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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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