Medical Negligence in Victorian Britain: The Crisis of Care under the English Poor Law, c. 1834–1900 9781441125460, 9781474210812, 9781441140593

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Medical Negligence in Victorian Britain

Medical Negligence in Victorian Britain The Crisis of Care under the English Poor Law, c. 1834–1900

Kim Price

Bloomsbury Academic An imprint of Bloomsbury Publishing Plc

Bloomsbury Academic An imprint of Bloomsbury Publishing Plc 50 Bedford Square London WC1B 3DP UK

1385 Broadway New York NY 10018 USA

www.bloomsbury.com BLOOMSBURY and the Diana logo are trademarks of Bloomsbury Publishing Plc First published 2015 Paperback edition first published 2016 © Kim Price, 2015 Kim Price has asserted his right under the Copyright, Designs and Patents Act, 1988, to be identified as Author of this work. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage or retrieval system, without prior permission in writing from the publishers. No responsibility for loss caused to any individual or organization acting on or refraining from action as a result of the material in this publication can be accepted by Bloomsbury or the author. British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library. ISBN: HB: 978-1-4411-2546-0 PB: 978-1-3500-0202-9 ePDF: 978-1-4411-4059-3 ePub: 978-1-4411-4786-8 Library of Congress Cataloging-in-Publication Data Price, Kim, (Historian) Medical negligence in Victorian Britain: the crisis of care under the English Poor Law, c1834-1900 / Kim Price. p. cm. Includes bibliographical references and index. 1. Physicians–Malpractice–Great Britain–History. 2. Poor laws–England–History. 3. Poor–Medical care–Great Britain–History. I. Title. KD2960.M55P76 2015 344.4204’1109034–dc23 2014035362 Typeset by Integra Software Services Pvt. Ltd Printed and bound in Great Britain

For Lauren To help you on your journey

Contents List of Figures List of Tables Acknowledgements 1

Introduction: The Nuances of Neglect under the New Poor Law

viii ix x 1

Part One 2 3 4

Victorian ‘State Doctors’: Medical Officers of the New Poor Law Negligence: The ‘Psychological Moment’ Controversies: The Poor Law of Negligence

21 49 73

Part Two 5 6 7 8

A Latent Failure: The Crusade against Outdoor Relief Survival of the Fittest: Indoor Neglect A Catch-22 Conclusion: The Patients’ Voice – Seen but Not Heard?

Notes Select Bibliography Index

103 123 151 175 187 221 228

List of Figures Figure 2.1 Figure 2.2 Figure 2.3 Figure 2.4 Figure 4.1 Figure 4.2 Figure 5.1

Average starting salary for a medical officer by decennial period Quantification of start salaries (in £) for all workhouse medical officers, between 1834 and 1899 Quantification of start salary for entire period for salaries under £100 Distribution of the ‘start salary’ for workhouse medical officers throughout the nineteenth century Inspectors’ districts by decennial period Peak in (known) forced resignations and dismissals of workhouse medical officers in the 1870s Map showing charges of negligence against workhouse medical officers in the 1870s and 1880s (and numbered districts of Table 5.1)

38 39 40 40 79 94

112

List of Tables Table 2.1 Table 2.2 Table 4.1 Table 4.2 Table 5.1 Table 5.2 Table 6.1 Table 7.1 Table 7.2

Acceptable qualifications for a medical officer in England and Wales The supply of drugs by unions in the north-west of England in 1877 Inspectors and their respective districts in decennial periods, 1846–1876 Inspectors and their respective districts in decennial periods, 1886–1900 Inspectors’ districts during the crusade Reasons for leaving for all workhouse medical officers between 1860 and 1909 Extracts from the BMJ’s investigation of fifty provincial unions Permitted fees for medical treatment and attendance Representative large districts in Wales and England

30 34 76 76 113 121 130 158 170

Acknowledgements The manuscript for this book has been shelved, re-started and re-shaped several times over. Frequently, it was the kindness of colleagues, friends and family that have provided the spur to continue. The impact of others has been tremendous, but, inevitably, there will be those that I have forgotten and to whom I extend an apology in advance. Nick Sign and Margaret Thomas patiently taught me the skills of a historian at Suffolk College and gave me the confidence to pursue an academic career. Colin Jones and Hilary Marland supplied further inspiration at Warwick University, while John Stewart and Steve King elevated my PhD thesis to greater heights at Oxford Brookes University. In short, I owe an insurmountable debt of gratitude to Steve, who has been a friend and mentor over several years of hard-won scholarship. In a similar vein, it is impossible to divide friendship from the generous collegial help that I have received during the process of transforming research into a monograph. My research and writing has benefitted from conversations, guidance, readings, critiques and feedback from many other friends and colleagues in academia, such as Tracey Elliott, Tudor Georgescu, George Gosling, Elizabeth Hurren, Brian Hurwitz, Paul Lazarus, José Miola, Rob Pope, Melanie Reynolds, Thomas Sokoll and Alannah Tomkins. Alannah and Elizabeth deserve special thanks for critiquing some early chapter drafts and providing insightful suggestions (although they are in no way responsible for any mistakes or gaps in the final shape). Matthew Tompkins has also provided a first-class critical mind, libation and scholarly solace. The various elements of research that have come together in this book were generously funded with a PhD scholarship from the Arts and Humanities Research Council and a postdoctoral research fellowship from the Wellcome Trust, together with vital research and maintenance funds provided by Oxford Brookes University. The Centre for Medical Humanities at the University of Leicester has also been integral in providing me with a collegial space to converse, think and write. I am bound by word limitations to a collective expression of gratitude to the countless local archives and national collections that I have visited in England and Wales. I would also like to thank the team at Bloomsbury Academic, particularly Claire Lipscomb, whose vision and patience has supported this book from concept to publication. Finally, the generosity and support of old friends and family deserves acknowledgement: Ben Pike, with impeccable timing, sailed me around the coast of Greece for the perfect pick-me-up; two old friends, Rob Kendall and Michael Rushton, also receive citation for remaining true, despite the mystifying madness of long-term historical research. My siblings, Tara, Bryony, Nathaniel and Josephine (and their growing families), also deserve special thanks for providing endless joy and support. I would also like to thank our parents: Lester Goulbourne, who has been a voice of reassurance, wisdom and kindness; and Linda Price-Goulbourne, who provided the

Acknowledgements

xi

greatest gifts for a budding historian – a childhood soaked in the love of literature and (in aiding this manuscript) a skilled, willing and free proofreader. Finally, I am grateful to my wife, Gabriele, for understanding my obsession, and for allowing me the time and finances to write, at a time when I should have been fully focused on bringing our son into the world. Even with such wonderful support, ultimately, it was the personal experience of a ‘medical error’ that has bequeathed the passion to finish this book. Whilst I feel no gratitude for this, I am nonetheless compelled to acknowledge the role of my miraculous daughter, Lauren, who opened my eyes and led me away from every dead end and false avenue.

1

Introduction: The Nuances of Neglect under the New Poor Law

The legal inheritance Across the modern world, medical negligence has evolved into a specialist subject in law for many countries. Although there are some international patterns and national preferences, tort and contract law have come to dominate the legal remedies for actions against medical practitioners. The legal usage of tort has its antecedents in the Norman word for ‘wrong’, which covers negligence actions for a plaintiff who has been ‘wronged’ and thus seeks to redress an intentional or unintentional harm. The law of contracts applies to the contract made between people or entities (for example, a private patient and their health care provider) and also applies to the vicarious liability of employers for their employees (such as a public hospital’s responsibility for its medical staff ). Furthermore, in spite of diversity in legal practice, in most countries ‘the same circumstances may give rise both to an action in tort (or delict) and one for breach of contract’.1 This opening chapter will therefore explore relevant elements of this complex legal inheritance, teasing apart the traditional history of modern medical negligence law in Britain, and subsequently use this to re-situate the place of the poor law within an accurate historical socio-legal context. Dieter Giesen, an expert on international medical malpractice law, argues that different systems of law have led to a bifurcation in practice. Countries with a tradition of Civil Law (notably Germany, Italy and Switzerland) have been more likely to adopt a contractual view of the ‘physician–patient’ relationship.2 In contrast, Common Law countries, such as England and Wales, have adopted ‘a more noncontractual, and mostly tortious approach’.3 According to Giesen, this can be dated back to 1768 in England, when the famous Sir William Blackstone (the ‘first Vinerian Professor of English Law’ at the University of Oxford) published ‘one of the most influential legal text books ever written’.4 In Commentaries on the Laws of England, Blackstone insisted that ‘the proper Common Law remedy for damages against physicians was an action of trespass on the case’.5 This underpins the modern law of torts in England, which ‘… aims first of all at the prevention of wrongful harm caused by others and if things go wrong, at compensating injuries or distributing losses thereby suffered’.6 In turn, the compensatory basis for litigating against a doctor has tended to be better served by a tort action in English Law. The early

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Medical Negligence in Victorian Britain

modern progression towards tort law, however, belies the subsequent enigmatic characterization of medical negligence law in modern England, a theme returned to in Chapter 4. Complexities are further obfuscated by a discordance between determinist accounts of legal ‘progress’ from the late nineteenth century (leading to Bolam, described below) and parallel historiographies for medicine and culture. This is understandable; legal studies have a different remit to the social or medical historian. Nevertheless, a preference for Black Letter Law has resulted in the broad-brushing of relevant sociological processes in history in the literature for law. This has led to an oversimplification of critical elements of historical patient neglect that may not be visible through the lens of law, such as doctor–patient interactions, medical professionalization and the interpretative application of laws (and legislation) in different health care settings. Moreover, an esoterically legal view of the past, written by and for specialists in medical law, can exclude processes that are not recognizably relevant to modern contexts. As such, subjects that may appear irrelevant have been excluded, such as Victorian poor law doctors being charged with negligence in a quasi-judicial setting. Notwithstanding the dominance of tort, other legal remedies in England are often overlooked. The legal literature makes generalizations about patient neglect before the major changes that occurred to medico-legal remedies in the twentieth century. Arguably, there is a distinct framing of medical negligence in modern England that has predominantly stemmed from two directions: growing notions of patientcentred health care environments, on the one hand, and doctor-dominated legal processes on the other. While patients’ rights have arrived neither in contract nor in statute – fuelling the need for aggrieved patients’ recourse via tort – there has been a controversial relocation of power (from lay judiciary to medical professionals) since the Bolam precedent of 1957. Legal writers have noted the power shift with Bolam, but there has been a misleading tendency to search for tort antecedents to this. Arguably, such accounts have therefore overstated the power of the medical profession before Bolam and placed too much emphasis on actions for negligence in the court records.7 As a result of this, there is a discordant determinism to the history of medical negligence before Bolam. The emphasis has been placed on the inevitability of a Bolam-type precedent from the early-twentieth century, but – in cultural and political terms – the power shift was extraordinary. After Bolam, the power to judge health practitioners was placed firmly into the hands of the medical profession.8 Understanding the Bolam-esque formulation of modernday medical negligence is nevertheless a useful way to comprehend the contrasts between past and present. Bolam was the name of a mental-health patient who was injured during electroconvulsive therapy at Friern Hospital, which led to an action of medical negligence. Judge McNair’s guidance to the jury has continued to resound throughout the subsequent half century, including his oft-quoted words: ‘A doctor is not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art.’9 It was a landmark precedent in medical law that remains effective to this day (although there have

