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

David Gagan and Rosemary Gagan's For Patients of Moderate Means: A Social History of the Voluntary Public General Hospital in Canada, 1890-1950 is a broad look at the evolution of Canadian hospitals. Its organization is both thematic and chronological. A history of the voluntary general hospital from the late nineteenth century to the birth of government-sponsored hospital insurance constitutes the first three chapters. During these six decades the hospital evolved from an institution mostly for the sick poor, to an essential modern institution for all Canadians. Chapters four to six look at the major stakeholders in the voluntary public hospital: doctors, nurses, and patients. 'Mrs Jones and Mr Grant,' a chapter on patients' experiences that includes a fascinating 'tour' of a typical hospital, is particularly interesting.Its narrative style recalls Guenter B. Risse's Mending Bodies, Saving Souls, in which each chapter revolves around a fictional character. Indeed, throughout this jargon-free and meticulously researched book, the Gagans portray the stakeholders of the Canadian hospital as so many actors in a great drama. Particularly gripping are their accounts of how the medical profession used the hospital to justify the cultural authority of scientific medicine and how social class determined the quality of medical care that hospitalized Canadians received in the early twentieth century.

Gagan and Gagan's considerable interest in quantitative methods is showcased in the book's appendices. No fewer than nineteen charts and graphs analyse admissions, hospital costs, patient data, births, duration of stay, patient mortality, and a host of other statistics. This unprecedented wealth of data on the Canadian hospital is a treasury for researchers in the history of Canadian medicine.

For Patients of Moderate Means breaks new ground in three important ways. Although the book explores a familiar time, it is the first attempt at a synthetic history of Canadian hospitals. Until now, that is, Canadian scholars have mostly studied individual institutions or regional hospital typologies. Still, the book would not have been possible without the pioneering case studies of J.T.H. Connor, Geoffrey Reaume, Denis Goulet, and Shelley Hornstein, as well as David Gagan's own 'A Necessity Among Us': The Owen Sound General and Marine Hospital 1891-1985. Second, Gagan and Gagan are well versed in the surveys on early-twentieth-century hospitals in the United States, and thus ask early on how our hospitals evolved differently from those south of the border. And third, the authors have relied on an impressive array of sources and used both qualitative and quantitative methods to paint a complex portrait of the modern institution.

These same innovations underscore the book's limitations. For Patients of Moderate Means purports in its subtitle to be a Canadian survey, but the authors actually generalize not from national data but from in-depth research in specific places such as Cornwall, Owen Sound, St Catharines, Toronto, Winnipeg, and Vancouver. Second, the answer to whether Canada's hospital evolution is distinct is, disappointingly, no. In the end, the book suggests that our hospitals followed a similar course to those studied by Risse, Charles Rosenberg, Morris Vogel, Rosemary Stevens, and others. And finally, the authors' archival bias towards money and people means that readers are given little sense of the hospital as a real place - located in a particular spot, constructed of special materials, and arranged in a careful way. Sadly, the book does not include a single photograph of a Canadian hospital.

Still, For Patients of Moderate Means opens a new era in the history of Canadian hospitals. While the present and future of the Canadian hospital remain murky, its past is notably clearer.