published a decade earlier and it was also a
collection of contributions to a seminar on the elderly.94 This problem and
service oriented ‘social gerontology’ was represented in the written
assessment through a research project in which candidates were allocated a
section of a common topic selected by the supervising committee, such as
for example, ‘Planning for Ageing Australians’.
The clinical skills relevant to geriatric medicine were found in a
combination of psychiatric and general medicine texts.
British
contributions predominated in both areas. The texts chosen for the reading
list for the Diploma program included Brocklehurst’s edited work, The
Textbook of Geriatric Medicine and Gerontology, Ferguson Anderson’s
Practical Management of the Elderly, Brocklehurst and Hanley’s,
Geriatric Medicine for Students, Hodkinson’s An Outline of Geriatrics.
95
These texts reflected the work done by British physicians in adapting the
concepts of general medicine to the elderly patient at risk of needing
custodial care.
Their pragmatic approach produced the handbooks
characteristic of geriatric medicine, in which developments in the various
specialties of general medicine and surgery were aligned with the
degenerative conditions that contributed to the multiple disease conditions
characteristic of the geriatric patient. British developments in psychiatry
were also predominant. In the texts recommended for Diploma candidates
the use of the term ‘psycho-geriatrics’ showed the extent to which
psychiatrists there had developed specialist knowledge related to the topic
92
For details of Everitt’s career see Chapter Five.
The surveys included: NSW Consultative Committee, ‘The Care of the Aged’, 1965, F.
Ehrlich, R. V. Horn, & S. Sax, ‘The Demography of Disability – An Australian Example’,
NSW Department of Public Health and Council of Social Services of New South Wales,
1969, F. Ehrlich, ‘Chronic Illness in NSW – Needs and Services – a Demographic
Approach’, Health Commission of New South Wales. S. Sax The Aged in Australian
Society, Angus & Robertson, Sydney, 1970, A. Stoller, ed, Growing Old In Australia,
Cheshire, Melbourne, 1960.
94
See Chapter Four.
95
This list of texts is taken from the undated copy of the reading list noted above. The
rehabilitation text was F. H. Krusen, F. J. Kottke, & P. M. Ellwood, Handbook of Physical
Medicine and Rehabilitation, W. B. Saunders Co, Philadelphia, latest edition.
93
271
of mental illness in old age since the mid-1940s when their attention had
turned to the mental disorders of old age.96
The desire on the part of the Hospitals and Charities Commission to ensure
that geriatric medicine in Victoria was confined to the provision of nonacute medical services was reinforced by the selection of institutions
accredited to provide training posts. The Geriatric Hospitals, or Centres as
many of them were now known, were the principal institutions. Others
included Willsmere Psychiatric Hospital, the Geriatric Division of
Caulfield Hospital, the Repatriation General Hospital at Heidelberg and
Montefiore Homes, one of the largest voluntary agency institutions.97 The
common element amongst these institutions, in relation to the Diploma
course, was the provision of non-acute care and rehabilitation services.
The overall effect of the introduction of the Diploma program, in
highlighting the emergence of a class of institution or services devoted to
the needs of the geriatric patient, was to emphasise the non acute aspect of
this patient’s care.98 In this respect the objective of the Hospitals and
Charities Commission was achieved. Doctors were trained to manage the
needs of infirm old people from an institutional base outside the acute care
system.
Nevertheless the question of whether geriatricians would provide medical
services during an acute phase of illness persisted in the minds of the
medical practitioners involved in the training program. It has already been
noted that in developing this program, Malcolm Scott had emphasised the
96
The recommended texts were as follows, B. Pitt, Psychogeriatrics, Churchill
Livingstone, 1974, L. Bellak, & T. B. Karasu, Geriatric Psychiatry, Grune & Stratton Inc.,
London, 1976.
97
Minutes Meeting Victorian Postgraduate Geriatric Medical Training Program, 17/2/75,
2/2/76, Personal Papers Dr. John Shepherd.
98
The problem with including Willsmere Hospital amongst the institutions suitable for
training posts for Diploma candidates, was that it was under the control of the Mental
Health Authority, a separate administrative body from the Hospitals and Charities
Commission that supervised most of the institutions involved in this program. The Mental
Health Authority had no structure for paying candidates not employed by it, Minutes
Meeting Medical Superintendents, Managers and HCC, 11/12/74. In the mid-1970s the
Repatriation Hospital provided fertile ground for the development of geriatric medicine
because the ex-service personnel for whom the hospital was intended were ageing.
However instead of promoting geriatric medicine, the hospital administration responded to
this trend by taking steps to open the hospital to civilian patients to ensure variety in cases
for the purposes of medical education and practice. The involvement of the Repat with the
Diploma program, which may, in these circumstances, have been short-lived, is not
mentioned in the most recent history of the hospital although the introduction of geriatric
services in the 1980s is recorded as a prominent step in the development of the field of
geriatric medicine, Hunter-Payne, op. cit. pp.95-103, p.164-165.
272
advantages of producing something that could be absorbed into either of
the physician training programs developed by the Australian Association
for Physical and Rehabilitation Medicine or the Australian Geriatrics
Society. In light of R. B. Lefroy’s presence amongst the office holders of
the Society, and his earlier definition of geriatric medicine as containing a
component of acute care, it is likely any training program developed by
the Society would include this element.99 On these grounds it may be
assumed that provision was made in the Diploma program for the
development of such clinical skills although there was limited chance of
doing so in most of the accredited institutions.100 In fact there was an
element of acute care in the services provided from the Geriatric Hospitals
because they were aimed at the needs of patients who were neglected in
existing hospital services. As Boyne Russell made clear in her report on
the pilot geriatric service at Mount Royal, old people could be acutely ill,
beyond the point of being cared for by a general practitioner, and still not
be recognised as such by the public hospitals. Even in the case where the
old person in ‘trouble’ had the hospital insurance that permitted prompt
admission to a private hospital, their symptoms might not be correctly
interpreted.
It was as a result of steps taken by a member of Mount Royal Committee
of Management that the possibility of developing the acute care
component of geriatric medicine received more prominence. When John
Shepherd returned from an overseas tour in the early 1970s, he made a
number of recommendations to his committee of management, including
the establishment of a Professorial Chair in Geriatric Medicine. At the
time he had no expectation that this suggestion would amount to anything.
However, one member of the committee was not prepared to let the matter
go, and, in Shepherd’s words, ‘he knew a lot of people and he pushed and
pushed and before long we were talking to the Vice-Chancellor’ (of the
99
Lefroy, 1966, op. cit. pp.204-210.
Dr Leslie Wilson, a visiting physician geriatrician from Aberdeen, was present at one of
the meetings where the Diploma program was under discussion. When asked for his
opinion, he expressed the view that as the program was structured it would be best located
in a geriatric department of a general hospital, VPRS 4523/P2/1010/1973-170, meeting
13/3/74.
100
273
University of Melbourne).101 A letter from the Vice-Chancellor to the
President of Mount Royal committee dated 1972 suggests that discussions
between the two institutions had started soon after Shepherd made his
suggestion.102
Even at this early stage it was clear that any relationship between the
University and Mount Royal was not going to be an easy one.
The
President of the committee of management initiated correspondence in a
letter outlining the committee’s plans for establishing a research unit for
the study of gerontology.
There is no indication that the committee
explored the possible meanings of this term. The Vice-Chancellor replied
that while the University would not be able to contribute financially, it
would consider the possibility of Mount Royal becoming an affiliated
institution for teaching purposes once the unit was established.
Furthermore, it would be happy to have representatives of Mount Royal on
any committee to select the Director of such a unit. The Mount Royal
committee was probably taken aback at being relegated to a secondary
position in this peremptory manner. It may have been their response along
these lines at a meeting in November of that year, between them, the
Victorian Minister for Health, and representatives of the University, that
led the latter to propose a more distant relationship. In the event of a
Director being appointed, the University agreed to recognise this person as
lecturer and to provide one or two teaching periods in the medical
course.103
Undaunted, it appears, by having to proceed alone, the Mount Royal
committee continued with the project of establishing a research unit. It
expected to raise $200,000 from donations and on this basis sought the
cooperation of its long-time partner in developing the field of geriatrics,
the Hospitals and Charities Commission, in guaranteeing the salary of the
Director of the unit. The Commission’s response was that, in accordance
with its responsibility for geriatrics defined as ‘care of the aged’, not
gerontology, the study of the ageing process, it was only prepared to fund
101
Personal communication from Dr John Shepherd, 23/2/98. Possibly this Committee
member was Mr. Lionel Adams as the minutes of the Institute committee for the meeting
held on the 17/2/78, referring to Adams’ recent death, note that he ‘more than anyone else’
was responsible for establishing the Institute.
102
VPRS 6345/478/1625.
103
Ibid.
274
a position in which geriatrics, defined as ‘care of the aged’ was paramount.
At the insistence of the Commission the title of the Director was to be
‘Director of Gerontology and Geriatrics’.104 Bolstered by support from the
Commission and voluntary donors, the committee approached the
Commonwealth Minister for Health. By this time a sub-committee had
been formed to oversee the establishment of the institute to be known as
the Mount Royal National Research Institute of Gerontology and
Geriatrics.105 At this stage the University had a change of mind and
indicated its willingness to play a part in the project although, at this time,
January, 1974, there was no indication that the Director of the proposed
Institute would occupy a Professorial Chair. Instead it would be left to the
appointee to investigate the possibility of establishing a Chair of
Gerontology, and in the interim this person would be granted Senior
Associate affiliation with the University.106
The change of mind on the part of the Faculty of Medicine was, no doubt,
stimulated by the recommendation made by the Universities Commission
to the Federal Government, that funding be made available to groups
setting up health services, particularly if they were sponsored by a
104
Ibid.
The members of the sub-committee were, Messers D. Don, L. Adams, T.N.D. Stevens,
and Sir William Upjohn, all members of Mount Royal committee of management. Sir
William, long retired from his prominent position as a member of the medical staff of the
Royal Melbourne Hospital, was also a member of the committee of management of
Greenvale Village Geriatrics Centre in its early days, and of the committee of management
of the Royal Melbourne Hospital. Other members of the sub-committee were; A.J.
McLellan, Hospitals and Charities Commission, Dr John (SJH) Shepherd, Medical
Superintendent of Mount Royal and representatives of the University of Melbourne and the
Faculty of Medicine – Sir Robert Blackwood, Professor David Derham and Professor Sir
Lance Townsend. Minutes of Meetings of the Sub-Committee, Personal Papers Dr
Shepherd. Sir Lance Townsend’s involvement is somewhat surprising in view of the
conclusion reached in the report on the provision of hospital services in Victoria, of which
he was one of the authors. The comment was made that while there was indeed a need for
rehabilitation services to be provided as an extension to existing hospital services, there
appeared to be little justification for making distinctions on the grounds of age.
106
Minutes Meeting of Institute Sub-Committee 24/1/74.
105
275
University.107 The more cooperative attitude on the part of the Faculty of
Medicine certainly seems to follow the agreement in December, 1973, on
the part of the Hospitals and Health Services Commission, to provide
funding for activities at the proposed Institute at the rate of $30,000 for
three years, providing such activities were confined to ‘clinical’ and
‘social gerontology’. Further enquiry on the part of the interim committee
of the Institute, confirmed that the Directorate could use these funds for
teaching purposes.108 Representatives of the University and the Faculty of
Medicine, were, no doubt, induced to overcome a reluctance to enter into a
cooperative venture with Mount Royal, by the advantages of participating
in the venture without any financial outlay, while at the same time
satisfying demands in relation to medical education in neglected areas. It
was not just that the institution was ‘beyond the pale’ in respect to
acceptable medical institutions.
Its committee of management was
unaccustomed to subordinating its will to any other body and fully
intended retaining its status as proprietor of the new establishment.
Such an impressive array of support for ‘geriatrics and gerontology’ did
not necessarily mean support for developing a medical specialty in
geriatric medicine.
The establishment of a research institute and a
107
The minutes of this first meeting of the sub-committee indicate that Professor Derham.
Vice-Chancellor, had come to this conclusion from his reading of the report submitted by
Committee on Medical Schools to the Universities Commission in 1973, Minutes Meeting
24/1/74. The Report noted, ‘It is necessary to evolve a new philosophy in respect of
general practice in the medical curriculum’, to equip medical students better to deal with
the problems of illness they were presented with in general practice. In this
recommendation the Committee on Medical Schools coincided with the aims underpinning
the Community Health Program - to encourage the organisation and provision of primary
health services which emphasis prevention and rehabilitation, and to develop the
epidemiological and social research to provide a body of knowledge to support this form of
practice. The coincidence was not accidental; it arose out of cooperation between the
Hospitals and Health Services Commission under the Chairmanship of Sidney Sax and the
Universities Commission headed by Professor Karmel. A Department of Community
Medicine was established at the University of Melbourne but it was not attached to any one
Health Centre. In his report ‘Community Practice in Australian Medical Schools’, E. G.
