Medicine and Charity Before the Welfare State

Jonathan Barry, Colin Jones

• Publisher: Routledge
• Year: 2002
• ISBN:
  9781134833450
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

What have been the roles of charities and the state in supporting medical provision? These are issues of major relevance, as the assumptions and practices of the welfare state are increasingly thrown into doubt. This title offers a broad perspective on the relationship between charity and medicine in Western Europe, up to the advent of welfare states in the 20th century. Through detailed case studies, the authors highlight significant differences between Britain, France, Italy and Germany, and offer a critical vocabulary for grasping the issues raised. This volume reflects recent developments relating to the role of charity in medicine, particularly the revival of interest in the place of voluntary provision in contemporary social policy. It emphasizes the changing balance of "care" and "cure" as the aim of medical charity, and shows how economic and political factors influenced the various forms of charity.

1
IMAGINING MEDIEVAL HOSPITALS

Considerations on the cultural meaning of institutional change

Miri Rubin

Some of us, social historians interested in poverty and its relief in the medieval world, have been attracted in recent years to the study of hospitals. In the absence of a medieval bureaucracy engaged in the provision and supervision of relief, and given the dearth of comprehensive documentation relating to poverty and the poor, medieval hospitals seem to provide one of the few areas offering scope for a close study of the experience of poverty and its relief. Medieval hospitals were usually endowed institutions, and since they often existed under the tutelage of the church, they generated a variety of legal and ecclesiastical documentation. In the countryside, these institutions owned land and were involved in the business of parochial as well as manorial administration; in towns, they often acted in the urban property market, leaving their mark in sources related to the purchase and exchange of tenements, in rentals, and in records of ownership disputes. Through the careful juxtaposition of these materials it is possible to trace the institutional histories of individual hospitals, and occasionally, wherever statutes, rules, exceptional law-suits or evidence of benefactions have survived, we are allowed a glimpse into a hospital’s day-to-day life. But these glimpses are rare and, on the whole, do not allow us to recreate a full picture of the nature of life, relief and patronage experienced in the medieval hospital. That this is so is a source of frustration to those of us who have studied hospitals as ‘bridges’ to the poor, as well as of exasperation to some of the readers of our works.¹

But it is not the absence of material alone which blights the study of medieval hospitals and the poor treated in them. Those reading descriptions of medieval hospitals often complain about the unfamiliar nature of such institutions: medieval hospitals seem to fulfil only a few of the functions expected of them by our contemporaries. No matter how good our archive we hear little of the type of medical care, the number of inmates and their ailments, little about rates of cure, regimes and routines maintained in these houses. Occasionally a stray kitchen account, a fragment of a work of an, a testament, or a tax-return, may provide a more detailed picture of hospital life, and these are triumphantly highlighted by the historian.² But through such flashes we seldom capture the sense of routine, of the nature of relief offered, of treatment, or of subsequent cure and recuperation, let alone a picture of the social relations which developed under and around the hospital’s roof. To complicate matters, not only have medieval hospitals left very little evidence about treatment, but they additionally, and maddeningly, emerge as institutions in which a whole array of non-medical activities took place. They were venues for money-lending, liturgical practice and intercession, for pastoral work, a retirement-house for elderly and well-to-do burgesses, they could provide accommodation for clerics and students, and scope for speculation in the land-market. The discovery of such non-caring activities under the guise of charity has induced some critics to claim that medieval charitable activity was a myth, and that looking at hospitals is an ill-conceived project.³ Such critics would maintain, and not without some reason, that far more effective, and far more revealing, are those studies which aim to explore forms of communal relief and mutual help which took place outside institutions and to a large extent informally, within family, in provision for the aged in rural communities, in neighbourly help, in other words, in the moral economy of pre-industrial society.

Such a ‘structural’ approach to arrangements for relief, which imputes to them a strong fit to other social institutions and which falls in with demographic and economic features, is undoubtedly true. Thus provision for need within a system where extended families prevailed will differ from that arising where nuclear families are the rule. Furthermore, the structure of rural indigence and of urban poverty, and even within these spheres the distinct types of ‘shallow’ and ‘deep’ poverty recently discussed by Paul Slack,⁴ each requires different solutions and can be contained by differing preventives. And this has, on the whole, been ignored.

