Medicine, Disease and Society in Britain, 1750 - 1950
Medicine, charity and the care
of the poor
Lecture 4
Lecture Themes
• Links between sickness and poverty
• Access to medical care for the poor
• Increasing population, urbanisation
and industrialisation
• Increasing pauperism
• Was charity work always a good
thing? Did it produce results? Did it
heal/cure/treat effectively?
Lecture Outline
• Poor Law Legislation – Comparison of Old
and New Poor Law
• The role of medicine within these laws
• Charitable Provision: Hospitals and
Dispensaries
• Who did they provide care for?
• What care did it provide?
• How were the Infirmaries organised and
administered?
• Voluntary, cottage and specialist
The Old Poor Law
1601 The Elizabethan Poor Law was a national Act for England and Wales
1662 Act of Settlement - provision of Workhouses
Parishes or Townships unit of organisation
• a compulsory poor rate
• the creation of 'overseers' of relief
• provision for 'setting the poor on work'
Medical Provision
•
Medical men employed by contract, or paid per case, great
variety of provision, including unqualified healers
•
Personal contact with poor important, idea of expensive but
short-term solutions – flexible system
•
Out-relief key aspect of medical provision, workhouses
usually less important
Medical expenses at Birmingham workhouse, 1743-4.
Expenses for medical relief of indoor paupers in the Mirfield (Yorkshire)
Workhouse
Out Door Relief - The Old Poor Law System in early-19thC England.
The Poor Law Reform Movement
Industrial revolution: development of the towns, rapid population growth,
first experience of modern unemployment and the trade cycle.
Poor rates increased: 3 principles of the reform movement
• Malthus. He argued that population was increasing beyond the ability of
the country to feed it. The Poor Law was seen as an encouragement to
illegitimacy, and this would lead in turn to mass starvation.
• Ricardo. His 'iron law of wages' was believed to show that the Poor Law
was undermining the wages of independent workers. Together with the
"roundsman system", where paupers were hired out at cheap rates to local
employers, the Speenhamland system was thought to depress wages. The
advocates of reform thought they were helping independent workers.
• Bentham. He argued that people did what was pleasant and would not
do what was unpleasant - so claiming relief had to be unpleasant, a last
option. This was the core of the argument for "stigmatising" relief - making it,
in the happy phrase of the time, "an object of wholesome horror".
Poor Relief Expenditure, 1750-1833.
Per capita relief
spending (shillings) by
county, 1802/3.
Proportions of
county populations
in receipt of relief,
1802/3.
Per capita relief
spending (shillings)
by county, 1831.
The Poor Law of 1834
1832-1834 The Poor Law Commission emphasised two principles:
• Less eligibility: the position of the pauper must be 'less eligible',
or less to be chosen, than that of the independent labourer.
• the workhouse test: there was to be no relief outside the
workhouse.
1834 Poor Law Amendment Act
This established a national Commission for England and Wales.
The Scottish Poor Law was not introduced till 1845
The New Poor Law
Poor Law Amendment Act 1834 and Medical Order 1842
• Boards of Guardian administer Poor Law
• Poor Law Unions unit of organisation – large, contained several
parishes, less personal contact
• Poor Law Medical Officers employed under contract. Work
through Relieving Offices who judged on social rather than
medical criteria
• Cost cutting was driving force
•Principle of ‘less eligibility’ and ‘workhouse test’ enforced –
Workhouse (indoor relief ) used rather than outdoor (medical
treatment often only form of out-relief)
•‘Deterrence’ replaced ‘entitlement’. Conditions varied but often
dreadful
Picking oakum in the work house, 19thC.
This vast new workhouse, opened on 4 August 1849, was for the united
parishes for Fulham and Hammersmith. The largest workhouses not only
segregated the poor according to age, sex, and health, but provided
separate accommodation for each of the sexes according to ‘good’ and
‘bad’ character.
