Surgeons are, like everyone else, fallible human beings, gendered and embodied themselves, just like their patients. They have home lives and social lives, as well as surgical careers. In the final section of the book, questions are asked about the culture within which so much technological and scientific innovation took place in the early twentieth century, in an attempt to understand why so many people were prepared to trust surgeons so much for so long.
Chapter 5: Achieving Distinction
In theory, all doctors were entitled to perform surgery as a part of their medical practice, and many general practitioners built up an ‘interest’ in surgery, moving from minor operations to more major procedures as they acquired experience and confidence.[i] Until after World War II, a large proportion of surgery in rural areas continued to be performed by general practitioners. However, from at least the 1890s, major surgery such as abdominal operations was increasingly the province of specialists and in urban areas, an increasing proportion of surgery was performed by specialist doctors who did little else. In Australia and New Zealand, as in Britain, the emergence of full-time surgeons and other specialists depended on a network of general practitioners who were prepared to refer patients for specialist treatment. Urban specialists therefore needed to build their reputations with general practitioners just as much as with their patients. In rural areas, however, those who performed surgery depended very much more directly on the good opinion of their patients.
Accordingly, the first part of this chapter outlines the differences between the practice of surgery in rural and in urban areas, whilst examining the ways in which surgeons built their careers and acquired distinction. The second part of the chapter goes on to describe the characteristics of a range of surgical lifestyles in the interwar years and outlines some of the ways in which home and social life could be seamlessly integrated to support the reputations of successful surgeons as trustworthy experts.
Trust and the moral economy of surgery
During the 1920s and 1930s, surgery shared in the public confidence in the efficacy of scientific medicine and the good intentions of its practitioners. This level of trust in medical practitioners is in marked contrast to attitudes to drug manufacturers.[ii] Harry Marks has shown how regulations and restrictions on the introduction of new drugs in America from the late 1930s were linked to widespread suspicion of commercial motives, and similar attitudes to drug companies prevailed in Australia and New Zealand.[iii] However, the motives of surgeons were not suspected in the same way, and surgery was not subjected to the sort of tests of safety and efficacy that were beginning to be applied to drugs. Surgeons were free to adopt, adapt, or invent any surgical procedure as they saw fit. Between the 1880s and the 1940s there was an enormous increase in the range of surgical procedures and the number of surgical patients, but before the 1950s there was seldom good evidence as to whether or not operations ‘worked’ or were safe.[iv] Patients, therefore, had to make a leap of faith in agreeing to submit to them. They had to trust the surgeon, and this trust has three major components:
1: trust in the efficacy and safety of the treatment;
2: trust in the technical competence of the medical practitioner;
3: trust that the medical practitioner will act in the best interest of the patient.
As was shown in chapter 1, late nineteenth century surgeons had to win the trust of their patients, whose confidence in, and consent to, surgery could not be taken for granted. All three of the components of trust were open to question. Surgeons had to talk to their patients and persuade them to agree that surgery was in their best interests. In the early twentieth century, that pattern of behaviour changed significantly. The hospitalisation of surgery was associated with a progressive decline in patient autonomy, and at the same time, the authority of surgeons rose. They were increasingly professional, and they were increasingly confident in the appropriateness and efficacy of their modes of treatment. Quite possibly they were also becoming more competent. They were certainly becoming more experienced. But most importantly, they were increasingly trusted to act in the best interests of their patients. Effectively, many patients withdrew from an active role in decision-making about their own treatment, especially in urban areas where they were referred to a specialist surgeon by their general practitioner. As we saw in the case of Thomas Flynn, sometimes patients may have been manipulated or even coerced to agree to the recommendations of experts, but the structures within which doctors and others were allowed to exercise such power also reflect rising levels of societal trust in the benevolent use of medical expertise.
Those people who built up referral practices as full-time surgeons were necessarily acknowledged by their peers as having special expertise. Sometimes such a reputation was simply acquired through experience, but doctors who were particularly interested in surgery had a number of other options for raising their profile and achieving distinction among their peers. Some doctors became surgeons gradually over time, giving up their general practice bit by bit as their surgical workload increased. But by the turn of the twentieth century young doctors increasingly frequently deliberately planned surgical careers for themselves, and an important component of such a career was to obtain a public hospital position as honorary surgeon to in-patients. Such positions, especially at the major teaching hospitals, carried with them considerable prestige, and it was perceived to be easier to build up a large (and lucrative) private practice from such a base than from private practice without a hospital appointment. Partly, this was because such appointments implied peer endorsement of competence; partly such appointments placed surgeons in the position of teaching surgery to medical students and young doctors, and hence building up a network of general practitioners who knew them personally. But an important feature of honorary public hospital appointments was that they were honorary; those who held them worked for free. This conferred on them the status and trust that went with such honourable behaviour.
Recently, a Professor of Population Health was quoted as saying that people are rarely in medicine primarily for monetary gain.[v] There is a long and complex tradition behind beliefs of this kind about medicine.[vi] From its beginnings in the mid-nineteenth century, for instance, the British Medical Association frowned upon advertising by its members. But by the early twentieth century, professionalisation within medicine was associated with broader conceptions of appropriately moral behaviour. Medical practitioners were not expected to engage in the exclusive pursuit of economic self-interest. In meeting this objective, doctors who performed unpaid work in public hospitals had an advantage over doctors who worked entirely in private practice. There may inherently have been less suspicion of their commercial motives and more trust in their benevolent intent, because they devoted a highly visible part of their time to this honorary work. Effectively, specialist surgeons with public hospital appointments worked within a ‘moral economy.’[vii] They were subject to a complex set of relationships and expectations where social obligations and group understandings of right and wrong influenced both individual and group behaviour. Consequently, their work was not driven exclusively by the logic of market forces.[viii] This is in contrast to the ideas surrounding the justification for the pursuit of individual economic self-interest, which dominate early twenty-first century understandings of the phrase ‘market economy.’[ix]
During the twentieth century, there were two major political approaches to health care in Australia. On one side there were those who favoured a mix of charitable provision for the poor and private provision for the rest, with or without varying methods of voluntary insurance. On the other side, there were those who favoured government provision for all with the option of private provision for those who were prepared to pay extra.[x] With the benefit of hindsight, an interesting feature of the many heated debates on these issues over a long period of time was the assumption by all parties that health care provision for the poor should not be left to market forces. In this sense, throughout the twentieth century the provision of health care in Australia (as in New Zealand, Britain and Canada) was influenced by concepts appropriate to a moral economy, as well as by commercial considerations.[xi] Whilst some of those who worked in this industry, including doctors and nurses, were expected to consider their patients first and their pockets second, it was widely assumed that others (such as drug companies), would be driven more exclusively by the profit motive. Among the benefits to surgeons of taking up honorary appointments and working within this moral economy was a growing level of trust in their benevolent intent. But in order to succeed, surgeons had to build a reputation as not only trustworthy but also expert.