Saint, notes that an interest in establishing chairs in geriatric medicine was ‘a collateral’
development of the Community Health Program, and went on to comment, ‘It is hard to
avoid taking a view that this interest has been opportunistic, a response to pressures exerted
by affiliated hospitals or health departments in Commissions understandably anxious to
give leadership in a neglected area of clinical medicine.’ Saint’s report was published in
1981 and he noted the poor result in this case, ‘Backup resources have been slender and
integration of teaching with the department of community medicine is weak’, Saint, 1981,
op. cit. p.14.
108
One of the first steps taken by the sub-committee was to apply to the Federal Minister
for Health, the Hon. D. Everingham, for assistance with funding. In January 1974, the
Chairman, Denzil Don noted correspondence from Sidney Sax, Chairman of the National
Hospitals and Health Services Commission, dated December, 1973, setting out the details
of this funding. Minutes Meeting Mount Royal National Research Institute of Gerontology
and Geriatric Medicine Committee, 24/1/74.
276
professorial unit to provide clinical services did have the potential to
support the development of geriatric medicine as a specialist medical field.
However, a range of other interests were brought into play in this project,
interests that were, in Victoria, more soundly established and powerful
than the newly formed Australian Geriatrics Society. The Hospitals and
Charities Commission was certainly prepared to do what it could to
enhance the standing of ‘geriatric medicine’ as part of its responsibility for
overseeing ‘care of the aged’ in the State, but not at the expense of its
long-standing plan to limit the provision of such services to institutional
settings outside the acute hospital system.
The Mount Royal Committee of Management was interested principally,
in advancing the standing of the institution and ‘geriatrics’ meaning ‘care
of the aged’. If this led to the promotion of any specific medical expertise,
well and good, but the committee had shown no sign over the previous
twenty-odd years, to set aside its interests in favour of advancing medical
interests. In addition, although the Committee was, it appears, ready to
take on ventures that might add to the stature of their institution, they did
so in a manner that immediately limited the success of such ventures. This
had been the case in their early collaboration with the Royal Melbourne
Hospital in building and operating the first Geriatric Unit opened in
1957.109
The same attitudes of penny pinching and reluctance to
relinquish control came to the fore in the case of the Institute. When
Derek Prinsley, the English physician who was eventually appointed as
Director of the Institute in 1976, took up his position he found, as he stated
in his first report on the Institute, ‘no premises, no staff and no income’.
Furthermore he was confronted by a committee of management which
believed that ‘… a count of how many left and how many right
hemiplegias were admitted was a suitable contribution to research in
gerontology’.110
When he attempted to attend the Mount Royal
Committee of Management meetings, as representative of the University,
the Committee frustrated his efforts by not notifying him when meetings
were held. Then, when called to account by the Hospitals and Charities
109
See Chapter Three.
D. M. Prinsley, ‘Biomedical Research Priorities at the National Research Institute of
Gerontology and Geriatric Medicine’, Proceedings 19th Annual Conference Australian
Association of Gerontology, 1984, pp.8-10.
110
277
Commission, cited a hospital by-law that a paid official of the hospital
could not be a member of the Committee. Even when the Hospitals and
Charities Commission countered this objection by pointing out that
Prinsley had been appointed to the Committee, not elected, the Committee
stood firm, citing legal opinion supporting its stance.111
The interest expressed by the Faculty of Medicine was most probably, as
Eric Saint was later to describe it, ‘opportunistic’, not reflecting any
genuine interest in cultivating the medical care of infirm old people.112
While the Faculty did encourage the introduction of lectures into the
undergraduate program, it showed no interest in absorbing the Diploma of
Geriatric Medicine into its revamped Master of Medicine course. The
academic standard of the program may have provided cause for concern
but that could have been improved in the process of being included in the
Master’s degree had there been any genuine interest.113 The entry of the
Hospitals and Health Services Commission into the field brought another
line of interest that fed into local interests but not necessarily those who
wished to promote geriatric medicine as a specialist field of medical
practice. The Commission’s views were compatible with the desire of the
committee of management of Mount Royal to preside over a prominent
institution, and with the desire of the Hospitals and Charities Commission
to establish geriatric medicine as a field of medical work outside the acute
hospital.
The Hospitals and Health Services Commission had decided to foster
expert medical and paramedical services for the infirm aged by promoting
the development of a small number of Centres of Excellence around the
country. This aim fed into the desire of the Mount Royal Committee of
Management to maintain, what it believed was its prominent position in
the field of geriatrics.
It was also compatible with the desire of the
Hospitals and Charities Commission to establish the practice of geriatric
medicine outside the acute hospitals and in the form of rehabilitation
treatment associated with coordinated welfare services. The Hospitals and
Health Services Commission envisaged that, while Centres of Excellence
111
VPRS 4523/P2/8283.
Saint, 1981, op. cit. p.14.
113
Minutes Meeting Victorian Postgraduate Geriatric Medical Training Programme
Committee, 28/7/80, 11/10/82.
112
278
would promote geriatrics, they would operate principally as educational
and research resources for community health services. In keeping with
this objective the grant to the proposed Mount Royal Research Institute
from the Commission was intended to foster the provision of services, not
for studies of the ageing process.
It is clear that this was well understood by Victorians who were interested
in research in ageing. In February 1976 a symposium was held in the
Microbiology School at the University of Melbourne to discuss the
development of biological research into ageing, but there appears to have
been no expectation that the proposed Research Institute at Mount Royal
would be involved.114 The research at Centres of Excellence would serve
to establish standards of service for the aged and infirm, and generally
foster the development and coordination of services for them throughout a
specific area.
Although these Centres were intended to be ‘clearing
houses’ for the latest developments in geriatric medicine, their primary
role was not to promote this specialty, but to provide a means of dispersing
the knowledge associated with it.
For this reason the Commission
regarded the establishment of Chairs of Geriatrics in Universities as
undesirable – isolating geriatric medicine in this fashion would diminish
the effective spread of the ‘gospel’ of geriatrics – care of the aged.115
R.B. Lefroy, President of the Australian Geriatrics Society protested at this
representation of geriatrics. In a letter to Professor Karmel, Chairman of
the Australian Universities Commission, the body concerned with
promoting education in geriatrics for medical practitioners, he claimed the
document that had come from the Hospitals and Health Services
Commission to assist the Universities Commission, was ‘erroneous and
114
MacKay, op. cit. 1977. Dr Ian MacKay was a member of the Committee of Mount
Royal National Research Institute for Geriatric Medicine and Gerontology, and, at the same
time, Director of the Clinical Research Unit at the Royal Melbourne Hospital and the
Walter and Eliza Hall Institute, a situation in which he could have experienced a conflict of
interests.
115
Draft copy, ‘Geriatrics in Health Personnel Education’ Hospitals and Health Services
Commission, Archives Australian Society for Geriatric Medicine.
279
misleading’, in representing geriatrics as ‘“basically the provision of
Community Health Services for the elderly”’.116 The recommendation that
the appointment of a lecturer in geriatrics to Departments of Community
Practice would be a satisfactory means of training doctors for work in
caring for the ‘elderly and disabled’, Lefroy pointed out, meant that the
medical care of this group remained outside the mainstream of medical
work – the teaching hospital. The creation of ‘Centres of Excellence’
would reinforce both the existing isolation of geriatric medicine from
general medicine, and the view that it was principally concerned with a
form of community based welfare services.117 The lack of response to
Lefroy’s letter indicates how little the advocates of geriatric medicine
contributed to the process in which the new order of hospital and health
services was constructed.
Lefroy concluded his letter by reiterating the Society’s ‘strong’ support for
Chairs in Geriatric Medicine. The Society was, however, not involved in
the events that led to the establishment of the first such Chair in Australia,
at Mount Royal. This situation illustrates not only the extent to which the
Society had yet to establish itself as an authority, but also the degree to
which the promoters of the Chair saw no connection between their actions
and the promotion of a specialist field of medical work.
The first
advertisement for the position of Director of the proposed Mount Royal
National Research Institute of Gerontology and Geriatrics failed to result
in an appointment.118 David Wallace, the physician who first took on the
task of developing a geriatric unit at Greenvale Village in the late fifties
was one of two local applicants, neither of whom was appointed. In view
of the emphasis the HCC placed on the management of a geriatric service
in supporting this appointment, it was quite likely that lack of experience
in managing a geriatric service accounted for this.
Sidney Sax, in
116
Letter dated 14/5/76 from Professor R. B. Lefroy, President of the Australian Geriatrics
Society to Professor Karmel, Chairman Universities Commission, Archives Australian
Society for Geriatric Medicine.
117
Ibid.
118
The minutes of a meeting of a special committee to consider applicants for the position
of Director indicate that six enquires were received from the United Kingdom, one from
New Zealand. Minutes of Meeting of Selection Committee, 15/7/74. The selection
committee consisted of four representatives from Mount Royal – the President of the
Committee of Management, Denzil Don, committee member, L. Adams, M.E. Atkinson,
Manager, Dr John Shepherd, Medical Superintendent, university representatives are not
listed but may have included Professor Pennington and Professor Sir Lance Townsend,
Letter, 5/6/74 from M.E. Atkinson, Manager, Mount Royal to Professor David Derham.
280
providing a reference for one of these candidates reinforced the
Commission’s view when he emphasised the difference between the
practice of geriatric medicine (the provision of specific services) and the
practice of medicine among elderly people.119
It is likely that suitable candidates from overseas were deterred by the
lowly position of the Director in relation to the University because in
February, 1975, the interim committee of Mount Royal Institute for
Gerontology and Geriatric Medicine met to discuss a letter from the
University advising that the Council had passed legislation providing for
the appointment of the Institute Director as Professor of Gerontology and
Geriatric Medicine.120 Shortly after, an advertisement was drafted inviting
applications from persons ‘with Postgraduate Medical qualifications in
physical and social medicine’, with senior research experience, and
qualified to carry out clinical teaching. It may be concluded, in view of
David Race’s association between social medicine and the provision and
coordination of welfare services to enable infirm, elderly people to remain
living in their homes rather than be admitted to institutional care, that in
the advertisement, the term referred to experience in supervising a
geriatric services.
Derek Prinsley, the English consultant in geriatric
medicine who took up the appointment as Director and Foundation
Professor of Gerontology and Geriatric Medicine. in July, 1976, certainly
had experience in administering a geriatric service and in this respect
would have suited the Commission’s requirements.121
By the time Professor Prinsley arrived to take up his position, the facilities
of Mount Royal had been separated into several divisions, each
119
David Wallace, at the time of his application was a physician at the Royal Newcastle
Hospital in New South Wales. The other candidate was Dr Ian Webster, a Melbourne
trained doctor and honorary physician at Royal Prince Alfred Hospital in Sydney.
Webster’s interest in old age was exhibited by reference to a joint paper with Arthur
Everitt, the physiologist working on the ageing process in rats, on the topic of ageing and
breathing, at the meeting of the International Association of Gerontology in Leningrad.
Webster was later appointed Professor of Community Medicine at the University of New
South Wales, from Personal Papers Dr John Shepherd.
120
Leslie Wilson, the physician geriatrician from Aberdeen, who had given his opinion on
the Diploma Program, was also asked for an opinion regarding the position of Director of
the new Institute. He wrote back saying that the individuals he had spoken to regarding the
position as it was first envisaged, had said it had ‘too indefinite a University role’ in their
opinion, Minutes Meeting Institute Committee, 4/2/75.
121
Professor Prinsley was appointed consultant in geriatric medicine to Teesside Hospitals,
in the United Kingdom in 1959 and held this position until his appointment at Mount
Royal.
281
responsible for providing geriatric services to a specific municipal area
within the region allocated to the hospital.122
One of these divisions
became a Professorial Unit under Prinsley’s direction. His appointment
encouraged the Acting Executive Director of the Royal Melbourne
Hospital to propose an affiliation between Mount Royal and the Royal
Melbourne at the beginning of 1977. While the participants may not have
been aware of the fact, this was a revival of a relationship, not an
innovation. The coooperative relationship between the two institutions
was an element in the development of the first purpose-built geriatric unit
at Mount Royal in 1957.123
The arrangement gave the physician
geriatrician a consultative role in the acute hospital but there was no
question that the geriatrician occupied a position similar to the other
physicians attached to the Royal Melbourne.124
Late in 1976, the Royal Australasian College of Physicians agreed to
award its Fellowship to physicians who completed the advanced training
in geriatric medicine developed by the Australian Geriatrics Society.125
The appointment of Derek Prinsley as Foundation Professor of
Gerontology and Geriatric Medicine was then also linked to the
broadening of possibilities in training in geriatric medicine in Victoria.126
The Hospitals and Charities Commission responded by creating registrar
positions at Mount Royal, similar to those already created under Malcolm
122
Annual Report Mount Royal, 1977. This must not be taken to mean that Mount Royal
had established facilities of an acceptable standard. In 1974 the hospital had to restrict
admissions because staff would not work in the overcrowded wards, VPRS 4523/P2/381/7105.
