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Sickness in the Workhouse Poor Law
Medical Care in Provincial England, 1834-1914
Alistair Ritch
Rochester Studies in
Medical History University of Rochester
Press / Woodbridge: Boydell & Brewer, 2019 Hardcover. xiv+298 p. ISBN
978-1580469753. $125 / £95
Reviewed by Ginger
Frost Samford
University
In studies
of Victorian medicine, the workhouse infirmary has rarely received the
attention of hospitals or medical schools, particularly those in large
population centers such as London and Edinburgh. Yet, as Alistair Ritch
asserts, the workhouse infirmary was a major source of medical assistance for
the English poor, one that had a responsibility for populations across the
country and one upon which later, more generous systems built. The focus of
this book is two geographically close unions: one in Birmingham, an industrial
urban area, and the other in Wolverhampton, a more rural community with a
scattered population. The time frame is 1834-1914, from the passing of the New
Poor Law to World War I. Ritch’s sources consist of the voluminous records of
the poor-law guardians, but he supplements these with government documents,
newspaper reports, and writings by the doctors who worked in the respective
unions. Ritch
argues throughout the book against the assertion that the New Poor Law’s
emphasis on less eligibility inevitably led to substandard care. On the
contrary, the poor law medical officers used the same treatments practiced in
local voluntary hospitals, and most of the staff were dedicated to their
duties. The worst period was in the 1830s and 1840s, both because of uncertainties
about the functioning of the New Poor Law and severe economic strain.
Nevertheless, Ritch sees a steady improvement which did not halt even during
the period of “crusade against out-relief” in the 1870s and 1880s. Birmingham,
a better funded and more centralized parish, was often in advance of
Wolverhampton, but both expanded services as necessary. Overall, the workhouse
was a major site of care for the aged infirm, those with infectious diseases,
the mentally ill, and those suffering with physical impairments. Ritch stresses
that workhouse infirmaries were especially important for those with chronic
conditions; such treatments were monotonous and thus unexciting to hospital
doctors and the medical establishment. Both
Birmingham and Wolverhampton workhouses became “medicalized” by the early
nineteenth century; between a fifth to a third of inmates in the unions studied
were under medical care between 1834 and 1914. The classifications were
obscure, with terms like “old age” and “infirm” covering a multitude of issues,
but even the lower number attests to the centrality of the Victorian workhouse
as a place for medical treatment. In addition to the many “infirm” inmates, the
workhouse had fever wards, though that role caused conflict with the town authorities,
as the workhouse authorities feared infections spreading through their
institutions. Another contentious role was that of housing the mentally ill,
partly because a minority of these patients proved difficult to control. Moreover,
epileptics, those with venereal diseases, and the insane were housed together,
which hardly promoted careful treatment. Still, these limitations, and the lack
of resources for mental health, were typical of the age. On all cases that
required specialist care, the guardians bargained with the town and county
authorities about where best to house them, with a minority transferring to
asylums or specialist hospitals. Indeed, a theme of the book that could have
used more explication is the overlap of poor-law guardians with local officials
and heads of charitable organizations. This combination (and cooperation) of
these stakeholders could be oppressive to the poor, but it did allow
coordination in determining the best place for sick or injured inmates. Ritch
devotes three chapters to the day-to-day work of the medical staff. The
workload for both doctors and nurses was “immense” [127], and the pay was not
generous. Birmingham had its own, full-time medical officers, but Wolverhampton
used outside, part-time doctors, a common contrast between urban and rural
parishes. Doctors’ workloads were too high, which led to conflict with
guardians over low pay, long hours, and harsh conditions. Occasionally, as
well, patients complained of ill treatment or neglect, though given the high patient
load, most doctors did well to keep them as fit as they did. Ritch spends one
chapter explaining various treatments, which included drugs, alcohol, baths,
diets, and, mostly alarmingly given England’s weather, open-air treatments.
Though most compare unfavorably with modern medicine, none were substantially
different from the treatment given in local hospitals. For example, despite
having to buy the drugs out of their salaries, few doctors appear to have
substituted the cheaper option of alcohol if it was not the recommended
prescription. Nevertheless, after reading about these “cures,” the reader
cannot help but conclude that benign neglect was likely a better option for all
but the worst conditions, a silver lining to the high patient loads. Many probably
recovered due to the improved diet and rest rather than the “cures.” At any
rate, Ritch finds few complaints from patients, though this does not
necessarily mean that they were content. Some may have been, but others may
have expected little help from appeals to the guardians and thus not bothered;
one simply cannot know. A major problem with a reliance on poor-law records is
their lack of voices from the paupers, as Ritch readily acknowledges. The
chapter on nursing is a useful supplement to the more typical accounts of
Florence Nightingale’s reforms, war nursing, or London hospitals. Nursing in
the early part of the nineteenth century was of low quality, often done by the
paupers themselves, and confined largely to cleaning. The larger arc of professionalization
is one of Ritch’s themes, as well as the feminization of the nursing staff.
