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Medicine transformed: on access to healthcare

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Medicine transformed: on access to healthcare

Introduction

Access to healthcare is important to all of us. Did the arrival of state medicine in the twentieth century mean that everyone had access to good medical services? If you fell sick in 1930 where could you get treatment – from a GP, a hospital, a nurse? This course shows that in the early twentieth century, access to care was unequally divided. The rich could afford care; working men, women and children were helped by the state; others had to rely on their own resources.

This OpenLearn course provides a sample of Level 2 study in Arts and Humanities.

Learning outcomes

After studying this course, you should be able to:

  • describe the wide range of methods of promoting health, preventing disease and providing care that were available to patients of different social groups and classes

  • demonstrate an awareness of the inequalities of services – in terms of both quality of care and access to different services – open to different social groups and classes

  • assess the significance of the roles of central and local governments, the private sector and voluntary associations in providing medical services

  • understand the concept of ‘medicalisation’ and assess the degree of power doctors had over people's lives in the early twentieth century.

1 Access to healthcare, 1880–1930

The late nineteenth and early twentieth centuries have often been described as a period of progress, when the poorer classes gained access to a whole range of medical services previously reserved for the wealthy. In the past, this opening up of care was largely attributed to the state. Across Europe, central and local governments created health insurance schemes and new welfare services to provide the poor with access to care, from general practitioners (GPs) to outpatient and hospital care, and treatment for specific complaints such as tuberculosis and venereal disease. This movement culminated in the 1940s, when it was the boast of the British government that the National Health Service provided care for all ‘from the cradle to the grave’. However, more recent studies by historians of medicine have shown that improved access to health services was also provided through charities. Old voluntary organisations, such as hospitals and dispensaries, expanded their work and strove for greater efficiency, employing professional administrators. New charities were founded, providing novel services, including help for mothers and babies. Improved access to healthcare also came about through private insurance schemes to provide GP and inpatient care to the working classes.

While historians of medicine agree that this period saw greater provision of medical services, especially for the poorer classes, some researchers have questioned whether improved access to care was an unalloyed good. They have argued that not everyone benefited equally from improved services. Improvements in access to care were unequally distributed. New medical services were often limited to the very poorest, or to particular groups, such as working men or women and children, and levels of provision varied between countries and regions. Provision of care did not guarantee a high standard of service: detailed research by some historians has shown that the poorer classes often received a lower quality of care than their wealthier counterparts. Others have argued that there were drawbacks to more accessible medical services. They have described the early twentieth century as a period of ‘medicalisation’. As patients gained greater access to medical professionals – doctors, nurses and health educators – they became passive consumers of medical services. At the same time, the medical profession no longer simply dealt with the sick, but increasingly took a role in monitoring the lifestyle and behaviour of healthy people. As a result, people became increasingly dependent on medical practitioners to guide their lives.

In this course, I explore these issues through a study of the health-care services available in Britain at the end of the nineteenth and in the first decades of the twentieth centuries, using a wide range of sources. Where material is available, I make comparisons with the care available elsewhere in Europe. I cover all aspects of healthcare – from disease prevention, through care in the home, general practitioner services and finally care in institutions. I explore the access to medical services among different social groups and assess how much control practitioners had over their patients' lives by 1930.

2 Patterns of disease

Before looking at how people dealt with ill health, you need to know what sort of medical conditions were prevalent. Between the nineteenth and twentieth centuries, all over Europe, the prevailing pattern of mortality changed. Infectious diseases, which had killed huge numbers of people, were gradually brought under control. As life expectancy increased, degenerative diseases, associated with old age, began to cause more deaths. However, although people were living longer, they actually spent more time off work because of illness. James Riley's studies of the records of friendly societies, which offered health insurance (these are discussed in more detail later), have shown that workers were no longer dying from infectious diseases. Instead, they survived illness, but spent a long time recovering their health and strength (Riley, 1989, pp. 159–92).

The friendly society records show that the complaints that caused workers to take time off were not the same as those that dominate mortality statistics (Table 1).

Table 1 Comparison of mortality with sickness recorded by friendly societies in England and Wales
Leading causes of death in England and Wales among men, in 1908Leading causes of sickness in three friendly societies, 1896–1919
Cause% of totalCause% of total
Heart disease14Accidents16
Tuberculosis14Poorly identified13
Old age8Influenza and catarrh13
Cancer8Bronchitis9
Bronchitis7Rheumatism4
Pneumonia7Lumbago14
Cerebral haemorrhage5Gastritis22
Accidents5Carbuncle32
Bright's disease43Tonsillitis1
Influenza3Skin ulcers1
Apoplexy2

1Lower back pain, caused by muscular inflammation or arthritis

2Inflammation of the stomach lining, causing pain and discomfort after eating

3A local infection, similar to, but larger than, a boil

4Now recognised as a number of kidney diseases, all associated with the presence of albumin in the urine

(Adapted from Riley, 1997, pp. 191–2, Tables 7.1 and 7.2)

If we ignore accidents and ‘poorly identified’ complaints, the most common ailments among the working-class men insured by the friendly societies were respiratory infections – influenza, colds and bronchitis – followed by joint and muscle problems, such as rheumatism and lumbago. Few workmen reported sick with degenerative diseases. Nor did they take time off for tuberculosis (TB), one of the major killers at this time. TB was a chronic, but not disabling, disease, and men were able to work until they developed advanced symptoms.

Friendly societies insured a select group – fairly young, fit, working men – so their records are not representative of the whole population. General practitioners saw a larger cross-section of society. Records from their practice suggest that they treated a fairly similar range of complaints to those recorded by the friendly societies – respiratory infections, rheumatism and digestive complaints, such as dyspepsia and diarrhoea. GPs did not spend much time treating degenerative diseases since they could do little for such conditions. Their case records show how patterns of disease varied by class, area and season. Middle- and upper-class patients consulted doctors about obesity, gout and nervous complaints – conditions that were rarely reported by working-class patients. The poor suffered from rickets (a consequence of a poor diet), dysentery and diarrhoea (reflecting the difficulty of keeping food clean and fresh) and infectious diseases. GPs working in industrial areas had to deal with the results of accidents and occupational diseases: miners, for example, who worked in a damp and dusty environment, suffered from high levels of bronchitis, pneumonia and pleurisy. Everywhere, the incidence of respiratory diseases increased in the winter months, while digestive complaints were more frequent in the summer (Digby, 1999, pp. 192–3, 208–14).

Men were more likely than women or children to visit a GP (for reasons I discuss later), but not because women and children were any healthier. Children continued to suffer from a range of infectious diseases – tonsillitis, scarlet fever, chickenpox, whooping cough, measles and mumps. A survey of the health of working-class women in the 1930s found that they suffered from headaches, constipation, anaemia, rheumatism, gynaecological problems (often associated with childbirth), bad teeth, and ‘bad legs’, resulting from varicose veins, ulcers and phlebitis (inflammation of the veins) (Spring Rice, [1939] 1981, p. 37).

While people suffered from a wide range of complaints, two diseases prompted particular public concern – tuberculosis and venereal disease (VD). Both were seen as causes of national degeneration, causing high levels of disease which weakened the population and led in turn to the birth of feeble children (Figure 1).