123
See Chapter Three. The coordinating committee established when the purpose-built
geriatric unit was opened in the late 1950s, continued to meet at least until the end of 1969.
Present, at what may have been the last meeting in December, 1969, were Drs Sinclair and
Jamieson representing the Royal Melbourne, and Drs Shepherd and Butterworth and the
Manager of Mount Royal, Mr. M.E. Atkinson, RMH Archives/Medical Matters/No
1/24/1969.
124
VPRS 4523/P2/381/7-105. In 1985, Prinsley, and M.C. Woodward, then a trainee in
geriatric medicine, described this relationship at a meeting of the Australian Association of
Gerontology, M.C. Woodward, D.M. Prinsley, ‘A Model of Geriatric Services in Acute
Hospitals: The Royal Melbourne Hospital-Mount Royal Hospital Inter-Relationship’,
Proceedings 20th Annual Conference, Australian Association of Gerontology, 1985, pp.6567.
125
This did not mean that the Australian Geriatrics Society wanted to take on an
accrediting role – while the Society promoted its training program as a means of acquiring
specialist skills in geriatric medicine, it was still possible for any medical practitioner
granted Fellowship of the Royal Australasian College of Physicians to work as a
geriatrician. The idea underpinning this approach was to maintain as close a connection as
possible between general medicine and geriatric medicine, Lefroy, op. cit. 1988, p.71.
126
Prinsley himself was not aware that this was possible, finding out only when R.B.
Lefroy wrote on behalf of the Australian Geriatrics Society, to welcome him, Archives
Australian Society for Geriatric Medicine, General Correspondence File.
282
Scott at Mt Eliza and at Caulfield, under Bruce Ford – both of whom were
advocates of broader rehabilitation medicine.127
The link between
Prinsley’s appointment and the revival of the association between the
Royal Melbourne and Mount Royal, and the introduction of registrar
training positions into Mount Royal, obscures the point that Boyne
Russell, a qualified and experienced physician in geriatric medicine, had
been on the staff of Mount Royal since 1972. Since she had established a
geriatric service in the form of the Brunswick Community Care Program
in 1973, she was also in a position of being able to supervise a registrar in
a self-contained and comprehensive service and capable of interacting
with Royal Melbourne medical staff on equal terms. Any answer to the
question of why Russell appears to have been overlooked must, regardless
of other factors, also include gender – being female in the male dominated
world of the Commission, the Royal Melbourne medical staff, the Faculty
of Medicine and the Committee of Management of Mount Royal ensured
invisibility.128
The question of what form of expertise would be developed by the
physician-geriatricians trained at Mount Royal has already been answered
to some extent. David Race, Chief Clinical officer in the Hospitals and
Charities Commission was consistent in his refusal to agree to the
provision of acute care in the geriatric services. However, as noted above,
because these services were directed towards the needs of elderly patients
neglected within general hospital services but who were often acutely ill, a
certain element of acute care provision was inevitable. No doubt Derek
Prinsley expected his work to include acute care as he had come from a
hospital system where such provision was part of the work of the geriatric
department. In a report compiled during his first six months at Mount
Royal he noted that his position could be divided into three separate
elements, of which ‘clinical medicine’ was one. There must have been
sufficient doubt relating to the provision of short-term care in acute illness
amongst Victorian geriatricians, because at a meeting of Medical
127
Ford and Scott were both founder members of the Australian College of Rehabilitation
Medicine which replaced the Australian Association of Physical Medicine and
Rehabilitation. The inaugural meeting was held in 1980.
128
Russell’s teaching ability and her overall contribution to geriatric medicine were
recognised on her retirement from Mount Royal after twenty years, when she was offered
honorary life membership of the Society, Australian Society for Geriatric Medicine
Archives/General Correspondence File/Letter dated 26/2/93.
283
Superintendents and Managers of the Metropolitan Geriatric Centres, in
July 1978, Malcolm Scott asked for clarification of this point. David
Race, consistent as ever, replied that the ‘hospital’ beds in the geriatric
centres were intended for ‘assessment and the development of treatment
plans, not for the treatment of acute illnesses’.129 Notwithstanding the
Commission’s views, the annual report for Mount Royal for 1978 noted
the opening of a 24-hour medical centre equipped with X-ray facilities.
However even if Mount Royal was exceptional in the extent of acute care
it provided, this still fitted the role the Hospitals and Health Services
Commission had designated for it as a Centre of Excellence.
The training program established by the Australian Geriatrics Society
reflected the range of opinion within the Society as to what form geriatric
medicine could take.
An approved training post needed to provide
experiences in Geriatric Medicine, Rehabilitation, Community Care and
General Medicine as core training with experience in two of three areas –
General Medicine, Neurology, Psychiatry or Psychogeriatrics.
It is
interesting to note that while there was room for some flexibility in
relation to training posts suitable for core training, the essential
components necessary for a training post to be approved, were
Domiciliary Consultations, Multi-disciplinary assessment and care,
Medical Rehabilitation, Home Care and Permanent Care.130 Mount Royal
satisfied most of these requirements, and in the early 1980s, the addition of
a psychogeriatric unit extended the possibilities available to trainee
physicians.131 Regardless of the clinical experience available at Mount
Royal, the positions open to graduates in the other Geriatric Centres
ensured that, on the whole, the practice of geriatric medicine would be as
129
VPRS 6345/578/78/941, op. cit., and Minutes Meeting Medical Superintendents and
Managers of Metropolitan Geriatric Centres and Hospitals and Charities Commission,
14/6/78.
130
From notes sent by the Australian Geriatrics Society to the Chairman of the National
Specialist Qualification Advisory Committee, undated, Archives Australian Society for
Geriatric Medicine.
131
The establishment of this unit did not represent any coordination between the Geriatric
Hospital and psychiatric services. It was a step taken by Mount Royal Hospital, in the
same independent manner in which most hospitals established their services and its
desirability was questioned by the Directors of both the Hospitals and the Mental Health
Divisions in the Victorian Health Commission which had, by then taken over the
responsibilities of the various authorities, including the Hospitals and Charities
Commission, that supervised the provision of hospital services, VPRS 6345/111/1592.
284
David Race had planned. None of the other geriatric centres, new or old,
had a close association with a teaching hospital. While they were all
situated in a regional relationship with these institutions, the geriatrician
was confined to the provision of the assessment and rehabilitation services
as first envisaged by the Hospitals and Health Services Commission in the
mid 1950s.
The beginning of the 1980s in Victoria saw the emergence of geriatric
medicine as a special interest available to medical practitioners at the level
of general practice or consultant physician. General practitioners were
able to cultivate a special interest in geriatrics through the Diploma of
Geriatric Medicine and the Family Medicine Program supervised by the
Victorian Faculty of the Royal Australian College of General Practitioners.
Increasing competition for postgraduate training positions amongst
medical graduates, and exposure to the influence of physicians such as
Prinsley and Russell, led a small number of doctors to include the training
program developed by the Australian Geriatrics Society in their physician
training. By the early 1980s four physicians had qualified as geriatrician
physicians and 17 doctors had graduated from the Diploma in Geriatric
Medicine program.132
While physicians were generally younger doctors at the beginning of their
careers, Diplomates were a mixed group. The range of ages in candidates
– from the twenties to the late fifties and early sixties – suggests the course
represented a variety of different possibilities to candidates.133 Lack of
evidence in this matter precludes any detailed comment. What can be said
is that the course seems to have provided an opportunity for doctors well
on in their careers to change direction, a characteristic common to the
doctors who first took on the role of geriatrician in the late 1950s and early
1960s. The Diploma program also provided a career path for women
doctors who had been unable to follow their male colleagues along the
usual routes of either specialist training or general practice because of
other commitments. They used the Diploma to gain access to the positions
132
Annual Report Mount Royal, 1981, 1982.
The breakdown of age groups shows throughout the first ten years: in the age group 2130, 23 began the course and 13 Diplomas awarded, 31-40, 27 began and 9 Diplomas, 41-50
years, 17 began and 9 Diplomas, 51-60, 13 began, 6 Diplomas, 60+, 2 began and 1
Diploma awarded, Minutes Training Committee Meeting, 27/2/85.
133
285
the Hospitals and Charities Commission created in the geriatric services,
or as regional geriatricians or in some cases, as a stepping stone to
specialist physician training either in general medicine or psychiatry.134
Doctors from overseas also benefited from the extension of medical work
in the provision of geriatric services both as geriatricians in the
institutional setting and as regional geriatricians.135
Conclusion
In the decade between 1972 and the early 1980s the recipient of
benevolent care, the ‘old person in trouble’, underwent the final stages of a
process of redefinition that had begun in the late 1950s, when the first
attempt was made to introduce geriatric services into Victoria’ s hospital
system. The appearance of the ‘sick man’ in the work of geriatricians at
the end of the 1970s, marked the emergence of a specialist field of medical
practice defined in terms of health and illness in old age. The formal
status of the first locally trained physician geriatricians who qualified in
the early 1980s was quite explicit. They had completed a training program
developed by the Australian Geriatrics Society and recognised by the
Royal Australasian College of Physicians. The physician geriatrician was
included in the listing of medical specialties published by the
Commonwealth Department of Health in 1977, and a few years later in
1984, in a local publication put out by the Victorian Medical Postgraduate
Foundation.136
The notion of sickness associated with the work of physician geriatricians
was, on one level no different from that of other medical practitioners, it
was associated with a disturbance in physiology that was amenable to the
134
These positions would have been even more attractive when equal pay for women
doctors was introduced into State Public Service and all public hospitals in the late 1960s
or early 1970s. The Commonwealth made this move somewhat later, E. Sandford Morgan,
A Short History of Medical Women in Australia, no publisher, no date, p.48. In Victoria,
the report presented by J.V. Dillon in 1959, on the terms and conditions of doctors’
employment in the State’s hospitals, recommended equal pay for women doctors.
135
Personal communication from Mrs Marion Shaw, March, 1997.
136
Commonwealth Department of Health, Handbook on Health Manpower, Part 2,
Australian Government Publishing Services, 1977, p.36. In this publication the
occupations of medical practitioners were divided according to whether they were
associated with a recognised post-basic course of training. Occupations that were, were
designated as medical specialists, p.20. Geriatric medicine was also listed as a subspecialty of internal medicine in a publication of the Victorian Medical Postgraduate
Foundation, Medical Careers in Australia, 1984, p.38.
286
same diagnostic methods used in other patients.
At this level the
difference lay in the attitude of the doctors involved who were prepared to
pay attention to a group of patients who were not only of little interest to
other hospital specialists, but who were likely to have been made sick by
the treatment they were given. On another level, however, this notion of
sickness differed from the conventional one in that it was associated with a
more ambiguous measure of success - the restoration of social competence
within limits that were set by the individual, rather than cure associated
with the establishment of a physiological norm. It was only when patients
did not respond to conventional medical treatment or when their social
competence was threatened, that their ‘sickness’ brought them within the
purview of the physician geriatrician.
This notion of ‘sickness’ was inherently unstable because it was tied to a
model of medical practice that was unsuitable for the needs of a certain
group of elderly people. In theory, as physician geriatricians exerted more
influence on medical training and overall practices changed, the need for
this role could disappear. However, in Victoria in the early 1980s when
the first locally trained physician geriatricians took up their positions, this
situation was far from sight, the instability of this notion of ‘sickness’ was
associated with the social and professional conditions in which they were
situated. Mount Royal Hospital was an exception amongst the Geriatric
Hospitals in its close association with a general hospital. In the absence of
strong medical leadership in directing the line of development of geriatric
medicine, other influences had free play.
Amongst these were the
Hospitals and Charities Commission, which sought to establish geriatric
services as complementary to acute care services, not as part of them.
From the perspective encouraged by the Commission, it was not so much
the ‘sick man’ who was the focus of the geriatrician’s attention, but the
‘dependent old lady’ described by Bruce Ford, medical rehabilitationist.
Doctors in the other Geriatric Hospitals also treated old people who were
acutely ill, but only because these patients were unwanted anywhere else.
This aspect of their role was unofficial and related to the inefficient
functioning of the hospital system.
