1 THE HISTORY OF MEDICINE AND HEALTH IS VAST in both scale and scope. Recent contributions from Atlantic Canada represent, in microcosm, a sampling of this expansive literature: Ronald Rompkey’s The Labrador Memoir of Dr Harry Paddon, 1912-1938 (Montreal and Kingston: McGill-Queen’s University Press, 2003) is the edited memoir of a Labrador medical missionary; David A.E. Shephard’s Island Doctor: John Mackieson and Medicine in Nineteenth-Century Prince Edward Island. (Montreal and Kingston: McGill-Queen’s University Press, 2003) is a biography of a prominent physician from Prince Edward Island; W.G. Godfrey’s The Struggle to Serve: A History of the Moncton Hospital, 1895-1953 (Montreal and Kingston: McGill-Queen’s University Press, 2004) is an institutional history of a New Brunswick hospital; and Peter Twohig’s Labour in the Laboratory: Medical Laboratory Workers in the Maritimes, 1900-1950 (Montreal and Kingston: McGill-Queen’s University Press, 2005) is a history of laboratory workers in the Maritimes. This diversity of subjects in terms of individuals, institutions, and infrastructure is matched by the diversity of methodologies – from traditional medical biography to social history revisionism to class and gender analysis. Three are set in the 20th century, with Island Doctor examining a 19th-century story. The slate of authors likewise reflects the multi-disciplinarity of health history. W.G. Godfrey and Peter Twohig are professional historians while Ronald Rompkey is a writer and professor of literature and David Shephard is a physician for whom history is an avocation. Making comparisons among these authors’ markedly different styles and approaches presents significant challenges. Nevertheless, this review will link them together by focusing on how each contributes to our growing understanding of the interplay of region and health and, in particular, the political, social, and cultural importance of region.
2 Ronald Rompkey’s work editing The Labrador Memoir of Dr. Harry Paddon, 1912-1938 adds another title to the several already produced by this author about individuals involved in missionary work in Labrador.1 This most recent contribution is a significant addition to the history of health in the region because Paddon was principal physician to the world-famous Grenfell Mission for over 20 years and his memoir offers a "behind the scenes" look at those mission activities. Over the course of his career, which spanned the first three decades of the 20th century, Paddon covered over 25,000 miles to build and maintain an infrastructure of health care services in an area that had hitherto received little attention from the colonial government. Rompkey’s book details the rise and survival of the mission clinics, the programmes created by a seemingly tireless staff, and their relations with and impact on many scattered communities in the eastern Arctic. The text is replete with dramatic travel tales throughout this northern region. Some of the most interesting tales involve efforts to curb an outbreak of smallpox, endemic tuberculosis, and the 1918 influenza epidemic – a crisis complicated not only by isolation but also by famine (pp. 158-68). Paddon peppers stories of routine hospital activities and bureaucratic details of the efforts to establish agricultural and home economics programmes with heroic tales of kitchen table surgery and exotic tidbits of northern folklore like abominable snowman sightings (p. 92).
3 The memoir provides fascinating accounts of medicine practiced in extreme conditions while also providing insight into the epidemiological history of the region. The main scourge and clinical preoccupation of Paddon and his colleagues was tuberculosis. As Rompkey points out in his introduction, the significance of the "white plague" in Newfoundland and Labrador history can scarcely be overstated; the disease was responsible for two-thirds of adult deaths in the colony throughout the interwar period (p. xxxvi). In Paddon’s memoir historians are granted a rare, first-person view into efforts on the ground to manage morbidity and mortality associated with this disease. Since endemic tuberculosis in Newfoundland and Labrador is likely one of the most devastating and intransigent public health problems in 20th-century Atlantic Canada history, on this basis alone the Paddon memoir makes an important historiographical contribution.