Figure 1
Figure 1 This poster, issued in 1926 by the National French League against the Danger of Venereal Disease, neatly encapsulates the perceived risks associated with three diseases in the 1920s. Death watches a three-horse race, in which Tuberculosis (150,000 deaths per year) narrowly beats Syphilis (140,000 deaths per year), while Cancer causes only 40,000 deaths. These mortality statistics do not correspond to those recorded by the Registrar-General for England and Wales; in 1910, deaths from tuberculosis were thirty-two times greater than those attributed to syphilis. However, the Registrar-General's report acknowledged that there was a serious under-reporting of syphilis deaths by doctors, who did not wish to stigmatise their patients, and so recorded syphilis deaths under other disease categories. Wellcome Library, London

There was also a widespread belief among the public and medical practitioners that the pace of modern life – in which information flashed through the air by telegraph, and people travelled by train and steamship at previously unimaginable speeds – caused ill health. The modern lifestyle was associated with physical disorders, including dyspepsia, diabetes and liver complaints. It was also blamed by some practitioners for an apparent epidemic of nervous diseases, such as hysteria and neurasthenia. Symptoms of anxiety, depression, insomnia, pain, involuntary movements and nervous tics were believed to result from the strain of modern life on the nervous system. In Russia, neurasthenia was associated with a cultivated ‘western’ lifestyle (Goering, 2003).

3 Preserving health

3.1 Introduction

Surrounded by the ever-present threat of ill health, not surprisingly, people expended a good deal of time and energy on trying to stay well. The late nineteenth century saw a new emphasis on promoting health, which was defined as ‘a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity’ (quoted in Riley, 1997, p. 199). Health was not simply a desirable end in itself. The pursuit of health was portrayed as a moral duty: parents had a responsibility to protect both the health of their children and their own health, so that they could support their families. Health also became a political concern: the future strength of the nation was seen to rest on the good health of children – the future generations of soldiers and workers. At the beginning of the twentieth century, popular beliefs about the best means of preserving health were little different from those prescribed two thousand years earlier in classical Greece – good diet, fresh air, exercise and cleanliness. Such a lifestyle would keep the body in the best possible condition to fight off germs and diseases.

3.2 Health and wealth

While all classes regarded good health as desirable, access to various means of preserving or promoting it varied according to economic circumstances. For the upper and middle classes, with substantial amounts of disposable income, a wide range of options were available. They could access information about how to protect their health through books and articles in magazines. Many of these books were written (or at least claimed to be written) by doctors and other health-care professionals. An article about pregnancy in the opening number of Woman magazine in 1932, for example, was allegedly written by ‘Mumsie, the wife of a famous children's doctor’ – a persona neatly combining medical authority and the status of an ordinary wife and mother (Beddoe, 1989, pp. 14–15). The 1920s saw a boom in baby-care books, aimed at middle-class mothers, which not only gave practical advice on feeding, bathing and clothing, but also set out the stages of physical and psychological development, thus unwittingly creating the first generation of mothers worried that their babies walked and talked ‘late’ (Unwin and Sharland, 1992).

Generally, the wealthier classes enjoyed the sort of varied diet thought to promote good health. They could afford meat, fish, fresh fruit and vegetables (Burnett, 1979, pp. 213–39). However, some wealthy individuals worried that they ate too much, and dieting to obtain a slim figure was a well-established activity by the 1920s. Others were concerned that their diet was too rich, and in the pursuit of health adopted simple, more ‘natural’ diets. They stopped consuming alcohol, tea, coffee and meat, and ate fruit, vegetables and cereals (the word ‘muesli’ was adopted into the English language at this time). The popularity of ‘health foods’ (such as ‘Hovis’ wholemeal bread) and vegetarianism grew from the mid-nineteenth century to become a mass movement in Germany and surrounding states by 1900, although it was much less popular in Britain. The quest for a healthy diet was closely linked with other movements – such as unorthodox medicine and feminism, whose supporters argued that overly elaborate diets tied women to the kitchen (Meyer-Renschhausen and Wirz, 1999). Even ordinary foodstuffs were marketed for their health-giving properties (Figure 2).

Figure 2
Figure 2 In this advertisement, the image, caption and description of Ovaltine, a proprietary brand of malted milk drink, clearly link food with health. The appeal here is to a mother's desire to build up her children's health and strength; the message would have been a poignant one at a time before immunisation, when many children died from infectious diseases. Other advertisements stressed the benefits for adults, promising that a cup of Ovaltine at bedtime would ward off ‘night starvation’. Wellcome Library, London

Exercise and fresh air, two more building blocks for good health, would appear to be open to all. However, only the upper and middle classes had the cash and the leisure time to participate in the craze for healthy exercise which began in the late nineteenth century. They could afford to buy bicycles, tennis rackets and golf clubs. They could also, following the German example, go rambling and hiking in the countryside, and pay to attend gymnastic exercise classes. Exercise was clearly gendered. Men and boys took part in team games (such as rugby, football and cricket), athletics and German gymnastics, which made use of apparatus such as vaulting-horses and parallel bars. Such activities were thought to develop a competitive spirit and build strong muscles, desirable qualities in the next generation of workers and soldiers. Women, too, were encouraged to exercise – not to build muscles, which were regarded as undesirable in the female sex, but to cultivate health. For women, exercise was thought to prevent curvature of the spine, chlorosis (a mysterious complaint, whose main symptoms were tiredness and a pale complexion) and hysteria, and a strong, fit body was thought to guarantee easy births and healthy offspring. Cycling, tennis, golf, team games requiring skill rather than strength (such as hockey) and Swedish gymnastics, which involved stretching the body with the aim of developing flexibility and coordination, were seen as beneficial forms of female exercise (Fletcher, 1984, pp. 1–55; Stewart, 2001, pp. 151–72).

3.3 Hygiene

Good hygiene – a clean home and a clean body – would also appear to have been available to all classes, but again, it was easier for the wealthier classes to achieve these goals. Newer houses, with bathrooms and laundries, modern plumbing and sanitary facilities, and servants to do the hard work, ensured that the middle and upper classes could enjoy regular baths (hot and cold), clean clothes and clean homes.

Exercise and good personal hygiene were not just a means of protecting health but were also pursued for aesthetic reasons. Women, for example, took exercise to promote grace and suppleness, and bathing was presented as a way for them to pamper themselves with scented soaps and oils, not just to get clean (Stewart, 2001, pp. 65–72). The Ladies Diary and Housekeeper for 1917 provided beauty hints, allegedly written by ‘an eminent MD’, who suggested that ‘a cheerful disposition’ would prevent wrinkles and gave a recipe for a cream to soothe the blistered hands of overenthusiastic sportswomen. A revolution in women's clothing came about through a similar mixture of aesthetics and concerns about health. By the 1900s, tightly laced corsets were seen as a hazard to health, squashing women's internal organs (thus threatening the health of future babies) and preventing them from inhaling health-giving fresh air. Very long skirts also prevented women from taking exercise. Despite objections from some men, who found women wearing culottes or bloomers ‘manly’ and rather disgusting, women increasingly wore lighter clothing with shorter skirts and flexible stays and brassieres. By the 1920s, short tennis dresses were even considered to be chic (Stewart, 2001, pp. 72–4, 169). At this time, men's clothing also became lighter (Figure 3).

Figure 3
Figure 3 Advertisement for Dr Rasurel's hygienic underclothing, 1906. Note the associations between the clothes being advertised and health. The reader is assured that the clothes are ‘hygienic’; they carry the name of a doctor, and the family pose surrounded by green plants, presumably in the open air. Rural settings were always seen as being more healthy than the urban environment. Wellcome Library, London

3.4 Health and the working class

However, for a large proportion of the population, altering diet, clothing or behaviour in the pursuit of better health was well nigh impossible. The working classes, who made up the vast majority of the population, survived on tight budgets. In 1913, the typical workers’ wage of £1 per week just covered the essentials of food and rent, and left limited opportunities to follow a healthier lifestyle (Pember Reeves, 1913). The staples of the working-class diet were white bread, margarine and tea. These cheap foods filled up hungry stomachs, but did not provide a balanced diet (Burnett, 1979, pp. 182–212). In 1901, one-quarter of the population were not getting enough to eat: as late as the 1930s, research showed that half the British population were eating a diet deficient in some vitamins and minerals (Burnett, 1979, pp. 245, 301–19). Just as members of the poorer classes found it difficult to afford a good diet, they also lacked the money, time, equipment and transport, never mind the energy after a long day at work, to take exercise. Personal hygiene too was difficult to achieve. Many working-class women struggled to keep their homes clean, but the poor condition of their houses, the lack of a bathroom and often hot water, and shared laundry facilities meant that the poor were inevitably dirtier than the middle classes. Doctors and midwives going into poor homes sometimes complained of the smell of their patients.