Introduction: The Nuances of Neglect

3

been recent in-roads into ‘revolution’).10 Since Bolam, even a ‘reputable minority view’ can be used to formulate a defence.11 As the legal scholars, Fenn and Whelan, argue, ‘… the effect is that it is the medical profession rather than the judges which sets the legal standard of care in practice’.12 The Bolam test (as it became known) gave free reign to the medical profession in the courts; a controversy which has hardly diminished over the subsequent half century.13 Under the test, four fundamental factors have contributed to a compensationcentred legal culture in England: first, a patient must confirm that he or she was ‘owed a legal duty of care’ by the health practitioner (the ‘defendant’ in cases of medical negligence); second, the action must establish that ‘the defendant was in breach of that duty of care in failing to reach the standard of care required by law’; third, there must be damage or injury to the patient; and fourth, it must be proven that this was caused by the ‘breach’ – commonly, the actions of an individual.14 The kaleidoscopic world of today’s biotech medicine, however, was the stuff of science fiction in the 1950s. The unintended result of Bolam, therefore, has been to make it harder for plaintiffs to disprove a defence of ‘reasonable’ practice against a twentyfirst-century profession that has developed a multiplicity of esoteric approaches to treatment.15 It has had the effect of removing the power of evaluation from the judge or jury and diminishing the influence of non-medical expertise. To many observers, it was the coronation of a distinctly British legal definition of medical negligence that has artificially depressed the success rate of litigation. Two experts in medical law, Margaret Brazier and José Miola, suggest, ‘Bolam, out of control and out of context, came close to acquiring demonic status in some quarters.’16 Thus historians need to be careful about evaluating and comparing court cases before and after Bolam. Before the mid-twentieth century, there were few outstanding features that differentiated a doctor’s negligence from that of any other professional. Neglect of a patient was mostly dealt with under the laws for professional negligence. The legal historian, John Baker, therefore observed that contract law has been used in England as a legal remedy since 1602, and ‘to this day a negligent private surgeon may be sued in tort or contract at the plaintiff ’s selection’.17 He perceptively suggests that ‘… there is nothing modern about the concept of negligence in itself; what has changed is its primacy’.18 Contract and tort thus still overlap today, but the emphasis has shifted to the harm-centred approach of a tort action over the ‘obligation’ of contract, which was a primary consideration in the past. This transition began in the nineteenth century, but there has been little research into the pre-Bolam social and legal constructions of medical negligence. Before the mid-twentieth century, a legal precedent with similar elements to Bolam may have been anticipated by some contemporaries, but it was by no means assured. Recent historians have noted the weakness, not the strength, of the British medical profession at the turn of the twentieth century. The medical law historian, Angus Ferguson, therefore argues that the leading legal publications of the late nineteenth century reflected the ‘medical practitioner’s vulnerability to legal action’.19 This may have led to an expectation of change, but there has been no convincing empirical research into actions of medical negligence in or beyond the court records to prove or disprove this.

4

Medical Negligence in Victorian Britain

A distinct lack of engagement with legal redress before the mid-twentieth century has resulted in a virtual historiographical lacunae between the compensation boom in Victorian railway accidents and the rise in medical litigation described for the late twentieth century. Legal scholars have rightly suggested that mid-Victorian train accidents, of which there were many, brought the modern form of tort law and signalled a ‘boom’ in railway accident litigation.20 Although the medical profession played an increasingly significant and high-profile role in injury assessment and testimony, beyond this, the law reflected public ambivalence towards medical practitioners. In spite of their ‘vulnerability’, and a concurrent ‘crisis’ of medical malpractice legal actions against ‘physicians’ in mid-nineteenth-century North America,21 the generally accepted view of legal history is that there was no cognate experience for medical professionals in Victorian Britain. Without qualitative research, the sociological reasons for this remain unexplained – and, without quantitative research, such a view cannot be challenged. Certainly, the Victorian law provided none of the special rights to exclusive professional authority that was later associated with doctors after the Bolam test. In theory, then, they were more vulnerable to legal action in the past. In terms of Black Letter Law, the medical profession had no exceptional rights in the nineteenth century. The modern benchmark of ‘reasonable care’ was evident in law, but it stemmed from generic professional negligence under the legal concept of the ‘reasonable man’.22 Doctors, like other professionals, were judged by comparison to what an ‘ordinary man’ would do under the circumstances.23 This was famously articulated by an early-twentieth-century judge who guided a jury to appraise the actions of a medical practitioner ‘by the conduct of the man on the top of the Clapham omnibus. He is the ordinary man’.24 Nineteenth-century courts were directed to assess if a defendant had exercised due care and diligence, but there was no comprehensive medico-legal explanation of what this may be. Thus, court precedents tended to overrule medical claims to exclusive knowledge: ‘It [was] for the judge to direct the jury what standard to apply and for the jury to say whether that standard [had] been reached … the law requires a fair and reasonable standard of care and competence.’25 The power to decide on courtroom medical matters, and the acceptable ‘standard of care’, therefore, remained in the hands of laymen throughout the nineteenth century. Politicians, court officials, local dignitaries and parish overseers were all backed by the law to confront and question medicine. Ferguson therefore describes a pre-Bolam legal landscape in which doctors had few exceptional rights under the law: ‘The ease with which claims could be brought against doctors by patients or fellow practitioners was a problem exacerbated by the difficulty of disproving any accusations.’26 This is Bolam turned inside-out. Furthermore, for most of the nineteenth century, doctors had to arrange for their defence themselves. It was a costly procedure and most doctors would dismiss libellous action or public slurs because they could not afford the defence fees. According to legal historian Clifford Hawkins, ‘If a victim of slander or libel, [a doctor] had to sue his prosecutor himself or suffer in silence – and lack of expert advice might prejudice his case … .’27 In turn, charges were only properly defended

Introduction: The Nuances of Neglect

5

through public appeals – most often in newspapers and journals. Thus, with the increasing use of vicarious liability in the late-Victorian era, the final quarter of the nineteenth century heralded the formation of a number of liability insurance companies.28 This included medical defence associations, such as the Medical Defence Union, which was inaugurated, itself, due to increasing charges of negligence and libel in the late nineteenth century.29 Retrospectively, this may have seemed like the ideal moment for a medical litigation boom, but legal academics have described only a slight increase at the end of the nineteenth century.30 Contemporary records hint otherwise, but (as argued above) there has been no quantitative research into national and local court records. Arguably, at this time – despite the ‘new’ financial worth of suing a doctor – most aggrieved patients did not have social or financial access to legal remedies. The same financial inability of doctors to defend themselves would have applied equally – indeed, more so – to the limitations on actions against them, which were beyond the means of the vast general populace of England and Wales. Teff argues that, as a result of this, ‘… in the late-nineteenth and early-twentieth centuries it was very unusual for patients to sue their doctors. Conventionally considered an almost presumptuous thing to do, it was in any event beyond the means of all but a tiny minority’.31 Thus, it tended to be in extreme cases, such as manslaughter, that the general public brought charges of medical negligence to English courtrooms in the nineteenth century. The traditional legal narrative, therefore, argues that charges against doctors in the United Kingdom were relatively rare until the late nineteenth century, and that numbers of court cases only became significant in the decades that preceded Bolam.32 This may be so, but more research could prove otherwise. Either way, such a law-dominant perspective can be misleading. It defines the sociological dimension of patient neglect by the strength of its hand in litigation. It could be argued that the legally defined medical negligence action, described above, expresses neither the social and professional milieu that underpins an adverse event nor the historical prohibitions to complaining and legal recourse. Furthermore, the need to blame an individual (notably, to receive compensation under tort law) presents a distortion. The requirement for evidential constructions of individual accountability (under tort and contract remedies) can mean that hazardous system processes and latent failures are maligned in court records. In other words, the socio-legal – and sometimes political – constructions of a blameworthy scapegoat may have gone unchallenged by legal historians. Moreover, it has been suggested by health sociologists that present-day records of actions for medical negligence exclude the majority of dissatisfaction and obscure the extent (and social implications) of patient neglect. Ultimately, it is this shift away from the court records – in order to learn about sociolegal constructions of medical negligence – that has the deepest resonance with this book’s subject matter. The sociologist, Rudolf Klein, incisively observed that the filtering relationship between litigation and complaining misses the bulk of patient dissatisfaction.33 He argued that this resulted in an ‘iceberg’ of unmeasured patient dissatisfaction under the twentieth-century National Health Service (NHS).34 A similar point of view is

6

Medical Negligence in Victorian Britain

also apparent in recent legal studies, which demonstrate that the ‘vast majority’ of medical dissatisfaction and grievance passes unvoiced.35 Alan Merry, an expert in medical law, describes the current limits to litigation in this way: ‘… only a minority of patients do complain, and many of these complaints are resolved locally through the processes administered by health care institutions. It follows that the vast majority of medical errors are in fact not dealt with (or recognized) by the law at all’.36 In turn, the framing of medical negligence as a precise legal action has also blinkered studies from the alternative legal processes for local resolution and the administrative structures for dealing with patient dissatisfaction.37 As such, the socio-legal scholar, Linda Mulcahy, argues, ‘Academics and practising lawyers have paid little serious attention to such systems of redress and even less attention to the issue of the place of complaints within the regulatory state.’38 Experts in patient safety and legal medicine have thus begun to pay more attention to the administrative machinery of dealing with complaints and patient neglect.39 Historians have been slow to react to this movement away from the court records. This book will therefore bring a historical dimension to a wave of scholarship in law and sociology that seeks to analyse the full panoply of legal methods for dealing with, and defining, negligent care. Given the legal heritage described above, medical negligence under the new poor law would seem to be an anachronism. Before legal aid, the Welfare State or the NHS, the ‘pauperized’ patients of the workhouse system would appear to have had no expectation of patients’ legal rights and no recognizable path to recourse if they did. According to the current view, they would have been able to access neither contract nor tort legal remedies. In so far as the administrative structures of the new poor law were created to manage pauperism – not medical care – facilitating standards of care and complaints of negligence seem anathema to its designers. As described below, paupers’ ‘health care’ was provided in a ‘deterrent’ setting in which they supposedly had few rights and no income to bring a charge or action of negligence against a doctor. In contrast, this book will bring forward new research and demonstrate that charges of neglect against poor law doctors occurred with surprising regularity and that pauper complaints were not ignored.40 Medical officers were answerable to their employers – not their pauperized patients – but paupers could challenge the standard of care they had received and make formal complaints.41 Sometimes this could escalate into an official inquiry conducted by a poor law inspector. It was the irregular legal process and the consequent outcomes of these inquiries that, together, make poor law negligence such a unique episode in legal, medical and social history. The ambiguity of this quasi-judicial process reveals the Victorians’ conflicted expectations of the practice of medicine and, in turn, their difficulties in dealing with and defining medical negligence under the new poor law. Ferguson rightly argues that, in the nineteenth century, ‘Statute laws were often sufficiently open to interpretation to envelop practitioners in grey areas of subjective judgement.’42 This was clearly demonstrated in the administration of the English poor laws, especially in the employment and disciplinary regulations for doctors. Medical negligence was, in turn, defined by a system that avoided penetrative reform and sustained the blameworthiness of individual doctors’ negligent practice.

