Medicine, Charity and Mutual Aid: The Consumption of Health and Welfare in Britain, c.1550-1950

This collection of 12 essays originated in a number of conference papers addressing the theme 'History from Below: the Urban Poor and the Reception of Medicine and Charity in Western European Cities'. The essays in the book examine the consumption of health and welfare in Britain, or more accurately, in England, with the main chronological focus being on the 19th and 20th centuries. Both collectively and individually, they challenge the existing historiography of health and welfare and offer new insights into the complexities of the relationship between providers and consumers of charitable and mutual aid. In particular, the essays explore the agency of the poor, and not so poor, with regard to the developing urban economy.

Rejecting historical approaches which regard recipients of charitable assistance and medical treatment as passive or deferential, the editors, Anne Borsay and Peter Shapely, have brought together a collection of essays which focus on recipients of support as 'consumers'. This description reflects the central theme of the book: that those who received support were able to exercise a degree of choice and influence. The essays in Medicine, Charity and Mutual Aid set out to explore the history of medical care and charitable assistance from the perspective of these consumers. The emphasis on 'consumption' signals an important shift in emphasis from histories of health and welfare which examine the provision (or production) of charitable assistance and which are concerned mainly with the motivation, power or status of donors, doctors and other professionals. As the editors acknowledge, there are real difficulties in examining the attitudes, feelings and actions of recipients since 'the poor left few records and their perspectives were generally unrepresented though other media' (p. 3). Thus, while Stuart Hogarth had access to the autobiography of a man who was for some time a patient at Manchester Infirmary, most contributors had to use a range of sources to examine the role of consumers. If the presence of the latter is somewhat obscured in some essays, this may reflect the methodological problems of revealing the agency of the poor and sick.

Hogarth's essay, 'Joseph Townsend and the Manchester Infirmary', makes a major contribution to our understanding of social relations within the hospital. He challenges Foucauldian approaches to the history of medicine, which suggest that by the late 18th century the relationship between doctor and patient had changed to such an extent that patients were no longer able to contribute to their own diagnosis and treatment. Through a detailed study of the autobiography of Joseph Townsend, a 21-year-old textile worker admitted to Manchester Infirmary in 1827, Hogarth offers an alternative analysis of the doctor-patient relationship. By privileging the patient's narrative, Hogarth reveals the ways in which Townsend was able to influence his treatment, negotiate his status as an in-patient and persuade his doctors to undertake a novel surgical procedure to rectify a disability acquired as a child. Townsend's testimony demonstrates the affective nature of the relationship between doctor and patient and the changes the patient experienced in his 'inner world'. While Hogarth warns against replacing an interest in power with an interest in emotion, his account draws on the social history of the emotions to show how patients like Townsend helped to shape the institutions in which they lived, worked and received treatment. It is a fascinating study of personal and professional relationships in an institutional setting.

While Hogarth provides a patient's account of daily life in a voluntary hospital, six other essays examine the relationship between patients and medical institutions. A focus on institutions is characteristic of much recent research on the social history of medicine and this collection is no exception. The contributors aim to analyse medical establishments from the perspective of the patient, and all succeed in this to a greater or lesser extent. In some essays, however, the concept of the patient or inmate as a 'consumer' is problematic. Anne Borsay's excellent essay explores a number of institutions for deaf children and shows how these institutions were supported by a mixed economy of care based on fees, donations, and later, state funding. Her essay also shows how child recipients were used in marketing: first, in terms of the politics of display, when visitors were encouraged to view the children in the institutions, and second, in terms of the construction and marketing of children's narratives. Biographical information, memoirs and letters purporting to be the personal testimonies of deaf children were used for fundraising purposes, while donors assumed the responsibility of speaking on behalf of those 'denied the power of pleading for themselves' (p. 78). As Borsay argues, these 'voices' bore little resemblance to the children's experience and she uses a number of sources to contrast the lived experience of the children with the sentimental rhetoric that was produced. Neither the children nor their families can be considered as 'consumers' and Borsay concedes that, despite small acts of resistance, the children were virtually powerless in these disciplinary institutions.