As far as the broader community was concerned, the notion of sickness
that geriatricians sought to establish was obscured amidst a growing
287
provision of nursing home beds. The Federal government had attempted
to impose restrictions on this apparently inexorable demand. By the late
1970s, the number of nursing home beds provided in the Geriatric
Hospitals had decreased, but those provided by the voluntary agencies and
private businesses had increased. Reluctance on the part of other medical
practitioners to acknowledge even the limited role of the geriatrician in
providing restorative treatment, ensured that the community as a whole,
continued to emphasise the provision of beds, not the provision of
services. Even when members of the community were aware of what a
Geriatric Service had to offer, as Boyne Russell found, they were not
always appreciative of the possibilities offered by the redefinition of old
age infirmity as ‘sickness’.137
137
Russell, 1977, op. cit. p.111.
288
CHAPTER 7
MEDICINE OF SENESCENCE OR MANAGING THE
SYSTEM?
In this thesis I wanted to identify the conditions that made it possible for
medical practitioners in Victoria to establish a specialist field of practice
defined in terms of health and illness in old age. My aim was to clarify the
process of specialisation within medicine in Victoria and to identify what
this process can tell us about the public understanding of old age. The
purpose of this final chapter is to assess the interactions between ideas,
interests and social structures in which the emergence of the specialty of
geriatric medicine was embedded, in relation to this objective.
The
chapter is divided into two sections. The first examines the integration of
geriatric medicine into the professional and institutional environment in
which hospital services were provided in Victoria. The second section
examines how defining a specialist field of medical practice in relation to
health and illness in old age shaped the public understanding of old age.
The specialty of geriatric medicine emerged out of the activities of diverse
groups. Amidst a growing clinical engagement with diseases associated
with increasing age, a segment of the Australian medical profession sought
to establish an orientation and organisation of medical practice to deal
with problems of illness and disability they thought were neglected within
the existing focus on personal, curative medical services. The Victorian
government bureaucracy responsible for the organisation of hospital
services acted to ensure the most efficient use of public funds in an
environment where autonomous, local committees of management
provided publicly funded hospital and welfare services.
The Federal
government also sought to control a growing expenditure on age-specific
hospital and welfare provisions, the result of ad-hoc decisions taken to
deal with the exigencies arising in the course of managing the system of
national, publicly subsidised, voluntary hospital insurance introduced in
the early 1950s. At the local level, a small band of medical practitioners
sought to integrate their work in the geriatric hospitals with mainstream
medical practice as their respective committees of management
maintained and augmented a century-long tradition of providing care for
aged Victorians. During this period elderly Victorians, defined as such on
289
the basis of age of eligibility for the Age Pension, became more visible in
a population enlarged by a higher postwar birthrate and immigration.
Specialists in Name Only
Integration
When the first locally trained physician geriatricians qualified in the early
1980s, their formal status as specialists was quite explicit. This formal
status however did not reflect any degree of integration into mainstream
medicine in Victoria, and this was one of the tasks that confronted them.
At the national level, as R.B. Lefroy, one of the principal actors in
promoting geriatric medicine, noted, the association between the
Australian Geriatrics Society and the College marked the beginning of an
integrative process, not an endpoint.1 Possibly the College was more
disposed to view the Society’s proposal favourably because the ground
had already been prepared in the earlier efforts of the Australian
Association for Physical Medicine and Rehabilitation to gain College
recognition for a training program in a socio-medical field of practice.
Recognition of the specialty of rehabilitation medicine certainly appears to
have had more significance in the history of the College. The appointment
of a Specialist Advisory Committee on Rehabilitation Medicine is listed
amongst the events that were significant in the life of the College for 1975,
whereas the appointment of a similar committee in relation to geriatric
medicine shortly after, passed unremarked.2
Rehabilitation medicine was given more prominence because the doctors
who promoted it operated from a long-standing organisational base.
Where the Australian Geriatrics Society had only been in existence for a
few years when its members applied for College recognition, the
Association for Physical Medicine and Rehabilitation, which applied
around the same time, had been in existence since the mid-1940s. The
Diploma course supervised by this Association, in cooperation with the
Postgraduate Medical Association, had been available for some years.3
The advocates of rehabilitation medicine were thus in a much better
1
Lefroy, 1988, op. cit. p.71.
R. Winton, Why the Pomegranate? A History of the Royal Australasian College of
Physicians, The Royal Australasian College of Physicians, Sydney, 1988, p.48.
3
See Chapters Two and Five for the Australian Association for Physical Medicine and
Rehabilitation. The Australian Geriatrics Society is now known as the Australian Society
for Geriatric Medicine.
2
290
position to play a part in the policy-forming activities of the short-lived
National Hospitals and Health Services Commission in the years between
1973 and 1975, when the first funding programs were introduced to
support medico-social hospital services.
The efforts of the medical
rehabilitationists were reinforced by the recommendations of the
Woodhouse Committee of Inquiry into compensation and rehabilitation
which reported in 1974.4 The advocates of geriatric medicine on the other
hand, played little or no part in the policy-making of the mid 1970s. In
these circumstances geriatric medicine was seen as a subsidiary activity
within the broad field of medical rehabilitation and as an element in
community medicine concerned with the provision of welfare measures.
While this outcome did not reflect the ideas of those geriatricians who
emphasised the provision of acute hospital services as a component in
geriatric services, it was not altogether contrary to the wishes of some of
their colleagues.
When Sidney Sax defined geriatric medicine as the
provision of age-specific rehabilitation services in the mid-1960s, in a
lecture to postgraduate nurses at Concord Repatriation Hospital in New
South Wales, he was most certainly describing the form of practice being
developed (albeit slowly) in this environment.5 The adoption of a broad
definition of geriatric medicine by the founders of the Australian
Geriatrics Society accommodated the variations in work settings of
geriatricians.
When the first locally trained physician geriatricians began to establish
themselves in Victoria early in the 1980s, it was already clear that some of
their colleagues were beginning to make their way along the path set for
them by funding for rehabilitation medicine and community medicine
programs. At the end of the 1970s the Association for Physical Medicine
and Rehabilitation was transformed into the Australian College of
Rehabilitation. Malcolm Scott was a founding member of the College and
in 1978 he was nominated as liaison officer in relation to medical
rehabilitation,
between
the
Commonwealth
and
the
Victorian
6
government. Scott, a physician, whose early interest in rehabilitation had
4
Report of the National Committee of Inquiry, Compensation and Rehabilitation in
Australian, Chairman, Mr Justice W.O. Woodhouse, Australian Government Publishing
Service, 1974, p.222.
5
Sax, 1965, op. cit.
6
VPRS 6345/64/X1091/7 and VPRS 6345/555/2381.
291
led him to become involved in rehabilitation services at the Heidelberg
Repatriation Hospital, had worked hard to establish geriatric services
according to the lines laid down by the Hospitals and Charities
Commission in Victoria, first at Greenvale and then at Mount Eliza. In
1983, Gary Andrews was retiring president of the College.
Having
completed his physician training in geriatric medicine under Professor
W.F. Anderson in Glasgow in the late 1960s, he returned to New South
Wales and took up the position of medical superintendent at Lidcombe
Hospital. He became first president of the Australian Geriatrics Society
when it was formed in 1972. At the time he delivered his presidential
address in 1983 he held the position of Professor of Community Medicine
at the University of New South Wales.7
The tendency, at the national level, to emphasise the rehabilitation and
community-based services components of geriatric medicine coincided
with the aims of the Hospitals and Charities Commission in Victoria in its
support for geriatric services. However, the first locally trained physician
geriatricians in Victoria were exposed to a somewhat broader experience.
Under the tutelage of Derek Prinsley and Boyne Russell, they were
introduced to the clinical skills developed by British physicians to treat
patients who did not readily fit the template of clinical work in the acute
hospitals. It was a form of training in which the link between geriatric
medicine and general medicine was quite clear. In a medicine developed
around a ‘norm’ of physiological function, the clinical skills of the
physician geriatrician lay in that practitioner’s openness to dealing with a
norm that was ‘neither a matter of semantics nor statistics, but a burning
issue to be decided afresh at every clinical intervention’.8
Prinsley’s
formulation of the clinical skills of the geriatrician as the capacity, ‘to see
the sick man in the old person in trouble’, encapsulated a clinical
perspective that had been shaped, not so much by the specific character of
illness in the aged person, as by the limitations of a view of disease as a
specific lesion in a specific organ or bodily system.
7
Proceedings of the Third Scientific Meeting, 1983, The Australian College of
Rehabilitation Medicine, 1983.
8
Quoted in D. Armstrong, The Political Anatomy of the Body, Medical Knowledge in
Britain in the Twentieth Century, Cambridge University Press, Cambridge, 1983, p.91-92.
292
‘Trouble’ in the sense of Prinsley’s phrase could, and often did, involve an
element of poverty and the neglect that saw old people’s infirmities
accounted for by ‘old age’. In 1970s Victoria however, it was just as
likely to mean exclusion from medical treatment because of anticipated
problems in discharge, and the introduction of a form of universal hospital
and medical insurance did nothing to change this situation.9 ‘Trouble’
might also mean that the hospital doctor or general practitioner did not
recognise illness in the signs and symptoms presented by an elderly
person. It also took the form of medically induced illness arising from the
effect of commonly used pharmaceutical therapies on an aged physiology.
Under the influence of the English-trained physicians at Mount Royal,
who also had access to the acute wards of the Royal Melbourne Hospital, a
form of geriatric medicine emerged which promised to address the needs
of that group of elderly patients G.V. Davies had identified in the early
1960s – a group that Boyne Russell brought to light once again in the mid1970s, in her report on the Brunswick Community Care Program.10
An optimistic view of the position of geriatric medicine in Victoria,
around the end of the 1970s, suggests that for a brief moment there may
have been an opportunity to integrate geriatric services with those
provided in the acute hospitals.
After all, it was owing to the
entrepreneurial approach taken by the Victorian medical profession, in
cooperation with hospital committees of management, that hospital
services had developed in the form they had. The Hospitals and Charities
Commission had been consistent in the view that geriatric services should
be an extra-mural appendage to acute hospital services.
There was
however sufficient ambiguity in the Commission’s attitude that, combined
with the spark of interest that the appointment of Derek Prinsley provoked,
9
A principal element in the reforms related to health services introduced by the Whitlam
government, was the establishment of the Health Insurance Commission in 1975 and the
first form of Medibank, a universal, publicly funded hospital and medical insurance
scheme. Aged Pensioners were, for the first time, treated in the same fashion as other
adults, being eligible for services provided by general practitioners and specialists, R.B.
Scotton & C.R. Macdonald, The Making of Medibank, Australian Studies in Health Service
Administration, no 76, School of Health Services Management, University of New South
Wales, Kensington. Old people who did not respond to hospital admission in the same
fashion as younger adults were no more welcome under this system.
10
Davies, 1961, op. cit; Russell, 1976, op. cit.
293
the opportunity may have existed to establish a close link between the
practice of geriatric medicine and general medicine in the acute hospitals.
The Royal Melbourne was not the only teaching hospital that expressed
interest in the services of the physician geriatrician. The Queen Victoria
Hospital did also, as did St Vincent’s hospital.11 The latter, somewhat
unusually for the metropolitan teaching hospitals, already had a purposebuilt rehabilitation wing and home care service. The former had been
funded by the Hospitals and Charities Commission although the hospital
had not requested such facilities and the latter had been established by
hospital administrators of their own volition, to meet patients’ needs.12
Unfortunately, neither Prinsley, nor the other physician geriatricians
working in Victoria at the time – D.H. Blake and Boyne Russell – were in
any position to made much of this opportunity. All of them were outsiders
in the parochial Melbourne medical world: Russell because she was
female, and only recently returned to Melbourne after an absence of some
years; and the other two because they were newcomers to the city.
Overall, not one of these physicians was in a position to pursue the cause
of geriatric medicine through the arcane ways of the close-knit Melbourne
medical fraternity, the interest-riven world of hospital administration, and
the rigid division between the treatment of mental disease and physical
disease. John Shepherd’s hope that Professor W.F. Anderson would take
on the position that was eventually accepted by Derek Prinsley, was most
likely based on the realistic assessment that only a strong personality with
11
VRRS 4523/2/381/7-105, letter to Manager of Mount Royal Hospital from CEO at St
Vincent’s; Archives Geriatrics Society of Australia, letter dated 10/2/77 from R.B. Lefroy
to Dr E. Wilder, Chairman Victorian Hospitals and Charities Commission in which Lefroy
refers to plans made by the Queen Victoria Hospital with regard to geriatric medicine.