Yet no matter how diverse and structurally embedded the provisions for need, there is another area of concern which can hardly be ignored, and which is none the less ill-captured within models that attempt to fit the demand for, with the supply of, relief. Mediating between need and its relief are the processes of identification and interpretation of need, the decision to act, and the formulation of strategies for action in the minds of those able to relieve. This sphere is almost totally neglected by students of relief institutions, and it is particularly here that a fresh look at hospitals could now yield rich returns. In their shifting usages and meanings hospitals reflect changes in the choices and in the priorities of relief, they force us to consider the ways in which relief and social responsibility were perceived, and more importantly, how these were understood and constituted in a given culture. Relief is always a product of deliberation; and it is discursively constructed. Since we shall never recover the whole web of relations which constituted a ‘moral economy’ of the Middle Ages, we are in fact forced to contend with the dynamic interactions operating at the loci of charity, relief and exchange. As we do so, we shall uncover the language of relief, within which the predicted and structurally fitting solutions, their choice or their rejection, made sense, and without which or outside of which, they come to us bearing altogether little meaning.

To say this is to step away from any functionalist approach which would see straightforward and effective processes of adjustment determining responses to new social realities. Rather, to speak of a discourse of charity is not to talk of a single position on charity, nor of a necessary fit between it and some objective need experienced by the poor. It is rather to insist that ‘objective’ need is never transparently encountered by us or by our historical actors, but rather a version seen in terms of a discourse on social obligation, wellbeing, merit and virtue which interprets the problem and within which responses to it are constructed. And this response can fail or succeed in meeting experienced need, or in agreeing with other discourses on charity and poverty. The discourse of charity then problematizes and makes the indigence of others more or less relevant to those able to redistribute. Allocation of resources does not operate ‘efficiently’ since maintenance and relief of as many people as possible is not a coherent or a universal interest by any means, nor is it universally and similarly perceptible by all. Yet relief systems do evolve, a degree of redistribution is effected in most societies, and as such it is always negotiated within the domain where culture and politics merge, through the language of social relations and its attendant meanings. In other words, there is no reason to assume that an equilibrium between supply and demand for relief is an aim, even in cases where serial material allows us subtly to trace the creation of such a balance, without due consideration of the variety of aims which motivate charitable action. The relation between need and provision is mediated through a nexus of perceptions of social roles, of the nature of relations and obligations, of the symbolic value of giving and receiving. Furthermore, in deployment and use of the language of relief different understandings of responsibility can coexist: those of the laity and the clergy, of men and women, of merchants and artisans, burgesses and peasants. The boundaries of responsibility become more clearly articulated only when a system of subscription is enforced, and even then the meaning of contribution and the assessment of a system’s adequacy cannot be gathered merely from formal pronouncements. Even when relief is bureaucratically provided, measured against allegedly universal standards, the ongoing nature of need and of the imperative which engages friends and strangers to relieve it, is constructed within a cultural field which we must identify and consider.

To acknowledge this is not to dispute the strong correlations between types of material need and the particular forms of provision designed to meet them. Indeed, the link is powerfully demonstrated in Richard Smith’s analysis of the provision for aged tenants within the manorial system,⁵ or in the types of distributions devised by Italian charities such as Or San Michele in fourteenth-century Florence.⁶ But a language of charity and obligation interposes between the identification of need, its interpretation, and finally the response to it. This language articulates incentives to altruistic behaviour, but harbours a considerable variety of possible courses of action, so varied at times that it can provide avenues for evasion on the issue of giving, resulting in a less than efficient system. What is most striking in popular religious instruction of the later Middle Ages is just such broadness and variety of demands for charitable action, within a powerful idiom of charity and brotherhood.⁷ Medieval hospitals existed within this cultural setting, and were designed and shaped by it; this is to say that involvement in their foundation or maintenance through benefaction was no simple response to normative religious dictates.