By the beginning of the twentieth century, for the first time governments and charities stepped in to try to improve the diet, exercise and hygiene of the poorest sections of society. While organisations all over Europe shared the goal of guaranteeing the physical health of the nation, the level of provision varied between different countries, reflecting national political agendas.

3.5 The health of mothers and children

The health of mothers and infants was one target for action. France was among the first to introduce infant welfare schemes, as low birth rates, high infant mortality and defeat in the Franco-Prussian War led politicians to fear for the future strength of the nation. Diarrhoea among bottle-fed babies was singled out as a preventable cause of high infant mortality. From the 1890s, charities and local authorities set up infant welfare clinics called gouttes de lait, which encouraged mothers to breastfeed, gave out free milk to those that could not, and provided free regular medical examinations to check on babies’ development. Charities also provided free meals to pregnant women and the mothers of small children. To improve the health of older children, municipal authorities set up school canteens to provide free and subsidised meals. These schemes proved very popular: in Paris in 1901, over 1,400 babies were brought to clinics: in some towns, up to one-third of all mothers and infants attended. Government bodies in Britain looked to France as a model of good practice, but did not simply copy French child welfare programmes, fearing that to provide food would usurp the role of the family breadwinner and overstep the proper limits of action. Hence, the few ‘milk banks’ set up in Britain around 1900 offered subsidised rather than free milk. Instead, charities focused their efforts on education. Lectures and demonstrations on ‘mothercraft’ were offered at welfare centres (Figure 4). In Britain, efforts to provide free school meals for older children were hindered by the same reluctance to interfere in family life. Even after they were given powers to provide school meals in 1906, many local authorities were reluctant to do so and, by 1912, only around one-third of local authorities provided school meals (Dwork, 1987, pp. 93–166, 167–84).

Figure 4
Figure 4 Leaflet advertising the new Mother's and Babies' Welcome in St Pancras, London, 1907. A charity, founded in 1907, the St Pancras Welcome offered a comprehensive range of services to mothers and babies. These were not free, but available for a small fee. Wellcome Library, London

Historians are divided over the impact of such policies. Some have argued that the authorities in Britain chose to provide education, rather than food, as a cheap but ineffective solution to the problem of child poverty. They have portrayed education in ‘mothercraft’ as patronising and often impractical. Other researchers, such as Deborah Dwork, are more sympathetic, arguing that, given the government's reluctance to interfere in the family, education was a practical and effective way of helping mothers, and one which the mothers themselves appear to have found useful (Figure 5).

Figure 5
Figure 5 Infant Welfare Centre ABC, East and West Molesey Infant Welfare Centre, c.1930. Documents such as this have prompted historians to view the education provided by Infant Welfare Centres as patronising. Here, mothers are taught in the same way as infants, by learning an ‘ABC’. Alternatively, the ‘ABC’ can be seen as a light-hearted celebration of the work of the centre, presented in a simple and appealing manner. Wellcome Library, London

Governments also provided working-class children with access to physical exercise (PE) through school. Again, wider politics dictated the level of provision. By the 1930s, schoolchildren in Germany, Czechoslovakia, Russia and Italy were taught games, drill and gymnastic exercises. These facilities were much admired by British government ministers (although they did not approve of the regimes that funded them), who attempted to establish PE as a regular part of the school curriculum. Exercise was presented as a cheap form of preventive medicine, which would help to prevent ‘flat-feet, curvature of the spine, adenoids, deafness, “mental deficiency” and respiratory problems’ (quoted in Welshman, 1996, p. 34). However, in Britain, local authorities were again slow to act, and provision of PE was patchy in the state school system. Hampered by a lack of trained instructors, and the fact that many children could not afford appropriate clothing and shoes, the periods of exercise were shorter and less frequent than those provided in private schools.

Education in hygiene was provided by both charities and local government. In Salford, before the First World War:

The Ladies' Health Society worked bravely among us … Together with the ‘Sanitary Society’, they visited the ‘lowest classes’ and found ‘much that is saddening: but there are bright spots – clean homes, pretty little sitting-room kitchens … clean hearths, chests of highly polished mahogany drawers, a steady husband, a tidy wife and children’ … The Society also sold ten hundredweights of carbolic soap and distributed six hundredweights of carbolic powder [disinfectant] … The corporation lent out its whitewash brushes, distributed free, bags of lime and bottles of a preventive medicine popularly known as ‘diarrhoea mixture’, and urged hygiene on all the populace.

(Roberts, 1971, pp. 57–8)

Children were taught basic hygiene – about the need to bath weekly, to wash their hands and faces daily, and to scrub their fingernails – as part of the school curriculum. Girls (but not boys) were taught about healthy clothing – garments should be loose, warm and frequently washed.

3.6 Health education

The poor were not the only targets of health education. Campaigns against tuberculosis and venereal disease were aimed at all classes. Advice was dispensed through exhibitions, lectures, classes, posters, radio talks and films. Tuberculosis, the public was told, was best combated by a generally healthy lifestyle – fresh air, exercise and hygiene. The 1939 film Stand Up and Breathe, made by the National Association for the Prevention of Tuberculosis (NAPT), promoted all sorts of outdoor recreation as a means of guaranteeing health. Venereal disease could be avoided by restricting sexual activity. Campaigns sought to inform the public of the dire effects of VD – some exhibitions included graphic wax models of syphilitic lesions – in the hope that people would refrain from sex outside marriage, or, if they became infected, that they would come forward for treatment. In this educational material, ‘loose’ women were often portrayed as the source of infection, trapping vulnerable men (Figure 6). Innocent wives were the ultimate victims of VD. Infected by philandering husbands, they had sick or stillborn children (Davidson and Hall, 2001).

Figure 6
Figure 6 Poster warning of the dangers of syphilis, c.1930. The text reads: ‘Syphilis is a social scourge. Its victims are innumerable. Many suffer from it without knowing. Syphilis among parents is one of the main causes of sickness and death among newborn children and infants. A great number of chronic infections originate in syphilis. Syphilis is a serious disease, but fortunately curable. For those infected it is a duty to obtain treatment and to avoid transmitting the disease.’ Notice the image of a glamorous woman, with fashionable haircut, makeup and jewellery, set against the less detailed image of the man. Women who had sex outside marriage – often pejoratively called ‘amateur prostitutes’ or ‘problem girls’ – were frequently blamed for infecting men with syphilis. Wellcome Library, London

4 Domestic care

Despite their best efforts, everyone fell ill at some point in their lives. Although historians of medicine write a great deal about how the sick were cared for by doctors and in hospitals, in the past (as nowadays) minor complaints were diagnosed and treated at home, almost entirely without the help of medical professionals, using special diets and home-made or bought-in remedies. As with preserving health, poor families had relatively few resources for treatment. They might seek advice from neighbours or friends, or perhaps a health visitor. Those prevalent joint and respiratory ailments described earlier might respond to simple forms of treatment. Linseed or onion poultices were used to treat boils or painful joints, and hot footbaths were given as a remedy for colds. These would have been within the resources of all but the very poorest. In rural areas, ancient magical remedies, such as using snails to treat warts, persisted well into the twentieth century. Poor families might also be able to produce some simple foods aimed at helping a sick member feel better – for example, gruel, soup or egg dishes.