Given the ideological conflict which developed between doctors and educationalists over whether deaf children should be taught to communicate manually or orally, it might be expected that organisations such as the British Deaf and Dumb Association, and later the National Institute for the Deaf, would have protected the interests of the children caught up in this dispute. However, opposition to signing and the desire to 'normalise' deaf children influenced deaf people's own organisations, and in the 1930s, children already fluent in signing were physically prevented from communicating in this way and punished for so doing. Borsay analyses the history of deaf establishments from the perspective of the deaf children, but she also highlights some of the factors which contributed to the harshness of these institutional regimes and she thereby increases our understanding of the political economy of care. Her account reveals the darker side of the market in health and welfare and shows that some 'consumers' had little power.

If deaf children had little influence in terms of their education, the parents of children at Great Ormond Street Hospital exercised a degree of choice over the duration of their children's hospital treatment. Andrea Tanner's study of the London children's hospital uses a database of hospital admissions and case notes to analyse how families viewed and used the hospital. Although 90 per cent of the children treated were out-patients, the great dilemma facing some parents was first, whether to agree to their child's admission to a ward, and then, whether to leave them in hospital for the duration of the treatment. As Tanner shows, there were many obstacles for working-class parents to contend with in bringing their sick children to hospital, but parents nevertheless sought treatment for their children, and when medical opinion suggested it was necessary, they agreed to their children being admitted. The database reveals age and gender differences in admissions and in the premature removal of children from Great Ormond Street Hospital. Parents removed their children if they considered the treatment to be ineffective or misguided, or if they thought their child was unhappy. Tanner provides a detailed analysis of the possible reasons for the removal of children from hospital, and her account reveals the complex relationship between the hospital and the London working class. She concludes that 'parental prerogative remained a powerful control on what was - and what was not - acceptable in terms of child medicine'; however, there is little to suggest that parents were able to transform the hospital procedures they found so problematic (p. 161).

Family members were often responsible for the admission of mentally ill patients to Holloway Sanatorium. This luxurious private asylum was designed for the middle class, though the respectable poor might also be admitted, especially after 1889 when the hospital was registered as a charity. Anne Shepherd provides an interesting insight into the liberal regime of the hospital and her account of the range of recreational facilities available to patients, challenges the view that such hospitals were oppressive. The majority of patients were discharged within a year, though readmission was not uncommon and a number of patients remained for several years. Shepherd reveals the circumstances which led to families requesting admission for family members, often unmarried daughters, when their behaviour was considered to be intolerable. While these cases provide some insight into the demand for such provision, the perspective of the patients is not evident in this essay. The fact that some patients elected to stay at Holloway on a voluntary basis suggests that the care given in the hospital was appreciated, but we do not hear from the patients themselves.

A different kind of sanatorium is examined by Flurin Condrau, though the idea of fresh air, rest and appropriate exercise was common both to sanatoriums for tuberculosis (TB) and to those for the mentally ill. Condrau's reappraisal of the historiography of TB and of the role of such sanatoriums is persuasive and he provides an interesting analysis of the fluidity of the concept of 'success' with regard to treatment. Drawing on a detailed knowledge of sanatoriums in both Germany and Britain, and using a range of sources, including statistics and literary sources, Condrau challenges histories of the sanatorium which emphasise either the futility of this form of treatment, or the disciplinary nature of institutional care. Although Condrau rejects accounts which minimise the agency of the patients, we are told relatively little of the experience of treatment from the perspective of the working-class patient. Condrau discusses the economic problems endured by these patients' families and the alienating experience of being treated in semi-rural locations, but unlike his earlier study of a German sanatorium (1), this essay gives less attention to the patients themselves. There are some extracts from personal testimonies, but most relate to the problem of re-integrating into society after treatment.

Two essays explore the relationship between prospective patients and those who controlled entry to the voluntary hospital sector. Jonathan Reinarz examines a number of voluntary hospitals in Birmingham in the 19th century, while Barry Doyle examines voluntary hospitals in Middlesbrough in the 20th century. Reinarz's essay examines different models of hospital provision and considers the enquiries made into prospective patients' respectability and financial resources. He argues that those seeking treatment knew how to depict themselves as the 'deserving poor' and he shows how hospital staff frequently turned a blind eye to acts of disorder on the ward. Although personal enquiries and a system of fees were introduced in some hospitals to manage excess demand, the efforts of hospital administrators to 'know' their patients did not necessarily mean they were able to control them. Thus, at the women's hospital, some women did not return for follow-up appointments, while at the Queen's Hospital working-class men who contributed to the Hospital Saturday Fund assumed they had a right to treatment, and some became life Governors and contributed to hospital policy. Reinarz concludes that by the end of the 19th century 'the lines between donor and recipient had begun to blur' (p. 133).

