By Eli Anders
Imagine the process of recovering from an illness or surgery. Certain activities probably come to mind: plenty of rest, taking time off work, eating nourishing food, perhaps binge-watching a television series on Netflix. Just as important, you probably imagine yourself at home in bed, or, if not, wishing you were. Our ideas of recuperation and recovery are intimately tied up with our notions of the home as a safe and restful space, shielded, at least to some extent, from the pressures and stresses of the workplace and the outside world.
In Victorian England, an ideal for many recovering patients was, at least in this respect, precisely the opposite: not to return home, but to spend a few weeks or months in an institution specifically designed for the needs of convalescents. These convalescent homes, as they were often called, began to appear in the middle of the nineteenth century, but became an increasingly popular destination for patients in the following decades. By the end of the century, more than three hundred convalescent homes had been established, each serving anywhere from dozens to hundreds of patients each year.
Not all recovering patients aspired to visit convalescent homes. Wealthy patients were unlikely to visit hospitals of any sort as they had the means to hire private physicians who tended them during both sickness and convalescence. Such patients could afford to travel to a spa or coastal health retreat to recuperate. By the mid-nineteenth century, however, a number of physicians and medical philanthropists began to focus on the difficulties faced by discharged working-class hospital patients. Charitable support for such patients was by no means a new idea. Since the late eighteenth century, “Samaritan” societies affiliated with the major voluntary hospitals had offered relief to discharged patients, usually in the form of clothes or limited funds. However, as the population of working-class patients seeking treatment in the charitable hospitals of London and other English cities grew dramatically, many reformers began to see this limited relief as insufficient. They established convalescent homes as spaces where patients could recuperate under nursing and medical supervision, away from—and helping them to fortify themselves for—the stresses of everyday working life.
Such homes were not designed as mere annexes to urban hospitals. Though rest, nourishment, and reprieve from work were all considered necessary to healthy convalescence, just as essential was where the process of convalescence took place. The vast majority of convalescent homes were established not in cities, but rather in countryside or seaside towns, where patients had access to the benefits of fresh and “healthful” air. In other words, these establishments held out the promise of health by virtue of the places in which they were located and the types of therapeutic spaces they provided.
In fact, the appeal of convalescent homes drew much of its power from a frequent contrast drawn both to the hospital and to the working-class home. Many contemporary advocates saw convalescent homes as a critical counterweight to the perceived dangers of hospital design and placement. A prominent spokesperson for this view was, not surprisingly, Florence Nightingale, whose Notes on Nursing and Notes on Hospitals sounded a rallying cry in the early 1860s for increased attention to ventilation and site-selection in order to prevent disease in hospitals. Nightingale stressed that, while planners ought to utilize placement and architecture in order to increase hospitals’ healthfulness, “it is a rule without any exception that no patient ought ever to stay a day longer in hospital than is absolutely essential.” She thought that all hospitals “in populous districts” should have their own convalescent branches “at a convenient distance in the open country,” for
next to removing hospital[s] out of towns, there is nothing which would add so much to the efficacy of such institutions, or at the same time be so great a blessing to the sick poor, as henceforth to look on convalescence as a state as much requiring its special conditions and management as sickness; and to provide for it accordingly.
To an extent, convalescent homes were part of the solution to the practical limits of hospital reform. Nightingale thought that hospitals themselves ought to be moved to the edges of towns, where they could take advantage of more salubrious air and better ventilation. Since the major hospitals were unlikely to undertake such dramatic and expensive moves, however, Nightingale saw convalescent homes as a viable means to get patients out of poorly ventilated city hospitals as quickly as possible. Convalescent cottages in the country or by the sea would maximize patients’ exposure to fresh air and the outdoors, while removing them from the dangerous conditions of urban life for sufficient time to make a complete recovery.
Convalescent homes were seen as superior to hospitals not simply because of their more healthful locations, but because they offered convalescents a change from the dreary, institutional atmosphere of hospital wards. “The first necessity of a convalescent hospital,” wrote Nightingale, “is that it should not be like a hospital at all.” The primary reason?