Leeds Union Workhouse became part of St James’ Hospital
and is now the Thackray Museum
Engels, Condition of the Working Classes (1844)
‘Englishmen are shocked if anyone suggests
that they neglect their duty towards the
poor. Have they not subscribed to the
erection of more institutions for the relief of
poverty than are to be found anywhere else
in the world? Yes, indeed - welfare
institutions! The vampire middle classes first
suck the wretched workers dry so that
afterwards they can with consummate
hypocrisy, throw a few miserable crumbs of
charity at their feet’.
Growth in Charitable Medical Institutions
• Voluntary Hospitals:
1720 Westminster
1736 Winchester
1800 (34), 1861 (230)
• Dispensaries:
1770 Aldersgate Street
1800 (33 of which16 in London)
• Specialist Hospitals:
1804 Moorfields Eye
1860s there were 66 in London
• Cottage Hospitals:
1859 Cranleigh
1875(148), 1895 (290)
The architecture of many of the eighteenth-century British voluntary
hospital reflected the wealth of its benefactors and was reminiscent of
contemporary country houses of the landed gentry.
Doncaster Dispensary, 1792-1867. These images show the small,
simple premises that housed the institution in the mid-nineteenth
century.
Middlesex Hospital, London, early 19th Century.
Ward at the Middlesex Hospital, early 19th Century.
Who was eligible for care?
• ‘Deserving poor’, ‘industrious or labouring
poor’ ‘proper objects of charity’
• Not paupers but those who could not afford
to pay for care themselves
• Hoped that medical treatment would avoid
pauperisation and encourage good and
thrifty habits. Rules encouraged the reform
of the poor
Several categories of patients
were excluded
• Children under 7
• Pregnant women
• Infectious diseases
• Venereal diseases
• Chronic diseases
• Terminally ill
• Insane
Hospital Treatments
• Sore legs, cough, scrofula (skin
disease), lame hips, paralysis, fractured
elbow, worms.
• Accident cases also seen
• Usually more men than women
treated, with a focus on young
working men
Organisation of Infirmaries
• Subscribers - right to nominate patients
• Governors - managed institution
• Medical staff - honorary appointments
• Matron and apothecary
• Patients - free treatment
This undated picture is labelled Luton cottage hospital. But Luton's mid to
late 19th century cottage hospital was literally in a cottage - in High
Town Road.
Gateways to Death?
• Florence Nightingale (1850s) - hospitals did
harm
• Thomas McKeown (late 1970s/1980s) - C19
hospitals positively did harm
• John Woodward (1980s) - hospitals treated
many patients successfully
Why did hospitals develop?
‘Humanity, self interest, religion and the pursuit
of social status made common cause to
help those deemed unable to meet the
cost of private medical care’. Keir Waddington
The expansion in numbers of hospitals arose
‘not because of changes in medicine or
perceived medical need, but because the
economic and social climate changed in
ways that made these institutions attractive
to a range of political views’. Marguerite Dupree.
Charitable giving
• Pre C18
• Individual, posthumous, religious
motivation
• Georgian
•
•
•
•
•
•
Collective
Associational
Living donors
Practical help
Secular
Cultural context- the benevolent
economy
Charitable motivations
• Altruistic
• Christian charity and
civic virtue
• Economic
• Maintained the
labouring classes,
• Reduced Poor relief
• Upheld the social
structure
• Reduced tensions
between classes
• Created middle class
identity
• Contributed to the
reform of the poor
Roy Porter, ‘Gift relationship’
‘An Act of conspicuous, self-congratulatory,
stage-managed noblesse oblige underlay
the infirmary. Poverty, malnutrition,
premature ageing, occupational accidents
and diseases would remain the abiding
realities of life for the labouring classes, as
would the coercive police functions of the
poor law for ensuring a tractable labour
force. The infirmary threw a cloak of charity
over the bones of poverty and naked
repression.’
Conclusion
• Differences between old and new
Poor Law – were the poor any better
off?
• Why was the workhouse/hospital
established?
• Who did it benefit?
• How successful was the hospital at
treating patients?