In the early twentieth century, almost no formal training in surgery was available in Australia or New Zealand. Expertise was generally acquired as the result of self-directed learning by individual doctors and there were a number of ways in which they could build reputations as more knowledgeable and experienced than their general practitioners colleagues. They could travel overseas and spend time watching famous surgeons there; they could give papers at medical conferences in Australia or New Zealand; they could publish papers in the Australasian medical journals; and they could take additional specialist qualifications. Until after World War II, such postgraduate qualifications were usually obtained in Britain. In particular, the Fellowships of the Royal Colleges of Surgeons of England and Edinburgh and, to a lesser extent, Ireland, were the benchmark surgical qualifications in Australia and New Zealand until at least the 1950s. Australasian surgeons were influenced by both British and North American surgery, and many of them travelled to see for themselves the new procedures that were being developed. In the 1920s, it was quite common for Australian and New Zealand surgeons to make round the world study tours, visiting operating theatres in North America as well as Britain. Consequently, as was noted in the introduction, by World War II, the average surgeon in Australia or New Zealand was likely to be just as well informed about developments in his or her specialty in the United States as about developments in the United Kingdom. However, this mainly applied to full-time specialist surgeons in urban areas. Rural practitioners had to find other ways to build their reputations.
Surgery in rural areas
Surgery could bring in valuable extra income for a doctor who was struggling to make ends meet, but surgery only gave a practitioner an edge over his or her competitors if the operations not only went well, but were known to have gone well, thus enhancing the doctor’s reputation. In this context, advertising was important, and doctors had two different audiences for their behaviour: their patients and their colleagues. Advertising to patients or the public was seriously frowned upon, and later expressly prohibited, by the codes of conduct of the British Medical Association. According to an 1895 editorial in the official journal of its Australasian branches, any advertising beyond an announcement of change of address or commencement or resumption of practice reduced members ‘to the level of quacks and charlatans,’ although some allowance could be made for doctors in rural areas.[xii] In practice however, doctors did advertise, but usually indirectly. Whilst specialists generally advertised to their colleagues in one way or another, general practitioners needed to make themselves known to their patients, and this is well illustrated by the career of Dr Billy Little. Dr Little, who lived in Warracknabeal in the wheat growing area of northwest Victoria, has left us the story of his early years in practice through a series of letters that he wrote home to the woman he may have wished to marry, one of Canada’s first women doctors.[xiii]
Dr Little did his initial training in Canada, before travelling to Edinburgh for further experience and qualifications, and then migrating to Australia. He had never practised as a doctor before arriving in Victoria, and his letters are full of references to the ways in which he thought his behaviour might influence what his private patients thought of him. ‘I am only on trial, as it were,’ he wrote. ‘People look and wonder whether to trust me or not. Once a name is made everything goes smoothly.’ He was very much aware of the importance of his reputation for his success in practice, and that surgery carried particularly high risks for his good name. ‘It is a very easy matter to cover up any mistakes in practice of medicine,’ he wrote, ‘but it can’t be so easily done in surgery.’ But he was more than happy to take the risk and his letters indicate that in his first year of practice in 1890, he ‘tapped’ patients for hydatids and for empyema (a collection of pus in the lung), as well as performing tonsillectomies, tracheotomies for diphtheria and at least one craniotomy. It is clear that he was performing most or even all of these operations for the first time.
I cut a young man’s tonsils off abt. a month ago. He had been doctoring for yrs. with sore throat. As soon as I examined him I told him they would have to come off, to which he agreed. I sent away for a Tonsilatome [tonsillotome], cut them off and charged him $15 for the job. His throat is cured.[xiv]
Operations were newsworthy, and major surgery in particular was often reported in the local newspapers. Dr Little was also keen to have news of his successes passed on through less formal networks of patients and their friends. After performing a craniotomy, for instance, he wrote: ‘The woman is making a good recovery and is a good advertisement for me.’
Surgical operations in rural areas were routinely performed by general practitioners who, of necessity, dealt with the full spectrum of medical practice. Specialist surgeons in the cities argued that their rural colleagues were consequently jacks of all trades, and masters of none, and there may well have been some justification for this accusation. But Australian and New Zealand surgeons, including some GP surgeons in rural areas, did develop special expertise in one particular form of surgery. In 1898, Dr Ritchie published a paper concerning five cases of hydatids in the Wimmera area of western Victoria in the Intercolonial Medical Journal of Australasia. Hydatid cysts, a stage in the complex multi-host life cycle of a tape worm, were particularly prevalent in humans in South Australia, Victoria and New South Wales. Robert Ritchie attributed this not only to the close relationships between men and their dogs (the principal host for the worm stage of the parasite), but also to the lack of rapidly flowing water, so that hydatid eggs once discharged into a stream or dam were not washed away.
…practically all the Wimmera water supply, once it has become contaminated, remains so during the life of the ova… Another factor of some importance is the great heat of the summer, which causes those working in the fields to be glad to relieve their thirst anywhere.[xv]
The two main treatments for hydatids at the time were tapping, that is making a small incision, inserting some sort of tube or suction device and draining the cyst in which the parasite was living, or making a larger wound in order to empty the whole cyst. Either procedure might be attended by complications of one sort or another. It might be difficult or impossible to find the cyst; there might be one or more ‘daughter’ cysts; a cyst might burst, releasing its contents into other spaces within the body and, in any case, the wound might become infected.
So why did patients agree to submit to these procedures? The answer is that patients and/or their friends did not always agree to submit. Their agreement depended on their relationship with the doctor who was urging the surgery, and that, in turn, could depend on a complex set of factors. ‘His parents were unwilling to allow surgical interference,’ wrote Dr Ritchie of an eight year-old boy who he had diagnosed with hydatids, ‘but were at last prevailed upon.’ Clearly, the persuasiveness of the doctor was an issue, and that, in turn, might depend on how certain he was himself that this was the best course of action, and that he was competent to carry it out. Dr Ritchie was prepared to indicate in print to an audience of his colleagues that he sometimes had doubts about whether or not to operate, and which operation to perform: ‘After much hesitation,’ he wrote, of a 28 year-old man who was personally convinced that he had hydatids, ‘I needled the left base, and, after several insertions, drew off clear hydatid fluid…’ This patient had hydatids in his lung, so that surgery to remove the cyst was a relatively difficult procedure, involving the excision of two inches of the ninth rib. Dr Ritchie described the hydatid cyst as: ‘about the size of an emu’s egg. This was removed and a drainage tube inserted. He took the chloroform very well…’ The surgery was performed in the Horsham Hospital, where the patient remained for some time because he contracted a post-operative erysipelas infection. The acceptance of germ theory and the adoption of some version of aseptic operating techniques did not mean an end to post-operative wound infection. What it did mean, however, was that post-operative infection was no longer taken for granted. On the contrary, germ theory indicated that it could be prevented, and instances therefore had to be explained. In this case, Dr Ritchie blamed the drainage tube. ‘If I had read Dr. Wood’s paper before the … operation,’ he wrote, ‘I would not have used a drain tube as the cyst was clean, and risk of contamination from the air passages is small.’
