The evolution of the cottage hospital.

IN THIS essay I have endeavoured to outline the trends in medical practice which led to the formation of the cottage hospital. The cottage hospital was something special, quite different from the other types of hospital. To understand these differences it has been necessary to mention the way other kinds of hospitals developed. The influence of these new hospitals on general practice in the nineteenth century may be compared with the influence of group practice and health centres on medical practice today. It was a movement which injected a new spirit into the minds of family doctors. It is difficult to define what a cottage hospital really is. Individual inspiration, local needs and what could be provided in the neighbourhood conditioned the kind of establishment which was formed. Essentially, it was a small building, usually one already standing, which was used as a hospital without any major alterations being made to it. All the doctors in the area were allowed to admit patients to it, and in-patients were expected to pay a small weekly sum for their keep. But the variations on the theme were many, and for this reason alone the story is necessarily discursive. 'Hospitals are for people', so says the 'Hospital Plan of 1960.' Today this statement is a platitude, but until fifty years ago hospitals were for the poor only. During the lifetime of many of us there has been a revolution in the use of hospitals. In Anglo-Saxon times, the religious houses had their infirmaria for the treatment chiefly of their own sick who were looked after by monk physicians. There were also some hospitals-that is places where the sick could be received and looked afterquite unconnected with the monasteries. Bede, speaking of the death of Caedmon in about the year A.D. 680, wrote, 'In his neighbourhood there was the house to which those who were sick and like shortly to die were carried. He described the person that attended him ... to make ready a place there for him to take his rest'.' Abbot Warin (died 1193) of St. Albans who had studied at Salerno made regulations concerning the care of the sick and the building of hospitals and other matters of medical interest. The hospitals of his time were sometimes hospices or places of rest and sometimes hospitals for the care of the leprous. They were distributed widely over the country. In Devon, for instance, there were leper hospitals in Exeter, Honiton, Totnes, Barnstaple and Torrington. The study of old wills tells us that they were well supported and that it was not unusual for a testator to leave legacies to more than one. As the influence of the church diminished and the incidence of leprosy waned, some of these hospitals were diverted to other uses and some, as at Nottingham, became the responsibility of the town corporation. After the Reformation many of them declined but some continued long after, usually as alms houses. In Stuart times, except for the two Royal foundations of St. Bartholomew and St. Thomas, England was almost