Introduction: The Nuances of Neglect

7

The context of medical provision under the new poor law In order to appreciate why this matters for poor law history, this section will succinctly explain some relevant aspects of the ongoing debates over the poor law. With thematic constraints on space and ambit, what follows does not present a comprehensive depiction of the complexities that have bedevilled centuries of commentary and historiographical discussion about the English poor law. Besides, it is unnecessary to rehash the numerous literature surveys, written by noted poor law historians. Among the least prosaic and most relevant of those are works by Anthony Brundage,43 Anne Crowther,44 David Englander,45 David Fraser,46 David Green,47 Bernard Harris,48 Lynn Hollen Lees,49 Alan Kidd,50 Steve King51 and Michael Rose.52 This section will, instead, highlight those areas of the Victorian poor law that have led to questions about the standards of medical care that it provided. Standards of care and medical negligence (though not as legal constructs) are overtly or implicitly referred to throughout the literature. Given the lack of serious engagement, though, those subjects appear to have been considered peripheral or anachronistic to poor law scholarship. Yet, they are issues that can cut to the heart of Victorian welfare provision, interacting, for example, with the intentional and unintentional effects of local and central policies, and the extent and limitations of medical provision. As such, this book presents a micro-history of the medical terra firma under the new poor law, but, at every step of the way, it interacts with the climatic changes of a turbulent political environment. By the start of the nineteenth century, the English poor laws had been in existence since Elizabethan times. Essentially it was a legal provision, enacted in statute law (1601), to ensure that the most destitute and needy would not starve, the sick could be treated and the ‘idle’ may be set to work.53 The taxes for this were levied at a local level, called the poor rate, and the funds were administered by the overseers of the poor. Generally, poor relief was split into two categories: indoor relief, which included institutional provision, such as workhouses and almshouses; and outdoor relief, which was a comprehensive array of subsistence and domiciliary medical relief, provided to the poor. A variety of assistance had therefore developed in early modern England in order to provide relief at the local level. By the turn of the nineteenth century, however, the range and extent of this provision had attracted widespread condemnation. Ratepayers were critical of the expanded remit of poor law provision, the expense of which had been reflected in their raised payments to the poor rate. There was general discontent with the perceived indiscriminate provision of relief and, in turn, political and public pressure for legislative reforms. Consequently, a Royal Commission was appointed to investigate the poor law in 1832. It has been rightly acknowledged by historians for its bias. The Commissioners set out to prove that the law had been usurped and abused by a perceived mass of profligate and work-shy poor. The ‘evidence’ for this was amassed in the interviews conducted at a local level with welfare providers and interested ratepayers, such as magistrates, overseers and clergy. The Poor Law Amendment Act of 1834 was a direct result of the Royal Commission’s findings. The administrative system that existed after this

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act instantly became known as the ‘new’ poor law, while the previous centuries of relief provision were labelled the ‘old’ poor law.54 The historical economist, William Lubenow, observes that the Commissioners ‘intended it as neither a mechanism for the elimination of poverty nor for the promotion of social mobility. The most it was intended to accomplish was the transformation of the idle and improvident into industrious members of the working classes’.55 Under the infamous principle of ‘less eligibility’, the new poor law had therefore been created to deter all but the neediest cases of want and destitution. In order to achieve this objective, the new poor law provided the legal apparatus for parishes to unite under unions, which were then headed and administrated by local boards of guardians, with a fresh emphasis on the workhouse as the hub of poor relief. Guardians became powerful authorities whose ambit grew under the Victorians (extending into auxiliary local provisions, such as public health). Only the pre-existent locally enacted incorporations were exempt from the Poor Law Amendment Act, but these were later also subsumed. The workhouse ‘test’ lay at the heart of the guardians’ new powers. The ‘bastille’ characterization of the ‘House’ instantly became an iconic symbol of social oppression and control. Although there were workhouses in existence already, particularly since (Gilbert’s) Poor Relief Act of 1782, the new poor law was socially, politically and religiously divisive.56 The religious sanctity of the family was a primary concern. Pauperized families entered a strict disciplinarian regime in a new poor law workhouse, where they were split up and divided among the relevant sections (e.g. girls, boys, able-bodied men and married women). This added a punitive element and streamlined management of the workhouse according to Benthamite utilitarian designs (e.g. minimizing staffing and overhead costs).57 Ultimately, the new poor law was politically controversial because it was a national enterprise with, for the first time, a central authority: the Poor Law Commissioners (1834–1847), who instantly gained infamy. The historian, David Eastwood, argues that they were part of an ‘attempt to redistribute power within the English polity away from the localities and towards the centre’, but, if so, the Commissioners’ authority was tempered and short lived.58 Initially there was widespread public resistance to the workhouse system, but generally this settled down within a few years.59 Critics came closest to winning dissolution in 1847, but, after the downfall of the Commissioners in the same year, the poor law became, once again, a controversial but persistent feature of the political landscape. In part, it remained for so long because a large amount of the country’s guardians ignored the directives that came from the centre. As such, economists highlight the localism of rates, which continued to form the basis of relief, administered not by a ‘national agency’, but by local guardians.60 Except for Edwin Chadwick’s short period of influence, as secretary to the Commissioners, the poor law administration took a deliberately passive role.61 This was in keeping with the contemporary politics of ‘disinterest’ – a pattern of Victorian governance that distanced itself from the Georgian ‘war machine’ and the selfprofiteering of that era, and sought instead to create greater trust in Parliament’s ability to govern effectively, fairly and ‘cheaply’.62 Under the Victorians, good ‘British’ governance was thought to be that which avoided ‘despotism’ or State-like central power,

Introduction: The Nuances of Neglect

9

which was commonly and derogatively associated with the continent.63 A balance was always sought between central and local power. Nonetheless, this balance weighed heavily in favour of laissez faire and localized governance. For most of the nineteenth century, this meant a kind of invisible central government, mediating and supporting local administrators.64 The Victorian poor law was thus seen by contemporaries as an authoritarian incursion into English Liberty, but anti-centralization and laissez-faire sentiments ensured there was no centralized bite. Most recent historians therefore agree that it was the weakness, not the strength, of the centre that characterized the new poor law.65 It did not alter local practices within a uniform and centrally orchestrated national strategy. Furthermore, it was the intention of the central authority to be a sort of depository in which information was gathered from the localities, compared and then put into ‘best practice’ guidance.66 The central poor law authority changed twice more under the Victorians, but all three incarnations of the central body followed the pattern of avoiding ‘despotism’.67 The Poor Law Board replaced the Commissioners in 1847, but it was only a Board in name. In practice, the permanent officials ran and administered the poor law until 1871, when the poor law became the major department in the newly formed Local Government Board (LGB). Far from the traditional account of centralized politics, most of the time, the Commissioners and their successors sat on the fence or backed local power bases. Instead of enforcing policies, they issued circulars, directives and guidance to the local boards of guardians. The early years of the Commissioners (and the first two decades under the LGB, discussed below) were therefore exceptional. At first, the Commissioners pushed guardians to withdraw outdoor relief entirely and rigidly apply the workhouse test; the central objective being to force the ‘idle’ and ‘malingerer’ to find work. Relieving officers were employed by all unions in order to sort the needy from the malingerer and investigate applicants for relief (and to monitor the status of ongoing recipients). However, the total withdrawal of outdoor relief – a means of support that had existed for centuries – was difficult to put into practice. For example, some guardians recognized the need for short-term support (for the temporarily unemployed, sick or injured poor) as a bulwark against long-term pauperization; other guardians, though, had an interest in suppressing local wages and using outdoor relief as a supplementary benefit for local agricultural workers. Moreover, across the country, guardians and relieving officers found that they were regularly faced with cases of genuine want and sickness. It was frequently difficult for them to distinguish the ‘deserving’ from the ‘undeserving’. In turn, a great deal of unions ignored the Commissioners and continued their traditional welfare practices, and issued out-relief, in much the same way that they had done under the old poor law.68 In short, the State did not significantly intervene to alter the relative autonomy of local administration of welfare until the turn of the twentieth century.69 The consensual view of the new poor law, therefore, is that the image of a centrally run system was deceptive. Power remained in the hands of local boards of guardians throughout the nineteenth century. As such, the new poor law was intensely fractured and diverse in practice.70 The historical geographer, Felix Driver, therefore suggests that the tensions that riddled the system resulted in a ‘workhouse policy’ that was always compromised. Many historians would agree with

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Medical Negligence in Victorian Britain

Driver’s observation that the new poor law presents ‘a history of struggles’ – ‘struggles within the central poor law authority itself, between the poor law authorities and other sources of authority and expertise, between popular movements and the State, and between central and local authorities’.71 Changes that did occur happened over a long period of time and within the dynamism of central–local working relations — through conflict, agreement and resolution. In recent years, historians have therefore sought to explain the welfare system under the new poor law in terms of its diversity and regionalism. Welfare historians, such as Steve King, have pushed for greater refinement of the ‘substantial spatial differences’ in national poor law policies, which were often mere ‘sanctions’ of local diversity – a ‘codification of prevailing local practices and sentiment’.72 The misleading nature of contemporary public debates and (ignored) central regulations, led Lynn Hollen Lees to suggest that historians turn from ‘what was said to what was done’.73 This meets with the unintended effects of statutes, described by Ferguson, which were ‘open to interpretation’ and contrary to practice. Despite appearances, then, the new poor law ‘was in practice internally differentiated’ – both from one region to another and in the ways that local practice departed from central policy.74 As such, it continued a tradition of regional diversity in the administering of the English poor laws. Medical relief after 1834 mirrors this diversity, but, in other respects, Victorian poor law medicine underwent change from the old poor law, not continuity. After 1834, medical relief was transformed by the unintended alterations to medical provision that came in the wake of the Poor Law Amendment Act.75 Within a few years, unions were directed to appoint medical officers, but local distortions of vague policies shaped their daily work. The Commissioners had focused on ablebodied paupers and the economics of managing pauperism. In contrast, as Anne Digby observes, ‘presumably from the beginning and certainly when the first statistics were published by the Poor Law Commissioners, able-bodied adults were a minority of those in workhouses. Between 1848 and 1870, they usually represented somewhere between 13 and 17 per cent of workhouse inmates’.76 As a result of this, neither the workhouses nor the new poor law were designed for the most numerous pauper classes: the sick, aged, disabled and children.77 The subsequent piecemeal expansion of medical services provided by the poor law was a by-product, necessitated by the high numbers of sick and poor that occupied the workhouses and relief lists.78 As the medical historian, Ruth Hodgkinson, opines, ‘the new Poor Act of 1834 made only the briefest allusion to medical relief ’, and the only ‘medical’ guidance provided in the Act was that ‘Justices of Peace could sanction an order for medical attendance in case of sudden or dangerous illness.’79 Historians, such as Bynum, have therefore noted the ‘accidental’ nature of the new poor law’s workhouse infirmaries, but emphasized their development into a loose system of State hospitals.80 This was, however, a long time in coming and the literature continues to conflict over the timing and effect of the ‘systematic’ development of a poor law medical service and Victorian ‘State hospitals’.81 Other historians, such as Digby, persuasively conclude that the new poor law ‘loaded the dice against the development of an adequate system of medical care’,82 and, likewise, Hilary Marland and Joan Lane observe that it heralded a decline in the ‘quality and range’ of poor law medical relief after 1834.83