A few country doctors built far wider reputations as specialist surgeons, rather than GPs who operated. One of Dr Little’s neighbours in the Wimmera district of northwest Victoria was Dr Tom Ryan, who moved to Nhill, 100 kilometres west of Warracknabeal, in 1898. Dr Ryan was described as ‘erect, stern, uncompromising, with a passion for surgery.’[xvi] Over the years, Dr Ryan gradually set up what was effectively a training school for country general-practitioner-surgeons. Each patient was carefully examined, including using the X-ray machine, and any surgery was discussed and planned with Dr Ryan’s assistants several days in advance. He worked the nurses and his assistants very hard and the story is told of one of his assistants fleeing through a back window and catching the train back to Melbourne. We may suspect that it took a strong-willed patient to argue about their treatment with that kind of personality. Dr Ryan developed a considerable reputation in the surrounding areas, including across the border in South Australia, and by the 1920s, patients were travelling to Nhill by train from a wide area, often staying in what was known as ‘Ryan’s wing’ of the local hotel. Soon after the formation of the Royal Australasian College of Surgeons in 1927, he was made one of the Fellows, a rare accolade for a doctor outside any of the major cities.
Becoming a surgeon and travelling to learn
Surgery was taught as a part of the general training of a doctor, and every doctor was theoretically entitled to perform surgery, even if he or she had received no additional training or qualifications. However, some doctors spent more of their time operating than others. In Britain, there was a distinct difference between elite surgeons, with honorary appointments at the famous teaching hospitals, full-time surgeons with appointments to less prestigious hospitals, and general practitioners who also performed surgery. However, many full-time surgeons, and virtually all members of the surgical elite, could be distinguished by the letters ‘FRCS’ after their name. They had passed the examinations admitting them to Fellowship of a Royal College of Surgeons, whether of England (FRCS Eng), Edinburgh (FRCS Ed), or Ireland (FRCS I). Membership of the Royal College of Surgeons of England (MRCS) was one of the most common nineteenth-century qualifications for general practice as a doctor. In contrast, the FRCS was a higher qualification, taken by those who intended to make their living as specialists in surgery.
In Australia and New Zealand, members of a small elite group held Fellowships of one or other of the British colleges of surgeons and there was also a larger group without specialist qualifications, most of whom had become full-time surgeons on the basis of a combination of inclination and experience. Australian and New Zealand surgeons kept up to date with events elsewhere in the world at least partly by reading the international surgical journals, and general practitioners with an interest in surgery were likely to buy the latest British or American surgical text books. But as Harry Collins and other sociologists of science have pointed out for scientific experiments, they are very hard, if not impossible, to replicate for those who just read written information about the experiment.[xvii] Collins highlights the importance of detailed first hand knowledge of an experiment in order to successfully replicate it elsewhere. This is equally true for surgery, and it is therefore perhaps more surprising that procedures were attempted ‘from the book’ than that surgeons travelled to learn.[xviii] New surgical procedures are hard to learn by just reading published descriptions, especially when the procedure is in any way conceptually novel. In the early years of the twentieth century, the runaway success of Chicago surgeon Franklin Martin’s ‘wet clinics’, where he provided the opportunity to watch surgery performed, set in train the formation of the American College of Surgeons. By then, Harvey Cushing, William Mayo, George Crile and other elite American surgeons had already organised a surgical travelling club to watch surgeons at work around America, and subsequently also around Britain and Europe. The idea became popular and other surgical travelling clubs were formed in North America and Britain.[xix]
Travelling to learn was associated with a clear appreciation that not everything necessary for the successful performance of an operation could be specified in a written text. As historian of science Mario Biagioli puts it: ‘the knowledge necessary for the successful replication travels with bodies and not only with texts.’[xx] Similarly, David Turnbull argues that ‘a vital component of local knowledge is moved by people in their heads and hands.’[xxi] There was also a strong element of scepticism. Surgeons were disinclined to believe published results if they conflicted with their own experience. From at least the 1890s, Australian and New Zealand doctors continued to travel to learn after (and sometimes long after) they had obtained their initial medical qualifications. This did not just apply to surgeons. Like doctors from elsewhere, for instance, Australian and New Zealand physicians flocked to Germany in 1895 to learn about diphtheria anti-toxin. While the pattern of visiting Germany and France was in decline long before World War I, Australian and New Zealand medicine was never isolated from events in Britain. Further, despite the enormous distances involved, there was an increasing trend towards travelling around the world, traversing the United States as well as visiting Britain, in the search for first hand information on the latest developments. Australian and New Zealand surgery developed within an asymmetrical international context, where many, if not most, Australasian surgeons travelled overseas to watch and learn, some of them making repeated study trips during which they might or might not also acquire additional specialist qualifications. But British and American surgeons virtually never travelled to Australia or New Zealand to learn. If they made the journey at all, it was to teach.
Australians and New Zealanders founded their own college of surgeons in 1927, and well over one third of the 207 senior full-time surgeons who they enrolled as Founding Fellows had both Australasian and overseas qualifications. Those surgeons who had set out to specifically obtain post-graduate qualifications in surgery had gone to enormous trouble and expense to do so, travelling to Britain and spending time there studying for a fellowship of one of the British colleges of surgeons. But this is only the tip of the iceberg. Many more surgeons had spent time studying surgery overseas without necessarily taking a British fellowship, and many made multiple study trips overseas. Brisbane surgeon Lillian Cooper, for instance, made two extended study trips to Britain and America, without taking a British fellowship.[xxii] She also had a prolonged opportunity to study overseas surgery, serving in the middle-east during World War I. Sydney surgeon Robert Gordon Craig never took a British fellowship, but he made overseas study trips every five years, including multiple visits to the Mayo Clinic.
Where we have biographical details, it is clear that a great many surgeons travelled overseas to improve their surgical knowledge, whether or not they took any further formal qualifications, and as a group, surgeons were extraordinarily well travelled. By the early 1930s, well over half of those admitted to Fellowship of the new Australasian College of Surgeons had practical exposure to the way surgery was performed outside Australia and New Zealand, and in the 1920s and 1930s, more than a third of Australian and New Zealand surgeons held qualifications from both sides of the world. This pattern of travel was particularly characteristic of the more prominent surgeons, the ones for whom there are press cuttings and biographies and who were awarded knighthoods. Comprehensive information is simply not available, but provincial surgeons may well have travelled overseas less frequently. However, only a few of those surgeons who held major teaching hospital appointments had no overseas experience, and Australian and New Zealand surgery, especially at the elite level, was very much exposed to developments in surgery elsewhere. Despite the distances involved, Australasian surgery was never isolated from events in Europe or North America.
There was also considerable exchange of information and ideas between the Australian States and New Zealand. Australasian doctors tended to act as a medical ‘block’. They shared journals, they shared organizations and they shared conferences, and many of them travelled between the Australian States and New Zealand on an almost annual basis to attend such conferences. At any of the many Australasian medical conferences in Sydney or Melbourne in the early twentieth century, there were likely to be more delegates from New Zealand than from Western Australia, and important Australasian conferences were also held in New Zealand and Queensland. Interstate and trans-Tasman rivalries were important, but there was also a great sense of Australasian collegiality. This was furthered by the social side of medical conferences. Surgeons were not just disembodied intellects; they were men (and sometimes women) of their times. From an early date, their gatherings to exchange information and ideas were also social events. Surgeons and their families were members of the travelling classes, a distinct social elite. Just as an example, the box shows the social events which were organised in conjunction with the fifth session of the Intercolonial Medical Congress of Australasia in Brisbane in 1899. This conference was attended by more than 160 doctors, including three women, and while there were social functions almost every afternoon, all the mornings were devoted to listening to papers presented by delegates.