12
Annual Report St Vincent’s Hospital 1976. Mrs Marion Shaw reports a conversation
with one of the Sisters of Charity, the Order that ran the hospital, in which the sister
administrator expressed puzzlement at why the rehabilitation unit had been funded when
they had requested permission to build a new pathology unit, Personal Communication
from Mrs. Shaw, 11/11/97.
294
a well-established reputation in the field of geriatric medicine could hope
to make any impact on these formidable obstacles.13
In the absence of any independent action on the part of Victorian
geriatricians to organise and actively promote their role, it was the
administrative purposes of the Hospitals and Charities Commission that
prevailed in determining the scope of activity for the physician geriatrician
in Victoria.
The Commission’s objectives were supported by the
interpretation, at the national level, of geriatric medicine as a subsidiary
activity of medical rehabilitation, in association with community-based
welfare services. David Race, Chief Clinical Officer in the Commission,
made the extent of the geriatrician’s role clear in his address to community
groups in 1974, and the positions available to the newly qualified
physician geriatricians confirmed this orientation. Two of them took on
the task of establishing the long-planned new centres in outlying suburbs,
centres situated well away from the teaching hospitals, and the other two
took positions in existing services at Mount Royal and Caulfield
Rehabilitation Hospital.14
Although the physician geriatricians who qualified early in the 1980s were
officially recognised within the profession and by the government bodies
concerned with regulating the remuneration of specialists, they were
almost as isolated as their general practitioner predecessors in the 1960s.
Their workplaces separated them from their physician colleagues, and the
lack of interest, if not outright animosity, evinced by general practitioners
towards the role of geriatrician, did not diminish. Evidence for this may
be found in the frequent and defensive, affirmations on the part of the
13
Letter dated 18/9/75, to Dr John Shepherd from Professor David Penington. It appears
that Penington, going to England on other business, had agreed to seek out possible
candidates for the position of Director of the institute proposed for Mount Royal and to
interview doctors who had applied when the position was readvertised. It seems that
Shepherd had suggested that Penington talk to Anderson who Shepherd thought might be
interested in taking on this task. Anderson’s response was that he was not really interested
but if Mount Royal were ‘in a hole’ in two years time he would reconsider the matter.
Personal Papers Dr John Shepherd. Anderson himself accounted for his success in
establishing geriatric medicine in Scotland and overcoming entrenched prejudice against
doctors who worked with infirm old people as second-rate practitioners, only because of
his ‘outstanding record, with so many fellowships and prizes that he could not easily be
dismissed’, Thane, 2000, op. cit. p.451-452.
14
Dr Len Gray at Bundoora, serving the northern suburbs, and Dr R. Scholes, at what came
to be known as the Peter James Centre, in the eastern suburbs. Both centres had been
under consideration since the early 1970s. Dr Peter Lucas went to Caulfield Rehabilitation
Hospital and Dr J. Tulloch remained at Mount Royal.
295
advocates of geriatric medicine of the importance of the role of the GP in
providing medical care for the elderly.15
This animosity was not
diminished by the steps taken in the mid 1980s, by the Federal
government, to introduce a system whereby all applicants for nursing
home admission were to undergo a process of assessment under the
supervision of a geriatrician.16
Furthermore, where the first general
practitioner geriatricians had the support of the medical administrators in
the Hospitals and Charities Commission, this support disappeared in the
reorganisation of the health services bureaucracy in the late 1970s when
recommendations of the Syme-Townsend Report were implemented. The
Hospitals and Charities Commission was amalgamated into a larger body,
the Victorian Health Commission, along with the Department of Health
and the Mental Health Authority and the Commission of Public Health.
At the suggestion of Marion Shaw, executive officer in the Geriatrics
Division of the Hospitals and Charities Commission, this division was
combined with the extra-mural psycho-geriatric services provided by the
Mental Health Authority, and the welfare services provided by the
Department of Health, to form an Extended Care Division.17 The new era
was reflected in the naming of the ‘geriatric service’ established by Len
Gray, one of the newly qualified physician geriatricians, in outer-suburban
Bundoora – Bundoora Extended Care. The use of the term ‘extended care’
was, in part, the consequence of a movement that got underway in the
15
Sax, 1965, op. cit. p.26; Lefroy, 1966, op. cit. p.206; A.M.A. (Victorian Branch) Monthy
Paper, no 110, 1972, p.4; ‘Geriatrics’ editorial, MJA, vol 1, 1975, p.87. In 1987 R.W.
Warne, a physician in geriatric medicine at Mount Royal, was taken to task by a general
practitioner for failing to mention the importance of the part played by the GP in providing
medical services to elderly people, in an article describing the development of geriatric
medicine, R.W. Warne, ‘Issues in the Development of Geriatric Medicine in Britain and
Australia’, MJA, vol 146, 1987, pp.139-141; ‘Geriatric Medicine’, letter from I.G.
Chenoweth, MJA, vol 146, 1987, p.400.
16
In Chapter Five it was noted that in the early 1970s, in an effort to exert some control
over admissions to nursing home care, and thus over a growing financial responsibility, the
Federal government introduced a system whereby an official form had to be filled out by
the doctor supervising admission, and verified by a medical officer attached to the
Commonwealth Department of Health. A decision to admit was rarely, if ever, contested.
In the two reports on ‘care of the aged’ that issued from the Federal government in the mid1970s, assessment was recommended both as a means of curtailing costs and ensuring that
dependent old people were assisted in a manner that maximised their independence, not
their dependence. For assessment to be effective it was necessary to establish a degree of
local coordination in the provision of services and a range of services. These were
included amongst the recommendations that were finally implemented by the Federal
government following yet another report, In a Home or at Home, Report from the House of
Representatives Standing Committee on Expenditure, (Sub Committee Chairman L.
McLeay) 1982, Australian Government Publishing Service, Chapter 8.
17
Personal communication from Mrs Marion Shaw, March, 1997.
296
mid-1970s, to promote the needs of disabled people who could benefit
from the services provided in the geriatric centres but who were excluded
on the grounds of age, and in part an attempt to minimise the connotation
of permanence associated with the expression ‘long-term’ in reference to
the care provided for the infirm aged and disabled.18
In 1980 a medical practitioner was appointed in charge of this Division.
Strangely, in view of the expertise that had accumulated amongst
Victorian geriatricians over the preceding years, it was not one of these
practitioners but a surgeon who had developed an interest in
rehabilitation.19
It is not clear whether this situation arose from the
ignorance of policy makers and their advisers of the expertise that was
available, or whether they chose to ignore it. It may also have been the
case that the stance of Victorian geriatricians, who on the whole appear to
have shown no interest taking on administrative responsibilities of this
kind, did not encourage overtures. The result was that the general trend in
Victoria to define the role of the physician geriatrician in relation to
services located outside the acute hospital was reinforced. Any other
possibility that may have lingered around the Hospitals and Charities
Commission disappeared in this new administrative entity, and
geriatricians themselves had no say in matters relating to the conditions in
which they worked.
The only sign of recognition accorded to Victoria’s physician geriatricians
was the presence of Boyne Russell in the Working Party on Extended Care
of the Aged and Disabled that was established at this time. Possibly it was
18
Minutes Meeting Medical Superintendents, Managers and Officers of Hospitals and
Charities Commission, 12/3/75, note that the Geriatric Hospitals now need to formulate
new policy in the light of legislation to ensure that younger adults suffering from chronic
illness and disability could not be excluded from institutions on grounds of age, see Scotton
& Ferber, 1978, op. cit. p.221.
19
Dr A.R. Moore, FRACS, combined his position in the Health Commission with an
appointment as staff specialist at the Rehabilitation Hospital at Hampton where he was
appointed Medical Director in 1985. Moore had previously worked as surgeon at the
Royal Melbourne Hospital. His contact with geriatric medicine came with an appointment
as surgeon for Mount Royal Hospital where he would have seen what was done in the
provision of geriatric services. Like Bruce Ford, Director of Rehabilitation Services at
Caulfield Hospital, Moore also had a ‘humanist’ qualification. Where Ford’s was in the
field of sociology, Moore gained a Master of Arts degree. As Senior Lecturer in Surgery in
the medical school at the University of Melbourne Moore introduced a short course that
called ‘Medical Humanities’, using excepts from literature related to medical practice, to
encourage students to consider medicine as an art, not just a science. The texts and some
excerpts form the discussions in this seminar are reproduced in, A.R. Moore, The Missing
Medical Text, Humane Patient Care, Melbourne University Press, Melbourne, 1978.
297
her influence that led to the inclusion of a note to the effect that
development in the provision of extended care depended on changes in the
provision of acute medical care for this group.20
The effect of this
statement was somewhat diminished by comments to the effect that there
was no expectation that the Health Commission would sponsor the
development of geriatric medicine. It was indeed a sign of change that the
inadequacy of acute care for some elderly people was noted in an official
document in Victoria. Previously this point had been confined to the study
published by G.V. Davies in the early 1960s, and Boyne Russell’s report
on the Brunswick Community Care Program ten years or so later. There
was, however, no intention in the state’s health bureaucracy of
acknowledging such a need in the organisation of acute hospital services.
In contrast to the nascent orthopaedists in England, studied by Roger
Cooter, who acted as specialists before they could demonstrate the
trappings of specialist status, these first physician geriatricians in Victoria
were designated specialists before they were in a position to act as such.
They did not so much define their specialist role as have it bestowed upon
them as part of the process in which a charity model of care for the aged
and infirm was transformed into a service model based upon professional
assessment of need.
This transformation was part of a growing
bureaucratisation of the provision of publicly funded hospital and welfare
services, as both state and federal governments sought to control
increasing expenditure. The provision of geriatric services, available to all
citizens as a matter of entitlement, with the associated requirement for
efficient management, sat uneasily with the humanitarian recognition of
the neglect that saw infirm old people confined to institutional care as a
matter of course.
No sooner had the first steps been taken in establishing geriatric services
in Victoria as a setting for the specialist physician geriatrician, than the
effects of the economic downturn that distinguished the 1970s from the
more prosperous 1950s and 1960s were felt. Speaking from the vantage
point of 1984, Sidney Sax noted that from the end of the 1970s, ‘planning
and expansion of organised geriatric services gradually gave way to hard-
20
VPRS 4523/P2/524/8670. Discussion document related to the report of the Working
Party on Extended Care of Aged or Disabled Persons, June, 1981.
298
fought struggles to hold ground already won’.21 The situation was further
complicated by the replacement of the centralising and innovative
Whitlam government at the federal arena by a conservative regime under a
Liberal-Country Party Coalition which at once set about pursuing a
decentralising agenda. As responsibility for hospital and welfare services
shifted back to the states, the existing tendency in Victoria toward
fragmentation of services was reinforced.
In addition, the support
provided by the Hospitals and Health Services Commission for sociomedical hospital services diminished. The shift towards conservatism in
the federal arena favoured the conservative element in the medical
profession which, in Victoria, had shown little interest in the provision of
rehabilitation services.22
Defining the geriatrician’s work
How was the role of geriatrician to be defined in these circumstances?
David Armstrong has noted that in defining geriatrics in relation to old
age, geriatricians faced the problem of differentiating between age-related
changes and those attributed to disease when the same classificatory
device – changes in tissues and cells – was used to describe both forms of
change.23 It has been suggested in this thesis, a suggestion inspired by
Armstrong’s discussion of geriatric medicine in a later work, that the
structure of the geriatric service and emphasis on clinical experience and
judgement in the role of the physician geriatrician provided a practical
response to this problem.24 In Victoria, if physician geriatricians had
themselves played a stronger role in establishing the conditions that made
21
S. Sax, ‘Perspectives on the Development of Gerontology in Australia’, Proceedings 20th
Annual Conference, Australian Association of Gerontology, 1985, p.8. Geriatricians,
situated as they are on the boundary between acute medical services and services related to
care of the aged, are particularly susceptible to fluctuations in funding and shifts in
responsibility between the states and the Commonwealth. Once again in the early 1990s
geriatric services were curtailed as efforts were made to restrict public funding of hospital
services at the state level while there were minimal constraints on the federal funding of
fee-for-service medicine through the national health insurance scheme, L. Flicker & L.
Gray, ‘Issues in Geriatric Medicine’, Australian Journal on Ageing, vol 16, no 3, 1997,
p.107-108.
22
The National Hospitals and Health Services Commission was abolished following the
replacement of the Whitlam government by the Fraser government at the end of 1975.
However a Social Welfare and Health Policy Secretariat was established with Sidney Sax
as head, to be responsible for development and review of federal policy, Scotton & Ferber,
op. cit. p.332. Following the review instigated early in 1976, of the various bodies that had
been conducting inquiries, the Working Party on Rehabilitation Needs and Geriatrics was
terminated immediately.