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As further symptoms of this, there were no medical advisors or medical practitioners appointed to positions of authority. Countless attempts were made through Parliament and by the agitation of various reform associations, with only temporary and inhibited successes. Despite the pervasiveness and importance of disease, sickness and disability to the ambit of the new poor law, there was no convincing pattern of medical inspection (beyond London) throughout the entire Victorian period.84 Public health developed in tandem with the poor law, but, for reasons explained in this book, the senior medical officers in public health had little influence on poor law medicine. In spite of the lack of central direction, the ‘new’ poor law legislation had, however, provided a significant economic opportunity for unions to create large workhouse infirmaries and reform their medical services. Some did, but, for many guardians, it also justified wholesale withdrawal of the range of (expensive) medical treatments that had been provided under the old poor law. The Medical Orders of the 1840s and 1850s led to improvements in the medical services of the new poor law, but the most hazardous systemic faults began in 1834 and continued unabated: the low salaries of medical officers, their dependence on private income and their subsequent part-time attendance – and, as such, the inadequate and unreliable supply of medicaments provided by them; the continued lack of trained and professional nurses; and, overall, the continuing negative and variant effects of lay authority over medical expertise. It must therefore be accepted that there were extreme limits to poor law medicine. There were anomalous unions, who took matters into their own hands, but the central leadership encouraged policies and overlooked practices that sustained hazardous system faults. As such, the poor law’s medical service remained neglected and substandard, and ‘almost by default’, as Kidd describes, ‘found itself responsible for a range of welfare services’.85 What was debated in contemporary professional associations and within Parliament differed greatly from what was achieved in poor law medical practice on the ground. The lack of fundamental legislation behind poor law medicine had a detrimental impact on workhouses and their ability to provide a standard of care that came near to nineteenth-century expectations. In turn, Victorians were accustomed to regular accounts of neglected pauper patients in the newspaper columns and to hearing lurid details of cases that had been raised in Parliament. Instead of acknowledgment by the central authority, there was an attitude of denial and the perpetuation of a culture of blame, which avoided the common faults dredged into the system of providing medical relief. Official inquiries into negligence thus sought figures of blame, which served political expediency – whether inspectors intended it to or not – by avoiding expensive and controversial nationwide reforms. One figure emerged as the ideal scapegoat to hold to account for problems that were misleadingly systemic – the medical officer. Generally, the only ‘medical’ relief provided by the poor law came from the district or workhouse medical officers.86 As Lane observes, ‘Clearly they were the crucial figure in providing for the sick under the New Poor Law.’87 After the Medical Act of 1858, medical officers were verifiable professionals – qualified and skilled practitioners – but they were also, as Crowther notes, underpaid and contracted part-time. This presents a dilemma for historians: medical officers of the workhouse were not there most

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Medical Negligence in Victorian Britain

of the time and district medical officers regularly disobeyed orders for attendance. Crowther’s oft-quoted criticism of medical officers lay with their torn loyalties: ‘The workhouse doctor was still hampered, not only by the apathetic central authority and economical guardians, but by his own professional views, and particularly the conflict of interests between his private practice and his workhouse duties.’88 The problems of a distracted poor law doctor have therefore been noted by historians, but the scale and impact of medical officers’ absurdly impotent employment arrangements have been underestimated.89 Both district and workhouse medical officers were equally affected by a divergent interest in private and poor law patients. Put simply, their ‘divided loyalties’ affected their performance as medical officers and severely compromised their ability to meet their contractual obligations, which led to the neglect of pauper patients. As such, basic attendance was the most ambiguous – and problematic – aspect of the rules and laws governing the duties and employment of poor law doctors. The damning conclusion that must be drawn from the new poor law medical services is that, if Crowther, Digby and Lane are right (which this research affirms), the medical officers could not plausibly carry out their duties effectively. On paper, the English poor law presented an impressive ‘system’ of medical welfare – surpassing global equivalents in its generosity and scope – but in reality it was a paper tiger. It fell apart, wherever and whenever it was strained. Local events could put particular pressures on different regions at different times (e.g. recessions, epidemics, housing problems, industrial decline – even meteorological extremes), which would then interact with latent failures in the workhouse system to amplify the national occurrences of neglected pauper patients. In the 1860s, for example, cases of negligence in London’s workhouse infirmaries had become such a cause for concern that the famous Lancet medical journal instigated its own commission to investigate the workhouse infirmaries of England’s capital city. The Lancet Commission uncovered conditions that shocked the nation and the very public agitation led to the Metropolitan Poor Act of 1867. Traditional historians saw this as a step towards an early NHS (and underemphasized the role of negligence in forcing reform). However, the Metropolitan Poor Act was confined to London. There were localized initiatives in some unions, but there was no centralized progression to a State-run ‘hospital’ system in the nineteenth century. After the 1860s, the medical officers’ drive to reform national poor law medicine was stopped in its tracks and their association failed in its objectives. Conversely, 1867 marks the beginning of a long phase of failure for the Victorians who sought nationwide reforms in the medical services of the poor law. In the 1870s and 1880s, the operation of the poor law became noticeably more cynical towards all applicants for relief under the newly formed LGB (1871–1919). In 1869, George Goschen, the last president of the Poor Law Board, clarified a fresh approach to reducing pauperism that underpinned the policy of the newly formed LGB. He set out his ideas on cutting outdoor relief in a circular known as the Goschen Minute.90 It led to the LGB inspector, Henry Longley, setting out a strategy to target all forms of outdoor relief.91 In contrast to the intermittent dispauperization policies of previous decades, the Longley Strategy included a significant drive to cut back on domiciliary medical provision, which was to have a devastating effect on poor

Introduction: The Nuances of Neglect

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law medicine as a whole. The intention was to cut back on expenditure and prevent overlaps in public and philanthropic provision. The LGB (including some medical officers) was therefore closely involved with the Charity Organisation Society and other voluntary organizations, in order to thoroughly investigate applicants for poor relief and charity. The 1870s was the high point of the crusade (with a petering out from the mid-1880s into the early 1890s); nonetheless, it was a potent social movement, which drew in supporters from across Victorian society. The medical historian, Elizabeth Hurren, has persuasively argued for a historical revision of the Longley Strategy and the ‘crusade’. According to Hurren, It ‘dominated government thinking on welfare provision’, and welded central to local policy in an unprecedented fashion.92 Inspectors were at the hub of the LGB’s crusading fanaticism, and they used all means at their disposal to encourage local administrators to cut benefits and make the population more self-reliant. This included regional conferences and, arguably, their legal powers in official inquiries. Notwithstanding Hurren’s research, the LGB’s part in the crusade was more widespread and nationally pervasive than historians have acknowledged.93 This book therefore argues that, during the 1870s and 1880s, care in the community came under a prolonged pressure from the widespread withdrawal of a range of assistance. It will provide further evidence that the crusade reached farther than the fifty ‘model unions’ described by the cultural historian, Karel Williams.94 The LGB pushed for a total withdrawal of State support except for institutional care (workhouses, asylums and infirmaries), which was never achieved. Nevertheless, as a result of the crusade policy environment, some of England’s poorest and most vulnerable were refused outdoor relief. Many of those had survived on a mixed economy of makeshifts in a family home for many years before being refused further payment.95 Some of those would have suffered extreme poverty before entering the workhouse. Arguably, the most numerous categories of patient that did succumb at this time, and enter the workhouse, were especially ill-suited to its harshness; such as the disabled, mental-health patients (including epileptics) and those with learning disorders. In turn, workhouses and their infirmaries were unprepared and ill-equipped for the predominant classes of inmates that arrived during the crusade. The ensuing neglect of patients was more visible in the infirmaries, but it was not confined to the workhouse. District medical officers also came under pressure from funding cuts and obstruction over the issuing of orders (and fees) for certain attendances. They were caught in a catch-22, whereby they made dangerous choices about which patients to neglect (in terms of not being there) and which ones to attend. As such, the crusade had formed a double-edged sword for standards of care in both outdoor and indoor medical services. Medical negligence occurred most frequently along the expanding fault line between medical needs and medical expenditure. Official inquiries into the numerous charges of negligence that ensued against poor law doctors, however, were frequently overseen and ‘judged’ by inspectors with a vested interest in the crusade, particularly in cutting expenditure on medical services. Given the divided nature of a poor law doctor’s role, it is surprising that more historians of poor law medicine have not focused on this fundamental period and the interaction of negligence, official inquiries and the crusade. With the notable exception of Hurren,

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Medical Negligence in Victorian Britain

almost all previous poor law historians have underestimated the crusade policy and its impact on medical practice. This book sets out a clear link between negligent care, the stresses on medical attendances, and the ‘exodus’ of vulnerable cases into workhouses at this time. The combined effects of the crusade spanned two decades, which led to a drawn-out episode of systemic negligence and a concurrent rise in the charges of negligence against medical officers. At this time, the problems of medical negligence that had plagued the poor law medical services exploded into a full-blown crisis of care. *** Part One presents the history of the poor law medical services, but revises the inaccuracies, such as the long-held assumption that charges of negligence against medical officers declined throughout the Victorian period. The emphasis is also shifted to standards of care and the central place of importance that this held for Victorians. Chapter 2 therefore introduces the history of the medical profession in the nineteenth century and explains how this affected the working lives of those who contracted their services to the poor law as a medical officer. At a basic level, this chapter provides the context of professionalization at this time (for both medical officers and their identity as a doctor). The chapter will go further than this, though, and revise the history of medical officers by shifting the emphasis away from the successes of their movement and on to their considerable failures. Whether stemming from centralized policy or local practices, the funding of poor law medical services (including doctors’ salaries and fees) was at the heart of charges of negligence and the disciplining of doctors. This chapter will introduce some key issues in financing poor law medicine and explain the ways that free trade dominated the micro-details of doctors’ employment and the macro-funding of their medical provisions, both of which led to continued problems and the inability of medical officers to fulfil even the most basic requirements of their job. Chapter 3 extends the previous chapter and explores the broader policy environment, beginning with the Poor Law Commissioners in the 1830s and 1840s. The Andover Union scandal has been well documented and used as an example of neglect and low standards of care in this period. However, contemporaries were as shocked as we are today by the lurid stories of starved paupers gnawing at the rotting bones they were supposed to be grinding up. Standards of care and neglect were at the nub of public scrutiny into Andover. Public pressure led to the downfall of the Poor Law Commissioners. Medical negligence, though, was more central to a second, more famous, Victorian campaign: the Lancet’s Commission to investigate London’s workhouse infirmaries. This chapter will thus demonstrate that negligence – in legal and social terms – underpinned politicized debates over the Victorian poor law medical services. More controversially, charges of negligence against doctors were a central device in the waning successes of the medical officers’ association after the 1860s. It provides the first signal that there was a direct line from the system of medical officers’ employment to the neglect of patients, but that this connection was ignored by the central authorities.