Looking at medieval hospitals and identifying the language of charity within which they were conceived need not imply a blindness on our part towards the power relations which this language legitimized, nor an acceptance on our part of the merits or necessity of any given language of charity, its virtue or its aptness. Rather, by looking at hospitals, at the variety of activities practised within them in the idiom of charity, one can explore the range of possible meanings existing within this language. By discerning the preference of particular meanings of charity over others, and through the effect of such choices on the fortunes of hospitals, we can learn some hard facts about attitudes which settle on one, rather than on another, of the meanings existing within the charitable array. Potential givers were constantly assessing the fit of their actions with their resources in terms of the charitable idiom, to produce the most satisfying package of social and spiritual reward. The language in which grants to hospitals were made was that also used to describe the terms of loans arranged between hospital and patron, or even to establish outright sales between them. The impulse towards engagement in the public action of endowment and benefaction was influenced by ideas about well-being and social responsibility, as well as by an acute analysis of the elements of order and harmony in the town. All these evaluations were determined by the scope of meanings which the attendant language of charity offered, by the images of virtue, of merit and of intent which it recognized. Inasmuch as this language of charity was effective, it had to mediate between different groups and interests and in late medieval towns, from which most of our knowledge of medieval hospitals survives, between the clerical discourse and that of civic government and politics. Here in their ability to provide a variety of rewards, the hospitals fit into an ethos of exchange characteristic both of the current religious language and of urban culture. By looking at the charitable decisions made around hospitals one can discover a field of social interaction, through which much that is usually lost in purely institutional studies can be learnt. This reveals the symbolic values which lent acts of giving their meaning, and gave the giver his or her incentive to act, and more or less satisfaction.

Let me exemplify these possibilities through an urban hospital which I have studied closely, the hospital of St John the Evangelist in Cambridge, and against the background of many similar institutions.⁸ The hospital was founded early in the thirteenth century by a group of burgesses from the leading families of the borough. The Dunnings and Blangernons together with tens of more modest burgesses provided the initial endowment in the form of tenements in the hospital’s vicinity, lucrative properties in and around the marketsquare, together with tens of acres in the Cambridge fields and in neighbouring villages. To some extent their initiative was innovative; it was the product of the type of deliberation and sense of control and responsibility which burgesses were experiencing and expressing in the growing boroughs in the twelfth and thirteenth centuries. But the new venture in relief of sickness and poverty depended to a large extent on pre-existing models of organization. That is to say that choices and preferences formulated in the realm of urban politics and administration were being expressed through a prevalent language of charity, and poured into administrative forms borrowed from the religious sphere. This sphere provided early hospital founders with legal and organizational frameworks for perpetual endowment, for the enforcement of collective responsibility, for supervision and auditing, all within an idiom of charity with its attendant rewards. So the hospital was the product of a convergence of aims, capabilities and models and the inspiration of need, of utility and of virtue. The symbolic value of the charitable institution further allowed a whole host of activities to be pursued within its walls. That this is so cannot be adequately explained by recourse to a cynical claim that the patrons could do as they wished with their creature, because they could not. As a public venue, as a collective and communal institution, the hospital was watched and controlled, through the knowledge of its workings and perceptions about its tasks and merits. During the period which I have studied, three centuries of the central and later Middle Ages, reformulations redrew the lines between the groups involved in hospital foundation and management, and reorientated the understandings of responsibility through a complex process of observation and rationalization on the part of those who were able to provide relief. What I claim is that as the notions of shared enterprise and deserving need changed, the nature of activities within the public sphere, such as activities in and around hospitals, changed too. There are, of course, limits to the imaginable and practicable uses of a given institution, especially one which purported to serve the general weal, and which functioned by virtue of an idiom of charity, co-operation and responsibility. Thus the new activities maintained by medieval hospitals were not spurious; be they the maintenance of students, intercessory prayers or provision of sinecures, they reflect the scope of action legitimized and at least recognized by those controlling them. They are within the boundaries of the prevailing language of charity.

This is not to deny that some very simple determinants of a more material nature do influence the fortunes of houses of relief. The incidence of endemic disease, plagues, war, demographic trends, all will affect the forms and scope of relief. The virtual disappearance of many small rural hospitals from our records in the second half of the fourteenth century attests to the fact that small hospitals either literally died out or, in the case of those whose income was derived chiefly from land, could no longer subsist on their much depleted incomes after the sharp fall in land values after 1350. Similarly the foundation of leper hospitals and their subsequent demise with the decline of leprosy reflects the influence of external factors. This is fairly obvious; what is being stressed here is the way in which less obvious factors influence the fortunes of relief institutions, and attention is being drawn to less tangible and thus usually neglected influences.