23
D. Armstrong, ‘Pathological Life and Death: Medical Spatialisation and Geriatrics’,
Social Science and Medicine, vol 15A, 1981, p.254-255.
24
Armstrong, 1983, op. cit. p.91-92.
299
their specialty possible, a definition such as Boyne Russell’s, in terms of
context or chronological age, may have prevailed.25 As it was, Victorian
geriatricians were relieved of the problem of defining their medical role in
relation to old age infirmity because the Hospitals and Charities
Commission, the dominant party in establishing geriatric medicine in
Victoria, made an administrative decision to locate geriatric services
outside the field of acute hospital practice.
Victorian
geriatricians,
and
indeed
The problem that faced
geriatricians
and
medical
rehabilitationists throughout the Australian medical system, was to
integrate their socio-medical model of practice with the existing diseasebased model.
The location of geriatric services within the field of ‘aged care’ certainly
reflected an overall lack of interest in old age infirmity on the part of
mainstream medicine, and geriatricians’ lack of influence in the
organisation of hospital services in Victoria. However, it also reflected an
underlying orientation to medical practice characteristic of medicine in
Australia, an orientation that may be illustrated by comparing David
Race’s notion of social medicine with that of Eric Saint. When Saint
discussed social medicine, he did so by calling for a shift in clinical
philosophy so that all doctors would be equipped to think in terms ‘not
only of signs and symptoms, but also of population statistics, of housing,
of hospital administrative problems, of dietetics and of the rudiments of
psychiatry’.26 David Race, on the other hand, made it clear that geriatric
medicine exemplified a social medicine consisting in a range of welfare
measures made necessary by the undeveloped status of medical science in
relation to some aspects of old age degeneration.27 This formulation does
not contest the fundamental philosophy underlying medical practice in the
way Saint’s does. On the contrary, it reaffirms this philosophy and in
doing so is consistent with the ‘medical materialism’ that Gillespie
discerned in the Australian medical profession, whereby economic, social
and political phenomena were seen as manifestations of more fundamental
medical causes.28
25
B. Russell, 1977, op. cit. p.111; see Chapter Six.
Saint, et al, 1953, op. cit. p.764.
27
See Chapter Six.
28
See Chapter Two.
26
300
From the perspective of social medicine in the Victorian context, the
provision of geriatric services, and the role of the geriatrician, was a
practical response to a situation in which an ‘ageless’ medical science had
yet to come to grips with certain problems. It was, therefore, consistent
with the overall medical framework characteristic of the Australian
medical profession, that the geriatrician’s role would be defined in relation
to the provision of certain welfare services. In developing their role within
these parameters, geriatricians were free to draw on a growing body of
gerontological knowledge in the disciplines of biology, sociology and
psychology, and indeed to cultivate such knowledge themselves to the
extent that they could procure the funding to do so. As it was, in the
1980s the place they were offered within the overall organisation of
medical practice, through the funding measures provided by both State and
Federal governments, meant defining the geriatrician’s role fundamentally
in terms of service provision.
This is reflected in geriatricians’ own
definition of their role as:
… an appropriately trained specialist (FRACP or equivalent)
working within a multidisciplinary team of health professionals
providing health care in terms of medical, functional and social
needs for elderly clients on an area (regional) basis.29
However, in fitting so readily into the framework of service provision,
geriatricians faced the problem that health services are not always
rationally allocated and that political skills and leadership are necessary to
bolster the development of the specialty. It is worth noting that physician
geriatricians found a somewhat more sympathetic environment, at least in
terms of an administrative environment, in the hospitals run by the
Commonwealth Repatriation Department for returned service personnel.30
The justification of the role of geriatrician in terms of population health
and the rational organisation of medical services did not amount to much
in the interest-ridden environment of Victorian health services and the
competitive environment in which research funding was distributed. The
conditions that made it possible for doctors to establish a specialist
medical role in relation to old age infirmity in Victoria were notable for
29
Lefroy, 1988, op. cit. p.69-70.
See Sax 1965, op. cit. for New South Wales; see Hunter-Payne, 1994, op. cit. for
geriatric medicine in the Victorian Repatriation Hospital, p.164ff.
30
301
the absence of any energetic and strong leadership.
environment
This created an
in which geriatricians, in contrast to their
more
entrepreneurial colleagues, tended to adopt a somewhat passive stance in
promoting their expertise, an expertise that was implicitly acknowledged
in the public discussions on the topic of the ‘problem of old age’.31
However, in relying on the inherent logic of arguments about the needs of
a growing population of elderly people and rational assessments of
hospital provision, they failed to hone the political skills necessary to
establish their interests amongst all the others that were embedded in the
provision of hospital services. These specialists, situated on the boundary
between hospital services and welfare, were then at the mercy of every
shift in the political wind. In the 1980s after a Victorian branch of the
Australian Geriatrics Society was formed, ten years after the Society was
established, the interim committee was preoccupied with a manpower
study. Meanwhile, other academic and hospital interests were busy at
work establishing Chairs of Geriatric Medicine and disestablishing them
as though they had nothing to do with the specialty of geriatric medicine
and indeed the relationship was tenuous.32 The promotion of ‘geriatrics’ –
care of the aged – did not necessarily mean promotion of a specialist field
of medical practice.
The emergence of geriatric medicine as a specialist field of practice made
workable a system of medical care based on individualised, technical
services developed within a reductionist model of disease.
The
development of a field of medical rehabilitation, which included geriatric
medicine, meant that the narrow focus on curative measures in the acute
hospitals was not contested. The lack of public appreciation for the role of
the geriatrician suggests that the emphasis on curative measures in the
provision of health services was supported in the Victorian community.
31
For example, in the two inquiries conducted into ‘care of the aged’ in the mid-1970s, at
the instigation of the Federal government, the role of the geriatrician was acknowledged,
but only in circumstances where recommendations relating to policy could be made, not
implemented.
32
Minutes Meeting Interim Committee, Victorian Branch, Australian Geriatrics Society,
March 1984; Minutes Meeting Committee (Mount Royal) National Research Institute for
Gerontology and Geriatric Medicine, 6/12/84, notes a committee set up by University of
Melbourne to review the Chair in Geriatric Medicine and to make an appointment
following the retirement of Professor Prinsley at the end of 1986. As it happened the
position was reduced to associate professor level. At Monash University a Chair of
Geriatric Medicine was established in the early 1980s.
302
The second point in relation to the emergence of geriatric medicine and
the overall process of specialisation is that it testifies to the pervasiveness
of specialisation. It was possible that the system in Victoria - whereby the
Diploma in Geriatric Medicine provided a postgraduate qualification for
general practitioners who were then recognised as specialists by the
Hospitals and Charities Commission and paid accordingly - would prove
satisfactory at the local level. General practitioners interested in this work
would have found it worthwhile to develop their interest and the state-run
geriatric centres would have had a source of medical staff. If the links
between the Victorian Faculty of the Royal Australian College of General
Practitioners and, for example, the local Association of Geriatric Medical
Officers had been developed further, it might have been possible to
integrate the practice of geriatric medicine into general practice.
There were certainly local obstacles to this development. The reluctance
of the Association to develop a professional identity in place of the
parochial and narrow institutional orientation of many local geriatricians
tended to isolate geriatricians from their fellow general practitioners. This
was reinforced by the aversion amongst general practitioners to any close
association with state institutions like the geriatric centres, and to the idea
of practising medicine in tandem with other health professionals such as
nurses therapists and social workers.
However, local arrangements
became less sustainable from the 1960s on, in an overall shift to a national
organisation of medical services in relation to accreditation and training
and remuneration for medical services.
Local general-practitioner
geriatricians were effectively, if not intentionally, sidelined in the general
move on the part of the physician members of the Australian Geriatrics
Society to have special training in geriatric medicine accepted by the
Royal Australasian College of Physicians. The desire of these physicians
to integrate geriatric medicine with medical practice at consultant level
reflected the reality that doctors at this level dominated medical education
and training. If the principles of geriatric medicine were to be introduced
into the work of all medical practitioners, its practitioners had to operate at
the highest level of qualification.
Geriatric medicine was a late-comer to the proliferation of specialties that
began in the 1960s.
The overall trend towards specialisation was
303
reinforced when differential rates of remuneration were introduced into the
national system of hospital and medical insurance in the early 1970s and
the National Specialist Qualification Advisory Committee was established.
In these circumstances the general practitioner geriatrician in Victoria, the
geriatric medicine officer trained through the Diploma program, gradually
faded from view.
The third, and final point is that the development of geriatric medicine in
the form of service provision also reflected a process of specialisation in
which the Australian medical profession was able to maintain its
entrepreneurial character, while at the same time entering into a closer
relationship with government in the provision of health services. This
association - which had existed since the early 1950s in the federal arena,
when the British Medical Association had dictated the terms for a national
system of hospital and medical insurance – was obscured in the
arrangement whereby governments, both state and federal, provided
subsidies for medical services rather than the services themselves. Even
with the introduction of universal, publicly funded insurance, the
insistence on the part of the medical profession on retaining fee-forservice remuneration for medical services, ensured the status of geriatric
medicine would remain low.
In comparison with other medical
specialties, the service provided by the geriatrician was time consuming
and, ideally, required the services of the social worker, nurse and
occupational or physio-therapist. The possibilities for earning the same
level of income as their colleagues in the other medical specialties were
not there. In the early 1980s, an oversupply of physicians in the field of
gastroenterology did not encourage doctors to shift into the under-supplied
area of geriatric medicine.33
33
Newsletter, Australian Geriatrics Society, October, 1989, notes difficulty in recruiting
registrars to do their physician training in geriatric medicine, only half the number needed
was available.
304
Geriatric Medicine and the Public Understanding of Old Age
If the role of specialist physician geriatrician made an increasingly
specialised and expensive system of medical services workable, what
significance was there in the emergence of this role for the public
understanding of old age? The first steps to promote a special medical
role in relation to old age were taken alongside a general community
movement in which voluntary groups and professionals began to view old
people in Victoria from perspectives formed largely in the United States
and Britain, and publicised in the literature that proliferated on the
‘problem of old age’ from the 1940s onwards.
The first attempt to
formulate the local version of this problem can be found in the survey
undertaken by Bertram Hutchinson, a social investigator brought from
England by the Rotary Club of Melbourne. The advocates of geriatric
medicine in Victoria, were prominent in the field of activity that began to
take shape at this time around the needs of old people. The emphasis
geriatricians placed on the representation of old age as a period of activity
supported the objectives of groups like the Old People’s Welfare Council
as it took on the task of raising the status of the aged. It also supported the
voluntary groups in shifting their work from a basic provision of custodial
care to a professionalised activity providing age-specific services.
On the level of what was actually done and the formation of policy,
medical influence was not great, particularly in Victoria. In relation to
policy at both state and federal levels, the valid point that the needs of
some acutely ill old people were not met within the existing organisation
of hospital and medical services, was lost amidst the profusion of interests
and generalised formulations of the ‘problem of the aged’. The advocates
of geriatric medicine were caught in a bind because on one hand they, like
all medical specialists, needed the support of lay groups in making their
claim to specialist expertise. However, their interests were not always
advanced through this association. The point they made in relation to
hospital services, was lost amidst a maze of other matters in the field
classified as ‘care of the aged’. There was certainly a relationship between
the acute hospital services they advocated and community-based welfare
services but this was obscured in discussions dominated by ‘the problem
of old age’. Their task was made more complicated than that of other
medical specialists because the field they worked in straddled the unstable
305
ground of state/federal funding. A gain secured in one arena could be
undone by actions taken in the other, a situation exemplified by the
introduction of subsidies for nursing home care by the federal government.
Even when, in the 1960s and 1970s, there was greater acceptance of the
idea of providing community-based services instead of institutional care
for the chronically ill and disabled, geriatricians were at a disadvantage.
On one hand they were in step with this movement in seeking to shift the
emphasis away from the provision of institutional care for the infirm aged.
On the other hand, however, they were out of step because in this process
there was also a tendency to contest medical control. The distinction
between the role of the geriatrician in assessment and rehabilitation, and
that of the Health Department medical officer’s determination of access to
domiciliary services was one not everyone was able to appreciate. In the
1980s, when geriatric medicine was funded by measures designed to
provide hospital-based rehabilitation treatment, geriatricians were at a
disadvantage in access to private patients.
