Medical Charities, Medical Politics

Reviewed by: Medical Charities, Medical Politics: The Irish Dispensary System and the Poor Law, 1836–1872 Christopher Hamlin Ronald D. Cassell. Medical Charities, Medical Politics: The Irish Dispensary System and the Poor Law, 1836–1872. Royal Historical Society Studies in History, n.s. Woodbridge, U.K.: Boydell Press, 1997. x + 181 pp. $63.00. During the first two thirds of the nineteenth century, more by accident than by intention, Ireland acquired a comprehensive system of public medical care. The Irish and imperial parliaments from 1765 on had passed a series of acts establishing and funding county infirmaries, then dispensaries (initially seen as infirmary extensions), and finally fever hospitals. At the eve of the great famine of the mid-1840s, more than 750 institutions funded by a mix of subscriptions, county assessments, and treasury grants treated about a million cases a year. It was hardly a system—more a collection of local initiatives, many of them ill-sited or inadequate in other ways. But though a need for reform and coordination was universally acknowledged by the mid-1830s, an Irish Medical Charities Act passed only in 1851. Bills in the late 1830s had fallen victim to the multiple conflicts that permeated Irish state medicine: between the Dublin College of Surgeons, gatekeeper for infirmary appointments, and medical men with other (and often lesser) training; between the occupiers of land, whose taxes supported the medical institutions, and landowners who, through grand juries, voted their budgets; and among poor law reformers, as to how closely Irish practice would follow the hated English workhouse system—and all these against a backdrop of rising nationalism, agrarian agitation, and debate over Catholic rights. The 1851 act gave the rationalizing, centralizing Irish Poor Law Commission control over most public medical services, though the Dublin surgeons retained the county infirmaries. While historians of social policy like Oliver MacDonagh have admired the modernity of the Irish system, it has escaped detailed treatment. In providing that treatment, Ronald Cassell challenges well-established conventions about the public image of charity medicine and about the relations of state medicine to social welfare in general. One characteristic of Irish medical charities is that their subscribers often used them; hence, widespread popular antipathy never developed. Though medical men complained at this abuse of charity by able-to-pay patients, they had to acquiesce to those who made their subscriptions contingent on receiving free care. After 1851 this common practice acquired creeping legitimacy. The act offered dispensary medical services (including home visits) to “poor persons,” without requiring them to be indigent paupers. Again professionals protested, but because they persisted in asking unaffordable guinea-a-visit fees, the numbers of “poor” were necessarily large: in 1863 the dispensaries served roughly 16 percent of the population. Further, unable to gain control of the county infirmaries, the poor-law authorities began in the 1850s to allow workhouse infirmaries to evolve into general hospitals for noncontagious diseases. The result was a poor-law administration that combined rigorous enforcement of the workhouse test on able-bodied adults with a generous and comprehensive system of in- and out-patient medical care, one especially well adapted to the needs of the aged and the chronically ill. [End Page 780] Mortality statistics suggest that it was a remarkably successful system by the 1860s and 1870s, though Cassell cautions us against overstating the apparent improvement. The Irish practice of integrating health care into a system of social services influenced English practice, Cassell argues—initially in the establishment of the Metropolitan Asylums Board in 1867, and more significantly in that of the Local Government Board in 1871. In subordinating medicine to poor-law administration, a decision that earned it the censure of John Simon and of almost every subsequent historian of the subject, Gladstone’s government was not, according to Cassell, repudiating state medicine; instead, it was recognizing the inseparability of health and welfare—the perspective embodied in the Irish poor-law institutions. Here the key figure is John Lambert, secretary of the English Poor Law Board. Usually depicted as a bureaucratic drudge, Lambert emerges here as a pragmatic visionary of welfare policy. Cassell’s book is essential for anyone interested in the history of public

Dispensary · Family medicine · Famine · Irish · Political science · Politics · Treasury · Historical Economic and Social Studies · Historical Psychiatry and Medical Practices · History of Medicine Studies · Law · Medicine · Public Administration