Better-off members of society were able to adopt more elaborate forms of domestic treatment. Medical practitioners had an indirect input into their home care through advice given in books on nursing and even diaries. The Ladies Diary and Housekeeper (1917) contained useful notes for emergencies in alphabetical order, from ‘Abdomen’ to ‘Wounds’, including what to do in cases of strangulation and how to tell if someone was dead. In cases of hysteria, the Ladies Diary recommended not sympathising with the patient, but throwing cold water in her [sic] face, then administering an anti-spasmodic draught. (Perhaps life in the Edwardian home was not as quiet as we think!) Middle-class households had more resources with which to prepare home-made remedies. For example, a well-stocked larder was a prerequisite for making the cough mixture consisting of melted butter, black treacle and lemon, which was recommended in Everywoman a Nurse (1927). The middle and upper classes could also afford to treat illnesses using special diets. Nursing manuals published between the 1890s and the 1920s provided recipes for dishes to tempt the invalid's appetite and aid recovery, including beef tea (a broth made by boiling meat in water), rice pudding and egg dishes. Brandy was given as a stimulant to the very sick. Tonic wines, fortified with quinine or iron, and red wine (perhaps because of its colour) were reputed to strengthen the blood. By the end of the century, families could purchase patent invalid foods. Cod liver oil, now given as a source of vitamin D, was recommended as a rich food which helped patients to gain weight.

All classes purchased medicines to deal with illness within the family. These medicines were self-prescribed, and were often seen as a cheap alternative to paying for a doctor's services. Despite practitioners' bitter complaints that such medicines could do little good, and might even be harmful, the market in over-the-counter medicines boomed. In the mid-nineteenth century, the British population spent about £500,000 per year on patent medicines – by 1914, this sum had increased ten-fold (Digby, 1999, p. 228). Drugs and medicines were readily available – they were sold by retail chemists (Boots the Chemist thrived in this period, building up a chain of shops), grocers, corner shops and even by mail order, and were heavily advertised in newspapers and periodicals. Over-the-counter remedies ranged from the innocuous to the extremely potent. Thomas Beecham (after whom Beecham's Powders are named) began his career selling a preparation based on aloes, ginger and soap. At the same time, chemists sold morphine preparations, and new chemical drugs such as sulphonal (a sleeping drug). As well as medicines based on orthodox medicine, homeopathic and herbal remedies were also freely available.

Medicines were marketed to reach all classes. Hoechst, one of the largest German pharmaceutical firms, was not above selling exactly the same pain-relieving drug under four different names and at four different prices. The following reading is an extract from Robert Roberts's book The Classic Slum, which gives a picture of the trade in patent remedies in a corner shop in the 1900s.

Activity 1

Read ‘Self-medication’. Who buys these proprietary medicines and what conditions do they hope to treat with them? What is the author's view of the effectiveness of these remedies? How does it compare with that of the purchasers?

Click to view the article 'Self-medication'.

Answer

Roberts's account describes a flourishing trade in patent medicines. Everyone seems to buy remedies – even the very poor, who can buy a few pills for a halfpenny – and to take them frequently. Medicines were taken routinely, to counter constipation and as tonics to strengthen the body, as well as to treat illnesses. The remedies claimed to treat a huge range of complaints, often associated with a particular organ and rather vague symptoms (such as ‘premature decay’). However, Roberts suggests that constipation related to the starchy diet is the most common reason for buying them.

Roberts is clearly sceptical of the effects of many of these remedies and he claims that some were clearly detrimental, such as the tooth whitener. Some are all too effective – like the ‘knock-out drops’ given to babies – but are given for the wrong reasons. Despite Roberts's scepticism, the purchasers clearly have great faith in these nostrums, since they keep returning to buy more. They also make careful judgements between them – though Roberts claims that the efficacy of a medicine was less of a selling point than its colour, texture and packaging. In his comments about ‘Therapion’, and the fact that many of these patent medicines included some sort of laxative, Roberts hints at a reason for the popularity of these patent medicines – they made the purchaser feel better.

5 Calling in help

5.1 Introduction

When people did seek help for their ailments, most sought some form of outpatient care. For the upper and middle classes, during much of the nineteenth century, this meant calling in a general practitioner. The poorest could apply for help at the outpatient department of a charitable hospital or dispensary. Another source of help was to apply for assistance from local government – in some countries the local authorities employed doctors to care for the poor. In Britain, medical help was available through the Poor Law – the body responsible for all aspects of welfare. There was what historians call a ‘mixed economy of care’ – patients could either pay for the services of practitioners, or apply for free care from charities or local government agencies. The end of the nineteenth and beginning of the twentieth centuries saw a huge expansion in the availability of outpatient services – both through these existing outlets and through new facilities. The result was a patchwork of services, where the same care was available from numerous outlets, leading administrators to worry about inefficiencies and the over-provision of medical services.

5.2 General practitioners

General practitioners were the backbone of medical services. They dealt with almost every sort of complaint, from the serious to the trivial. Although it is often assumed that previous generations were prepared to put up with discomfort, in 1876, an anonymous correspondent to a friendly society magazine complained that ‘one of the most distinctive traits of this generation is its almost fidgety care about its health’ (quoted in Riley, 1997, p. 199). Working men went to the doctor with minor injuries, colds and headaches. One Yorkshire doctor recorded treating a patient for indigestion, toothache, hoarseness and hair loss (Riley, 1997, pp. 199–200). At the other end of the scale, GPs delivered babies in patients' homes, even applying anaesthetics and using forceps to speed the delivery. In rural areas, they performed major surgery. Harry Pearson Taylor, a GP on the Shetland Isles, recalled amputating a boy's arm after it had been crushed in a threshing machine. With the minister of the local church, he

improvised an operation table, and got the little man on it. I disinfected the area as well as I could under the circumstances, and got all I wanted ready. I chloroformed the boy, and the Minister kept him under while I disarticulated the elbow joint. The Minister, who … knew quite a lot about medicine and surgery, had put a tourniquet on the upper arm. The weather remained so bad for several days that I was storm stayed in the island, which gave me an opportunity to attend to the patient myself. Of course there were no nurses in those far back days, and had I been able to get back to Yell [his home island], the Minister would have had to undertake the duties of a nurse.

(Taylor, 1948, p. 76)

Despite the primitive conditions of his treatment, the child made a full recovery. However, the bulk of a general practitioner's work was more mundane. GPs prescribed medicines for a range of illnesses, treated injuries and local infections, lanced boils and syringed ears.

Middle- and upper-class patients paid directly for care from general practitioners, but they did not all pay the same fees. GPs charged according to the patient's income. In 1917, the Ladies Diary and Housekeeper provided a table of charges, based on the rental value of homes, suggesting that GPs would charge from 2s 6d to 10s 6d for a visit, and from 1 to 5 guineas for a midwifery case. By the early twentieth century, some medical practitioners built successful practices among the upper working classes, by lowering their fees to as little as 1s or even 6d – a price that put their services within reach of many working-class patients (Digby, 1999, pp. 100–3).