To get rid of the idea of being in hospital altogether from the minds of the inmates, and to substitute for it that of home. As long as they are hospital inmates, they feel as hospital inmates, they think as hospital inmates, they act as hospital inmates, not as people recovering.
Advocates argued that a calming and “home-like” situation was essential for patients’ mental repose and complete recovery. For instance, the proprietors of the Beach Rocks Sea-Side Convalescent Home in Sandgate, Kent, attributed the success of their facility not just to its favorable location and good ventilation, but also to the fact that it resembled “an English Home” and avoided “everything … that would stamp it with the cast-iron routine of ‘institutions.’” Convalescent homes, with spaces like sitting rooms, individual bedrooms, libraries, and game rooms, sought to emulate the peaceful conditions of the home, rather than the depressing environment of the hospital.
And yet, the idealized domesticity of convalescent homes was understood to be in stark contrast with the actual living conditions of the class of patients that sought relief in them. The benefits of rural and coastal sites were contrasted, not only to the conditions on hospital wards, but also to the unhealthy living conditions of urban-dwelling, working-class patients. Philanthropists like Joseph Adshead, a merchant and board member of the Manchester Infirmary, worried that the best medical care provided by voluntary hospitals or charitable dispensaries would be futile if patients simply returned to overcrowded slums, poorly ventilated rooms, and under-nutritious diets before they were fully restored to health. Adshead argued for the importance of “an intermediate provision between the hospital ward atmosphere and the … insalubrious atmosphere of the home of the patient.” In his view, the difference in health outcomes between poor and wealthy patients was not attributable to any difference in the diseases from which they suffered, or even to the medical care that they received (for poor patients had access to skilled and reputable physicians in charitable hospitals); rather, the difference arose during convalescence, when “the strengthening, the invigorating, re-creating influence is needed.” The rich, able to retreat to a country mansion, an inland spa, or a seaside resort, had the ability to seek out these influences themselves; the poor, relegated to stifling, filthy slums, could not.
Convalescent homes drew support from the belief that it was not just specific diseases, but deprivation and slum housing conditions that produced debility in the working poor. A pamphlet promoting the Children’s Convalescent Home in Broadstairs, Kent, for instance, described the living conditions that produced disease and that could be best ameliorated by rural convalescence:
[W]e felt constrained to look out for a site upon which we could erect a suitable building in which to receive a large number of little patients, of the class to which we alluded at the commencement of this paper — the Convalescents from our great Hospitals, and those tiny sufferers from the stifling courts and slums of our great cities and large towns, who, though perhaps their special disease may be only designated by that wide, yet ominous, term ‘debility,’ are yet slowly dying under its insidious grasp, for want of a few weeks of that bracing air for which their little lungs are pining, and of that nourishing diet which, alas! can never be theirs in the household which is simply existing at starvation point.
Convalescent homes represented the antithesis of urban insalubrity; they offered the possibility of calm and rest, fresh air and light, food and exercise. Indeed, for such children, “a few weeks … spent under the invigorating influence of fresh-sea breezes — days passed in the open air, and free, happy exercise away from the confinement of streets and towns” would “disperse all the symptoms of their former existence”; a timely stay would “convert puny, wan, and sickly little creatures … into hearty, healthy, robust children.”
Of course, we no longer send patients to country convalescent homes, even those who might benefit from an extended period of recovery or whose home situation might be ill-suited to fostering healthy recuperation. The perceived importance of convalescent homes in the nineteenth century, therefore, calls attention to the historical specificity of ideas about the relationship between healing and place. The emergence and popularity of convalescent homes occurred in the context of rapid and widespread urbanization and industrialization, as well as extensive concern about the public health risks of a deteriorating urban environment. It is perhaps not surprising, then, that such great importance should have been attached to the idea of locating practices and institutions of recuperation outside the boundaries of the urban environment.
