Charitable Knowledge: Hospital Pupils and Practitioners in Eighteenth- Century London (review)

Charitable Knowledge is a valuable addition to our understanding of medicine of the late eighteenth and early nineteenth centuries. It tells a multifaceted story of the emergence of medical authority from the complex interactions of medical personnel, charity patients, and lay governors of the London hospitals; indeed, the facets do not end with those three groups, but extend to hospital lecturers, physicians’ and surgeons’ pupils, and provincial practitioners, to private patients, and, through them, the expanding population and market culture of Georgian Britain.

The main line of analysis follows the “medical authority constructed in and through the voluntary hospitals of eighteenth-century London” (p. xii). Lawrence argues that the hospitals, founded as charitable institutions, remained under the control of lay managers who were both deeply traditional in rewarding established medical privilege—appointing Fellows of the Royal College of Physicians of London in preference to Licentiates, for example, and maintaining long-standing divisions between physicians, surgeons, and apothecaries—and distrustful of the increasing tendency of hospital staff and students to regard patients as “as objects of clinical inquiries” (p. 27). This tendency was exacerbated by the phenomenal growth in the number of physician’s and surgeon’s pupils and by the ever-increasing numbers of students attending private lectures given within and without the hospitals’ walls: as Lawrence points out, student ward-walking had no connection to a patient’s cure and thus was a departure from the primary obligation of hospitals to care for their patients. Hospital medical men justified their behavior by claiming that they were advancing medical knowledge—either explicitly, or implicitly, by presenting case histories from their hospital practice in their lectures and publications. Publications and membership in medical societies served to establish an “insider meritocracy” (p. 253) distinct from a practitioner’s actual rank within a hospital or in polite society. It is the norms and values promulgated by this meritocracy that formed the cornerstone of medical authority, with “good” medical knowledge presented as “safe,” objective, even—to historians interested only in great discoveries—boring. It is a measure of Lawrence’s accomplishment that she can derive an important insight from that apparent boredom: the hospital case history came to seem routine precisely because the careful clinical observation it embodied had become the routine experience of the London hospital practitioners and pupils.

Lawrence locates the origin of modern medicine in the London hospitals, and her argument shares features with those of Stephen Shapin and others who locate the origin of modern science in the institutions of its patrons. She displays a sophisticated command of the secondary literature, though the resulting theoretical edifice sometimes perches uneasily on her sources. The analysis is most convincing when dealing with the cadre of London hospital men who practiced, lectured, and published. Despite the subtitle, there is only one chapter dealing directly with hospital pupils. Did they adopt the values of the “insider meritocracy,” or retain those of lay culture? Did they long to become London hospital men, or did they adopt the values of county society? Even the charity patients who are both the subjects and objects of charitable knowledge seldom appear in the book’s sources, and the reader is left puzzled as to whether the hospital case histories at the core of the new medical authority differed in content, as well as context, from those taken from private practice. If Georgian hospitals had been for paying patients, would medical authority have been any different?

This ambitious study does for London hospital medicine what previous histories have done for Paris. It should be of interest to all historians of medicine.