Unions preferred to hire widows or single women; they only used married women
when they could be hired with their husbands. The turnover rate was high,
partly because women left when they married and partly because of abysmal pay.
As with many other issues in the workhouse, nursing improved in the 1880s and
1890s, with better-trained nurses and more emphasis on medical knowledge. A
major advance was the decision to take on probationer nurses, who paid for the
training and supplemented the more experienced staff. The experiment was
largely successful, an example of poor-law infirmaries’ willingness to
innovate. Ritch
largely proves his point that the poor-law guardians were not the stereotypical
bean counters who begrudged every bit of care to their sick inmates, though, of
course, poor law unions varied enormously. My work in the treatment of
illegitimate children in the workhouse also showed a willingness on the part of
the guardians to experiment (as with cottage homes and fostering). However,
Ritch’s sources have a built-in bias in favor of poor-law guardians, an
unavoidable problem in all histories dealing with the disenfranchised poor.
Historians must read against the grain to see subtleties in institutional
records. Most notably, Ritch’s subjects were part of the “deserving” poor,
those who landed in the workhouse through no fault of their own. They are not,
perhaps, the best example of the new poor law’s tenet of less eligibility; I,
for one, was not surprised to know that sick inmates received standard levels
of care, since my subjects (children) were also deserving. The censorious
attitude of Victorians about the poor rarely included those with infections,
impaired sight, or seizures. The treatment of the able-bodied, or those in the
casual wards, was likely different, though not necessarily overtly cruel. Some
recognition of the division between “deserving” and “undeserving” could have
added nuance to the analysis and Ritch’s defense of the care offered in
infirmaries. Like most
medical historians, Ritch focuses on illness and cures rather than larger
issues of health and wellness. The workhouse regime was often criticized
because of its unvaried diet and lack of chance of outdoor exercise, issues
related to both mental and physical health. Neither the guardians nor the
medical staff considered their inmates in a holistic way, but as a list of
symptoms. This tendency is a weakness of any hospital regime, where doctors and
nurses worked to heal specific ills and often ignored preventative health
measures. Such emphases de-prioritized public health, a limitation common to
Western medicine. In other words, the fact that the infirmaries followed
standard practices of the day was not always a good thing; their willingness to
innovate had limits, ones common to their time. In addition, a chapter on
institution-borne infections, accidents, medical malpractice, and attempted
suicides/assaults—any medical issues that were caused, in part, by the
workhouse itself—would have been welcome. Scattered examples of such ailments
appear in many of the chapters, and the subject is important enough to deserve
its own discussion. Gathering these issues into a chapter would have
highlighted the health dangers of institutions, the equivalent of
hospital-borne infections today. Despite the workhouse guardians’ best efforts,
institutionalizing large numbers of disparate people inevitably led to health
problems, accidents, and emotional scarring. Some recognition of this
limitation would have further complicated the picture given in this book
without changing the overall argument. For the
most part Ritch, a physician, is an engaging writer, one who explains various
diseases and treatments with great knowledge. He includes over fifty charts
that have a wealth of information on many topics; those interested in medical
history will find much to benefit them simply by perusing these. I also applaud
his willingness to focus on an area other than London, and to use two different
unions for comparison and contrast. All the same, the chapters have a sameness
in structure, too much fondness for rhetorical questions, and an over-reliance
on the word “however” (used 214 times in a 225 page book that includes several
pages that are entirely made up of charts). In addition, occasional errors
occurred, a result, I suspect, of the largely non-existent editing of academic
presses. A major part of the only full paragraph on p. 105 is repeated without
change on p. 111, something the copyeditor should have caught on the first
read. Lack of editorial oversight will, I fear, make these kinds of errors more
and more likely in the future. Despite
these mild reservations, Sickness in the Workhouse is a welcome addition
both to medical history and to studies of the poor law during the long
nineteenth century. Medical historians will appreciate its information about
treatments and ailments, while social historians will learn much from the
discussion of the working conditions. The wide variety amongst poor-law
institutions has limited historians’ understanding of welfare provision in the
Victorian age. Too often, historians base conclusions about the poor law by looking at
unions in large metropolitan areas, by solely using government documents about
the poor law, or, worse, by accepting as gospel novelistic depictions like
those in Oliver Twist (1838). This book is one of a
growing number of studies that demonstrate both the complexities of the poor
law in the Victorian period as well as the poor-law medical service’s influence—both
negative and positive–on the National Health Service that followed.
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