World War I
War gave its own particular impetus to overseas travel and experience. Many Australian and New Zealand surgeons went to South Africa during the Boer War, but World War I had an especially important impact on Australasian surgery. In 1914 newly qualified doctors in particular volunteered for the armed forces. While older doctors volunteered, too, there was something of an exodus of those in the younger age groups who had qualified in the two or three years before the war. They went to Europe to work, rather than to study, but never the less, steep learning curves were an almost universal experience for this generation of doctors. They learned new skills from the thousands of wounded men returning from the front, and they participated in the development of the emerging specialties of plastic surgery and orthopaedics.[xxiii] But for many, the immediate post-war era was as important for their careers as the war itself. Under an Empire-wide scheme, dozens of young Australian and New Zealand surgeons took up the opportunity to remain in Britain and study for the Fellowship of the Royal College of Surgeons of England.
After the war, many, if not most, Australian and New Zealand specialists continued the pattern of spending some time learning their craft overseas. Neurosurgeon Sir Douglas Miller, cardio-thoracic surgeon Rowan Nicks and orthopaedic surgeon McKellar Hall are just three examples. A number of the early Australian urologists also seem to have been both prepared to travel and very willing to learn from urologists in Britain and America. Keith Kirkland from Sydney and Henry Mortensen from Melbourne, for instance, were famous for the frequency with which they travelled to overseas surgical meetings. Those who travelled could see for themselves what was possible with the new techniques. Poor results when operating ‘from the book’ could be understood as the fault of the surgeon, not the new procedure, and practice could be followed by better results.
In the 1890s, there were relatively few specialists and very few specialties. Medicine, surgery, obstetrics and gynaecology, ophthalmology and ear nose and throat (ENT) specialists were the main ones recognised by their peers. However, many people who specialised in one of these areas continued to practice in another, and/or to act as general practitioners to their private patients, because they were not seeing enough patients in their chosen specialty to make a living from that alone. In the 1930s, for instance, Charles Augustus Thelander, who published in the area of gynaecology and was recognised as a gynaecological surgeon by the infant Royal Australasian College of Surgeons, continued to perform appendicectomies and other general surgical procedures. By the 1930s, the range of recognised specialists had increased enormously to include radiologists and pathologists, plus specialists within the broad field of surgery such as urologists, plastic surgeons and orthopaedic surgeons. The medical codes of practice did not allow them to directly advertise for patients, and so they all relied on their reputations with their GP colleagues to refer patients to them. While general practitioner and rural surgeons needed to somehow make themselves known to potential patients, specialist surgeons needed to make themselves known to their colleagues, in order to attract referrals.
Australian doctors with honorary appointments to teaching hospitals found it far easier to build a reputation for special expertise than their country colleagues. A busy private practice was a clear marker of success, but obtaining a public hospital appointment was the most visible bench mark of a career that was well on the way. An honorary appointment at a major teaching hospital represented peer acknowledgement of competence. Consequently, members of the surgical elite were identified by their public hospital appointments, listing them at the beginning of their journal articles. This marked their status as specialist surgeons, as opposed to general practitioners who sometimes performed operations. The other marker of their status was the address of their consulting rooms. In their private practice they were identified not by the private hospital where they operated but by the street on which they worked. Some particularly independent minded individualists did not conform, but most specialist surgeons (and physicians) clustered together in clearly defined locations. In Sydney, this was on Macquarie Street and in Brisbane it was on Wickham Terrace. In Melbourne it was on Collins Street and the phrase ‘Collins Street surgeon’ clearly marked a doctor out as being what Christopher Lawrence has called a ‘medical aristocrat’, a specialist rather than a general practitioner.[xxiv] It was their consulting rooms, rather than any particular hospital, that formed the public, and possibly also mental, focus of their private practice.
While some surgeons were flamboyant exponents of self-promotion, the practice style that came to dominate the public image of surgeons by the 1930s was that of members of the social elite who had chosen a life as hard-working experts in the public interest. Images, of course, do not always have a substantive basis, but the surgeon who was perhaps most promoted by his admirers as fitting this picture was George Syme. In his biographical sketch, Ivo Vellar noted that his nickname was ‘“Silent Syme.” A man of great intelligence, a clear thinker noted for his probity and strict adherence to ethical standards…’[xxv] When delivering the second Syme Oration in his honour in 1933, F. Gordon Bell noted that Syme’s professional utterances were ‘weighty and carefully considered’ and that he was essentially a ‘safe’ surgeon, with a profound influence, in his ‘silent and unobtrusive fashion,’ on surgical thinking in Victoria.[xxvi]
Syme’s uncles were the founders of the Age newspaper and his family sent him to Wesley College and the University of Melbourne, and then on to England in 1885, where he obtained surgical experience and the FRCS. He returned to an appointment as outpatient surgeon to the Melbourne Hospital in 1887, but did not make it to the top rung of the ladder as surgeon to inpatients until 1903. Meanwhile, he was happy to accept the position as foundation inpatient surgeon to St Vincent’s Hospital, opened by the Sisters of Charity in 1893. The surviving surgical case books from St Vincent’s confirm Gordon Bell’s opinion that he was a relatively conservative and ‘safe’ surgeon, not inclined to take risks on his patients’ behalf, but he could also be innovative at times. The overall image from the comments of his colleagues and his own publications is of a serious and possibly boring personality who would never knowingly do the wrong thing.