The overlap between donors and recipients is very apparent in Barry Doyle's study of the voluntary system in Middlesbrough, in which he examines the extent to which financial contributions to hospital funds allowed working-class patients access, not only to medical treatment, but to power in terms of hospital management. Doyle shows how the local working class were both consumers and producers of hospital services. His detailed analysis of the dynamics of power in the management of Middlesbrough's voluntary hospitals suggests that the move to more democratic structures, with increased trade union and trades council representation, challenged the authority of traditional elite, even if the latter remained dominant until 1946. Doyle's study of the politics of voluntary hospital care in the first half of the 20th century overturns assumptions regarding the moribund status of such hospitals and offers a more optimistic account which emphasises the cross-class, community-based nature of these organisations.

While much of the book is concerned with medical institutions, there are other essays which explore other forms of charitable assistance and mutual aid. The study of cathedral almsmen by Ian Atherton, Eileen McGrath and Alannah Tomkins is particularly interesting. This essay shows how, despite the humble tone adopted in petitions for cathedral almsrooms, almsmen did not behave as expected once a place had been secured. Many failed to perform any of their duties and refused to attend church services, while others took the stipend, but chose not live in the cathedral close. Despite this failure to conform, expulsions were rare, and when challenged, almsmen would appeal to a higher authority than the dean. As with other essays in this collection, this study suggests that dualistic models of donor and recipient fail to capture the complexity of the charitable relationship, which in this case involved three parties: the almsmen, the cathedral and the crown.

Sheila Cooper's essay on kinship and family also deals with the early modern period, and she offers an analysis of kinship which is broadly defined and which allows her to examine the high degree of reciprocity and trust involved in this form of support. Earlier historical accounts suggest that the nuclear family was inadequate to deal with the hardships of life, and that in many cases community support was essential for survival, but Cooper argues that 'life cycle service was a very important mechanism mitigating the problem of nuclear hardship' (p. 59) and that a number of people, not necessarily blood relatives, would provide accommodation, financial assistance or an occasional meal to needy kin.

The impact of enclosures in both rural and semi-urban areas in the late 18th and 19th centuries is examined by Sylvia Pinches. Although enclosure resulted in the expropriation of common land, some compensation was made through the creation of allotments, coal clubs and the recognition of limited rights to gather wood and furze, or to pasture animals. Entitlement was a matter of local dispute and Joseph Arch, the leader of the Agricultural Workers' Union, successfully challenged the omission of his name from the list held by the local coal club. Opposition was not always so effective, however, and charitable assistance was generally a poor substitute for traditional rights and, as Pinches concludes, a deep sense of grievance contributed to the class politics of villages and towns at this time.

Peter Shapely's essay on the Co-operative Men's Guild examines collective self help in the 20th century, but it is perhaps most interesting as a study of an organisation that never quite fulfilled its objectives. Unlike the Co-operative Women's Guild, this organisation's political agenda failed to attract working-class support and it became little more than a social club. The ideal of active citizenship and the belief that new forms of economic organisation would create a better society had a radical edge, but the ideas and language of The Cooperative Guildsman were infused with almost missionary zeal. How this was received during the depression of the 1920s and 1930s is not discussed, but membership remained around 5,000 throughout the 1920s and never exceeded 12,000.

The final essay in this collection is a critique by Pat Starkey of the attempt made in the 1970s to encourage the clients of voluntary social work agencies to have their say about the support they received. She argues that these efforts to record the views of clients were undermined by the crude methodology used and the inability of the researchers to distance themselves from their own agendas and see their interventions from the perspective of the clients. As Starkey argues, the voices reproduced were 'as much those of the researchers as of the clients' (p. 261). Starkey's essay provides a fitting conclusion to this collection of essays, in that it suggests the need for caution in assuming that we can reproduce the voices of the poor and the sick. Nonetheless, all these essays provide fresh perspectives on the history of medicine, charity and mutual aid; they question the binary opposition between providers and consumers and attempt to explore the diversity of relationships, which often involved the support of a third party, whether a trade union, an employer or the crown.

Notes

1. F. Condrau, '"Who is the captain of all these men of death": the social structure of a tuberculosis sanatorium in post-war Germany', Journal of Interdisciplinary History, 32 (2001) 243-62. Back to (1)