4 Labrador Memoir is also a rich textual source on the history of Aboriginal-settler society relations. In the many personal accounts of tuberculosis management before the availability of streptomycin, we learn how Paddon and the other medical staff employed not only clinical but also socio-cultural means to control the disease through diet and education. Some activities, such as the establishment of home economics and agricultural programmes, would have repercussions on the economic activities of entire communities. Other, more personal accounts and anecdotes reveal the individual, subtle, cultural effects of their activities. Paddon, for instance, did not think twice about assuming custodial care for a two-year old girl with a vitamin deficiency – keeping her against family wishes for several months so that he and his staff could ensure proper diet, administer regular doses of cod-liver oil, and "needed discipline" (p. 97). As Kathryn McPherson has argued, scientific medicine as a part of 20th-century public health endeavours often functions as a "technology of power" in Aboriginal-settler society relations.2 Paddon and his colleagues actively engaged in the colonial process as it unfolded in Inuit and Montagnais communities and there is much material in this memoir that explores how this technology functioned in the medical missions of the Eastern Arctic. Since Paddon’s medical work also often extended to non-Aboriginal male fishers and trappers, the memoir also helps reveal class relations and the changing nature of work as Labrador "developed" economically. Contextualizing medical missionary activity as part of the broader colonial process is a useful framework for scholars who are interested in analyzing and comparing this missionary activity with endeavours in other areas of 20th-century "hinterland" development.
5 The book is also valuable to the field of life-writing and history. In Labrador Memoir Rompkey gives the physician’s own voice primacy, and his editorial hand is only evident in places where he identifies relationships, provides explanations of otherwise unfamiliar cultural references and practices, and where he offers translations of Aboriginal vocabulary and local idiom. Apart from a biographical sketch of Paddon and a snapshot social history of Newfoundland and Labrador in the brief introduction, Rompkey largely recuses himself from historical interpretation. Paddon, for his part, considers himself an "interlocutor" with an almost anthropological role to play in "revealing" the eastern Arctic though his writings. Rompkey lets Paddon do this, thus allowing the doctor-author to simultaneously reveal himself.
6 Although Rompkey acts as a mostly unobtrusive guide through the doctor’s journals, he does contextualize the memoir in valuable ways. Rompkey wisely refuses to categorize Paddon’s writings as strictly autobiographical, identifying his work as a memoir of the north written in the tradition of early 20th-century adventure narratives. Rompkey notes that Paddon wrote sections of it with fund-raising for the mission in mind, and developed his narratives to highlight the need to advance the economic development of Labrador. As editor, Rompkey points out that these dual objectives seem to have encouraged the physician to heighten drama and otherwise tailor his narratives so as to gain the attention of potential donors or put forth a plea for the political empowerment of Labradorians. These objectives inform the work as much as Paddon’s stated desire to bear witness to a moment in time in Labrador history. Most historians would recognize many aspects of Paddon’s prose and subject orientation as a variation on classical nation-building narratives; Rompkey himself points out that the "trope of construction" is one of the most obvious narrative tools the physician employs to organize his stories (pp. xliii-xliv). An appreciation of these contexts are important for any future use of this material as a historical source in research or teaching, and consideration of same will encourage future writers to go beyond Rompkey’s introductory frameworks and build on the growing body of theoretical literature that discusses life-writing in history.3
7 Sources from the work of rank and file medical practitioners are certainly rare and generate much excitement and interest when they surface. In the case of Island Doctor, David Shephard has been fortunate to uncover not only manuscript recollections but also several casebooks and the personal diary of a 19th-century Charlottetown physician. With these sources, Shephard has created a social biography of Scottish-born doctor John Mackieson, who plied his medical trade in Prince Edward Island from 1826 to 1874. Shephard takes painstaking care to place the work of the physician within the social life of colonial Charlottetown, situating the doctor as a representative participant in the 19th-century development of the medical profession.
8 Overall, the author has built an interesting and well-rounded story about an ambitious immigrant doctor in a small yet growing colony. Mackieson’s career began in general practice, but it included several positions working for municipal and colonial governments. Mackieson held positions as port health officer for the capital city, medical superintendent of the Charlottetown lunatic asylum, surgeon general to the local militia, and, toward the end of his career, medical attendant to the Charlottetown jail. Scandal touched his career twice: once in 1847 when he failed to adequately quarantine the Lady Constable, a ship carrying typhoid (pp. 47-9), and also at the end of his career when he was the central figure in an inquiry into the unethical treatment of patients at the lunatic asylum.
