Patients, Power, and the Poor in Eighteenth-Century Bristol.

The history of medicine may seem tangential to the social historian; but every so often a work appears that so successfully bridges the disciplinary divide as to demand the attention of scholars broadly concerned with problems of social change and cultural signification. Concentrating on central themes of modernizing processes in an age of industrialization, Mary Fissell's Patients, Power and the Poor in Eighteenth-Century Bristol is one such book.

Embracing a time-span from the 'traditional' medical milieu of the mid-seventeenth century through to the 'modern' world of the New Poor Law, and focusing upon the Bristol region (though that notorious 'great emporium' could serve as a cypher for Birmingham, Manchester or any similar site of rapid urbanization), Dr. Fissell explores profound transformations in the medical outlooks and the practical health care of the lower orders in context of the high/low culture struggles. At the risk of oversimplifying an argument rich in documentation and comfortable in handling complexity, it could be said that the typical late-seventeenth century lower class or petty bourgeois Bristolian was likely to be keyed into a multiplicity of overlapping health care systems. As is demonstrated by a profusion of examples, these included magical, astrological and faith healing, typically reliant upon spells and rites and often practised by those 'wise women' who were commonly the 'oracles' of their village; home-brew herbal medicine and other forms of self-help kitchen physic; and, not least, regular medicine which, though typically beyond the pockets of the poor, could be available to them through various forms of private and public charity. Patients picked the forms of therapy they preferred; everyone was, in a sense, his or her own physician.

The eighteenth century--so often but misleadingly presented as a fallow period ('the lost half century in English medicine' is a commonly-attached label)--saw remarkable changes, For one thing, going with the flow of the emergent consumer society, medicine grew more commercialized. There were swelling numbers of itinerants and regulars alike, and practitioners opted to operate within the force-fields of the medical market-place. Scores of proprietary and patent medicines achieved saturation advertising in newly-founded provincial newspapers; and drug stores, selling penniworths of opiates and other nostrums, proliferated to meet the new passion for pills. Even domestic medicine drew more heavily upon shop-bought drugs.

This commodification of medicine probably impacted most upon the respectable classes. For the indigent by contrast, Dr. Fissell shows, the turning-point was the foundation of the Bristol Workhouse in 1696, and, above all, the establishment of the Bristol Infirmary in 1737, as an expression of that general medico-charitable impulse recently documented in Medicine and Charity Before the Welfare State (London: Routledge, 1991), a volume edited by Jonathan Barry and Colin Jones. As Dr. Fissell justly stresses, the traditional reputation of Georgian hospitals as 'gateways to death' is wholly undeserved: all available records suggest that the Bristol Infirmary played a genuinely positive role (if, at bottom, a fairly minor one) in nurturing the health of ordinary people.

The true significance of the hospital lay not in its cures, but in its role, material and symbolic, in the reformation of vernacular medicine. Though the Infirmary was instituted under the auspices of Bristol's notables, its day-to-day running soon fell principally into the hands of the medical staff, above all the surgeons. Largely trained in the Edinburgh University 'medical factory', such men brought an aggressive professionalism to their job. Out went the vestiges of magical and folk medicine; out went the old-style diagnosis that had been almost exclusively dependent upon the sick person recounting his or her 'complaint' to the doctor ('taking the history'). All this was replaced by the practitioner inspecting the sick person for diagnostic signs, which could, in turn, be expressed in the technical and often Latinate jargon of scientific medicine: cynanche, tussis, ulcus cruris (leg ulcer), and so forth. Through the invention of the Infirmary and similar institutions, the people were deprived, in the name of progress, of the medical belief systems that gave personal meaning to their suffering. In brief, paralleling the new controlling from above of popular sports, festivities and beliefs, so popular medicine too was 'reformed'. No longer was it every man his own physician; medicine, the doctors now emphasized, was too complex, too consequential, to be left to the sick. Patients, Dr. Fissell aptly notes, were 'deskilled', and a patient-driven system was replaced by a doctor-driven medical economy.

Thus, to use the rhetoric of Ivan Illich, the hospital 'expropriated' the health of the poor: they were medicalized. More dramatically, Dr. Fissell underscores that a conspicuous function of the Bristol Infirmary lay in dissecting the remains of patients who had died there (and, not infrequently, bringing in extra cadavers, courtesy of body-snatchers). She thus confirms the point so ably made by Ruth Richardson in Death, Dissection and the Destitute: A Political History of the Human Corpse (London: Routledge & Kegan Paul, 1987), that the practice of 'anatomizing' was viewed by the people as violation and violence, a vengeance expressly blurring the distinction between the sick and the criminal. The corpses of the indigent became teaching fodder for professionals, and operations themselves excited fear as unwarranted and perhaps heartless medical experimentation. In the popular mind, there was an elision of hospital and jail, medicine and punishment.

It is here one regrets that Fissell's volume stops early in the nineteenth century. Her account of the changes in mentalite and practices, culminating in the New Poor Law of 1834 with its notably punitive Poor Law Infirmaries, carries real conviction. But, as with so many studies of attempts from Above to eviscerate popular culture, doubts remain as to the long-term success of the enterprise. Dr. Fissell sometimes writes as if the voice of the poor was silenced. But was it? One could easy recast her story, so that it told of the continuation of a 'suppressed' vernacular medicine only in new bottles, certainly well into the present century. In particular, were not the new modes of fringe medicine that emerged under Victoria but old kitchen physic writ large?

These are large and undecided questions. For the meantime, we are in Dr. Fissell's debt for having suggested them in her richly documented account of a changing medical economy in the age of industrialization. This superbly crafted regional study of the interaction of conflicting medical experiences and agencies is sure to become the model for many more such studies.