For Patients of Moderate Means: A Social History of the Voluntary Public General Hospital in Canada, 1890-1950 (review)

In their pathbreaking overview of the social history of Canadian public general hospitals, David and Rosemary Gagan present an intriguing assessment of the complex role that hospitals played in contributing to the development of the Canadian system of federally and provincially financed hospital and medical-care services. Drawing on the archival material available for general hospitals in Vancouver, Cornwall, Owen Sound, St. Catharine, Toronto, Hamilton, Winnipeg, and New Westminster, as well as government reports, professional journals, and the growing national and international literature on the emergence of hospitals, medical technology, and health-care professions, these historians situate their study in both the historical trends that they observed and contemporary debates about the future of health care in Canada. By structuring their study to provide three chapters that examine the changing focus of Canadian hospitals from charity-based warehouses for the sick poor to doctor's workshops for all, followed by three thematic chapters in which the roles of doctors, nurses, and patients are more fully explained, the Gagans have produced a book that will be of great use to medical historians and their students, and of relevance to policymakers, journalists, and politicians.

The opening section of the book skillfully presents the period from 1890 to 1920, when hospital construction increased and existing institutions "modernized" their physical plant and patient population. Urbanization, industrialization, and immigration contributed to the pressure on health-care facilities, and the international models provided by British and American hospitals prompted Canadian philanthropists, municipal authorities, and middle-class citizens to begin demanding that hospitals expand their treatment beyond the deserving indigent. As hospitals started to construct private rooms and semiprivate wards, conflict with the traditional imperative of segregating chronic from acute patients, or ethnic groups from paying patients, challenged hospital administrators and their volunteer medical staff. In effect, hospitals became a multitiered microcosm of society as lay boards were unable to eliminate care of the poor and turned to middle-class paying patients as the source of revenue to support increasing hospital costs. As the Gagans demonstrate, however, nearly 50 percent of the Canadian population was unable to pay for hospital care, and during the 1920s even those who could afford the service began to question rapidly rising costs for ancillary services such as X rays and access to operating rooms. The Great Depression illustrated clearly the need for significantly greater funding from federal and provincial sources as it highlighted the limitations of dependence on "patients of moderate means" as hospitals' main revenue source.

In addition to providing this much-needed survey of hospital growth, the Gagans also offer an in-depth look at conflicts within the medical profession over access to hospital practice and the control of patient services, in response to efforts by lay boards of governors to impose Taylorite efficiency measures on staff and patients. As they indicate, general practitioners were successful in gaining admitting privileges in most general hospitals, but by the 1940s they were once again facing the specter of the loss of patients to specialists. As a result, these doctors were less than enthusiastic about proposals for a national health insurance plan unless their profession were guaranteed control of the "surgical workshop" and promised immunity from bureaucratic direction. In contrast, Canadian nurses had no such pretensions. Effectively summarizing the current literature on the role of nurses in contributing to the modernization of hospital life, the Gagans also make excellent use of George M. Weir's Survey of Nursing Education in Canada (1932) to demonstrate the class, educational background and attainments, and ethnic origin of nurses during the interwar years. They end this section of their...