In the late nineteenth century, working-class men began to obtain access to general practitioners through insurance schemes. In Britain, these schemes were run by friendly societies or sick clubs (Figure 7), in France, they were called sociétés de secours mutuels (mutual aid societies) and in Germany, Krankenkassen (literally a ‘sick box’). All worked on the same principle: for a small weekly payment, workers were entitled to financial help when ill, and had access to treatment from the society's doctor. A substantial portion of the male working population had some form of insurance cover. In Britain, friendly society membership peaked in 1900, when around half of the entire adult male population was insured. In France in 1902, over two million people belonged to some form of insurance scheme (Mitchell, 1991, p. 181). However, working women and the families of workers were often excluded from many of these schemes, and thus were less likely to go to a GP. In the twentieth century, state health insurance schemes gradually replaced the direct provision of medical care to the poor. Health insurance was set up in Germany in 1883, and in Britain in 1911 under the National Health Insurance Act. These schemes, which initially covered only the poorest workers, operated in the same way as private insurance, except that the workers' contributions were augmented by contributions from his employer and the state.

Figure 7
Figure 7 Membership certificate of Flint Glass Makers' Friendly Society, nineteenth century. This elaborate certificate exemplifies the virtues aspired to by members of the Flint Glass Makers' Friendly Society. The main vignettes show scenes of glass processing – the common occupation of members. The female allegorical figures represent industry (with her spindle) and justice (with the scales and sword). Wellcome Library, London

The combination of low fees and private and state health insurance produced a huge expansion in the number of patients who consulted a general practitioner. In Britain, the number of GPs doubled between 1860 and 1914, while the number of patients attending each practitioner remained roughly constant (Hardy, 2001, p. 17). However, not everyone was equally well provided with care. Even in the twentieth century, patients in remote Scottish islands faced a journey of several hours to consult a doctor. The situation was much worse in the eastern regions of Russia, where in 1913 the ratio of licensed practitioners to population was less than 1 in 10,000 (Hyde, 1974, p. 18).

While more people gained access to GP services in the first decades of the century, not everyone received the same quality of treatment. Patients who paid a higher fee received a better quality of care. General practitioners would call on wealthier patients in their homes, discuss the case, and offer advice as well as therapy (Figure 8). Better-off patients were more likely to receive a thorough physical examination, using diagnostic instruments. They were also more likely to have specimens sent for laboratory tests, and to receive new treatments, such as vaccine therapy or insulin for diabetes. They also benefited from referral to specialists for further diagnosis or treatment (Digby, 1999, p. 200).

Figure 8
Figure 8 In this cartoon, the two well-dressed ladies share the following exchange: ‘“Isn't it tiresome! I've just got a lovely new bicycle, and now my doctor absolutely forbids me to cycle! What would you advise me to do?” “Change your doctor.”’ The cartoon neatly captures the new craze for bicycling among women at the end of the nineteenth century – a fashionable pursuit, as well as a means of getting healthy exercise. It also reveals something of the upper-class attitude towards doctors – they are there to serve, and can be dismissed if the patient disagrees with the practitioner's opinion. From Punch, 29 January 1898, p. 45

Well-off patients could afford to employ several practitioners if they were unhappy with the treatment offered by their original doctor. However, this was a mixed blessing, if the doctors disagreed. For example, when Sir Leslie Stephen fell ill in 1902, he was initially attended by the family practitioner, Dr Seton. The family then called in Sir Frederick Treves, a distinguished surgeon, to give another opinion. Seton thought Sir Leslie was improving, Treves thought that he was seriously ill and required an operation. The family accepted Seton's view, and he remained in charge of the case until the autumn of 1903, when another surgeon, Hugh Rigby, was called in. He brought in a GP (Dr Wilson) to visit every day. The efforts of all these medical men had little effect – Sir Leslie died in February 1904 (Trombley, 1981, pp. 77–80).

Patients paying the lowest fees or receiving care through an insurance scheme received a much more basic consultation. In the next reading, Anne Digby examines state-funded care provided through the National Health Insurance Act of 1911.

Activity 2

Read ‘Services under the National Health Insurance Act’. In her view, did the National Health Insurance scheme provide good-quality care to all? Were both patients and doctors satisfied with the quality of the service?

Click to view the article 'Services under the National Health Insurance Act'.

Answer

Digby makes clear that ‘panel’ patients received a lower-quality service in virtually every aspect of care than did private patients – including the surgery accommodation, the range of medicines prescribed, the length of consultation and the quality of the dressings. However, patients seemed happy with the service – relatively few of them changed their doctor or complained about the care they received. Digby suggests, however, that this may have been because they had low expectations of a service that they saw as similar to that provided by earlier sick clubs. Despite the long hours and heavy workload, doctors also seemed reasonably happy working under the National Health Insurance scheme, which provided them with a guaranteed income. However, she also notes instances of doctors not accepting that panel patients should receive poor care: for example, some were accused of ‘over-prescribing’ (i.e. not conforming to the expected standard of prescribing) and others complained about the use of poorer-quality bandages for their panel patients.

Digby's account may give the impression that patients were powerless in the face of a form of rationing of care, imposed by government and the medical profession. In fact, they exerted control over how they used the National Health Insurance system. Some commentators complained that patients abused the system by going to see their doctor for no good reason (Figure 9). Although doctors might appear to be ‘fobbing off’ their patients with stock medicines, in fact practitioners complained that patients expected to leave the surgery with a bottle of medicine (most drugs were dispensed in liquid rather than tablet form in this period). They were therefore forced to act in response to patient demand. Some of these frequently prescribed medicines had little pretensions to do any good. Elsewhere in her book, Digby reports that one doctor handed out coloured aspirins. In another practice, one of the stock medicines ‘was labelled “Mist. ADT” or “Mist. Any Damn Thing” [‘Mist.’ is an abbreviation of the Latin word for ‘mixture’ ] which was given to “somebody you thought there was nothing wrong with, and you could do nothing for”’ (Digby, 1999, p. 198). More alarmingly, another practitioner

prescribed a mixture … called Mist. Explo. It was a clear yellow liquid made from a few bright yellow crystals dissolved in water. The crystals were apt to ignite if left to dry in the sunlight, hence the name Mist Explosive. I don't remember the exact chemistry of this wonder drug but it was a derivative of picric acid and quite harmless when well diluted and used as a bitter tonic.

(Porter, 1999, p. 196)

Such medicines seem little different to patent medicines, which doctors so frequently condemned.

Figure 9
Figure 9 While contemporary commentators (as well as historians) expressed concern about the poor standards of care provided by panel doctors under the National Health Insurance scheme, patients were criticised for overusing the service. The caption to this cartoon, entitled A Cheap Diversion, reads: ‘“Let's go to the music-hall? “Naw.” “Let's go to the sinnemer, then?” “Naw.” “Well, come on, let's go and see my panel doctor?” “Right-o.”’ From Punch, 1913, p. 46. Wellcome Library, London

5.3 Irregular and unorthodox practitioners

In the twentieth century, unlicensed practitioners continued to be an important source of medical advice. Faced with illness, people of all classes consulted relatives, neighbours with a reputation for curing or the local retail chemist – who had no medical training but a wide knowledge of therapies. Substantial numbers of patients from all classes chose to consult unorthodox practitioners who offered ‘natural’ forms of healing. Herbal medicine remained popular among working-class patients, and flourished in the industrial north and midlands of England. There were perhaps 2,000 herbalists practising before the First World War, and many more working part-time (Brown, 1985). By contrast, homeopathy declined in popularity in Britain and over much of Europe (with the exception of Germany and Holland). In 1874, there were around 300 practitioners in Britain; by 1909, there were 196 (Nicholls, 1988, p. 182). The decline of homeopathy did not herald any general slide in the popularity of unorthodox medicine. The early twentieth century saw the rise of Christian Science – a sect founded in 1879, whose followers rejected orthodox medical treatment in favour of mental and spiritual healing – and of osteopathy – a system of treatment devised in 1874, which was based on manipulating the joints.