By the time that surgeons in Australia and New Zealand decided to found an antipodean college of surgeons in 1927, Syme was nearing the end of his career, but he was also widely respected and the obvious first president. Who better to convince general practitioners that the college of surgeons was not being formed to boost surgical incomes at the expense of their own? Even when he was a young man, it is hard to imagine that patients ever doubted that Mr Syme had their best interests at heart, and by the time that he was knighted in 1924, Sir George was the quintessential example of a trustworthy surgeon. The other venerable hero associated with the founding of an Australasian college of surgeons (and for whom there was also a regular memorial lecture) was Robert Hamilton Russell, an Englishman of the generation who trained under Lister. He migrated to Melbourne early in his surgical career and became known for his innovative repair of both hernias and fractures. Unlike Syme, he was also known for his eloquence, but it was a gentlemanly and reserved eloquence, and one of his many affectionate obituaries emphasised his ‘gentle dignity.’[xxvii]
But not all surgeons had such a benign image. Hamilton Russell and Syme’s near contemporary, Sir Alexander MacCormick, for instance, was probably a more brilliant technician than either of them, and even more famous in his day, but he was remembered for making a fortune from his Sydney private practice, rather than for quiet probity. In his essay on the history of surgery at the Royal Prince Alfred Hospital, H. H. Schlink associated MacCormick with ‘daring surgical triumphs.’[xxviii] Douglas Miller was one of his admirers and told the story that when Nellie Melba was dying, MacCormick said ‘She wanted to rent my house once. I’d as soon lend my shirt as my house,’ and that MacCormick was ‘exacting and unsympathetic with … Jews and graziers.’[xxix] It is difficult to imagine anyone telling such stories about Syme or Hamilton Russell, although there is no doubt that doctors’ attitudes to patients varied enormously and there were a number of widely held prejudices. There are few examples of doctors who had a good word to say about the drunk, the dirty or the overweight, for instance. Quiet digs in case reports such as: ‘… more vigorous cleansing of his skin, of which he was much in need,’ were not at all uncommon.[xxx]
A doctor’s success was linked to their reputation, whether with patients or with colleagues, and not all doctors had a good reputation. Alexander Francis, who later specialised in ENT surgery, began work as a general practitioner in Barcaldine in 1892 with what he described as a ‘lucky case.’ A well-known local resident was suffering from typhoid. ‘The patient’s life hung by a thread for some weeks,’ he wrote, ‘but she recovered and after that everything was easy for me.’[xxxi] But Dr Francis noted that a colleague in a neighbouring town, who he was sure was a perfectly competent doctor, had a run of bad outcomes in his first few weeks and had to leave town. The man was never able to gain the confidence of his Queensland patients, but went on to a successful practice in New South Wales. For country doctors such as this, it was a local reputation with patients that mattered most. For city specialists, the position was rather different. Douglas Miller, one of Australia’s first neuro-surgeons, decided to specialise in surgery quite early in his training and spent some time as an informal apprentice to Sir Alexander MacCormick in Sydney. In his autobiography, Dr Miller argued that this experience was enormously important for his future career, not only because of the valuable lessons he learned from MacCormick, but also because of the network of relationships that he built up among Sydney’s leading physicians. In the 1930s, when Dr Miller finally went into practice as a specialist in his own right, after a prolonged period gaining surgical experience in both Sydney and London, some of the most eminent physicians in Sydney already knew who he was and had formed an opinion of his character and competence. They were an important source of patient referrals as he built up his private practice. Douglas Miller also built a reputation for himself in Sydney as a lecturer in anatomy and surgery as well as through his honorary appointment at St Vincent’s Hospital. These were highly competitive appointments and Miller only succeeded in winning them after acquiring considerable experience, including a prolonged period of study in England. The road to successful private practice as a specialist was a long one, requiring an almost obsessive interest and total involvement in the work.
Another wonderfully exciting case [wrote Douglas Miller] was that of a young girl who for some time had been very unsteady on her feet and had frequent falling attacks before developing severe headaches and failure of vision … On opening her head I immediately encountered a large circumscribed cystic tumour … The referring physician was watching and I remember his excitement when he hurried out of the theatre to report all the details of what was the first modern brain operation he had seen…[xxxii]
Miller did not mention discussing the risks of this novel sort of surgery with the patient and her family, or having any trouble in persuading them to consent. He simply took it for granted that he knew what was best for her. Specialists might be well into their thirties before they began making a significant amount of money, but meanwhile, they had acquired experience, they had acquired expertise, they had acquired confidence and they had acquired status with their colleagues.
Surgical lifestyles A: Work
In Melbourne in 1932 at the fifth annual meeting of the Royal Australasian College of Surgeons (RACS), leading surgeons demonstrated operations at the Melbourne, St Vincent’s, the Alfred, the Women’s, the Children’s and the Eye and Ear hospitals. All of these were public hospitals. They were supported by a combination of charitable donations, government subsidy, contributions from those patients who could afford to pay something towards the cost of their treatment and various other (often ad hoc) fund raising activities. All these hospitals had some full time medical staff, but the senior medical staff essentially worked part time, for free, under the honorary system. At the 1932 meeting, the College did not organise a single operative demonstration at any of the 207 private hospitals in Melbourne, where patients paid the hospital the full cost for their care and also (separately) paid their doctor. There are many possible explanations for this, including the generally smaller size and poorer facilities of private hospitals in this era. But the straightforward reason is that private hospitals were not used for teaching. Medical students did not follow surgeons or physicians through the wards and cluster round beds to hear their verdicts on diagnosis and prognosis. Private hospitals were private.
In Australasia, as in Britain, (but not in the United States) the undergraduate teaching hospitals were all public hospitals. The postgraduate education of surgeons also relied increasingly on public hospitals. Trainee surgeons spent most of their time observing their seniors and gained little practical hands-on operative experience, but what experience they did get was generally on public hospital patients, especially in emergencies and after hours. For instance, in 1927, Douglas Miller went to England to study for the FRCS. Despite the fact that he had ‘witnessed and assisted at a vast number of operations’ he got his first personal operating experience on poor law patients at the Hackney Hospital in the East End of London.[xxxiii] It therefore seemed natural to the surgeons organising the program for the 1932 meeting of the RACS (Alan—later Sir Alan—Newton and Hugh—later Sir Hugh—Devine), that all operative demonstrations would be at public hospitals. They were accustomed to performing public surgery, that is to say, performing in front of an audience of medical students and other doctors, on (poor) public patients in public hospitals.
Surgeons were identified by their public hospital appointments. A ten-page article on Sir Hugh Devine, for instance, has two separate sections devoted to his role at St Vincent’s Hospital, Melbourne, but does not once mention a single private hospital (in Australia) where he worked.[xxxiv] This is not a failing of the article. It simply reflects the fact that surgeons were not identified by their private hospitals. Devine lived in the prestigious suburb of Toorak, he sent his three children to elite private schools and he and his family made multiple trips to America, Britain and Europe. On one trip to Europe he had an audience with the Pope and on a subsequent trip to England, his daughters were presented at Court in London. Yet Devine did not make any of the money to pay for all this at St Vincent’s Hospital. His work there was part time and unpaid. Neither did he come from a wealthy background. He made a substantial income in the time left over from his very public work at St Vincent’s through his private practice. Public hospitals depended on private hospitals. The one could not exist without the other. This was not because of direct cross subsidy (although this was an important component in the financing of Catholic health care). It was because surgeons (and physicians) worked for free in the public hospitals. They therefore had to make a living somewhere else. The result was a symbiotic relationship between two interlocked economies, one driven by market forces, and the other a moral economy, driven by the logic of a gift relationship.
