Medicine, charity and the care of the poor

1. Medicine, Disease and Society in Britain, 1750 - 1950 Medicine, charity and the care of the poor Lecture 4

2. 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?

3. 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

4. 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

5. Medical expenses at Birmingham workhouse, 1743-4.

6. Expenses for medical relief of indoor paupers in the Mirfield (Yorkshire) Workhouse

7. Out Door Relief - The Old Poor Law System in early-19thC England.

8. 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".

9. Poor Relief Expenditure, 1750-1833.

10. 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.

11. 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

12. 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

13. Picking oakum in the work house, 19thC.

14. 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.

15. Leeds Union Workhouse became part of St James’ Hospital and is now the Thackray Museum

16. 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’.

17. 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)

18. 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.

19. Doncaster Dispensary, 1792-1867. These images show the small, simple premises that housed the institution in the mid-nineteenth century.

20. Middlesex Hospital, London, early 19th Century.

21. Ward at the Middlesex Hospital, early 19th Century.

22. 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

23. Several categories of patients were excluded • Children under 7 • Pregnant women • Infectious diseases • Venereal diseases • Chronic diseases • Terminally ill • Insane

24. 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

25. Organisation of Infirmaries • Subscribers - right to nominate patients • Governors - managed institution • Medical staff - honorary appointments • Matron and apothecary • Patients - free treatment

26. 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.

27. 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

28. 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.

29. Charitable giving • Pre C18 • Georgian • Individual, posthumous, religious motivation • Collective • Associational • Living donors • Practical help • Secular • Cultural context- the benevolent economy

30. Charitable motivations • Altruistic • Economic • Upheld the social structure • Christian charity and civic virtue • Maintained the labouring classes, • Reduced Poor relief • Reduced tensions between classes • Created middle class identity • Contributed to the reform of the poor

31. 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.’

32. 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?