9 Shephard’s book offers many important insights into general practice of this period. Although not considered wealthy in his circle, Shephard points out that Mackieson enjoyed a comfortable life from the stipends and income derived from his various government appointments. Mackieson kept up the clinical side of his work even when he held salaried positions, and saw private patients from 1826 to 1858. Yet the scale of his practice was surprisingly small: over the course of these three decades, which constituted the prime years of his career, Mackieson had only 257 cases. This slim roster certainly suggests that private clinical practice was a very minor part of his professional life. And for this reason Mackieson’s career activities provide fascinating insight into medicine and patronage – undoubtedly facilitated by his marriage to the daughter of a lieutenant governor – while providing evidence of a sometimes ferocious competition among members of the medical fraternity of the small colony (p. 61). That Mackieson eventually became a central figure in the nascent health infrastructure in Prince Edward Island is illustrative of how closely intertwined the fields of health care and politics could be, or perhaps had to be, if one were to make a living from the practice of medicine in the 19th century.
10 Shephard is ultimately more focused on understanding the application of science in Mackieson’s everyday work. Island Doctor is dominated by details of the physician’s surgical work, his obstetrical activities, and his later-career treatment of the mentally ill. From the outset, Shephard positions his piece as a contribution to a growing historiography of general practice, comparing many details from Shephard’s cases to evidence in other biographies.4 Shephard finds, for instance, little to support the idea that mid-19th-century physicians had much competition from sectarian and lay practitioners. Yet one wonders about Shephard’s characterization of Mackieson’s career as "paradigmatic" (p. 22) when the definitive "paradigm" for general practice in this period has yet to be cast. It is easier, however, to agree with the author when he describes Mackieson as a "doyen" among Island physicians in the mid-19th century – a representative member of the medical elite.
11 One problem with the book, however, is the way it seems at times to wander into the realm of apologia since the scandal in Mackieson’s career, especially the inquiry into the treatment of patients at the insane asylum (p. 115), has been given harsh treatment in public history.5 The author takes pains to reference Mackieson’s "human courage" and "advanced thinking" in surgery, despite his apparent reluctance to use anaesthesia – a practice which may explain his one-third surgical mortality rate (pp. 60-1, 66). Shephard also casts other historical characters, such as troublesome "anxious female relatives" of parturient women, as foils against which the doctor’s superior "judgement and skill" are highlighted (p. 71). This commentary overlooks much sophisticated and nuanced work of historians who have examined how the incorporation of anesthesia affected the status and social position of the surgeon (at the childbirth bed and elsewhere), and how the patient’s race, gender, age, and ethnicity often dictated the application of these and other technologies.6 These concerns notwithstanding, Shephard has selected and reprinted at length especially revealing tracts from the case notes and the diaries while bringing rich details of the practical, political, and emotional world of a 19th-century Prince Edward Island doctor to light.7 These excerpts, which dominate three chapters of the book, provide an extremely useful reference for history of medicine teaching, and other research in this field will undoubtedly benefit from this effort to publish sections of this rich primary source.
12 In The Struggle to Serve: A History of the Moncton Hospital, W.G. Godfrey promises a rendition of the "new" hospital history — one that seeks to tell the history of medical modernization through the prism of a community-based institution. The book follows a chronology beginning with the creation of the first almshouse to care for the sick to the establishment of the contemporary modern building. The first two chapters chronicle the changing community role of the hospital from a 19th–century, chronic-care philanthropic institution, largely run by women’s organizations, to a curative institution with staff physicians, a professionalized workforce, and formalized management structure by the early 20th century. After detailing the successful integration of scientific medicine into the institution well into the interwar period, Godfrey then examines the changing disease profile among admitted patients while also documenting the changing scale and scope of procedures undertaken at the hospital. He pays considerable attention to the economic history of health care at the hospital, noting the financial and social impact of the advent of paying, middle- and upper-class patients to hospital service as well as the implications of government funding, the latter of which steadily increased as the 20th century unfolded.
