- For Patients of Moderate Means: A Social History of the Voluntary Public General Hospital in Canada, 1890–1950
In this strongly argued work the authors chart the progression of the hospital from a medically marginal institution that served primarily as a warehouse for the indigent ill to a factory for scientific medicine. The new hospital, argue the authors, promised to provide a scientifically mediated and specialized medical care for all that would be limited only by its ability to meet the demand. Fulfilling such a promise, however, as the authors point out, would have required a much more efficient use of the resources, both human and physical, better scientific knowledge, and far fewer errors in diagnosis and treatment than existed at that time. Apart from such serious limitations to the efficacy of the hospital, a definite hospital social structure also developed. The authors present a compelling case that as a result of the ongoing tension between the various stakeholders, factors such as class, gender, occupation, and ethnicity in the hospital culture very quickly replicated the structure of society itself.
The authors point out that although there have been many works in Canada that deal with hospitals, most focus on single institutions without dealing with broad questions, such as why community health developed when and how it did. They point out, however, that a substantial body of American literature on the social history of the hospital does exist and they are able to rely on this for dealing with Canadian hospitals because, despite national and local variations, there is a collective hospital history. In addition they make extensive use of statistical material drawn from government reports and from the archives of six hospitals located in three provinces. Relying once more on the idea of a collective hospital history, the authors argue that this material is sufficient to reveal a common pattern in Canada. Much of this archival data relates to financial material that shapes the work as a whole but does little to cast light on the actual experience of patients in the hospital.
In the first three chapters the authors recount the development of Canadian hospitals from the 1890s until the 1950s. They maintain that the basic structure of community-based health care was established by approximately 1920 but this structure was progressively destroyed by internal stresses that were exacerbated by the Depression of the 1930s. The long developing crisis in health care finally resulted in private insurance schemes and a national health policy. The next three chapters deal [End Page 479] respectively with general practitioners, nurses, and patients' experiences in the hospitals.
The first of these thematic chapters deals with the general practitioner, whose approach to medicine and position as an independent small businessman was definitely threatened by the establishment of a science-based medicine oriented around surgery. The often uneasy relations between the general practitioners, surgeons, various new specialists, and hospital administrators helped reveal some of the basic contradictions which existed in the new health system. The second theme concerns the role of nurses, and particularly how the never-ending search for ways of financing the hospitals led to the exploitation of student nurses as a cheap labour force.
The third thematic chapter explores the basic contradiction between the hospital as a workshop that delivered health to those who could afford the cost and the hospital as the traditional source of providing care to the impoverished. The providing of what often amounted to custodial care to the poor was contrary to the whole ethos of the new hospital. Moreover, the only way in which the hospitals could pay for their charitable work was to increase the costs to those patients who could pay. Serious resistance to this form of subsidization began in the 1920s and escalated into a major financial crisis in the 1930s, and it soon became apparent that a new type of support would have to be devised.
The authors have presented a compelling and comprehensive review of...