Charity and the London Hospitals, 1850-1898 (review)

In his introduction to this volume, Keir Waddington quotes the well-respected health reformer and hospital governor Henry Burdett stating in 1895 that "it was London's hospitals 'not our bridges, or railways or telephones' that were 'the real glory and abiding distinction of our civilisation'" (p. 13). It is a quotation illustrative of one of this book's great strengths: lucid discussion of the personalities and groups associated with the tumultuous changes occurring within the institutions of nineteenth-century medicine, as seen through the lens of economic and social change in mid- to late-Victorian British society. Waddington's research is original and his findings elegantly presented. He weaves a vast collection of primary source materials into an account offering considerable depth and breadth of comparison. This fine-grained approach enables him to address questions for which reliable answers are rare and hard-won: exactly how, and (to an extent) why, did the public give? and, of equal interest, just how did hospital administrators manage and develop both benevolent and noncharitable sources of income?

The extent of the financial and organizational crisis facing British hospitals by the late nineteenth century was huge. Roughly speaking, the voluntary (charity-supported) sector took on only "treatable" cases, while care of the chronic sick (and therefore the majority of illness) went on in the poorly funded and poorly resourced state-run workhouse infirmaries and dispensaries. Waddington argues against a view of Victorian British voluntary hospitals as in any way monolithic—in their sources of financial support, their administration, or their medical constituency focus. He chooses seven London hospitals—each in some way "representative" of other voluntary institutions—that, taken together, provide the book with its comparative backbone. For example, hospitals raising the majority of their money through endowments are compared to others focused on subscription methods. He also relates the activities of "general" hospitals to those appealing to special interests through service to an immigrant group or the provision of clinical teaching, or with a specialist-focus on particular patient groups or diseases.

In part 1 (by far the longest section) of the book, "Philanthropy and Funding," Waddington seeks (successfully) to dispel the assumption that Victorian voluntary hospitals survived passively on charitable donations: he points to the range of money-raising activities employed by administrators, from charity dinners, investments, and charges to patients, to borrowing and deficit financing—the list is a long one, and strategies differed between institutions. Furthermore, he vigorously disputes the assumption that the motivations and mechanisms of Victorian philanthropy were in anyway straightforward or easily reducible to discrete ideas such as paternalism, altruism, or Christian piety.

In part 2, "Philanthropy and Control," Waddington charts the increasing participation of physicians in the management and direction of the voluntary hospitals. The comparative nature of Waddington's analysis again enables him to speak with nuance and authority on the differences and similarities between institutional types, as well as offering a fresh examination of medical professionalization within hospitals. Many reformers in the voluntary sector wanted better coordination of hospital services and more reliable sources of income, but what united the vast majority of them (and would continue to do so well into the twentieth century) was the "threat" of state intervention in voluntary hospital services. These fears, and what eventually came to pass, are briefly discussed in part 3 of the book, "1897 and Beyond."

With this book, Waddington places himself within the growing field of economic history of medicine (exemplified for him by the likes of Anne Digby and Steven Cherry) that "has started to see a more complex system of hospital finance and connections between patronage, management, patients and funding than earlier, less critical studies of hospitals have revealed" (p. 3). Accounts of the hospital...