Book Review

Charitable Knowledge: Hospital pupils and practitioners in eighteenth-century London

N Engl J Med 1996; 335:1400October 31, 1996

Article

Charitable Knowledge: Hospital pupils and practitioners in eighteenth-century London
(Cambridge History of Medicine.) By Susan C. Lawrence. 390 pp. New York, Cambridge University Press, 1996. $69.95. ISBN: 0-521-36355-1

Physicians interested in the direction historians of medicine are increasingly taking with respect to the examination of health care institutions can do no better than to read this book. The subject of this work is how London hospitals in the 18th century evolved into important teaching centers and why hospital-based medicine became an essential vehicle through which physicians and surgeons were able to establish their reputations among their peers and the public. Lawrence has deftly handled an enormous amount of primary source material — hospital records, minutes of board meetings, journals, diaries, and newspapers — to produce a valuable portrait.

But it is the way in which this portrait is painted that differs so from the traditional way of doing research on the development of medical institutions. The book is, first of all, rooted in social history. It is not focused on great men — indeed John Hunter, for example, is mentioned only a few times — but rather on ordinary practitioners who in their daily, routine work helped shape the London hospitals. Lawrence examines the shifting occupational boundaries within and among the groups of practitioners: physicians, surgeons, and apothecaries. She focuses in particular on how an open-market system for instruction both inside and outside the hospital eventually led to a core educational curriculum for all three types of practitioners while keeping their respective ranges of practice activities relatively distinct.

Lawrence uses an analytic approach to examine the elements of these social transformations. At the beginning of each chapter she lists the issues that she will focus on and states her arguments in the first person; she then spends the rest of the chapter marshaling evidence to support her arguments and, where appropriate, challenge competing interpretations. Although this systematic approach to history often results in a more powerful presentation of ideas than can be wrought through the more standard narrative approach, it can also diminish the art of storytelling. Narrative historians usually aspire to create a seamless portrait in which ideas and events thematically follow a time line; for analytic historians, a constant moving back and forth in time as the topic at hand changes is of comparatively small importance. This book fits the latter pattern. Literally dozens of times, Lawrence states that an issue that would appear to belong in one place will, in fact, be discussed later, and she also offers frequent reminders of what was said previously. In retrospect, these prompts serve little purpose and should have been dispensed with.

The only important issue that Lawrence could have explored more satisfactorily is what she calls “safe science.” Lawrence argues that to maintain or advance their social status, hospital-based researchers of the late 18th century and early 19th century avoided the theological and philosophical implications of their findings in chemistry and physiology. In other words, these researchers purposely kept their mouths closed to avoid condemnation by the church, the state, and the public. Perhaps her interpretation is correct, but it is not evident from her data whether most of those researchers and other practitioners recognized these dangerous implications. Even if they did so, we do not know how they defined the domain of their expertise. What would have been useful is an exploration of the intellectual and occupational boundaries between the clerical and the medical professions during this period, to ascertain to what extent the silence of hospital researchers was principally an issue of safety, of nonrecognition of the implications of their work, and to what extent it was the result of the powerful forces keeping intact long-maintained and well-delineated professional borders.

These small criticisms aside, Lawrence has produced an excellent analytic study, one that adds fundamentally to our knowledge of the transformation of the early modern hospital and the development of medical education in England.

Norman Gevitz, Ph.D.
University of Illinois College of Medicine at Chicago, Chicago, IL 60612