The benefits of convalescent homes were understood in direct relation and contrast to other sites and spaces of healing. Just as convalescence itself represented a liminal, transitional phase between illness and health, convalescent homes were spaces that were not quite hospital, not quite holiday, and not quite home. They were, in many cases, the outgrowths of hospitals and shared many features, such as medical supervision, nursing care, and institutionalized nutrition. Yet what differentiated them from hospitals — their home-like design, salubrious location, and peaceful atmosphere — was what attracted both patients and philanthropists. Likewise, though convalescent institutions were “home-like,” they were very much not like patients’ actual homes; the benefits of their non-institutional design were understood in direct relation to the deficient domestic conditions in which patients often found themselves. The history of these institutions highlights the relational terms in which healing spaces are understood. The way particular places and spaces come to be seen as promoting or undermining health is deeply intertwined with the perceptions of related spaces and contexts. The emergence and rapid growth of a large network of convalescent homes in late nineteenth-century England, then, not only gives us insight into how Victorian medical thinkers conceptualized the needs of recovering patients, but also suggests the depth of contemporary concerns about the healthfulness of hospitals and the practical limits of urban sanitary reform.
Eli Anders is a PhD student in the Department of the History of Medicine at Johns Hopkins University. His dissertation explores the history of convalescent homes and practices in nineteenth and early twentieth-century England.
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 Emily Janes, ed., The Englishwoman’s Year Book and Directory (London: Adam & Charles Black, 1900).
 Florence Nightingale, Notes on Hospitals, 3rd ed. (London: Longmans, Green, Longman, Roberts, and Green, 1863), 107.
 “Miss Florence Nightingale on Convalescent Hospitals,” Daily News (London), August 22, 1860.
 Lynn McDonald, ed., Florence Nightingale and Hospital Reform (Waterloo, Ontario: Wilfrid Laurier University Press, 2012), 17.
 Hospitals faced other practical considerations that warranted the transfer of patients to convalescent homes. Many hospitals faced increasing patient loads during this period, which encouraged them to free up much-needed beds by moving patients to external facilities, such as convalescent homes. See John V. Pickstone, Medicine and Industrial Society: A History of Hospital Development in Manchester and Its Region, 1752-1946 (Manchester: Manchester University Press, 1985).
 Nightingale, Notes on Hospitals, 107.
 London Samaritan Society and Homerton Mission, “Particulars of Beach Rocks Sea-Side Convalescent Home, Sandgate, Kent” (London, 1895), 19, 1609/2863, British Library.
 Joseph Adshead, “A Plea for the Establishment of a Convalescent Hospital for Manchester and Its Surrounding Districts,” Transactions of the Manchester Statistical Society. 1860–61 (December 10, 1861): 23–45.
 “A Convalescent Home for the Children of the Poor, 5 Wrotham Crescent, Broadstairs.” (London, n.d., late 19th C.), F/MM/103, London Metropolitan Archives.
 Some health policy experts have, however, lamented the loss of this function in modern health care systems. See, for example, Daphne Fallows, Convalescence: A Neglected Need? (London: Cicely Northcote Trust, 1989).
 Of course, convalescent homes were hardly unique among Victorian medical institutions in attributing health benefits to the salubrity of particular places and the design of therapeutic spaces. Numerous historians of medicine have drawn attention to similar aspects of tuberculosis sanatoria, health resorts, and the like. See for just a few examples, Michael Worboys, “The Sanatorium Treatment for Consumption in Britain, 1890-1914,” in Medical Innovations in Historical Perspective, ed. John V. Pickstone (London: Macmillan, 1992), 47–73; Helen Bynum, Spitting Blood: The History of Tuberculosis (Oxford: Oxford University Press, 2012); Clare Hickman, Therapeutic Landscapes: A History of English Hospital Gardens since 1800 (Manchester: Manchester University Press, 2013); John Hassan, The Seaside, Health and the Environment in England and Wales since 1800 (Aldershot: Ashgate, 2003).