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Chapter 4 will move from the macro context of the previous chapters into the micro-mechanics of the legal definitions and social implications of medical negligence under the new poor law. The Local Government Board took over the Poor Law Board in 1871, which began an antagonizing phase for poor law doctors. Although there were distinct legal processes for charging a medical officer with negligence, the pressures from the treasury on poor law funding played a visible part in the LGB’s administrating of that process. Essentially, poor law administrators and doctors clashed on the issue of funding, with the latter consistently licking the preponderance of wounds. Clearly, non-medical personnel (e.g. inspectors, guardians and relieving officers) dominated the medical profession under the new poor law and this was reflected in the quasijudicial procedure of official inquiries. The central poor law authority employed legal rather than medical experts to oversee and inspect the ‘standards’ of poor law care and medical provision. Their method of inquiry, investigation and judgement was a direct conduit to the charges of medical neglect against medical officers. Charges of neglect were ‘resolved’ in the drama and theatre of official inquiries, but the medical officers consistently emerged as figures of blame – an ideal scapegoat for systemic faults that were, in many ways, beyond the control of a single doctor (only unity, which failed to materialize, may have countered the systemic issues). The denial of systemic hazards was ingrained by the latter part of the nineteenth century, when there was a popular crusade to withdraw outdoor relief. The crusade brought together the considerable faults in poor law medicine to create an ideal environment for neglect to occur and for doctors to be charged with negligence. Chapter 5 thus feeds into the backdrop provided by previous chapters and underpins Section two’s focus on welfare in the late nineteenth century. It argues that the permanent officials of the poor law, such as the legal secretaries and inspectors, had grown in influence by the time of the LGB’s inauguration in 1871. Furthermore, they were in opposition to the expansion of medical welfare. Under the crusade, the LGB joined with the Charity Organisation Society to target and make cuts to outdoor relief, including medical provision. Medical care was seen as a backdoor to idleness and State support. As Chapter 5 will argue, workhouse medical officers entered a critical phase of heightened neglect and a greater number of charges of medical negligence against them. Historians have been unaware of this aspect of British welfare history. Chapter 5 will argue that it was this policy that annihilated the medical officers’ chances to grow into an effective pressure group for reform. Moreover, the LGB’s approach to the active negligence of individuals avoided the mounting latent failures of a system under distinct pressures during the crusade. Chapter 6 describes a health care environment under severe funding and personnel pressures. It contrasts bleakly with the view that workhouse infirmaries, outside of London, evolved into adequate State hospitals under the Victorians. Even to contemporaries, most provincial workhouses were lacklustre institutes and running on empty. Although many infirmaries were renovated, and some removed, from their workhouse origins, staffing was never of a quality or density to make a difference. As such, survival of the fittest best describes the life of workhouse patient. If they were sick, but physically able to maintain themselves, the workhouse could be no more dangerous (and in many cases, arguably, less so) than the slums that many

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Medical Negligence in Victorian Britain

paupers had come from. The elderly, the disabled, children and those with a variety of mental-health issues and mental illnesses (bracketed under the Victorian lunacy laws), on the other hand, were the prime cases for neglect (or abuse) within the institutional environment of the workhouse. As such, this chapter will focus on the vulnerable patient groups that were most likely to suffer from neglect: the disabled, the mentally ill or those with learning disorders. Chapter 7 moves the discussion beyond the iconic workhouse space, to the system of making a claim for and receiving medically oriented outdoor relief. This subject is one of the most important but under-researched dimensions of poor law medicine. The claims procedure was a complete shambles. Though it was underpinned by the legal rights of paupers, in practice it was an unworkable system riddled with hazards – the epitome of the interconnectedness of latent faults and active failures, described in Chapter 4. District medical officers were contracted to attend to the poor part-time, which immediately handicapped their efficiency. In addition to attendances on pauper patients on the permanent relief lists, they were supposed to obey orders for ‘sudden’ and ‘urgent’ cases (emergencies). Such cases were due fees, but there was frequent interference from guardians and cutbacks in orders for emergency treatment during the crusade. In turn, the battles over fees led to medical officers ignoring calls for aid. This chapter will explain how and why poor law doctors were caught in a contractual catch-22 that underpinned some of the most consistent and dangerous elements of their negligent practices under the new poor law. Taken as a whole, those chapters demonstrate that the neglect of patients under the poor law has itself been neglected by historians. Partly, this has stemmed from wariness of socio-legal anachronisms and the challenge of assimilating this esoteric subject into cognate studies without slipping into Dickensian notions of ‘scandalous’ neglect. In this respect, the book will provide both a missing context and a contribution to the historians’ task of reanimating the lives of poor law patients. The agency of paupers – their narratives – remains at the vanguard of scholarship. Their ‘voices’, recorded in complaints and official inquiries, provides counterbalance to contemporary sensationalism throughout this book. The final chapter will argue that, in the light of its revisionist history, the role of the new poor law in ‘what came next’ (the changes to health care and medical law in the twentieth century) also lacks empirical research in several key areas. Although this book will have added to the process of redressing a small element of this imbalance, the final chapter suggests some directions for future research that could augment or dispute its findings.

Part One THE SONG OF THE UNION DOCTOR With looks all drabbled and spattered, With face weather-beaten and cold, An union doctor rode along – He was prematurely old. Tramp, tramp, tramp, In hail, and snow, and rain; And he sighed, ‘An union doctor I’, And this was his sad refrain. ‘Work, work, work! Each morning has its toil; And work, work, work! Work by the midnight oil. It’s O to be a slave To Poor-law Guardian’s rule; The day I first put on their yoke I was an egregious fool. ‘Work, work, work! Work for both hands and head; Work, work, work! Till the numb brain feels like lead. Oh, was not I a fool? For well I know the wage – A menial’s pay whilst young and strong, And – nothing for old age, For sixty pounds a year, With medicines to provide; It does not keep my serving lad And the horse on which I ride, Tramp, tramp, tramp, Amongst the desolate poor! How little they think, when they envy me, That I almost live next door.

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Medical Negligence in Victorian Britain ‘And yet amongst all those Who should be the poor man’s friend, I fear I am the only one Who an ear to their sorrows lends: But I cannot mend their woes, And it gives me much to say ‘I cannot afford the costly drugs That would drive your pains away.’ ‘And how can I say to them, ‘Drugs are not fit for you, But bread and meat and wine, And to live where the sky shines blue?’ How could I tell them this, When I could not offer a bone, Lest I take the bit from the hungry mouths of the dear loved ones at home? ‘Work, work, work! With no word of thanks or praise, But only a summons before the board On Board of Guardians’ days; With no word of thanks or praise, Except from the loving poor, Whose ‘God bless ye, doctor’, ever and aye Follows me from the door. ‘’Tis only when I think They are His especial care, That I trust and turn and pray, And drive away despair; And I work, work, work, Through rain, and wet, and cold, And hope that things perhaps may mend By the time that I am old. ‘And oh! I fondly hope For a good and happy time, When want will not be held as bad, As bad or worse than crime; When the poor, and sick, and aged, With criminal will share The warmth, food, and clothes, Of our rulers’ jealous care.

The Song of the Union Doctor

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‘And that a time may come, I fondly trust and pray, When the union doctor’s horizon Shall beam with a brighter ray; When those he serves shall learn to think He is not a mere machine, But a man who loves; and those he loves On his support must lean.’ With boots all drabbled and spattered, With face weather-beaten and cold, An union doctor rode along – He was prematurely old. Tramp, tramp, tramp, In hail, and rain, and snow, And he dwelt with a sad and weary sigh On an union doctor’s woe.

This poem appeared under the apt pseudonym, Esculapius, with the addendum: ‘Note by one who looked over the author’s shoulder – If the union doctors would join in an union of doctors, the union of doctors could very soon alter the position of union doctors, and be masters instead of servants’. BMJ, 2, 710 (8 August 1874): 194.

2

Victorian ‘State Doctors’: Medical Officers of the New Poor Law

Background To understand the specific context of poor law medical negligence, it is also essential to appreciate the myriad difficulties of practising medicine in the Victorian period. Linda Mulcahy said of today’s complaints systems, ‘The challenge to doctors posed by complaints cannot be fully understood without reference to the role played by medical professionals in wider society.’1 Although Mulcahy is describing the significant power of doctors today, those words also apply well to the lowly status of doctors in nineteenth-century England. The poor law historian, M. A. Crowther, observed with uncanny similarity that the ‘career of the medical officers must be seen in relation to the development of the medical profession as a whole’.2 ‘The Song of the Union Doctor’ vividly portrayed some challenging aspects to this development, but it misleadingly made a hapless victim of doctors. In contrast, this chapter will contextualize their day-to-day struggles within the broader culpability of the medico-political landscape. It will therefore describe their place in the tempestuous history of the nineteenth-century medical profession, and revise the traditional account, in order to better assimilate medical negligence into the historical narrative. In short, negligence was inextricably linked to the unstable status of nineteenth-century doctors and the interconnected problems of funding the poor law medical services. Financing medicine lay at the heart of latent failures in poor law medical provision, feeding into the active neglect of individual medical officers. In general, doctors were reluctant to become full-time medical officers – preferring the chance to make a better income from private practice.3 As a result of this situation, medical officers’ salaries flat-lined at a low level. This created a system that relied on the financial stability of independent private practices. In turn, some doctors could not afford the time or money needed to fulfil their poor law duties. It was this vicious circle – attributable to the self-interest of both poor law officials and medical professionals – that spawned the most significant latent failures in the provision of medicine by the poor law. Consequently, it was difficult for medical officers to gain public backing for reforms that would have bolstered the medical services, but also feathered their own beds. Medical officers did not harness mass support for

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their cause or campaigns in professionalization, and this impacted heavily on the adversarial nature of their relationship with employers, public and patients – and, as such, the charges of negligence made against them.

Public ambivalence Victorians were rightly cautious of medical claims to social and professional superiority.4 The first half of the nineteenth century witnessed the medical profession come of age before it was ready for the full role that it desired in society (and would achieve in the twentieth century).5 In keeping with this pubescent analogy, it was vocal in its desire for more independence, self-rule and respect, but inconsistent in keeping its promises of cure, healthy bodies and its own professional conduct. For most of the Victorian period, their ability to cure was justifiably questionable. In the 1830s, when the new poor law employed its first medical officers, the practice of medicine had hardly developed beyond the Renaissance. Surgical methods developed gradually throughout the century, but medical science did not improve dramatically until bacteriology arrived at the end of the period. Despite Victorian scientists correctly identifying the link between some diseases and their mode of infection, such as puerperal fever and cholera in the mid-nineteenth century, debates raged for decades as to the precise pathology. John Snow was thus able to isolate the Soho Pump in 1854, demonstrating that cholera was waterborne, yet the scientific community would not accept his theory until Robert Koch provided bacteriological evidence three decades later.6 For most of the period, Victorian medicine was hinged on flawed ideas of miasma and disease (that atmosphere, environment, ambient smell and putrefaction interacted with disease infection).7 As the distinguished nineteenth-century American physician, Oliver Wendell Holmes, wrote in 1883: ‘If the whole materia medica as now used, could be sunk in the bottom of the sea, it would be all the better for mankind and all the worse for the fisheries … .’8 Such internal doubts were not lost on the Victorian public, who commonly eyed medical practice with suspicion. The author of The Medical Profession and Its Morality (1886) exemplified this discontent: ‘If science, with all its boasting, and after its hecatombs of bloody sacrifices, had really made important advances in therapeutics, we should at least be able to point to some one or two unquestionable specific remedies for the most terrible scourges of mortality, such as cholera, or consumption, or cancer. Nothing of the kind, however, has been heard of … .’9 Purging, bleeding, leeches and ineffectual tonics and tinctures were among the gamut of dubious ‘treatments’ offered by doctors late into the nineteenth century. ‘Heroic’ medicine famously favoured the surgeon’s knife, but invasive procedures (such as amputation) could also transfer the ultimate arbiter between death and disability to the operating doctor. In addition, there was a consistent risk of iatrogenic harm or complications; such as suppuration, trauma or the spread of harmful bacteria by a doctor giving treatment. This was infamously illustrated in the sepsis of childbed (puerperal) fever, which was caused by cross-contamination borne on the doctor’s hands from dissecting cadavers and carried to obstetric procedure.10