5.4 Clinics and outpatient services

In addition to acquiring greater access to general practitioners in the late nineteenth and early twentieth centuries, poor patients also received more medical help from the outpatient departments of charitable hospitals and dispensaries. Hospital outpatient departments were an increasingly popular source of care: between 1860 and 1900, the number of patients attending the outpatient department of the London Hospital increased from 25,000 to 220,000. By 1910, there were 1.75 million attendances each year at outpatient and casualty departments across London, and provincial hospitals experienced similar levels of demand. Consequently, huge queues regularly built up, and patients had to wait for up to six hours to see a doctor. In an effort to reduce demand, some hospitals introduced a small charge for repeat consultations unless patients could prove they were unable to pay. Treatment was similar to that in a GP's surgery – a rapid examination and a routine prescription, although some patients were referred to specialist departments or admitted to the hospital as inpatients.

Charitable dispensaries, funded by wealthy donors, were an important source of care for working-class patients in the nineteenth century right across Europe–they were founded even in Russia, where there was no strong tradition of medical charity. At the end of the nineteenth century, the charitable institutions inspired the creation of provident dispensaries, which operated as a form of health insurance. In return for a small weekly subscription (one Northampton dispensary charged 1d for adults and 2d for families), members received basic medical treatment at the dispensary's premises. The work of these dispensaries has received little attention from historians. The York Dispensary is the subject of one of the few detailed studies, and, if it is typical, then dispensaries were lively institutions, responsive to a wide range of medical needs within the community. Founded in 1788, the York Dispensary quickly became an important source of medical care: in the 1880s, around 5,000 patients – roughly 10% of the city's population – called there each year. Attendance at the dispensary peaked in 1903–4, when 9,000 patients used it, but fell after the introduction of National Health Insurance. However, the numbers of women, children and the elderly – all uninsured under NHI – increased after 1913. As well as providing consultations with a general practitioner, the dispensary had a dental service, and an inpatient and outpatient maternity service. It also played a role in dealing with outbreaks of epidemic disease (Webb, 1988).

Around this time, other specialised dispensaries and clinics, dealing with specific diseases or particular groups of the population, opened their doors. Tuberculosis dispensaries were established by charities and local government as part of the campaign to control the disease. By 1938, there were 482 TB dispensaries in Britain, dealing with over 100,000 cases per year. In them, patients received physical examinations to check the condition of their lungs. They were given advice on diet and lifestyle to help combat the infection, and on how to avoid spreading the disease. Treatment was limited to cough mixtures and cod liver oil, which was supposed to strengthen the body and help increase weight. VD clinics providing free and confidential treatment to everyone were opened as a means of controlling the spread of infection. However, they were not attractive places – many clinics were poorly funded and rather forbidding. Clinics provided as part of the School Medical Service were more popular. Children in poorer families had little access to medical care, which their parents were unable to afford – unless a child was very ill, the parents were unlikely to call on the services of a GP. Not surprisingly, when local authorities were given powers to institute medical inspections of schoolchildren in 1906, they found many untreated complaints. ‘[I]nspection showed whole classes of children infested with head vermin; many had body lice. The worst would sit isolated in a small sanitary cordon of humiliation. They would later be kept at home, their heads shaven, reeking of some rubbed-in disinfectant’ (Roberts, 1971, p. 58). The First World War gave a new impetus to the School Medical Service: faced with the massive death toll on the battlefields, one commentator explained, ‘it behoves us to see that the rising generation is reared amid healthy surroundings and sent forth into the world under the best possible conditions’ (quoted in Webster, 1983, p. 73). Local authorities began to open clinics to treat common minor complaints. By 1920, there were 288 clinics in England and Wales, dealing with head lice, ringworm and orthopaedic conditions, providing dental inspections, free spectacles and (through local hospitals) the removal of tonsils and adenoids (enlarged lymphatic tissue between the nose and the throat, which can interfere with breathing) (Hirst, 1989, pp. 327–42; Webster, 1983, pp. 71–6).

5.5 Nurses, district nurses and midwives

While access to GPs and outpatient services was growing, access to nursing care was expanding in some sectors and declining in others. The numbers of trained professional nurses who were employed in wealthy households to care for seriously ill family members fell in the first decades of the twentieth century. These nurses stayed in the patient's home, carrying out the doctor's instructions, monitoring the patient's condition and providing general care – making beds, bathing the patient, giving medicines and keeping the sickroom in good order. The role of the private nurse was not an easy one: she had an ambiguous social position – above domestic servants but below family members. The ideal private nurse, according to one textbook, should possess ‘average intelligence’ but ‘more than the average amount of tact’ (Wightman, 1912, p. 10). Private nursing slowly died out after 1918, at the same time as did the live-in domestic servant. By this time, few households had enough room to accommodate a live-in nurse, and patients wealthy enough to afford a private nurse could get the same services in a nursing home (discussed in Section 6).

At the same time, poor patients were enjoying increasing provision of nursing care. The late nineteenth century saw the creation of new charities to provide the sick poor with nursing care in the home. Some of these organisations were secular, but a substantial proportion were religious, with care provided by orders of nursing sisters. These nurses paid short visits to their patients, caring for the sick, giving advice and sometimes helping with housework. From these fragmented charities, a coordinated district nursing service developed in Britain, which remained part of the voluntary sector until the 1950s. The backbone of the service was the Queen Victoria Jubilee Institute for Nursing the Poor in their Own Homes founded in 1889. In 1896, it had 539 nurses across the country: by 1914, there were over 2,000 Queen's Nurses. Existing nursing charities became affiliated to the institute, which provided six-month training courses for ‘village nurses’ who worked in rural areas (Dingwall et al., 1988, pp. 173–97).

In response to public demand, district nurses increasingly took on midwifery work, especially in rural areas. The demand for their services was in part driven by the increasing regulation of midwifery, and a reduction in the number of women working as midwives. From the early twentieth century, midwives attended the majority of births. Most were paid directly by their clients, and, as with other medical services, the better-off were able to afford practitioners who were better trained. Respectable working-class women would save up to employ a trained midwife to deliver their babies. The poorest women employed untrained midwives, often called handywomen, who charged lower fees and stayed on after the birth to help look after the household (Llewelyn Davies, [1915] 1978). However, in the early twentieth century, these untrained midwives were gradually pushed out of practice by the registration of midwives and new regulations on training (Dingwall et al., 1988, pp. 145–72; Loudon, 1992, pp. 172–92, 206–33).

6 Hospital care

In most aspects of medical care, the rich generally enjoyed better access to medical services and better-quality services than the poor. The only exception to this rule was hospital care. In the nineteenth century the ‘deserving’ poor – whose respectability was guaranteed by the need for them to have a letter of admission from a subscriber or employer – could receive medical and surgical treatment in charitable hospitals. The very poor could obtain care through Poor Law hospitals, which in 1926 were transferred into the hands of local authorities. As the voluntary hospitals became associated with high-quality care, some commentators complained that the poor received far better hospital care than the rich. If a poor person needed to undergo an operation, he or she might be treated in the latest, most modern facilities in a teaching hospital. A rich client would have to go through the same procedure in his home, in a room rigorously scrubbed but lacking specialised equipment.

In the late nineteenth century, hospital facilities were gradually opened up to all classes. The upper and middle classes could receive treatment in private wards or in beds on general wards. These were not cheap: when Guy's Hospital accepted paying patients in 1884, they were charged 1 guinea per week for a ward bed and 3 guineas for a bed in a private cubicle. By 1902, private hospitals could charge as much as 4 guineas (Abel-Smith, 1964, pp. 149, 194). Alternatively, wealthy patients could pay for care in private nursing homes, which began to appear in the 1890s. By 1921, there were 26,000 nursing-home beds in England and Wales. Convalescent hospitals also offered a comfortable environment in which to recover from illness – Thomas Cook, the holiday firm, even had a facility in Egypt (Abel-Smith, 1964, pp. 133, 339).