13 As the title would suggest, much of the drama in this hospital history revolves around challenges to make ends meet. By focusing on the ways in which the hospital commanded an ever-wider array of community resources, Godfrey demonstrates its growing centrality to the health care in the city and region. This also allows him to chart the wider range of activities demanded of the institution in exchange for these resources such as the expansion of special private wards, the construction of nursing residences, the growth of the nursing school, and the investment in technologies such as x-rays and laboratory capacity. These developments also illustrate the slow regionalization of health care services, offering both financial and demographic data that demonstrate the broadening care mandate and geographic service area of the institution. By the 1940s the Moncton hospital would serve not only residents in the city proper, but all of Westmoreland County and southeastern New Brunswick. Despite the fact that it played such a vital role in the local community, though, the Moncton Hospital always seemed to be in financial jeopardy. Godfrey recognizes the Moncton hospital as a "social institution" whose "struggle to serve" tells us much about the sometimes difficult job of garnering political will in order to provide equitable access to health services.
14 Throughout Struggle to Serve Godfrey also describes the comings, goings, and activities of the major figures involved in hospital construction, expansion, and management, including many strong personalities among the senior nursing staff. It is appropriate that Godfrey foregrounds the role of nurses and the nursing school, as both left an indelible mark on the hospital as it grew and expanded over six decades. Godfrey, for instance, examines the "brilliant administrative skills" of Alena MacMaster, Moncton Hospital’s long-time superintendent of nursing, in managing nursing students, hospital staff, and the board of directors in the 1930s and 1940s. This allows us to see the hospital not only as a place for medical care, but also as an important site of professional training and work for women. The details of MacMaster’s disciplined nursing education regime (p. 131) begs for deeper gender analysis than that provided in this history, but the nursing element of the Moncton Hospital’s story is comprehensive and well-contextualized; Godfrey’s attention to the immigration patterns that drove the interwar nursing labour shortage (pp. 128-30), for instance, very effectively highlights the Moncton Hospital’s role as a social institution central to the health, life, and career mobility of people in the wider community.
15 Godfrey argues in Struggle to Serve that the Moncton Hospital was created and persisted because of the collective dedication of community individuals. Godfrey’s exhaustive use of administration sources, such as trustee meeting minutes and managerial reports, certainly point in this direction. But not all hospitals in similar-sized Canadian communities who enjoyed community support would survive and thrive in the 20th century in the way that Moncton Hospital did. There are exceptional elements to this story that are downplayed in Struggle to Serve. Although Godfrey refers to the Moncton Hospital as a typical "small-town institution," in the context of Atlantic Canada history Moncton would play a critical and expanding role as an urban transportation and communications hub in the Maritimes. The Moncton Hospital’s transition to a regional health care centre, serving not only adjacent counties but also, by the late-20th century, Prince Edward Island, indicates a particular approach to late-century health care planning in Canada – one that would see the rationalization and centralization of specialist services and hospital care along regional lines. More than dedicated community support lay behind the survival and successful expansion of this institution. Struggle to Serve also tends to look past the bilingual and bicultural divide within the city, a divide that meant community resources would also be split between support of one secular, anglophone institution (the Moncton Hospital) and one francophone institution (l’Hôpital Régional Dr-Georges-L.-Dumont), which was, before 1962, l’Hôtel-Dieu de l’Assomption run by the Soeurs de la Providence. One wonders whether MacMaster’s efforts to regulate nursing credentials were seen as positive and progressive by the religious nursing orders who had formerly trained and credentialed nursing staff for the largely francophone Catholic institutions of the province.8
16 Medical modernization went hand in hand with the diversification of the staff working in the hospital, and so Peter Twohig’s Labour in the Laboratory, with its focus on labour at the laboratory bench, represents an important new contribution to the historical interface between science and hospital work. Since laboratory work was a critical component of the expansion of public health and the entrenchment of scientific medicine in health care, this work constitutes an important re-centering of historical scholarship on a group, mostly women, who worked in the "nooks and crannies" of the new and rapidly growing hospital infrastructure (p. 154). Instead of focusing on one institution, this work engages sources and stories from many laboratories throughout the Maritimes and thus provides a regional case study of a health human resource history.