When the inhabitants of the growing boroughs of twelfth- and thirteenth-century England engaged in the foundation of a hospital, this undertaking was envisaged as a collective enterprise similar to their control of the market, their supervision of water and food supplies, their maintenance of security. Hospitals founded by groups of leading burgesses often occupied sites which had been provided by the commonalty, or which had been purchased by one of their number. In the act of foundation a maturity of the collective urban enterprise was demonstrated, and yet within this co-operative endeavour some distinctly personal aims were being achieved: in personal rewards in the form of commemoration, through involvement in the management of the hospital’s property, in the facility of buying, selling and borrowing from a well-disposed institution, and finally through participation in acts laden with symbolic expressions of largesse, of authority, of virtue—of power. Even if we must go some way in agreeing with those who take cynical positions about the value of studying charitable institutions as indicators of aggregate levels of relief, or of attitudes directed at the poor, we cannot overlook or deny the value of such a study in revealing the relevant understandings which underlay any participation in the distribution of wealth. The type of relief and the ways in which they were linked to particular social and political objectives of the powerful provide perhaps the most interesting point of entry into the vast area of unwritten, informal and yet expected behaviours which we would all agree governed and produced a large part of relief opportunities. So a hospital’s records usually fail to tell us about the number of the poor, about levels of deprivation, about treatment. They can, however, reveal some of the occasions on which the interests and choices of the ‘haves’ produced redistributive activities and sustained relief institutions for others.

An important principle guiding the choices of those undertaking charitable initiatives was that of comparison and analogy in organizational forms. What strikes one in the earliest institutional articulations of charitable impulses, is that they borrowed and tested forms which had developed in other spheres. The attempt to endow an institution perpetually, to protect it from intrusion and to create in it a continuous flow of charitable-liturgical practice was met, in the twelfth and thirteenth centuries, by adoption of organizational forms from the sphere of secular religious life. Hospitals followed the patterns of secular collegiate houses—largely encompassed within the Augustinian rule—as religious institutions which functioned separately and independently within the secular world, ones which were provided with tools for self-management, and with means of subsistence for a perpetual body of priests and servants. The collegiate form was an important creation of the central Middle Ages, providing an alternative to the traditional forms of religious life in retreat in monasteries in the countryside, and it suggested itself to laymen as an attractive framework for the creation of a repository of charitable funds. Within such units a group of clerics— administrators, chaplains, servants—and inmates could be perpetually maintained, and the endowment could be held and protected under the multitude of exemptions, privileges and safeguards which applied to ecclesiastical properties. That an organizational pattern which had developed in the religious sphere was adopted to service the communal experiment in relief in towns does not imply any primacy to the spiritual motivations behind such acts. It was a safe and sensible choice in the early years of borough organization, when notions of and instruments for corporate projects were yet in their infancy, and when ecclesiastical endowment had already evolved over hundreds of years.

In the nature of institutional foundations which are meant to enhance prestige, the personal symbolic act of giving was always of vital importance in the charitable exchange. In these undertakings there always seems to h...

Table of contents

• COVER PAGE
• TITLE PAGE
• COPYRIGHT PAGE
• CONTRIBUTORS
• PREFACE
• INTRODUCTION
• 1: IMAGINING MEDIEVAL HOSPITALS
• 2: HEALING THE POOR
• 3: THE MOTIVATIONS OF BENEFACTORS
• 4: ‘HARDLY A HOSPITAL, BUT A CHARITY FOR PAUPER LUNATICS’?
• 5: TWO MEDICAL CHARITIES IN EIGHTEENTH-CENTURY LONDON
• 6: THE SOCIETE DE CHARITE MATERNELLE, 1788–1815
• 7: URBAN GROWTH AND MEDICAL CHARITY
• 8: THE COSTS AND BENEFITS OF CARING
• 9: LAY AND MEDICAL CONCEPTIONS OF MEDICAL CHARITY DURING THE NINETEENTH CENTURY
• 10: THE FUNCTION AND MALFUNCTION OF MUTUAL AID SOCIETIES IN NINETEENTH-CENTURY FRANCE
• 11: THE MODERNIZATION OF CHARITY IN NINETEENTH-CENTURY FRANCE AND GERMANY
• 12: GOVERNMENT AND CHARITY IN THE DISTRESSED MINING AREAS OF ENGLAND AND WALES, 1928–30
• 13: THE ACHES OF INDUSTRY