In the first half of the twentieth century, the annual reports of Australia’s public hospitals were a part of the cycle of exchange in a gift economy. Essentially, they were documents designed to publicly acknowledge gifts and to tell the donors what had been done with their time or money or gifts in kind. The Melbourne Hospital reports, for instance, began with a statistical summary of the number of doctors, nurses, patients, beds and operations performed (page 1) and then provided a tear out form for subscribers to fill in, either making a donation or leaving a legacy (page 2) before the title page: ‘Melbourne Hospital Report of the Committee of Management with Statement of Accounts Lists of Subscribers and Donors and Statistical Returns for the Year Ended 30th June.’[xxxv]
The Annual Reports of the Mater Misericordiae Public Hospitals in Brisbane generally began with a straight-forward statement of purpose. For instance: ‘The Sisters of Mercy have much pleasure in presenting to benefactors and subscribers the First Annual Report of the Mater Children’s Public Hospital.’[xxxvi] The Mater Annual Reports listed gifts in kind as well as in cash, so that we learn that in 1932 (mainly for Christmas) fifty named individuals and ten organizations made gifts of food or clothing. These included pumpkins, donated by Mrs. A. Bulgar, turkeys from Mr. Hickey, pillow slips from Mr. Laird and pyjamas, dressing gowns and face washers from the All Hallows Needlework Guild.[xxxvii] Catholic hospitals relied particularly upon gifts from members of the wider Catholic community.
While few Catholic doctors worked at the Melbourne Hospital, many doctors who were not Catholics worked in Catholic hospitals and the records of Australia’s Catholic hospitals are full of the names of Jewish doctors, for instance. But overall, it appears that both the Melbourne Hospital and the Mater in Brisbane had broadly similar relationships with their medical staff. Prominently placed in their reports was a general acknowledgment of the work of the honorary medical staff and a listing of their names, qualifications and precise honorary positions. Honorary medical staff were literally honoured by the hospitals for the gift of their time and expertise. The Melbourne Hospital Reports, for instance, feature the dates of graduation and appointment through the successive ranks of the hospital hierarchy for each ‘Honorary Medical and Surgical Officer.’ The exact sequence of appointments varied a little but the basic pattern began with an appointment as resident medical officer (RMO), possibly followed by a period as Registrar, and/or Medical Superintendent.[xxxviii] None of these were specialist surgical or medical positions, and they were all paid. Those who wished to specialise as surgeons at the Melbourne might spend a period as Surgical Clinical Assistant. Then came the great divide between the paid and honorary positions. Honorary staff typically spent a period as Surgeon (or Physician) to Out-patients, before the ultimate achievement of a position as Surgeon (or Physician) to In-patients. After retirement, some were honoured with an appointment as Honorary Consulting Surgeon (or Physician).
Public hospitals were places where gifts were given, received and acknowledged. But they were also places for teaching and learning and had been since long before there were any hospitals in Australia or New Zealand. Education was a part of the moral economy of gift exchange within the public or charitable hospital. The wards and operating theatres were also classrooms, not only for doctors, but also for nurses. Much of the kudos of honorary appointments was precisely because they were at teaching hospitals. Unlike the system in the United States, where teaching and research were not confined to public hospitals, in Australia and New Zealand, as in Britain, teaching and research took place at public hospitals, where doctors made the gift of their time and expertise. The position of honorary surgeon to in-patients at a major teaching hospital had many advantages, not the least of which was that there was virtually no one in a position to tell the incumbent what to do. Many were highly conscientious about their visiting times and their teaching responsibilities, but the stories about those who were not, are sufficiently common to make the point that honoraries did not have to come and go at set times. The jokes in the Melbourne medical students’ magazine about surgeons rushing out of the operating theatre to go and play golf are just one example.[xxxix] Honorary surgeons could play golf or tennis on week days if they chose, or they could work 14 hours a day, seven days a week. They were the aristocrats of the hospital world, their own masters (or mistresses), free to come and go as they pleased. For while the public hospitals gave them thanks second only to God, the private hospitals were even more concerned to keep their good opinion—and the business they brought with them.
While doctors competed for positions as honorary consultants at the major public hospitals, private hospitals wooed the doctors to bring them their patients. Public patients chose their hospital. That is where they went, and they were treated by which ever student or junior doctor happened to be on duty at the time. Private patients and/or their GPs chose their surgeon. The surgeon then generally made the decision as to where the patient would be treated. Private hospitals therefore depended on doctors to bring them business. It did not often walk in off the street in the same way as patients flooded into the public hospitals.
Within this system of interlinked public hospitals and private practice, surgeons came to enjoy enormous status and prestige both with the private hospitals, which depended on them to bring in patients, and with the public hospitals, which depended on them to work (and teach) on an honorary basis. The whole structure of this moral economy of medicine supported the status of elite surgeons (and physicians) as heroes, especially those who worked hard, built up large public hospital departments and ran busy private practices.
Surgical lifestyles B: Social life
Surgeons did not just travel to learn. They travelled for pleasure. Successful surgeons belonged to the upper middle class and in the inter-war years, this was associated with a very specific life style. Women of this class seldom worked for money, although there were a few doctors and other professionals. More often they worked for free. It was expected that they would spend several days a week working for charity. Even those women who had professional careers were expected to work for charity in their spare time. In 1932, for instance, under the heading ‘The Woman’s World’, the Melbourne Herald ran the following item:
Among interstate delegates who have come to Melbourne to attend the Royal Australian [sic] College of Surgeons fifth annual conference, which will open this evening, is a woman surgeon, Dr. Connie D’Arcy of Sydney. She has been here for a week staying at the Quamby Club. Although her profession comes first, Dr. D’Arcy manages to find time to participate in a number of welfare movements for the betterment of women and children…[xl]
Upper-middle-class women sat on committees and organised small armies of women who ran fetes and stalls and flag days for the Red Cross, or the Society for the Prevention of Cruelty to Children, or the hospitals. It was not only surgeons who were involved in the moral economy of gift exchange. So were many of their wives. They were members of what Kerreen Reiger has called the upper-middle-class charity network.[xli] Whether they were raising money for worthy causes or simply enjoying themselves, the activities of members of this group were regularly reported in the social pages of the newspapers. Such ‘news’ items were intensely formulaic. The reporter noted what the hostess was wearing and the flower arrangements, mentioned the venue and the occasion, and then listed the guests, beginning with the most famous, and/or those perceived to have the highest social status. The following extract from the Canberra Times is a typical example:
Gowned in a plum coloured georgette frock, trimmed with fine lace, and a black hat relieved with the same colour, Mrs. Earle Page was hostess at an afternoon tea given in the drawing room of the Hotel Canberra in honour of the wives and visiting doctors… Lord Stonehaven, the Governor-General was present, and before tea Mrs. Earle Page presented the ladies to his Excellency. Among those present were… Mrs. Gordon Craig (Sydney), Mrs. Sandes… Dr. Lilian Cooper….[xlii]
This report concerns a function held in association with the first Annual Meeting of the College of Surgeons of Australasia in Canberra in 1928. For members of the upper middle class, there was a distinct rhythm to the cycle of the year. While the opening of the duck shooting season (in 1932, it was on the weekend before the College of Surgeons meeting in Melbourne) did not have the same social cache as the opening of the grouse shooting season in Scotland, the autumn horse racing carnival was the focus of a significant round of social events, and the spring racing carnival, especially the Melbourne Cup on the first Tuesday in November, was as much an elite social event as any horse race in England. Some women made a trip to London every few years, had their frocks and gowns made in Paris and returned to Australia in time for Cup Week. Select Melbourne and Sydney dressmakers also made the pilgrimage to Paris, and returned to make copies of the latest fashions for those who could not afford to travel to France to buy the originals. Young women still ‘came out’ and their mothers arranged balls for the purpose. A select few enjoyed ‘the season’ in London and were presented at Court.
