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Graham Mooney and Jonathan Reinarz (eds) Permeable walls: historical perspectives on hospital visiting, Wellcome Series in the History of Medicine, Clio Medica 86, Amsterdam and New York, Rodopi, 2009, pp. vi, 352, €70.00 (hardback 978-90-420-2599-8).
Most of our experiences of the hospital world come from visiting friends or relatives; not so “patient visitors” (p. 8) we awkwardly enter the alien sick world, breathe its disinfected air, perch uncomfortably on the edge of its universe of medicalized order and control over bodies too sick to retain their own, and leave sooner rather than later, grateful that we still can. However, as the very title of this excellent and timely collection reminds us, so many other (overlapping) types of visitor have crossed this line—most similarly historiographically invisible—that the boundaries between the realms of sickness and health seem porous and fluid. In fact from c.1750 until c.1920s (arguably longer) the busy social relations between the outside community and the hospital reflected and shaped both the nature of society and of the institution. The articles here first cover charitable institutions: general, then specialist children's hospitals. The emphasis then changes to state provision: infectious disease, and mental hospitals. All hospitals emerge as inextricably connected to their communities and wider societies in so many ways, sometimes to the point of co-constitutiveness. Visiting emerges as about governance, citizenship, and the nature of civil society; as such it partakes in, and contributes to, the same changes that that society goes through in the changing mixed economy of health care.
Extending Charles Rosenberg's analysis, all types of visitors helped to make up a highly ordered and moralized community, which covered everyone in the building, and linked them with the socio-economic and moral order of the community and society in which they were embedded. Patient visitors were increasingly closely regulated and delimited as potential sources of moral and physical contamination, as the hospital became increasingly medicalized. Contributing governors with business backgrounds—“house visitors” (p. 8)— practised “deep philanthropy”, giving not only money but time. They inspected for economic efficiency and moral rectitude—a remit which included “medical” matters. These eminent gentlemen spun a surveillance web in which patients reported on staff, nurses on doctors and doctors on nurses. Meanwhile eminent Lady Visitors, as befitting their socially prescribed gender roles and public sphere contributions, became more involved in the patient experience—a limitation that again demonstrates the interlinking of hospital and wider community. These survivals of medieval and early-modern ecclesiastical visitations of charitable bodies remind us that the moral backbone of the hospital's power/knowledge regime was upheld by strong lay support while voluntary hospitals remained plugged into donations from the philanthropic socio-economic system. House visitors helped to maintain the standards necessary to provide a steady stream of funding from “public visitors” taking part in the “gift-relationship” of conspicuous giving in the new public sphere of bourgeois civil society; and to make sure the hospital did not fall foul of “official visitors” from charitable or state bodies. Such official visits increased as the expanding state took on more social roles and as charities were co-opted into the greater web of governance.
In a large collection highlights include Jonathan Reinarz's detailed investigation of these trends for hospitals in nineteenth-century Birmingham, and Andrea Tanner's study of their relationship to the development of Great Ormond Street Children's Hospital. Kevin Siena shows how especially careful stage-management of visiting was necessary to secure funding for the London Lock Hospital, since venereal disease was a far less attractive charitable funding opportunity than the foundlings, orphans, impoverished mothers and acutely ill respectable working people with whom the Lock vied in the highly competitive London charity market. Switching to local authority infectious disease isolation hospitals, Graham Mooney argues convincingly that visitors were seen as having compromised their status as respectable and healthy citizens. Visiting left them teetering on the precipice of disease, and thus also vulnerable to strong public health regulation of their behaviours, both inside and outside the hospital, to recover full citizenship. Leonard Smith shows how the official visitations of the Lunacy Commissioners became the vehicle by which the central direction of insanity provision was gradually established, and how they succeeded in raising standards in both public and private asylums. The other chapters on mental hospitals finally dissolve any lingering impressions of such intuitions as socially isolated: entertainers visited, balls were held, and staff sports teams toured, while patient visits, though often (increasingly) closely regulated, were sometimes viewed sympathetically as having a therapeutic purpose.
The warmth of the welcome visitors received depended on the types of visitors and patients being visited, as well as the type and financial security of the hospital, and many other socio-economic variables. This very diversity, though strengthening the argument about the historiographical importance of attention to visitors, does make it hard to unify these essays. Arguably the most important conclusion—that these studies show that Foucault's view of institutional power/knowledge regimes needs to be revised to incorporate more fluid relationships with civil society—is rather hidden under a bushel. In addition, inevitably some potentially fruitful new areas for investigation can only be touched upon: for example the roles of hospitals in knowledge transfer via administrative and medical staff educational visits.
Until direct participation of donors in hospital administration waned with increasing reliance on patient contributory schemes and local authority contracting of services, leading to a shift to professional administrators, visiting and visiting policy were integrally bound up with the socio-economic survival of hospitals. Official visitation regimes, though also becoming more formalized and professionalized, maintained the link between evolving patterns of social governance in hospital and civil society. Who came in, what they did and what they saw were key to securing funding and regulating social environments, and thus visiting was tightly controlled and often stage-managed to create the illusion of an idealized physical environment and moral universe. While there is some variation in quality and some contextual repetition between essays, and while the collection does not (as the editors acknowledge) cover military hospitals, these are very valuable contributions that develop the Porterian reorientation of medical history away from the profession and towards a wider social history of health care. As Catherine Coleborne's final article argues, the institution needs to be historiographically decentred: the meanings of illness and its treatment are not fully captured in analyses of the institution and its staff, but also lie in the multiple points of contact and interaction among the hospital world and family, lay and official visitors.