Those patients who were unable to afford private care, but not so poor as to qualify for charity gained access to hospitals either by directly paying a contribution towards the cost of their care or through some form of insurance. The British Provident Association offered a 1-guinea policy which paid for up to three weeks in hospital. More often, workers paid into a ‘Saturday fund’ – these were schemes where, in return for a small, regular contribution, patients were ensured access to hospital facilities (Abel-Smith, 1964, pp. 327–8, 338–9).

While hospitals were increasingly open to all classes, there were still serious geographical inequalities. Far more beds were available in London than in any other city, and there were more facilities in urban than in rural areas. From the 1860s, small cottage hospitals helped to fill this gap, providing care to all classes in rural areas. From the outset, cottage hospitals were funded partly by patients' contributions and partly by donations. They proved popular, and numbers grew rapidly: the first cottage hospital was founded in 1859, and by 1880 there were 180 such facilities. Most were small institutions – many had around twenty beds – staffed by local general practitioners. Although cottage hospitals could not boast the high standard of facilities of the voluntary hospitals, many had operating theatres where GPs or consultant surgeons performed quite complex surgery.

Not all hospitals offered equally good levels of care. The next reading gives a patient's view of being treated in two voluntary hospitals and a Poor Law hospital.

Activity 3

Read ‘Care in hospital’. What differences does Bella Aronovitch note between the voluntary hospitals and the Poor Law hospital? How does she describe the attitude of staff towards her, and what does she think of them?

Click to view the article 'Care in hospital'.

Answer

Aronovitch notes several differences between the voluntary and Poor Law hospitals. Larger wards, fewer staff, the numbers of geriatric patients and the uniforms mark out the Poor Law hospital. However, there are many similarities. She describes all the hospitals as being highly ordered institutions, organised to suit the staff, not the patients – for example in the rules on visiting times. None of the staff make any efforts to ensure that patients are kept amused, and as a result the whole environment is very depressing.

According to Aronovitch, all the hospital staff maintain a rather supercilious attitude towards her. No one is willing to discuss her treatment, or the likely outcome of her case. Indeed, some even joke about her condition in her presence. The consultants have the most superior attitude. Perhaps the consultant in the first hospital, who shakes hands with his private patients, would have spent more time talking to them. A woman doctor she finds easy to talk to – but she clearly still joins in the professional ‘conspiracy of silence’. Curiously, Aronovitch seems to accept the doctors' view that ‘this is the way things are’ and does not question their competence or complain about the ineffectiveness of the care she receives.

7 Conclusion: the medicalisation of society?

7.1 A review

All the evidence you have looked at so far suggests that historians are right to see a ‘medicalisation’ of society in the sense that when ill, people were more likely to consult a qualified medical practitioner in 1930 than they had been in 1880. The extension of medical services – combined with the increase in chronic complaints – meant that working-class patients in particular had much greater contact with general practitioners, health visitors and nurses. However, it is also clear that there were continuing variations in the level of health-care provision. Not all social groups enjoyed the same access to medical services. Working men were the chief beneficiaries of insurance schemes, infants and children had their own clinics, but women remained poorly served. Poorer sections of society did not enjoy the same quality of services as the wealthier classes.

Did the greater availability of treatment bring greater power to medical practitioners? Did patients become powerless consumers of medical advice?

Activity 4

Before reading the rest of this conclusion, pause and review the material given in this course, and try to identify any evidence of doctors' power over their patients. Is there any evidence of patients exerting control when dealing with illness?

Answer

The material presented here suggests that patients did regard medical practitioners as authorities and respect their advice and instructions. People were eager to consult practitioners and were prepared to wait for a consultation and advice. Despite the complications of her case, Bella Aronovitch did not question the competence of her doctors. However, patients were by no means passive or dependent on doctors. They took responsibility for their own health and illness, dealing with bouts of minor illness within the home and buying tonics and pills in the face of doctors' disapproval. Even when seeking medical help, patients exercised considerable choice over where to obtain help; if their finances permitted, they could call on several doctors, or choose to go to unorthodox practitioners. They forced doctors to fulfil their demands for medicines – even if the medicines themselves were of limited therapeutic value. Patients were not in thrall to the medical profession – while recognising and respecting the specialist knowledge of practitioners, they maintained forms of control over their health and their use of medical services.

7.2 The public take control

There is also good evidence which suggests that the public took control over their own health by choosing not to seek medical help, or by rejecting offers of help and treatment (Figure 10).

Figure 10
Figure 10 Not all visits from well-meaning charity workers were welcome. Lady-visitors who dispensed advice on child care were often portrayed as being nosy and interfering, and dispensing useless advice. In this cartoon, from the London Mail, 1915, the mother says to the district visitor: ‘Lumme miss! There ain't no danger of infection. Them children wot's got the measles is at the 'ead of the bed, and them wot ain't is at the foot.’ The working woman's comical response is presumably prompted by the visitor's advice to isolate the children suffering from measles – which was quite impossible in the small homes of the working classes. The cartoonist conveys the stereotyped character of the two women by their clothes. The middle-class visitor's fussy outfit of hat, gloves and umbrella contrasts with the plain and practical clothing worn by the mother. Wellcome Library, London

The Women's Health Enquiry survey of working-class women of 1933 showed that a large proportion of working-class women suffered from chronic illnesses which went untreated (Spring Rice, 1981, pp. 28–43). The next reading is an extract from this survey, published in 1939.

Activity 5

Read ‘The health of working-class women’ (. What reasons does the author give for the women not receiving treatment? In the light of this source, do we need to revise our idea that state intervention ensured healthcare for all sections of society?

Click to view the article 'The health of working-class women'.

Answer

The author suggests that while cost was the greatest barrier to healthcare, the women had many reasons for not seeking treatment: a ‘disinclination to fuss’ over themselves, greater concern with the health of their families, exhaustion, ignorance and prejudice. The women surveyed had a fear of any sort of operation – from minor dental work to major surgery.

The results of the Women's Health Enquiry survey showed that many women were not well served by government healthcare services – relatively few went to panel doctors or used clinics. The reading suggests that while ensuring that the population could afford medical advice and therapy was an important step towards ensuring healthcare for all, it was not the whole story. In order for the women in this survey to seek medical help, they also needed support in getting to the hospital or clinic and in looking after the home while they underwent treatment. Women also had to be cured of their fear of surgery.

Patients also rejected offers of care for venereal disease and tuberculosis. VD sufferers were reluctant to undergo the long and painful therapies used to treat syphilis and gonorrhoea, and often did not complete the courses of treatment. People infected with TB also refused opportunities for treatment, for fear of being stigmatised. There was a widespread fear of people with TB. Long after doctors realised that tuberculosis was infectious, many people continued to believe that the disease was hereditary, and would be passed on from parent to child. Patients were often unwilling to come forward for treatment or to follow the advice given, for fear of being identified as a ‘lunger’. One patient wrote: ‘It is depressing to find how frightened people are becoming of us. I am being turned out of my rooms, and this will make my fourth move in this particular town’ (Bryder, 1988, p. 223). People infected with TB were dismissed from their jobs, and even those who recovered from the disease found it very difficult to find employment.

Inpatient care in specialist sanatoria, with its emphasis on fresh air at all times and a rich diet, was also unpopular. In the following reading, Linda Bryder describes patients' attitudes towards the strict sanatorium regime.