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The early-Victorian medical profession struggled to shake off the doubtful image of the barber surgeon. It was a profession with a conflicted self-image and delusions of grandeur – ‘meddling and despotic’.11 The chaotic and divided character of medicine, at this time, has led medical sociologists and historians alike to question the Victorian phase of the ‘rise’ of medicine in English modern history.12 The ideal of beneficence (dating from the Hippocratic Oath) underpinned a host of medical endeavour, but it was also at the core of the profession’s burgeoning corporate image and their ability to gain ‘trust’ in the modern era.13 Medical professionals recognized that trust was central to establishing a patient pool and building a successful private practice. The most successful physicians tended to be those who had developed an effective (and lucrative) sympathetic bedside manner.14 Consequently, medical historians have focused on the tension between the ‘service function’ of doctors and ‘their need to take money’.15 Almost to the end of Victoria’s reign, medical and pharmaceutical work (the dispensing of drugs and medicine) was predominantly viewed as a ‘trade’. By law, a general practitioner was considered a trader when he was selling medicine. If, instead, it was offered as part of a consultancy, with no extra charge, they were not traders. This distinction created legal and social ambiguity.16 The law reflected public cynicism, bestowing few special rights on the medical profession. Lay officials (and, to a limited degree, patients) were thus relatively protected and backed by the law to confront and question medicine. Given their undistinguished socio-legal status, it is remarkable that doctors were not charged with negligence in the courts more often, as they were at this time in North America (a theme returned to in Chapters 4 and 8). The lack of special professional rights under the law resulted in a unique situation. Medical officers could be charged with neglect under the new poor law with an ease that was neither possible before the Poor Law Amendment Act of 1834 nor under the National Health Service that subsumed the extant poor law in 1948. Moreover, the adversarial nature of their relationship with their employers not only affected the ability of medical officers to meet their contractual obligations, but it also undermined their ability to defend themselves successfully against charges of negligence. As Chapter 4 will explain, the poor law’s use of contract law contrasted with the tort legal doctrine used to bring actions against doctors to the Victorian courts. Contemporary critics were thus able to argue that medical officers were singled out (in the non-court setting of a poor law inquiry) and held responsible for systemic problems beyond their control: ‘… the [Poor Law] Board take a scapegoat, and, in revenge for their own shortcomings, and as a sop to the Cerberus public, who are continually growling at the hardships inflicted on the poor by their guardian angels, sacrifice the scapegoat … of course, one of their own officials; and, in nine cases out of ten, their medical official’.17 A preternatural lay power was manifest in poor law administration, from the guardians up to the higher echelons, such as the famous secretary to the Poor Law Commissioners, Edwin Chadwick, who had a well-known anti-medical-profession philosophy.18 Even in the 1870s, William Golden Lumley, an influential assistant secretary, remained set against medical officers achieving a ‘higher’ social position. This ‘destiny may await them’, he said, but in the meantime ‘they must be considered as they are’.19 Such attitudes, discussed further in Chapter 4,

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Medical Negligence in Victorian Britain

ensured that the medical profession never achieved significant influence within the national authority of the Victorian poor law. As a result, there was no central cadre able to represent their point of view. The public press, both local and national, frequently published florid reports about disputes between guardians and medical officers whom they (or inspectors) had charged with ‘negligence’ or ‘neglect of duty’. As Chapters 6 and 7 will demonstrate, though, this was not without reason. Medical officers were known to regularly shirk their duties. For example, they chose when to turn up at the infirmary and often ignored orders for attendance on district cases. This led to some unions, such as Sheffield, instigating ‘card systems’ or other documentation, whereby guardians could closely scrutinize medical practice and check doctors’ attendance.20 As Chapter 1 explained, though, the gnomically misleading charges of negligence that ensued may have implied individual blame and culpability, but this shrouded a range of complex causative factors. Medical Officers, such as John Ward of Penistone Union, recognized that guardians were sometimes misleading the public and the central authorities. After Ward had attempted to negotiate a change in his salary (and relinquish the costs of supplying drugs), he was quickly forced into resignation for ‘neglect’ of duty. According to the guardians, Ward had not attended the workhouse regularly or personally (using an assistant to carry out the work) and had failed to keep accurate records. Yet, both of those breaches were related to ill-defined duties and were also relatively ubiquitous within day-to-day medical practice, nationwide, under the new poor law. Ward described the charges against him as ‘frivolous and vexatious and if any further evidence were needed to demonstrate the unsatisfactory regulations now inferred in medical matters, it is certainly here very fully given’.21 He was convinced that these were petty charges, trumped up because of friction between him and the guardians: I much suspect that the Guardians have a greater will to subordinate their medical officer to their unjust desire to withhold equitable compensation for services rendered – and to stave off inconvenient questions, than that they have any real feeling that he has not done his duty. The fact is that I have spoken the truth too plainly and it is disagreeable to them … .22

Such opinions may have been the result of soured relations, but it also reflects the need for caution in appraising doctors charged with medical negligence. Subjective interpretations of an acceptable standard of care and broad discrepancies in what constitutes negligence or neglect of duty have been commonplace throughout modern history. Mulcahy has said of complaints about relatively recent medical mishaps, that ‘there is a systematic distortion of meaning in interactions between doctors, patients and – to a lesser extent – managers’.23 This distortion can be a useful way to consider neglect under the poor law. Blame was no less emotive or contentious, then, than it is in the present. It concealed all manner of sins in the Victorian period. Chapter 4 will demonstrate that administrators, doctors, patients and the general public, among others, used negligence and neglect as terms to describe events that would, today,

Victorian ‘State Doctors’

25

come under the broad headings of ‘medical mishap’ or ‘adverse event’ (the acts of ‘error’ or ‘violation’, which can lead to litigious realization in court-room ‘clinical negligence’).24 It was riddled with cultural and legal ambiguities that would not fit today’s models of ‘error’, ‘violation’ or ‘patient neglect’. As Tom Reader and Alex Gillespie suggest, ‘neglect’ can be a ‘subjective construct’, which easily shrouds the subtle differences (and overlaps) between errors and violations.25 In this respect, it is more useful to examine the cultural, professional, systemic and legal contexts that framed negligence, than it is to judge the ‘active’ neglect of individual Victorian poor law doctors. Put crudely, the remainder of this chapter will contextualize the distorting effect of the medical profession’s perspective, and counterpoise this with close examination of the views of the public, poor law officials and paupers throughout subsequent chapters. Medical literature was drenched in a melodramatic and woeful tone, such as ‘The Song of the Union Doctor’, which sidestepped the doctors’ part in perpetuating their trials and tribulations. In 1863 the BMJ typified the professions’ reaction to allegations of neglect: ‘how often have we not had to record the virtuous indignation of “the Board” at the neglect of the doctor, their usual scapegoat, for not duly visiting some unfortunate pauper, when, as they must well have known, his physical powers were unequal to the work imposed upon him’.26 In spite of vivid accusations, the medical profession did not unite effectively against the poor law authorities. The early-Victorian medical profession was suffering from internal crises. It had neither a unified ‘professional’ character nor an overarching governing structure. Until the mid-Victorian era, medical officers were in no less disarray than the majority of their medical ‘brethren’.

Professionalization: The ‘great experiment’ The period from the Reform Act of 1832 (which established the middle-class electorate) to the 1870s is considered by some historians to be a time of ‘equipoise’ for many professions, particularly those that sought social standing and prestige.27 Others have seen it as a scramble for unity and power – ‘a time when professionconsciousness was becoming increasingly widespread in a number of occupations’ and the identity of the modern ‘British’ professional middle classes emerged.28 In terms of status, influence and earnings, the engineers ‘reigned’ over other professions – followed closely by the continuing constancy of the legal sector.29 Engineers had received notable (and deserving) public recognition for their expertise and achievements with prophylactic sanitary constructions – enshrined in the achievements of London’s famous ‘Sewer King’, Joseph Bazelgette. Victorian sanitary and public health acts brought administrative clout to improving health via medical monitoring and inspecting, but it was the construction of effective water supply and drainage – under the auspices of those acts – that brought dramatic improvements to health.30 Despite continued criticism of Thomas McKeown’s thesis (that social, economic and dietary developments facilitated a more healthy population), improved sanitation, diet and prophylactic engineering – where they were employed – brought visible improvements in health to areas in England where

26

Medical Negligence in Victorian Britain

medicine was frequently left wanting.31 The questionable ability of medicine to alleviate or cure the main diseases and ailments of the time, described above, did not prevent doctors from seeking more power and influence. Though deeply divided and (until the Medical Act of 1858) largely unregulated, the medical profession steadily grew in number.32 Nonetheless, the early-Victorian medical professionals were hampered by their low status and lack of unity. Medical professionalization – and the medical officers’ role in the process – can therefore be characterized as a disparate and divided profession in the process of reconstructing and reconfiguring itself for much of the early- to mid-nineteenth century. Most struggles were internal as apothecaries – traditionally the lowest order – and surgeons sought to remove the seat of professional dominance held by physicians. Despite being ostensibly less qualified than the lowly general practitioner (qualified in surgery and apothecary), the gentlemanly background, cultural elitism and classical education of physicians held sway and they lorded it over the rest of the profession.33 They were the authority in medical matters. The majority of medical officers were ‘general practitioners’, who were ‘kept firmly in a subordinate position’; both under lay poor law officials and within their own profession.34 London was the home for England’s elite and political classes; therefore, the most successful and influential physicians (and medical officers) tended to be based in the capital city. There was little to counter the domination of national medical matters by London’s elitist physicians. Thus, in 1832, the Provincial Medical and Surgical Association was established to represent the large number of doctors working outside of the capital. The Association was small-scale for decades, but it had big aims. In 1855 it was renamed the British Medical Association (BMA) and, two years later, their journal was also re-titled to the now famous British Medical Journal (BMJ). It was to become the most effective ‘voice’ for general practitioners. Even so, the BMJ remained a poorly managed affair until 1868, when Ernest Hart took over as editor. From then on, it emerged as a competitor to the Lancet and bolstered the membership of the BMA.35 The accession of the BMJ was therefore aligned with the coming of age of provincial general practitioners.36 As the Worcestershire-based founder of the BMA, Charles Hastings, had foretold, ‘Everything now conspires to make this present a fit time to begin our great experiment.’37 In addition to weakening London’s hold on the profession, the early form of the BMA also sought political influence, the unification of provincial medical men and, ultimately, the supremacy of orthodox medicine over competing alternative therapies. In 1805, there was a nine-to-one ratio of non-orthodox to qualified medical practitioners, and by the mid-nineteenth century – despite politic manoeuvring – the orthodox medical profession was still outnumbered by at least three to one: the 1841 census had shown 33,339 medical practitioners, but in 1853 there were only 11,808 qualified doctors.38 Both the BMJ and Lancet therefore dedicated themselves to exposing ‘quacks’. As late as 1859, for example, an incredulous Lancet reported that people were using a ‘Mad Stone’ to ‘cure’ rabies (whereby a milk-sodden stone was applied to wounds in order to draw out and absorb a ‘green substance’).39 To Wakley and the Lancet, it was another example of the appeal of questionable therapies to the

Victorian ‘State Doctors’