17 Since this is largely a history of women workers, Twohig foregrounds gender as he describes work on "the bench." Arguing that an institutional historical framework is inadequate for the study of hospital labour, Twohig notes that a complete understanding of the 20th-century hospital requires more attention to those occupations once designated as ancillary medical staff. This is not only important to round out and enrich the historical record, but such an approach allows us to understand how these staff members fit into the social organization of health care work and how their experiences were shaped by broader social and economic forces in the development of the health care system. Twohig’s look at laboratory workers suggests "that the hospital is really a series of linked work environments, many of which are gender-bound, that share the same physical space" (p. 157).
18 Twohig’s work is an impressive example of how effectively a labour history approach can illuminate health history by injecting a fresh perspective into a historiography dominated by institutions and individuals. In telling the story of laboratory workers, Twohig’s approach reflects that of the best new nursing histories and closely examines the social construction of "skill."9 This approach allows him to discuss how workers relate to medicine as a knowledge system – a social hierarchy arranged only in part according to level of training, but more often according to the perceived value of the laboratory tasks in the broader, physician-centred activities of diagnosis and treatment. The knowledge system framework enables the book to shed new light on old presumptions, such as the supposed objective value of scientific training. Twohig shows how much of the debate over laboratory workers’ salaries at Dalhousie University revolved around "the question of family maintenance," and when the university adopted a philosophy of never paying a family wage how this meant that the increasingly important work of a laboratory technician would almost inevitably be performed by young, unmarried men or single women (pp. 164-5).
19 Most significantly, Twohig’s important book challenges the common assumption that ever-greater specialization was the order of the day among all professionalizing medical fields in the early-to-mid-20th century. The book demonstrates, in terms of laboratory work, that there was actually a wide variation in workers’ training and that most laboratory workers were required to be technical polymaths. Especially in smaller hospital laboratory settings, Twohig maintains that the boundaries among skilled areas of work remained fluid well into the 20th century.
20 Twohig’s analysis is based on experiences in Nova Scotia and New Brunswick, with the few Prince Edward Island examples serving to add texture to the Maritime-wide scope. But the absence of comparable laboratory infrastructure in the smallest of the three provinces in turn raises interesting questions about jurisdictional imperative in the pursuit of health care infrastructure. While Twohig notes the uneven development of "modern" health care infrastructure among Maritime communities, his focus on the labour side of the laboratory question leaves one to wonder, for instance, if the absence of provincial laboratory facilities on the Island suggests a de facto regionalization of public health long before regionalization was a de jure policy in health service delivery in the Maritimes.
21 The health history of Atlantic Canada speaks to not only the experiences of discrete individuals and institutions, but also the broader regional contexts within which these histories are told. In his preface to Labour in the Laboratory, Peter Twohig characterizes the history of Maritime health care as "a bit of an orphan" (p. 15). Referring to the absence of a health focus in the flourishing scholarship of Atlantic Canada, Twohig’s observation calls to our attention not only the opportunity for more health history in regional history, but also the place of region in our understanding of the history of medicine. Although historians of medicine have recognized for at least two decades that considerable differences in the practice of health will reveal themselves along regional lines, the historiography of health and health care more often than not presumes that scientific medicine as a knowledge system often transcends national boundaries in its dissemination.10 Three of the books featured in this review are set in the 20th century, and it is a common assumption that the standardization in training and credentialing staff as well as the regulation of care procedures that went along with them resulted in a homogeneous health system. This emphasis on a homogeneous health system, in turn, features several standard assumptions: professional boundaries are more important to the stories of health than geographic or political ones, differences between rural and urban health care and practice are more significant than differences between health care and practice in Moosejaw and Charlottetown, and a well-trained nurse or doctor can be parachuted into a clinic anywhere in the world, fully functional as they are "without borders."