Activity 6

Read ‘Resistance to care – sanatorium treatment’. Are the patients happy to accept the prescribed regime? How successful are the sanatoria staff in imposing strict discipline on their patients?

Click to view the article 'Resistance to care – sanatorium treatment'.

Answer

Despite the gravity of their illness, the patients in TB sanatoria are not passive. They complain about the food, the spartan conditions and about having to sleep in the open air in bad weather (and not without good reason, it would seem!). They also fight against the rules and attempt to maintain normal patterns of life, by mixing with patients of the opposite sex and drinking. Ultimately, they reject the whole sanatorium experience by simply leaving – and Bryder's figures suggest that a very large proportion of patients did not go through the prescribed course of treatment.

Staff in the sanatoria are clearly keen to enforce the rules – they fight against complaints by trying to discredit the patient's judgement (although Bryder notes that the introduction of heating may have been a response to patients' discomfort). Their main sanction is to send patients home for breaking the rules. This may explain why staff are so dismissive of patients who discharge themselves – they are not only rejecting the care offered, but also subverting the main sanction used to enforce discipline.

Even patients in private sanatoria rebelled against the discipline. In 1909, Alice Clark, a young woman from a wealthy family with a history of TB, went to Nordrach-sur-Mendip, the oddly named English sanatorium modelled on a German institution. The regime there was particularly strict: patients had to conform to a rigid timetable, take their own temperatures four times a day and eat a prescribed diet. Alice Clark

found Nordrach-sur-Mendip a … cruel experience, for she was by now very sick and weak, complaining how bedroom windows were kept wide open at night even in subzero temperatures or during snowstorms, how she was required to empty her own chamber pot while in a high fever, and how she was forbidden to employ a nurse to attend to her. Separation from family and friends proved especially troubling to her. Within a few weeks she was writing that she felt she had been making better progress at home.

(Holton, 1999, p. 87)

Despite being allowed a sympathetic nurse (a fellow campaigner for votes for women), Clark left the sanatorium, and subsequently recovered.

Even when ill, then, patients maintained a degree of independence over whether to seek help, and whether to follow medical advice. They showed a similar response to education by health professionals, aimed at teaching them how to maintain a healthy lifestyle. This was not a new phenomenon. In the eighteenth century, physicians had written popular books on how to preserve health. However, the early twentieth century saw a huge expansion in the way this information was disseminated – through new media such as film and radio – and in the target audience. How well people absorbed these messages about healthy living is very hard to gauge. Books, exhibitions and health films were certainly very popular, attracting large audiences. A survey by the Women's Co-operative Movement found that working-class women wanted more sources of information, advice and support during pregnancy and when bringing up small children (Llewelyn Davies, 1978). Another survey of working-class women in the 1930s found that about half of the respondents had learned some skills though a welfare centre or clinic. A smaller number claimed to have received some education through a health visitor or district nurse. However, even if people were willing to listen to advice, this does not mean that they put it into practice. Some did – a few women practised the breathing exercises they learned in school into adult life (Spring Rice, 1981, pp. 82–90).

7.3 Childbirth

One aspect of life which is often seen as having been ‘medicalised’ in the twentieth century is that of childbirth. Historians argue that until the nineteenth century, pregnancy and birth were dealt with within families, with minimal input from medical practitioners. By the late twentieth century, pregnancy was labelled as a form of illness by some practitioners, births took place in hospital and pregnant women, new mothers and their babies were subjected to constant supervision by medical personnel. What about the early twentieth century? Had birth come under the control of the medical profession by 1930?

The answer has to be that it had not. Although obstetrics and gynaecology emerged as specialist areas of medicine around this time, doctors and nurses did little to monitor the health of pregnant women – in part because there was little they could do to help women in the event of complications. Even after local authorities in England and Wales established antenatal clinics, many women attended only once or twice. The medical profession did exert some control over birth, as a consequence of a concern about persistently high levels of maternal mortality. Not surprisingly, practitioners chose to focus on clinical problems associated with birth, such as sepsis and haemorrhage, rather than on social factors, such as poor diet and long working hours, which were also associated with death in childbirth. Their chosen solution to these problems was to encourage women to give birth in hospital, in sterile conditions and with medical staff on hand. The proportion of births taking place in hospitals began to rise at this time – from 15% in 1927 to 24% in 1933. This shift towards hospital birth was not entirely due to pressure from medical practitioners. Women welcomed the prospect of giving birth in hospital under anaesthesia – which midwives working in the home were not permitted to offer – and grasped the opportunity to take a few days' rest away from domestic responsibilities after the birth. The three-quarters of all babies that were born at home were also brought under a degree of medical supervision. In the twentieth century, midwives were required to be registered and to have gone through a set training programme. They were required to call in a GP if there were complications, and were told to use aseptic techniques (although these were very difficult to achieve in poor households) (Lewis, 1980, pp. 117–61; Loudon, 1992, pp. 234–53).

Even in 1930, doctors had at best limited influence over pregnancy and childbirth. Their input would have varied between classes. A middle-class women, able to afford regular visits from a general practitioner, and to pay for childbirth in a hospital or nursing-home, would have been under regular, if not constant, medical supervision. A poor mother would have had little contact with medical services during pregnancy and would have called in a midwife to attend at the birth (Llewelyn Davies, 1978). Overall, then, early twentieth-century medical practitioners had greater influence over the sick and the healthy than had their nineteenth-century counterparts, but this influence was not all-pervasive, and nor did it go unchallenged.

Conclusion

This free course provided an introduction to studying the Arts and Humanities. It took you through a series of exercises designed to develop your approach to study and learning at a distance and helped to improve your confidence as an independent learner. 

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Extract references
Aronovitch, B. (1974) Give It Time: An Experience of Hospital 1928–32, London: Andre Deutsch, pp. 38–43, 50–2, 55–6, 60, 62–7, 71–2, 74 (Reading 3).
Bryder, L. (1988) Below the Magic Mountain: A Social History of Tuberculosis in Twentieth-Century Britain, Oxford: Clarendon Press, pp. 205–11 (Reading 4).
Digby, A. (1999) The Evolution of British General Practice, 1850–1948, Oxford: Oxford University Press, pp. 318–22 (Reading 2).
Roberts, R. (1971) The Classic Slum: Salford Life in the First Quarter of the Century, Manchester: Manchester University Press, pp. 97–9 (Reading 1).
Spring Rice, M. (1981, 1st edn 1939) Working-Class Wives: Their Health and Conditions, London: Virago, pp. 39–43 (Reading 5).

Acknowledgements

This course was written by Dr Debbie Brunton.

This free course is an adapted extract from the course A218 Medicine and Society in Europe, 1500–1930, which is currently out of presentation

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Reading 13.1 Roberts, R. ‘The Classic Slum: Salford Life in the First Quarter of the Century’, 1971, Manchester, Manchester University Press. Courtesy of Manchester University Press

Reading 13.2 Digby, A. ‘The Evolution of British General Practice 1850-1948’, 1999, Oxford, Oxford University Press. Reprinted with permission from Oxford University Press

Reading 13.3 Aronovitch, B. 'Give it Time. An Experience of Hospital 1928-32', 1974, London, André Deutsch

Reading 13.4 Bryder, L. ‘Below the Magic Mountain. A Social History of Tuberculosis in Twentieth-Century Britain’, 1988, Oxford, Clarendon Press. Reprinted with permission from Oxford University Press

Reading 13.5 Spring Rice, M ‘Working Class Wives. Their Health and Conditions’, 1981, London, Virago, first edition , 1939

Figures 1 - 10 © The Trustees of the Wellcome Trust, reproduced with permission

All other materials included in this course are derived from content originated at the Open University.

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