Small and Special: The Development of Hospitals for Children in Victorian Britain (review)

Children’s hospitals flowered later in Britain than in France. The accepted wisdom of the early 1800s held that few parents would be willing to entrust their sick children to the care of strangers in medical institutions. Yet in the face of such skepticism, nascent pediatricians such as Charles West succeeded in opening more than a dozen children’s hospitals by the end of the century. Perhaps more remarkably, these institutions became quite popular with the working urban poor. It is this story that Elizabeth Lomax recounts in her thorough and absorbing survey. She successfully provides an account that does justice both to the medical events going on within the hospital and to the social matrix in which they took place. Perhaps not surprisingly, British children’s hospitals evolved along a path similar to that of their counterparts in the United States. In contrast to those in France, they were notable for being small and voluntary. Many of the themes that characterized their development—conflicts between hospital boards and medical staff, nurses and physicians, hospitals and donors—will be familiar to students of American hospitals of the period.

Lomax particularly excels in her efforts to show how the social context of the children’s hospital affected the rise of scientific pediatrics. The hospitals in her study varied, with respect to pathology as well as organization. Rickets, for example, was the number one diagnosis at Great Ormond Street in the 1870s, but accounted for only about 3 percent of admissions at Manchester Children’s Hospital. Physicians found themselves peering at the pathology of childhood through decidedly different sets of lenses. And while doctors gradually increased their control over the hospital environment, their power remained limited. In spite of their efforts to admit “interesting cases” rather than “worthy patients,” British pediatric clinicians never had access to as broad a range of patients as did their Continental counterparts. Lomax speculates that this factor contributed to a conservative style of practice, valuing careful clinico-pathological research over experimental trials. British children’s hospitals, in fact, were slow to introduce such dramatic symbols of scientific medicine as diphtheria antitoxin.

The great question behind the book—namely, why parents began to trust their children in large numbers to hospital care—is of course difficult to answer with so little of their testimony available. Lomax points to rising trends in hospital admissions as evidence of rising acceptance, and intriguingly correlates this trend with the parallel growth of boarding schools. She also rightly highlights the ways in which hospital boards sought to be advocates for their patients: such paternalism infuriated physicians, and sometimes impeded effective new therapies, but it did send a clear message to parents that their children’s interests came foremost.

But in the end, one can also suggest that hospitals gained trust only to a point. Britain, after all, focused on children’s, rather than infants’, hospitals. The distinction was critical, and again profoundly different from the experience of France: it was the problem of caring for infants, particularly young babies, apart from their mothers’ presence or breast milk that contributed to the astounding mortality afflicting French institutions such as Enfants Trouvés. And when the British finally did begin to admit infants at the end of the century, they encountered the same high mortality rates. Many infants, in fact, arrived in an emaciated state— suggesting that hospitalization was either akin to abandonment or, at the very least, a last resort after the failure of home therapy.

This is a meticulously researched study that will be essential to serious researchers studying nineteenth-century child health, and of great interest to pediatricians curious about the origins of their field.