Their better-organised
colleagues in medical rehabilitation had secured an arrangement with the
health insurance funds so that claims could be made for rehabilitation
treatment only when it was provided in a hospital under the direction of a
member of the Australian College of Rehabilitation Medicine.34
David Armstrong has brought a Foucauldian perspective to bear upon the
emergence of social medicine in Britain in the period between the wars
and just following the Second World War. Geriatric medicine with its
socio-medical model of illness in elderly people is included in this
process, which entailed a shift in the medical ‘gaze’ from the narrowly
defined space of the hospital ward into the broader social space of the
community.35 The ‘geriatric patient’ was identified by means of the social
survey, a tool that brought a previously undifferentiated mass of old age-ill
health and disability to light, in the form of changes in the ‘morbidity
spectrum’ from acute to chronic illness.36 The geriatric service provided
34
Australian Geriatrics Society, Federal Council Meetings, Minutes/Agendas, February,
1990, notes that the issue of accreditation of the geriatric centres in Victoria for the purpose
of claims on hospital insurance, was still unresolved. One of the largest health insurance
funds, Medibank Private took recommendations only from the Australian College of
Rehabilitation Medicine.
35
Armstrong, 1983, op. cit. p3-4.
36
Ibid. pp.85-87.
306
an organisational form for the panoptical surveillance of this patient as he
or she moved along the trajectory of decline to death. Armstrong cites
Sheldon’s survey of elderly people in the city of Wolverhampton as the
earliest example of ‘a technology through which power operated as a
positive force, making it possible to constitute and sustain ‘the very
conception of ‘natural history’ as applied to illness’.37
Moira Martin has criticised Armstrong’s interpretation of the disciplinary
potential of geriatric medicine in England in the 1950s on the grounds that
the most that was achieved was an improvement in the system of
classifying elderly people and ‘distributing them to the most appropriate
site in a network of care established by postwar reforms’.38
If the
disciplinary power of geriatric medicine in England was somewhat
uncertain in the 1950s, in Victoria there can be no doubt that even into the
1980s the ‘geriatric patient’ was a most unstable and indefinite category.
On the whole, medical practitioners in Victoria had little interest in
shifting the medical ‘gaze’ away from the hospital into the community.
General practitioners, for their part, were reluctant to relinquish their
entrepreneurial status and to act openly as accomplices with the state in
establishing a corporate society.
The stance taken by mainstream
medicine was reinforced by the persistence of community participation in
the provision of health and welfare services, either in the form of
voluntary societies or private business.
The slow replacement of the
charity model whereby volunteers and an untrained workforce cared for
the infirm aged, by a professionalised workforce and administration did
not minimise the importance of community ideas about the appropriate
response to old age infirmity. If the geriatric patient could be said to be
the product of disciplinary power at all in this period, it was the
administrative discipline that was first introduced, tentatively, with the
establishment of the Hospitals and Charities Commission and, later, the
Victorian Health Commission.
Even into the 1980s, this form of
‘discipline’ was limited in its power in relation to community groups
37
38
Armstrong, 1983, op. cit. p.86.
Martin, 1995, op. cit. p458.
307
although local administrative discipline was reinforced by the moves made
by the Commonwealth to establish the geriatrician as gatekeeper to
publicly subsidised nursing home care.
Notwithstanding Martin’s critique of Armstrong’s interpretation, and the
very uncertain development of geriatric medicine in Victoria, the central
point of Armstrong’s analysis remains undiminished.39
That is, the
emergence of the ‘aged subject’ marked a new cognitive and political
domain. The obstacles Martin identifies to the development of geriatric
medicine as a disciplinary power suggest that the emergence of such
power in liberal democracies may be more complex than appears from an
analysis of texts.
Martin’s interpretation may be read as amplifying
Armstrong’s analysis, giving it more depth, if less clarity, by highlighting
the competitive character of the process through which the postwar
‘elderly citizen’ was constructed. A focus on the slow development of
geriatric medicine in Victoria may obscure the point that when the role of
geriatrician was introduced, even in the late 1950s, old age was already the
object of disciplinary power - but power more aligned to the requirements
of government than to specialist fields of expertise.
Nicholas Brown’s insights into the operation of disciplinary power in the
1950s offer a way of interpreting an environment that was clearly more
unstable than Armstrong’s analysis allows for, while at the same time
making it clear that, around this time, a new cognitive and political
domain around old age was emerging. Brown describes a disciplinary
environment where a range of diverse groups, accustomed since wartime
to playing a role in public discussion and the formation of public policy,
sought to work out a way to come to terms with the changes brought about
by postwar affluence. These changes were seen in a growing materialism,
mobility and social fragmentation in Australian society.40
It was
indicative of the environment in which government operated at the time
that the participants included those involved in a changing model of
industrial relations, lobbyists for sectional interests, and others from
financial journalism and the discipline of economics. The concept of the
‘citizen as consumer’ emerged out of the varied and not easily reconcilable
39
40
Martin, 1995, op. cit. p.443.
Brown, 1995, op. cit. p.4.
308
standpoints that were represented in social analysis at the time. It was a
process where an accommodation was reached between the discursive
field of managing the needs of the population, and that of maintaining the
requirements for stable government.41
In linking the emergence of a discursive field with the requirements for
stable government, Brown’s interpretation offers a way of aligning
Martin’s conclusion that geriatric medicine in Britain in the 1950s did not
construct its object because it was too fragmented and uncertain a field,
with Armstrong’s insight that as ‘a medicine of the social was born’ in
interwar Britain, so did ‘a politics of the social become a possibility’. The
failure of both psychiatrists and geriatricians in Victoria to achieve
anything substantial in the form of disciplinary development prior to the
early 1980s should not obscure the point that, during the 1950s and 1960s,
a more diffuse discursive field related to old age did exist within the
broader concern to govern the citizen as consumer. This individual was
‘located in a more socially inclusive private sphere of desires and
aspirations’ which required regulation to prevent inordinate expenditure
on one hand, and oppressive taxation on the other. The citizen consumer
was described in the discourses of economics, industrial relations,
psychology, finance and business.42
The aged citizen consumers could be found in the subculture described by
the psychiatrist Herbert Bower in 1964.
It consisted of a rapidly
expanding group of old people with:
… fair financial power, ample free time and reasonable health
[who] could [be] expected to develop into a political pressure group
[but] does nothing of the kind. The old show no hunger for power,
have little solidarity and disengage themselves in a curiously
passive way from life around them.43
Dewedney and Collings found the working-class equivalent when they
surveyed the elderly residents of inner-city Richmond. To the puzzlement
of their middle-class interlocuters, these people were content to live
quietly amongst familiar surroundings without doing anything much in
41
Ibid. p.4-5.
Ibid. p.102.
43
Bower, 1964, op. cit. p.286-287.
42
309
particular, and resenting any endeavours on the part of professionals to
‘correct their apparent boredom’.44 The psychologist Ronald Conway, in
the early 1970s, linked the ‘tragic uselessness and spiritual sterility’ of so
many retired people to the psychologically barren utilitarianism that
informed the Australian philosophy of life.45
It could also be said that these complacent old people were exemplars of
the citizen consumer in the careful cultivation of their private lives. They
avoided the careless spending characteristic of securely employed
workers, and in home-ownership and a carefully regulated personal life
they did not threaten the collective well-being by calling upon public
assistance. The Age Pension was simply what they were entitled to after a
life-time of hard work.46 It was the poor aged who depended on the
pension for their whole income and who did not own their home, who
were the focus of the Keynesian economics which was the prominent
discourse in public life in Australian in the 1950s. Richard Downing,
Ritchie Professor of Economics at the University of Melbourne, paid
particular attention to the integration of the elderly (defined in relation to
age of eligibility for the Age Pension) into consumer society.
He
presented a five-point program for this in the early 1950s in which the
level of pension payments was adapted to the needs of beneficiaries. In
doing so he worked from the principle that there was ‘a given standard of
entitlement accruing to each citizen, to be realised in an environment
offering an assessment of need and an ethic of redistribution’.47
The first challenge to the prevailing economics discourse was made by
Bertram Hutchinson when he called for a remaking of a ‘social norm’ of
old age.48 Although Hutchinson was responding to the comments made by
the old people he surveyed, which conveyed feelings of alienation and
exclusion, when elderly people did organise to protect their interests it was
not their status that they were concerned about. Rather, it was the desire
44
M. Dewdney & J.S. Collings, Living on the Old Age Pension, Hospitals and Charities
Commission, Melbourne, 1965, p.113.
45
R. Conway, The Great Australian Stupor, An Interpretation of the Australian Way of
Life, Sun Books, Melbourne, Australia, p.183.
46
The economist Douglas Copeland coined the expression ‘milk bar economy’ to convey
the threat he perceived in an unbridled consumerism, to the overall well-being of the
nation, Brown, 1995. op. cit. pp.109-111.
47
Brown, 2001, op. cit. p.185ff.
48
Hutchinson, op. cit. p.4
310
to protect the benefits due to them in the form of the Age Pension that
brought them together.49 For those other elderly people who sought to
advance the status of the aged by forming the Old People’s Welfare
Council of Victoria, some of whom were associated with the Rotary Club
of Melbourne which commissioned Hutchinson to undertake the survey,
the project seems to have been yet another version of charity work albeit
with a gloss of professionalism.50
It is unlikely that the retired
businessmen and society women who took up the problem of aged as part
of a lifetime of voluntary work for the less fortunate, ever considered that
they needed the Elderly Citizens Clubs they encouraged the Department of
Health to fund.51 The warm reception received by the founders of the Old
People’s Welfare Council, first at the state level and then in the federal
arena, arose out of a shared set of social values, the same ones that
underpinned the citizen as consumer. In view of the ages of federal and
state parliamentarians at the time, shared generational values also played a
part.52
49
I. Ellis, ‘Pensioner Organizations and Action’, in Towards and Older Australia,
Readings in Social Gerontology, ed A.L. Howe, University of Queensland Press, St Lucia,
1981; Gilsenan, 1999, op. cit.
50
Norris, 1978, op. cit.pp.95-98. The Victorian Council proposed that leadership courses
be introduced for the secretaries and leaders of the Elderly Citizens’ Clubs, Newsletter,
National Old People’s Welfare Council of Australia, February, 1961.
51
The Lord Mayor of Melbourne, Councillor Disney, hosted the inaugural meeting of the
Victorian Old People’s Welfare Council, at the Town Hall. Mrs Herbert Brookes, daughter
of Alfred Deakin, and Mrs F.G. Tuddenham exemplified the socially prominent women
who, as members of the National Council of Women, Victoria, devoted their undoubted
capacities for leadership and organisation to addressing a range of social problems. ‘Old
age’ was only one of a number of issues the Council took up, others being mental illness,
education, the welfare of children and mothers and the rights of women to participate in
civil society, Norris, op. cit. Sir Giles Chippendall, first president of the National Old
People’s Welfare Council exemplified the businessmen and public servants who
maintained an active life after retirement, devoting themselves to the ‘problem of old age’,
Newsletters National Old People’s Welfare Council of Australia, Archives, Council for
Ageing, Victoria, Box 1. Chippendall entered the Commonwealth Public Service as a
messenger boy and left it having reached the position of Director-General of the Postmaster
General’s Department. He is described as a ‘tough-minded administrator who got things
done’, Australian Dictionary of Biography, vol 13: 1940-1980.
52
Holmes, 1976, op. cit. p.17; G. Henderson, Menzies’ Child, The Liberal Party of
Australia, 1955-1994, Allen & Unwin, St Leonards, NSW, Australia, 1994, p179. The
Victorian Minister of Health agreed that his Department would provide funding to assist
councils in establishing Elderly Citizens’ Clubs. When a National Council was formed by
existing state Old People’s Welfare Councils, the Prime Minister, Sir Robert Menzies
agreed to provide a most generous thirty thousand pounds annually for three years to assist
the Council in its work. By the end of the 1960s the names of federal and state bodies had
been changed to Australian Council on the Ageing and Victorian Council on the Ageing
respectively. VPRS 105546, Victorian Council on the Ageing
311
The emerging activism of ‘the aged’ in the 1950s, if such a positive term
can be used in relation to the restrained activities of the Old People’s
Welfare Council and the various pensioner associations, was directed
towards ensuring that the elderly were maintained within that ‘socially
inclusive private sphere of desires and aspirations’ through a range of agespecific welfare measures.53 To the extent that this entailed a redefinition
of the ‘norm’ of old age in general and not simply ‘poor old age’, it was a
redefinition not of what it meant to be old but of what it meant to be an old
consumer. The various age-specific subsidies that were made available
during the 1950s and 1960s, for housing, medical services, and long-term
care, were subsidies for private choice. They may be seen as part of a
process which Thane and Harper have defined as the ‘social construction
of old age’, a process whereby elderly people come to be defined and
categorised, and have characteristics attributed to them, which then
become normative’.54 When the psychiatrists Davies, Bower and Stoller
called for the psychological and sociological studies to build up a body of
knowledge to support older adults in the project of ageing ‘successfully’,
they were not so much voices ahead of their time, as representative of an
existing trend whereby problems of social order were approached through
the cultivation of personality.55 Their objective was to include ageing
adults in this process: an objective that was it appears, of little interest to
professionals at the time, including psychiatrists, in the overall concern
with adolescents, families and migrants.