27

‘credulous multitude’, who had an ‘ignorance’ of medical science.40 This discounts, though, the confusing range of the medical profession at this time. Until the midVictorian era, the average person would have had difficulty distinguishing the orthodox, ‘qualified’ practitioner from the ‘quack’.41 The accession of orthodox practitioners was therefore paramount to the profession in the early- to midnineteenth century.42 Medicine needed to be organized, united and professionalized – and those working for the State were a key part of this strategy. In turn, the BMA was pressed by Thomas Wakley (the radical founder and editor of the Lancet) to use the BMJ to fight for reform of the medical services of the poor law.43 Wakley was no stranger to reform. He had been involved in the pressure groups that had led to major health legislation, such as the 1832 Anatomy Act and the burial acts. He was also associated with the radicalism of unions and chartists – and he successfully fought for the release of the Tolpuddle Martyrs.44 In turn, and largely from Wakley’s charismatic influence, three different Poor Law reports were commissioned by the BMA – in 1836, 1840 and 1841 – and Parliament was lobbied to reform medical practice under the poor law.45 Wakley and Hastings tackled the poor law primarily because it provided a public space to gain legislative recognition of orthodox medicine. Furthermore, fringe medicine – such as bone-setting – was a cheap alternative to the private orthodox practitioner, which made it a formidable rival in poorer rural areas of the country. Bonesetters had also been employed alongside general practitioners under the poor law in some regions, with frequent accounts of their ability and effective treatment.46 Medical science, such as it was, needed the State to recognize the supremacy of orthodox practitioners. Demands were made to reform poor law medical welfare, improve the working conditions of medical officers and – importantly for the profession’s war on ‘quackery’ – ban unqualified doctors from holding State employment. However, there was no medical register for employers or patients to check doctors’ claims to qualification. To make matters worse, medical schooling was uncoordinated, and the plethora of qualifications and medical institutes baffled employers. Paul Vaughan, a historian of the Victorian medical profession, described the predicament: ‘… it was all very well to urge that ability, not cheapness, should be the true test of a practitioner’s suitability for a Poor Law appointment, but no one, including the boards of guardians, had any easy means of distinguishing the experienced medical man from the quack’.47 For example, in 1841, 1,830 eligible candidates applied for a vacant medical officer position in Lambeth; however, 320 had never been examined in surgery, 323 had never taken an exam in general medicine and a further 233 were completely unqualified.48 Across the country medical groups observed their lot with increasing frustration. They began to group together more effectively than before. Gradually, the cacophony of medical voices spoke with singular unity on the crucial intersecting issues of orthodox ascendency, professional unity and improvement in the profession’s social standing. The ultimate object was parliamentary reform, which would outlaw unqualified practitioners.49 After decades of united and constant pressure, the Medical Act of 1858 was legislative recognition of the profession’s burgeoning corporate identify. It

28

Medical Negligence in Victorian Britain

was underpinned by the creation of a medical register of recognized orthodox professionals. It was also the beginning of the General Medical Council (GMC), a body capable of taking away the licences of recalcitrant or substandard practitioners.50 Nevertheless, the widely varying standards of practice meant that relatively few doctors were struck off by the newly formed council. Moreover, it lacked legislative powers to supervise the profession. It issued guidelines, but there was a huge time lag between disciplinary precedent and, in the light of GMC hearings, the issuing of formal guidance to the profession. For example, its first disciplinary hearing regarding ‘breach of confidence’ was heard in 1869, but no formal guidance was issued to the profession for another 100 years.51 The Act of 1858 also stopped short of the medical profession’s wider goal of completely banning fringe medicine. Unorthodox medical practitioners were still legally able to trade, but the law courts no longer protected their transactions. In turn, the patient (or customer) had no legal protection from the dangers of fringe medication and drugs. Despite this, the Medical Act had nonetheless signalled the supremacy of orthodox medicine and it had provided the means to verify the qualifications and claims of doctors. The death knell of fringe medicine had also been sounded in the growing apparatus of State medicine. The legislation of 1858 dovetailed with similar internal measures within the poor law that had been pushed forward by Wakley and the BMA. Recurring appointment problems (publicized by the BMJ and Lancet) had forced the Board to issue an order in 1842, which called for more checks on qualifications.52 Much of this had come about because guardians put out tenders to find the cheapest doctor, often disregarding ability, skill and qualifications (which, until 1858, could not be checked anyway). The General Consolidated Order of 1847 cleared the legal terms and clarified matters. From then on, dual qualification in surgery and apothecary (also the basis of general practice) became the threshold for a poor law doctor (Table 2.1).53 Problems remained, however, which led to the Consolidated Orders of 1855, 1857 and 1859, which brought about the official end of guardians tendering for doctors. The latter order had reiterated and widened the edicts of former ones, but it was able to incorporate the access to medical qualifications provided by the Medical Act. As a result, ‘permanent contracts’ for medical officers became compulsory.54 Initially, English, Irish and Scottish surgical degrees were recognized, but for permanent contracts the Poor Law Board would only accept the addition of an English medical degree or Licence from the Society of Apothecaries.55 This was overturned after the 1858 Act, when acceptable qualifications were widened to include degrees and licences bestowed by some leading Irish and Scottish institutes. In spite of the Orders, issued between 1842 and 1859, tendering continued under a different guise. Local boards could employ medical practitioners with single qualifications under an annual contract (see Table 2.1) if there were no properly qualified applicants for a vacancy.56 This created a loophole that some guardians used to hold – what was in all but name – a yearly ballot to employ the cheapest surgeon. It thus remained possible for guardians to employ a medical officer without dual qualifications throughout the nineteenth century.

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Poor law rules could be stretched or slackened and, in turn, used to keep salaries low and to defy localized attempts by medical professionals to band together. Without effective national unity, there was little that individual medical officers could do to rectify the situation. The competitive nature of medicine (further discussed, below) impeded the ability of medical officers to join together. In Skipton, for example, local medical practitioners attempted to unite when a salary increase was refused to a workhouse medical officer. He had applied for a higher salary on the grounds that the salary had not increased for thirty years. An infirmary had been built in that time and thus the number of patients had trebled. The medical officer resigned and, with the support of local doctors, refused to take the position until he was reinstated with a higher salary. However, using the residency loophole, the Skipton guardians employed a non-local doctor with a single qualification.57 A further example was evident in Leeds. The union, there, dissolved the office of dispenser in 1877, transferring the dispensary duties to an assistant workhouse medical officer – saving £80 per annum. This caused indignation in the medical profession; mostly, because they considered it ‘derogatory’ and ‘undignified’ for a doctor qualified in medicine and surgery to also dispense medicine.58 When Leeds’ doctors united to shun the vacancy, the union went as far as Scotland to procure a medical practitioner willing to take the post. This type of strategy, whether intentionally or not, meant the poor law authorities could encourage competition and in consequence keep salaries as low as possible. Regulation loopholes, such as these examples, were used across the country by boards of guardians eager to drive down costs. The poor law had opened up a new area in competitive medicine. Guardians were given the authority to employ medical men who had not been resident previously – and the Medical Act gave them the means to check qualifications. Doctors could go where there was work and undermine local nepotism in medicine. The poor law had therefore provided a tempting opportunity for a young or downat-heel doctor to establish a private practice. Victorian doctors were notoriously territorial and interlopers would snap at the chance to gain a foothold into a new area with a fresh pool of patients. As a result of such manoeuvring, some medical officers offered their services for ridiculously low salaries (see Figures 2.2 and 2.3). They ‘got by’ through absconding from their duties, avoiding attendances and using their ‘assistants’ for poor law work – key issues in negligent practice that will be discussed in Chapters 6 and 7. A prominent medical officer named Richard Griffin (discussed below) claimed such regulatory abuse was rife. Griffin’s statistics indicate that approximately one-quarter of medical officers held a single qualification in 1859.59 Given the flexibility of entry, shown in Table 2.1, this was somewhat unsurprising. In 1862, Charles Hastings was back in Parliament, pleading for the House to halt the employment of inadequately qualified doctors ‘in order that competent medical advice be insured for the poor … . We regret that this has not been so strictly carried out as was expected from 168th Article of the Consolidated Order of 1847 and by subsequent order of the Poor Law Board, dated December 10th, 1859’.60 In spite of its toothless bite, though, the Order of 1847 remains one of the

30

Medical Negligence in Victorian Britain

Table 2.1 Acceptable qualifications for a medical officer in England and Wales The acceptable combinations of qualifications 1

Diploma or degree as surgeon from a Royal College or university of England, Scotland or Ireland

&

Degree in medicine from a university in England or diploma or license of the Royal College of Physicians of London

2

Diploma or degree as surgeon from a Royal College or university of England, Scotland or Ireland

&

Certificate to practise as an apothecary from the Society of Apothecaries of London

3

Diploma or degree as surgeon from a Royal College or university of England, Scotland or Ireland

&

Having been in practice as an apothecary on the first day of August 1815 (year of the Apothecaries Act, from when all apothecaries – general practitioners – were legally obliged to hold a Licence of the Society of Apothecaries)

4

Warrant or commission as surgeon or assistant surgeon in the Royal Navy or surgeon or assistant surgeon or apothecary in Her Majesty’s armed services or surgeon or assistant surgeon in the East India Company prior to August 1, 1826

5

A medical practitioner who was ‘duly licensed to practise’*, but not fully qualified by one of the ‘four modes’ above, was allowed to be employed by guardians if there was no adequately qualified doctor ‘residing within the district in which he is to act’ – or if the only person fully qualified was deemed incompetent, unfit or had been previously dismissed from employment with the poor law

6

A medical practitioner who was ‘duly licensed to practise’*, but not fully qualified by one of the ‘four modes’ above, was permitted to retain the office if they had already been in post in 1847 (when the General Consolidated Order was issued)

* (i) ‘A Bachelor of Medicine’ from a university was not considered a license to practise medicine. (ii) Those unqualified according to modes 1–4 were not permitted to hold a permanent post and were generally contracted on a one- or three-year basis. Source: Lumley, Medical Officer (1857): 12–16

most important and underestimated pieces of poor law medical legislation in the nineteenth century. It meant that, in theory, but not necessarily in practice, the poor had access to some of the most capable medical practitioners of the time. It also underpinned the rules and regulations, discussed in Chapter 4, that dominated the employment of medical officers until the early twentieth century. Employing general practitioners was also a shrewd economic manoeuvre by the authorities who now had one medical practitioner to do work formerly carried out by two. The Poor Law Board’s chief objective was to administrate expenditure and keep medical officers’ salaries as low as possible. By the end of the 1840s, a great number of medical officers were feeling the pinch. They were working harder than before the new poor law and for less pay. Workhouses were predominantly occupied by cases of chronic illness, such as aged, infirm, the disabled and a range of ‘incurable’ mental-health patients. The widespread low pay and demands on a medical officer’s (divided) time led to a more concerted effort at reform than had gone before. The BMA and its journal became the crucial platform for the medical officers to publicize and organize their objectives.