This class was no more immune from the effects of the depression than any other. Between 1929 and 1932, the big private balls more or less came to a halt. However, charity balls continued. In some instances, these were effectively more or less private parties, where most of the guests knew each other. The difference was that they had all paid for their tickets, with any money left over after the cost of the function going to a worthy cause such as the Children’s Hospital. While there were parties associated with the First Annual Meeting of the College in Canberra in 1928, the next few meetings were more austere. At the third meeting, in Melbourne in 1930, for instance, the motto of the conference was ‘strictly business’ and there were ‘no entertainments’. The garden party at the University of Melbourne in February 1932 was something of a half way house, before the full flowering of the social program in the later 1930s. Sir Holburt Waring, President of the Royal College of Surgeons of England, opened the headquarters building of the RACS in Melbourne on 4 March 1935. The College invited surgeons from all over the English speaking world, and many accepted the invitation. The opening was timed to coincide with the autumn racing carnival, and the meeting was incorporated into the celebrations surrounding the centenary of the City of Melbourne.[xliii]
Melbourne has been very gay during last week and many overseas and interstate visitors have been in town to attend the races, watch the progress of the polo tournaments, and take part in the varied festivities associated with the coming of the autumn season. A number of distinguished visitors came for the congress of the Royal Australasian College of Surgeons, and on Sunday afternoon Mrs. Hugh B. Devine (whose husband is vice-president of the College) gave a delightfully planned party at their home in Woorigoleen road, Toorak, at which the special guests of honour were the president of the Royal College of Surgeons of England (Sir Holburt Waring), the president of the Royal Australasian College of Surgeons (Sir Henry Newland) and Lady Newland, the president of the American College of Surgeons (Dr. Donald C. Balfour) and Mrs. Balfour, Sir D’Arcy Power (London) and Miss Angela Power…[xliv]
That week, Mrs. Alan Newton, Lady Newland, Mrs. B. T. Zwar and Mrs. Victor Hurley all gave parties for the surgeons and their wives, including visitors from England, Scotland, Canada, South Africa and the United States. All were reported in the papers, and the Melbourne public was also well informed about what Miss Angela Power and Mrs. Balfour (described as distinguished overseas visitors) wore to the races. The comings and goings of members of this class were regularly noted in the social pages, as they got on and off ships. Successful surgeons and their wives and families were integrated into a moral economy of working for charity, but they were also members of the travelling classes. Repeated study trips abroad fitted seamlessly into this way of life.
Notes for Chapter 5
[i] Pierre Bourdieu, Distinction, A Social Critique of the Judgment of Taste, trans. Richard Nice (London: Routledge, 1984), (1st pub. Paris, 1979); see also idem, The Field of Cultural Production (Cambridge: Polity Press, 1993); George Weisz, Divide and Conquer, a Comparative History of Medical Specialization (Oxford: Oxford University Press, 2006). Wilde, ‘Practising Surgery.’
[ii] N. Rasmussen, ‘The moral economy of the drug company-medical scientist collaboration in interwar America’, Social Studies of Science, 2004, 34:161-85; E. R. Brown, Rockefeller Medicine Men, Medicine and Capitalism in America (Berkeley, University of California Press, 1979); Bynum, Science and the Practice of Medicine; Warner, ‘The History of Science and the Sciences of Medicine’; for the importance of trust more broadly see: J. G. Bruhn, Trust and the Health of Organizations (New York: Kluwer Academic, 2001); E. L. Khalil, ed., Trust (Cheltenham: Edward Elgar, 2003); F. Fukuyama, Trust, The Social Virtues and the Creation of Prosperity (London: Penguin, 1995).
[iii]H. M. Marks, The Progress of Experiment, Science and Therapeutic Reform in the United States, 1900-1990 (Cambridge: CUP, 1997).
[iv] A. L. Cochrane, Effectiveness and Efficiency: random reflections on health services (London: Nuffield Provincial Hospitals Trust, 1972); K. F. King, ‘The Natural History of Orthopaedic Enthusiasms,’ Australia and New Zealand Journal of Surgery [A&NZJS] 1993, 63:429-34; M. L. Meldrum, ‘A Brief History of the Randomized Controlled Trial: from oranges and lemons to the gold standard,’ Hematology/Oncology Clinics of North America, 2000, 14:745-60; J. P. Royal, ‘A History of Sympathectomy,’ A&NZJS, 1999, 69:302-7; R. G. Springall, ‘Cholecystectomy: ironmasters and eggheads,’ Journal of the Royal Society of Medicine, 1988, 81:560-63.
[v] ‘Medical Marvel,’ University of Queensland Graduate Contact, 2004, 30: 30.
[vi] E. Freidson, The Profession of Medicine: a study of the sociology of applied knowledge (New York: Dodd, Mead, 1970); idem, Professional Dominance: the social structure of medical care (New York: Atherton Press, 1970); E. Willis, Medical Dominance, the division of labour in Australian health care (Sydney: Allen & Unwin, 1989).
[vii] E. P. Thompson, ‘The moral economy of the English crowd in the eighteenth century’, Past and Present, 1971, 50:76-136.
[viii] J. Le Grand, ‘From Knight to Knave? Public Policy and Market Incentives,’ pp. 21-30, and B. S. Frey, ‘Motivation and Human Behaviour,’ pp. 31-50, both in: P. Taylor-Gooby, ed., Risk, Trust and Welfare (Basingstoke: Macmillan Press, 2000); Adam Smith, The theory of moral sentiments (London: A. Millar, 1759).
[ix] Adam Smith, An inquiry into the nature and causes of the wealth of nations, 2 vols, (London, 1776); Eliot Freidson, The Profession of Medicine: a study of the sociology of applied knowledge (New York: Dodd, Mead, 1970); idem, Professional Dominance: the social structure of medical care (New York: Atherton Press, 1970); Evan Willis, Medical Dominance, the division of labour in Australian health care (Sydney: Allen & Unwin, 1989).
[x] J. Gillespie, The Price of Health: Australian Governments and Medical Politics 1910-1960 (Melbourne: Cambridge University Press, 1991); D. Green & L. Cromwell, Mutual Aid or Welfare State, Australia’s Friendly Societies (Sydney: George Allen & Unwin, 1984); J. S. Deeble, and R. B. Scotton, Health Care Under Voluntary Insurance: Report of a Survey (Melbourne: University of Melbourne, 1968); Sidney Sax, A Strife of Interests. Politics and Policies in Australian health services (Sydney: George Allen and Unwin, 1984); S. J. Duckett, ‘Structural Interests and Australian Health Policy,’ Social Science and Medicine, 1984, 18: 959-66; D. Mackay, ‘Politics of reaction: the Australian Medical Association as a pressure group,’ in H. Gardner, ed., The Politics of Health; the Australian experience (Melbourne: Churchill Livingstone, 1989), pp. 293-297; R. B. Scotton, ´Milestones on the road to Medibank and Medicare,” MJA, 2000, 173:5-7.