Throughout the 1950s and 1960s, as the conditions emerged in which
geriatric medicine became a specialist field of medical practice, the social
construction of old age proceeded to the extent that a historian of the
1970s included ‘the aged’ as a specific social grouping.56 The medical
profession played its part as advances in technique meant that the
degenerative diseases associated with old age became more amenable to
treatment.
Nascent geriatricians also contributed as they sought to
establish the provision of rehabilitation treatment as a routine measure for
old people at risk of needing custodial care. Their success in this project
53
Brown, 1995, op. cit. p.102.
Harper & Thane, 1995, op. cit. p.44.
55
Brown, 1995, op. cit. p.168ff.
56
F. Crowley, Tough Times, Australia in the Seventies, William Heinemann, Australia,
1986, p.248.
54
312
was uneven, but there can be no doubt that this emphasis on activity in
maintaining good health in old age contributed to the overall process in
which old age was brought into the discursive field of good governance
that was established in the postwar period. It is not accidental that the
body of knowledge that defined geriatric medicine in the early 1980s was
principally defined in terms of the provision of services rather than, for
instance, the diseases of old age, and that the ‘aged subject’ was found
mainly in government reports.57 Armstrong’s claim that as ‘a medicine of
the social was born’, so did ‘a politics of the social become a possibility’
can be sustained in relation to the emergence of geriatric medicine in
Victoria only by taking note of the particular circumstances in which this
process got underway. A medicine of the social which consists principally
of the provision of services designed to maintain the infirm aged as
participants in their communities, reflected the requirements for
integrating ‘the aged’ into consumer society as a means of making the
most efficient use of public resources.
There can be no doubt that the introduction of the role of specialist
geriatrician benefited a neglected segment of the Victorian population –
that is those old people, most of them poor, who were consigned to
custodial care without any consideration as to whether there could be any
alternative to incarceration. In circumstances where the infirm aged were
excluded from the acute hospital, it is understandable that the advocates of
geriatric medicine should emphasise rehabilitation and integration with
other hospital patients on one hand, and with community life on the other.
It is notable however, that in emphasising the benefits of providing active
medical treatment for a group that, in the course of the twentieth century
had been excluded from this sphere, two points are obscured. The first is
that many old people could not benefit from rehabilitation treatment. The
exclusion of nursing home care from the field of hospital provision meant
that unlike the private hospitals where acute medical treatment was
provided according to enforceable standards, private nursing homes were
57
A.L. Howe, ‘Gerontology in Australia: The Development of the Discipline’, Educational
Gerontology, 16, 1990, p.127-128; Report of the Committee on the Care of the Aged and
the Infirm, Chairman, A.S. Holmes, January, 1977, Australian Government Publishing
Service, Canberra; Report of the Australian Government Social Welfare Commission, Care
of the Aged, Chairman, M. Coleman, Australian Government, Canberra, 1975.
313
outside the geriatrician’s jurisdiction unless individuals were able to
establish the appropriate relationships with the private providers.
The second point that is obscured is that the natural end of old age lies in
death. If death was an affront to medical knowledge in the acute hospitals,
it seems also to have been out of place in the provision of geriatric
services. Death was certainly included amongst the topics covered in the
two gerontological texts that were published locally in the 1980s.58
However this recognition seems to have arisen more as a consequence of
the emergence of the hospice movement as a means of attending to an
existing neglect of the dying, than from any particular attention to the
point that death follows old age.59 In addition many old people died in
nursing homes, attended by staff whose training, if they had any at all,
may not have equipped them with the skills available to hospice staff, and
by general practitioners who may or may not have been interested in their
plight.
In the community, the emphasis on activity on the part of the aged care
experts (doctors, nurses, therapists and social workers), and on the part of
activists in the cause of ‘old age’, left no space at all for referring to death
as a natural event which is sometimes accompanied by intractable
difficulties. The social construction of old age left out death with the
consequence that those who could not benefit from rehabilitation – a
category which may have included individuals who were making their
own private accommodation with impending death - the unduly
loquacious, the disoriented and the unmotivated - were left in limbo.60
Marjory Warren promoted the development of geriatric services as a more
humane response to old age infirmity than ‘whispered’ arguments in
favour of euthanasia, and to the extent that the introduction of geriatric
services in Victoria provoked a more life-affirming response to old age
58
K. Kingsbury, ‘Some Last Choices’, in Towards an Older Australia, Readings in Social
Gerontology, ed A.L. Howe, University of Queensland Press, St Lucia, 1981; R. Webster,
‘Palliative Care in the Elderly’, in R.W. Warne & D.M. Prinsley, eds, A Manual of
Geriatric Care, Williams Wilkins and Associates Ltd, Sydney, 1988.
59
A distinction between adults dying from a disease such as cancer and the ‘aged and
infirm’ who may also be near the end of life, was made on the grounds that ‘in the first
place the age span is much wider and an substantial proportion of patients do not see
themselves as belonging to the category of the ‘aged and infirm’’, and that ‘there is the
certainty (with cancer patients) that, sooner or later, their malignant disease will kill them’,
D. Allbrook, ‘Dying of Cancer, Home, Hospice or Hospital’, MJA, vol 143, 1984, p.143.
60
G. Larkins, ‘Physical and Mental Problems of Ageing’, in Stoller, 1960, op. cit. p.28.
314
infirmity, this was successful.61 However the emphasis on activity in
public discourse left no room for a public view about preparing for death.
Any faltering in the will to live or difficulty in adjusting is addressed in
the form of additional services or a readjustment of medication. Possibly
this is be all that can be expected from hospital and medical services. The
problem is, however, that as old age has become medicalised to the extent
that a medical response is considered by both the lay public and the
profession to be appropriate in all cases of dis-ease, there are no other
legitimate categories for talking about death at the end of a long life. Any
contest to medical authority from the other professions that have
developed a role in relation to old age – nursing and social work for
example – did not necessarily contest the technical orientation of medicine
but merely substituted another form of it. During the 1970s and 1980s,
when the role of geriatrician was established in Victoria’s hospital and
medical services, it was in novels that the most eloquent examination of
the experience of dying in old age was to be found.62
61
Warren, 1946, op. cit. p. 842.
Hartshorn 1993, op. cit. lists Elizabeth Jolley’s Mr Scobie’s Riddle, Patrick White’s The
Eye of the Storm, and Jessica Anderson’s Tirra Lirra by the River, as exploring questions
related to old age and death. Hartshorn was a social worker who was involved in the
provision of services for the aged in Brisbane and an early member of the Australian
Association of Gerontology, see Chapter Five.
62
315
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APPENDICES
Appendix 1. Sample list of Geriatrics Conferences and participants,1964,
1969 and 1973, Geriatrics Conference 1956-1966, Geriatrics Conference
1967-1976, Hospitals and Charities Commission, Melbourne.
Conference: Community’s responsibility to aged, NZ view; Kew City Hall, 1964
Attended by: Visiting Med. Super, Chairman OPCW, Rehabilitation medicine,
District Nursing Service, State representatives – 3 medical practitioners, 3
administrators, Visiting physician, Institutional Administrator, Social Worker,
Architect
Representing: Auckland, Melbourne, Canberra Hospital, Melbourne DNS, Medical –
NSW, Qld, WA, Admin.- govt dept & institutional – Tas, Vic, SA, Royal Newcastle
Hospital, Grace McKellar Hse Vic, Old People’s Welfare Council, State Government
Conference: Preventive approach to geriatrics; chiropody; the pattern of permanent
care for the aged; dental problems in the aged; education for geriatric nursing; pastoral
care Mount Royal 1969.
Attended by: Foundation Prof Social & Preventive Medicine, Chiropodist, Director
Council of Social Services, Dean Faculty Dental Science, Principal Nurse Educator,
Minister of Religion
Representing: Monash University, Consultant to Mount Royal Victoria, University of
Melbourne, Mount Royal Hospital, Chaplain, Willsmere Hospital
Conference: Community health & care of the aged; voluntary agency institution;
aspects of care of the frail aged; domiciliary care, Caulfield Hospital, 1973
Attended by: C/wealth Advisor in Geriatrics and Gerontology, Ass. Chief Health
Officer, Med super., Community Health Educator, Panel of Nurse, Dentist,
Chiropodist, Social Worker
Representing: Commonwealth Govt., Community Services Dept.(no state noted),
Freemasons’ Homes, Dept. Social & Preventive Medicine, Monash Univ., RDNS,
Dental Hospital, Chiropodist to Methodist Dept of Adult Care, Medical Social
Worker, Southern Memorial Hospital Melbourne
348
Appendix 2: Officer Bearers and Members of Council Australian
Association of Gerontology, 1965 –1969, Newsletter of the Australian
Association of Gerontology, vols 1, nos 2, 4, 7; Proceedings of the Australian
Association of Gerontology, vol 1, no 1.
1965 following the First Congress of the Association
Dr Sidney Sax (President)
Sir William Upjohn (Vice President)
Dr David Wallace (Secretary/Treasurer)
Dr A. Everitt (Sydney)
Dr B. F. Ford (Canberra)
Dr. R. M. Gibson (Newcastle)
Dr. J. A. Foster (Launceston) Miss S. Ramsey (Social Work, Melbourne)
Dr. C. Robjohns (Adelaide)
Dr A. Ungar (Sydney)
Dr. R. M. Gibson (Newcastle) President
1966
Dr. D. Wallace (Goulbourn) Secretary
Dr A. Everitt (Sydney)
Dr B. F. Ford (Canberra)
Dr. R. B. Lefroy (Perth)
Dr. J. A. Foster (Launceston) Miss S. Ramsey (Social Work, Melbourne)
Dr. C. Robjohns (Adelaide)
Dr A. Ungar (Sydney)
Dr. S. Sax (Sydney)
Dr. P. Livingstone (Brisbane)
Dr. S. Nelson (Sydney)
1967
Dr. R. M. Gibson (Newcastle) Pres. Dr. P. Livingstone (Brisb.) Vice-Pres.
Dr. S. Sax (Sydney) Immediate Past President
Mrs. R. Inall (Canberra) Honorary Secretary/Treasurer
Dr. D. Wallace (Goulbourn)
Dr A. Everitt (Sydney)
Dr B. F. Ford (Canberra)
Dr. R. B. Lefroy (Perth)
Dr. J. A. Foster (L’ston) Miss D. Watkins (Melb, Geriatric Div. HCC)
Dr. C. Robjohns (Adelaide)
Dr S. Shepherd (Melbourne)
Dr H. Bower (Melbourne)
Dr K. Hirschfield (Qld)
1969
Dr. D.C. Wallace (Pres, NSW)
Dr. S.J.H. Shepherd (Vice Pres, Vic)
Dr R.M. Gibson (Newcastle)
Mrs E.W. Cooper (New South Wales)
Dr. B. Ford (Canberra)
Dr A.J. Forster (Tasmania)
Dr. R. Greenlees (South Australia)
Miss H. Ryan
Dr. S. Sax (New South Wales)
Miss D. Watkins (Victoria)
Dr J.C. Brierley (New South Wales)
Dr. K. Hirschfeld (Queensland)
349
Apppendix 3
Summary of provisions for elderly Australians in 1975, from, R. Mendelsohn,
The Condition of the People, Social Welfare in Australia, 1900-1975, George
Allen & Unwin, Sydney, 1979, p187.
‘At the Australian Government level the measures have included the regular
increasing of the maximum pension; the provision of supplementary
assistance for rent or board; free medical, hospital and pharmaceutical benefits
subject to means tests; the provision of repatriation benefits; subsidising the
construction of ‘approved’ accommodation, care in nursing homes, domestic
assistance, senior citizens’ centres, and ‘meals-on-wheels’; and the provision
of various other benefits such as telephone rental concessions and special tax
relief.
At the same time the estates, the private health sectors, the voluntary and
charitable organisations and to a lesser extent local governments have
provided most of the direct services. For example, the states have retained
prime responsibility for hospitals and health services, public housing, public
institutions for the aged and other welfare services. The voluntary sector has
played a significant role in sponsoring and running aged persons’ homes,
‘meals-on-wheels’ and home nursing, and the private sector has provided
primary medical care and nursing homes.’
Local governments have also sponsored aged person’s homes and some
provide facilities and services such as senior citizens’ centres, ‘meals-onwheels’ and domestic assistance. Most local governments provide some for of
rate concessions, by the deferment or remission of rates, for aged people with
limited means.
The responsibility for services to the elderly, therefore, is scattered throughout
all levels of government, the voluntary organisations and the private sector.’
350