22 Since Careless’s notion of "limited identities" proffered regionalism as a category of historical analysis almost half a century ago, Canadian historians have debated the meanings and value of region in the national narrative.11 Gerald Friesen recently outlined the variability of regionalism as a scholarly concept as it has been used to refer to imagined and intellectual concepts, geographic and environmental features, and economic and political frameworks over the course of the 20th century.12 The discussions on region in Acadiensis, if nothing else, show how historians’ unwillingness to settle on a fixed or dominant definition of region has not diminished its scholarly appeal.13 It is also an inspiring concept to historians of medicine. Megan Davies’s recent call to use regional studies in the creation of an "intellectual cartography" of the history of Canadian health and health care echoes Charles Rosenberg’s earlier and more broadly based plea for greater attention to local and regional studies in the framing of both disease experience and therapeutic endeavour.14 These scholarly appeals to action express a desire to add nuance and texture to dominant narratives about medicine and health and to explore and test established health-history paradigms against the place-bound cultures, geographies, and government systems created and experienced in North American communities. National histories of health and medicine, according to Davies, fail to account for how the transnational knowledge systems that characterized medical knowledge were often reinterpreted according to local conditions – the typical divide between theory and practice, determined by regional variation in disease experience and approach to care.
23 In terms of the history of health in Atlantic Canada, however, it is in the framing of the health care cartography that the creative challenge still lies. When we rationalize the historiographical importance of health history, we still put both region as a category of analysis and place as an intellectual concept well in the background. Shephard uses Mackieson to reveal the elements of a typical 19th-century general practice and Godfrey fits the story of the Moncton Hospital into the wider socioeconomic history of small-community hospitals in North America. In the process, these books pay attention to local contexts, but they largely rely on the reader to draw links to larger social history trajectories – such as careers of other medical immigrants or hospital service regionalization – that would lend their regional works more impact in the literature. In similar fashion, Rompkey’s editing of Paddon’s life story highlights unique local idiosyncrasies and exotica, and he does not take the step from interlocutor to author and contextualize Labrador Memoir as a story of regional development and colonization. Twohig’s book on Maritime-based laboratory workers is the only title under review here that attempts to straddle the demands of place and health historiography. On the one hand, Twohig frames the book as a case study of specialization at the laboratory bench; on the other hand, he also presents an analysis that self-consciously contributes to regional labour history and the politics that underpinned health care modernization.
24 These regional contributions are part of the efforts by the McGill-Queen’s/Associated Medical Services Studies in the History of Medicine, Health and Society to fulfill its mandate to represent health history from all corners of Canada. These four works offer lively and richly detailed histories of medical missionaries, long-lived and successful general practices, the many women and men who built and maintained community hospitals, and those who worked in laboratories as part of the burgeoning health care system in Atlantic Canada. Their analytical attention to local contexts demonstrates the historiographic strength of the social history of medicine, an approach once thought to be controversial.15 Yet regional explorations of health and medicine must do more than provide "local colour" to national narratives of health and healing. Instead, regional health histories have to widen their conversations beyond the historiographies of health and medicine and begin a discourse with regional social histories by foregrounding the concept of region.
25 A new interest in health and region, and a scholarly desire to explore the historical relationships between health and place, present Atlantic Canada health historians with an opportunity to play a key role in the future of Canadian health history.16 Region does not refer to static jurisdictions, but is now recognized to be a highly adaptive, creative, and relational concept. Over the last five years alone, Atlantic Canada historians have variously defined it geographically, environmentally, and linguistically. Occasionally regional frameworks are fruitfully defined by ignoring provincial or national borders; other times comparative studies highlight the importance of jurisdiction. Often, region is strongly expressed as an imagined community or as part of a cultural framework with no spatial aspect. If we draw on this rich literature and robust debate about the value and creative application of region, Atlantic Canada health historians seem well-placed to self-consciously explore the social, political, and cultural frameworks that give historical meaning to experiences of health and healing, medical policy, and problems with and benefits of health access. Stories of regional health and health care constitute more than exceptions to larger national or international narratives of health history. Indeed, it is only by critically contextualizing the local that we may transform the entrenched canonical interpretations about the advent and dispersal of scientific medicine, the efficiency ideals that led hospital service specialization and centralization, and even, to give a particularly Canadian example, the triumphalism embedded in the "road to Medicare" saga. The first steps toward a social history of health and medicine have been taken; the next step is to think of new ways to make "region" count.
SASHA MULLALLY
Notes