[xi] J. Rogers Hollingsworth, A Political Economy of Medicine: Great Britain and the United States (Baltimore: Johns Hopkins University Press, 1986); F. Honigsbaum, Health, Happiness, and Security, The creation of the National Health Service (London: Routledge, 1989); C. D. Naylor, Private Practice, Public Payment: Canadian Medicine and the Politics of Health Insurance, 1911-1966 (Montreal: McGill-Queen’s University Press, 1986).
[xii] Aus Med Gaz, 1895, 14: 118.
[xiii] Letter of Dr. Billy Little, Feb. 16, 1890, Warracknabeal, in: Margaret Gillett, Dear Grace, A Romance of History (Melbourne: Melbourne University Press, 1986), p.89.
[xiv] Ibid, April 10th 1890, p. 96. ‘Doctoring’ was a word for the behaviour of patients who went from one doctor to another, trying to find a cure for an intractable condition. Dr Little expressed all prices in his letters in Canadian dollars.
[xv] Robert H. Ritchie, ‘Some cases of hydatid disease,’ Intercolonial Medical Journal of Australasia, 1898, 3: 604-608.
[xvi] Edward Ryan, ‘Early medical practice in north-western Victoria,’ in Department of Medical History, University of Melbourne, ed., Papers Presented at a Seminar on the History of Medicine, 13-15 April 196, (Sydney: Australasian Medical Publishing Co., 1968), pp. 64-77.
[xvii]H. M. Collins, ‘The TEA Set: tacit Knowledge and Scientific Networks,’ Science Studies, 1974, 4: 165-86.
[xviii] Wilde, ‘See one, do one’; Schlich, Surgery, Science and Industry; Andrew Warwick, ‘X-rays as Evidence in German Orthopaedic Surgery, 1895-1900,’ Isis, 2005, 96, 1-24.
[xix] Owen H. Wangensteen, ‘Surgery and Surgical Travel Groups,’ Surgery Gynecology & Obstetrics, 1978, 147: 246-254; Peter Boreham, Surgical Journeys, A History of the Surgical Union which became the 1921 Surgical Travelling Club of Great Britain (Devon: Merlin Books, 1990); Wangensteen, ‘Surgery and Surgical Travel Groups,’ p. 253; Rutherford Morison, ‘Lord Moynihan, a Personal Appreciation,’ British Journal of Surgery, 1936, 24: 4-6; Sir Berkeley G. A. Moynihan, ‘The Ritual of a Surgical Operation,’ British Journal of Surgery, 1920, 8: 27-35.
[xx] Mario Biagioli, ‘Tacit Knowledge, Courtliness, and the Scientist’s Body,’ in Choreographing History, Susan Leigh Foster, ed., (Bloomington: Indiana University Press, 1995), 69-81, p. 71; Michael Polanyi, Personal Knowledge (London: Routledge & Kegan Paul, 1958), p. 53; idem, The Tacit Dimension (New York: Anchor Books, 1967).
[xxi]David Turnbull, Masons, Tricksters and Cartographers, Comparative Studies in the Sociology of Scientific and Indigenous Knowledge (Harwood Academic Publishers, 2000), p. 42.
[xxii] Lesley M. Williams, No Easy Path, The life and times of Lillian Violet Cooper MD, FRACS (1861-1947) Australia’s first woman surgeon, (Brisbane: Amphion Press, 1991).
[xxiii] Sandy Callister, ‘“Broken gargoyles”: the photographic representation of severely wounded New Zealand soldiers,’ Social History of Medicine, 2007, 20: 111-130; A. Bamji, ‘Sir Harold Gillies: surgical pioneer,’ Trauma, 2006, 8: 143-156; Joanna Bourke, ‘The battle of the limbs: amputation, artificial limbs and the Great War in Australia,’ Australian Historical Studies, 1998, 110: 49-67;
[xxiv] Christopher Lawrence, Medicine in the Making of Modern Britain, 1700-1920 (London: Routledge, 1994), p. 78.
[xxv] Ivo Vellar, The Doers, History of Surgery at St Vincent’s Hospital Melbourne 1890s-1950s (Melbourne: Publishing Solutions, 2002), p.11.
[xxvi] F. Gordon Bell, ‘The George Adlington Syme Oration, on hospital problems and surgical education,’ Australian & New Zealand Journal of Surgery, 1933, 3: 3-23, p.2.
[xxvii] Anon, ‘Robert Hamilton Russell,’ Australian & New Zealand Journal of Surgery, 1933, 3: 110-112, p. 112.
[xxviii] H. H. Schlink, ‘Royal Prince Alfred Hospital: its history and surgical development,’ Australian & New Zealand Journal of Surgery, 1933, 3: 115-129, p.122.
[xxix] Douglas Miller, ‘Sir Alexander MacCormick: Man and surgeon,’ Australian & New Zealand Journal of Surgery, 1969, 38: 189-195, 193.
[xxx] Stirling, p. 163.
[xxxi] Alexander Francis, Then and Now, The Story of a Queenslander (London: Chapman and Hall, 1935), pp. 123-4.
[xxxii] Miller, A Surgeon’s Story, p. 118.
[xxxiii] Miller, A Surgeon’s Story, p. 53.
[xxxiv] Vellar does mention his work as a visiting surgeon at private clinics overseas, such as the Mayo: I vo D. Vellar, ‘Hugh Berchmans Devine: Surgical Visionary and Great Australian,’ Australian and New Zealand Journal of Surgery, 2000, 70: 801-812. Vellar also mentions Devine’s private consulting rooms.
[xxxv] For example: Melbourne Hospital, Eighty-fifth Annual Report of the Committee of Management with Statement of Accounts, Lists of Subscribers and Donors and Statistical Returns, 1932.
[xxxvi] Mater Misericordiae Children’s Public Hospital Brisbane, First Annual Report, 6th July, 1931 to 30th June, 1932, (Brisbane: Sisters of Mercy, 1932), p. 1.
[xxxvii] Mater Misericordiae Public Hospitals Brisbane, Twentieth Annual Report, 1st July, 1931 to 30th June, 1932, (Brisbane: Sisters of Mercy, 1932), p. 13.
[xxxviii] See, for example, the 1933 entry for Julian Ormond Smith: ‘M.D., B.S., Melb.; F.R.C.S., Eng. Resident Medical Officer, 1st Sept., 1926. Registrar, 1st November 1927, to 31st August 1928. Out-patient Surgeon, 25th March, 1930.’ Melbourne Hospital, Eighty-sixth Annual Report of the Committee of Management with Statement of Accounts, Lists of Subscribers and Donors and Statistical Returns, (Melbourne: Spectator Publishing Co. Pty. Ltd.,1933), p.10.
[xxxix] ‘The Deluge,’ Speculum, 1932, 130: 54.
[xl] Herald, 17 February 1932.
[xli] Reiger, The Disenchantment of the Home.
[xlii] Canberra Times, 2 April 1928.
[xliii] Smith, The History of the Royal Australasian College of Surgeons from 1920 to 1935, 27.
[xliv] Australasian, 6 March 1935.