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A union of medical officers Members of the Provincial Medical and Surgical Association (precursor of the BMA) were thus regularly debating Poor Law medical reform. In 1847, the step was taken by the BMA to become more directly involved, and the Convention of Poor Law Medical Officers was inaugurated by its members.61 The secretary, C. F. J. Lord and the chairman Thomas Hodgkin, ‘the celebrated pathologist of Guy’s hospital’, led the Convention throughout the 1840s and 1850s.62 Convention news was reported intermittently throughout this period in both the Lancet and BMJ. Reporting centred on the poor remuneration of medical officers and their low status to ‘lay’ officials of the poor law. Although much of this early obsession with status stemmed from snobbery and a desire for wealth, lay power had a significantly detrimental impact on the poor law medical service. Chapters 4 and 5 will show that the overbalance of that power played a key part in the poor law’s idiosyncratic framing of negligence. The records of the medical officers’ reform movement, however, can be both qualitatively and quantitatively misleading. The vast tracts that discuss prescient and humane health reforms have given the impression to historians of a growing movement, making substantial gains. The archival records of their appointments, salaries, and of charges of neglect made against them, provide a stark contrast. Extant governmental archives, contemporary journals and the records created by medical officers (when disregarding the blarney) all provide a similar picture: medical officers accomplished almost nothing as a group and the vast bulk of their salaries stagnated at the bottom end, remaining that way throughout the nineteenth century (see Figure 2.4). Historians, such as Hodgkinson, have placed too much emphasis on the successful years of the 1860s, discussed in the next chapter, and their stated objectives – which were mostly ignored by the poor law authorities.63 In this way, the historical narrative has been skewed towards a misleading discussion of what they sought, and away from meaningful measurement of what they actually achieved. The medical profession as a whole argued that poor law medical officers were ill-used and that their salaries remained inadequate. To most of the profession, ‘The Song of the Union Doctor’ would have described well the reasons to avoid a poor law post. The Convention felt that the ‘trying and repulsive situations’, and the ‘moral character’ of a poor law doctor, ‘painfully’ affected the minds of its ‘highly honourable and sensitive class’.64 Articles in the BMJ and Lancet regularly mocked the salaries and working conditions of poor law doctors: ‘a burthen of responsibility that would make Atlas bow-legged in a fortnight! Rather gentlemanly pay this, to a member of a gentlemanly profession, from a gentlemanly public, is it not?’65 Conversely, Paul Vaughan, medical historian, felt that the Convention of Poor Law Medical Officers’ resolution of 1847 was one of the ‘most self-admiring’ of medicopolitical history.66 Whatever their personal motives, the Convention’s attempts at parliamentary reform were regularly reported in the BMJ (and its forerunners), but they accomplished nothing despite numerous parliamentary bills and committees.67

32

Medical Negligence in Victorian Britain

The apathy and lack of unity among poor law doctors, however, left Lord with doubts for future success against an indignant Poor Law Board. Out of a medical officer workforce that was estimated at 3,500 at any one time, only a handful regularly took an active interest in the Convention and national reform. This was a pattern that continued under the subsequent national associations for medical officers. Even at the high point of the medical officers’ reform years (in the 1860s), a generous estimate of their association’s members would have been no more than a fifth of the medical officers employed at that time. In 1854, Lord wrote, ‘there is danger of failure through want of united exertion and condensed evidence … . Let it be remembered, there is an official vigilant Board, very familiar with public business, who are not favourable to the cause of the medical officers’.68 In his final speech to the Convention, in 1854, Lord declared his doubt that there would be any future success. He had just faced an unsympathetic parliamentary committee who had enacted nothing except impotent recommendations. Lord recognized that those would go largely unheeded by guardians: He was sorry to find … so systematic an opposition from the agents of the Poor-law Board. He was not prepared to encounter a cross examination conducted, as his was, with so much party and political bias … . He did not think [therefore] that the present time was well fitted for renewed exertion … . Relative to the future prospects of the union medical officers, it was much deplored by all present that medical men were not true to themselves.69

Lord’s prediction of failure was subsequently embodied in Richard Griffin, who took up the reins in the following year. The Poor Law Medical Reform Association that Griffin subsequently formed is almost forgotten. Griffin was an unusual medical officer. He was a bona fide gentleman (his father was a French émigré who had fled Revolutionary France) and he was wealthy enough not to have to work to earn his living. Yet, he served as a medical officer for Weymouth Union and as a Justice of the Peace. He also dabbled in science – with discoveries in ornithology and natural history70 – but he seems to have been unable to garner support in the upper classes. His obituary in the Lancet, described an ‘independent’ man who lacked ‘tact’: ‘he was no courtier; he was not subtle; but he was essentially an English gentleman, seeing clearly, speaking boldly … ’.71 Perhaps because of his background, he was also unpopular with the rank and file. The Lancet jadedly described his vain attempts to appeal to public, officials and medical officers: ‘No one could fight a losing battle better than he … . So letter followed letter, petitions, memorials, and pamphlets dinned the truth into the most unwilling ears.’72 In spite of years of energetic agitation of the Poor Law Board and Parliament, a select committee quashed Griffin’s pursuit of poor paw medical reform in 1864, leading to defeat and his subsequent despair in the late 1860s.73 His premature death in 1869, it was said, had been caused by stress, accumulated in his tireless dedication to reforming the poor law medical services.74 Griffin had committed the final decade of his life to reforming the poor law medical service. However, his was a doctor’s reform agenda. Despite his best

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intentions, pauper patients seemed only to be a tangential consideration to the association under Griffin’s leadership. Following agitation in the medical press over the condition of medical officers, Griffin wrote to the BMJ offering himself as a coordinator and requested professional feedback.75 From then, the BMJ remained the chief form of communication for medical officers throughout the nineteenth century.76 The journal commented, ‘Mr. Griffin has responded to the appeal we made in the last number of the journal, and offers, as will be seen by his letter, to take the initiative in organizing a society to compel the government to treat medical officers in a more liberal and respectful manner than it has hitherto done.’77 By January 1856, the BMJ – bolstered by their new figurehead – had adopted a rhetoric of war: ‘Mr. Griffin has reached every union … in all probability a long time will elapse ere another of our brethren will voluntarily come forward to battle for his brethren.’78 In 1844 and 1854, parliamentary committees had looked into ‘medical relief for the poor’. The first recommended no changes. The latter committee recommended that the salaries of medical officers should improve and contracts for medical officers should be permanent, and advised unions to cover the cost of drugs.79 As discussed above, though, guardians could ignore advice and recommendations of circulars. Even strongly worded directives and orders were overlooked. Griffin’s movement pushed for reform in the shape of legislation or, at the least, more stringent orders. The moment for change seemed to have arrived, in 1861, when a select committee was appointed to examine the ‘administration of the relief of the poor’. The committee was renewed for several sessions and their long-delayed report was released in 1864. Charles Villiers was president of the Poor Law Board at this time and he also presided over the committee. It sidelined medical reform. Griffin had spent over a year compiling encyclopaedic statistics, in preparation for a lengthy consultation, but he was given just a few minutes to hand them in and speak momentarily to the committee. The snub enraged Griffin, but nonetheless he remained shocked at the report’s conclusion: ‘That there are no sufficient grounds for materially interfering with the present system of medical relief, which was made the subject of special and lengthened inquiries by Select Committees of this House in the years 1844 and 1854.’80 The only agreement that the Select Committee reached with Griffin’s ‘reform’ association was over the supply of drugs and medicaments: ‘[the] Committee however think the suggestion made that the Guardians should provide cod-liver oil and other expensive medicines is one of considerable importance’.81 In addition, Griffin included leeches, cotton wool, quinine, sarsaparilla and ‘ingredients for poultices’ as expensive.82 Although Griffin had been instrumental in setting this agenda, it was Joseph Rogers – who had joined the reformers in his role as the leader of the metropolitan medical officers – who persuaded the committee and gained recognition. The Board was swayed by Rogers’ oration, and issued a circular that advised guardians to supply expensive drugs. Even so, Table 2.2 shows that a decade later, only a minority of unions in the north-west of England were willing to supply all drugs – a region further discussed in Chapter 4. In 1877, there were 521 unions that paid only for cod-liver oil and quinine, and 182 unions that refused to pay even for those two ‘expensive’ drugs.83 Despite the guidance from the Poor Law Board, there remained unions who did not supply drugs or medical appliances at the turn of the twentieth

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Medical Negligence in Victorian Britain

Table 2.2 The supply of drugs by unions in the north-west of England in 1877 County of Union

Unions supplying all drugs

Unions supplying some drugs

Unions supplying no drugs

14

6

10

Derby

1

5

4

Nottingham

1

4

4

1

6

3

12

26

6

Lancaster

Cheshire Yorkshire WR Source: BMJ, 13 October 1877: 517

century. According to Crowther, ‘As late as 1910, many doctors were still relying on charitable gifts of old rags for bandages, as they could not afford to pay for surgical dressings from their stipends.’84 Essentially, most medical officers had to cover much of the cost of pauper treatments at their own expense. Despite his energetic work, Griffin’s legacy had therefore achieved few reforms. With failing health, he was still writing to Parliament in 1865 requesting salaries to be fixed on a ‘uniform and definite principle’ and additional payment for travel and tolls.85 By the end of 1868, Rogers was in the driving seat. He immediately amalgamated the metropolitan and provincial associations under the Poor Law Medical Officers’ Association (PLMOA). Rogers’ comparative success, discussed in the next chapter, ensured that he become the historically important figurehead. In contrast to his praise of Rogers, the historian, James E. O’Neill, described Griffin as ‘noisy and quasicomic’.86 Yet, although there is something of the blusterer about him, Griffin had undoubtedly laid the groundwork for the PLMOA. The key issues came to the fore under Griffin: medical authority, medical appointments, district sizes, salaries, drugs and medicaments. Griffin had taken up the reformer’s mantle in 1855, when there was little public enthusiasm for expensive alterations to the poor laws – and the Crimean War overshadowed public interest. At this time, medical officers had also done little to ingratiate themselves to an ambivalent Victorian public. His failures, though, were a useful lesson for Rogers. A comparison of the two leaders, and their configuration of the medical officers’ association, leaves no doubt that Rogers was more successful because – unlike Griffin – he networked in elite and influential London social circles, and harnessed public support. Rogers recognized this and publicly thanked Griffin (while inadvertently pointing out his faults): Having come to the conclusion that the course followed by my poor friend, Richard Griffin, of Weymouth, in continually calling attention to the grievances of Poor Law Medical Officers, would never eventuate in an improvement of their position, for the general public have never cared for our class in any way, I cast about to ascertain whether there could be any course adopted by which the attention of the public could be drawn to the shortcomings of the system,

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and decided that the only chance that existed, whereby an improvement could be effected, was by proving that an amended system of medical relief would eventuate in the diminution of the duration of sickness, and consequently of its cost to the ratepayers.87

Rogers struck the right chord (economy, self-interest and morals) at the right time and in the right place – London. He played an instrumental role in the important Metropolitan Poor Act of 1867. Rogers used cases of negligence to expose low standards of care. As such, the next chapter will discuss his association and detail the mid-Victorian medical officers’ fight for reform. Moreover, he used the association to defend medical officers against charges of negligence and as a method to publicize latent failures in the poor law’s management of medicine and economics. Looking back to the 1862–1864 Select Committee on Poor Law Medical Reform, Rogers indicated the difficulty of balancing patients’ and doctors’ interests: ‘I had to be guarded in my answers [to the Committee] as I was not desirous of bringing the charge against my medical brethren that they systematically failed to supply medicines for the sick, though very many have with more or less candour said to me “why do you bother about the supply of medicines? Go in and get for us an increase of our pay.” ’88 Despite the apparent self-interest of medical professionals, medical officers’ salaries were a loaded issue. Divided time and limited funds were major aspects of the systemic problems that led to heightened active neglect by individual doctors.

‘Rather gentlemanly pay this’ Almost all medical officers used their poor law post as a pathway to a profitable private practice, using a salaried poor law post to bring publicity and guaranteed funds. Holding the post could also dissuade competition from entering the patch of a successful local practice. The Poor Law Assistant Secretary, William Golden Lumley, observed, ‘… the office is one that rarely wants candidates, and it must be supposed that the common rule which guides mankind in the ordinary affairs of life operates in the medical profession’.89 The poor law authorities thus argued that the low salaries of medical officers would have been counterbalanced by a decent income from private practice. Given the restraints of extant archives, it is impossible to estimate how many actually achieved the common objective of a profitable private practice. A rural or inner-city private practice could struggle for years until the custom base – for example, via medical clubs or wealthy patients – increased to a level that could support a doctor’s professional expenses and domestic responsibilities. Probably, once this goal was achieved, most medical officers would quit. Those that stayed on after establishing a practice, tended to leave their contracted poor law duties to an assistant (discussed in Chapters 6 and 7). This left a mixed national workforce of medical officers, made up of the inexperienced, desperate, ambitious, ideological and the established medical

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Medical Negligence in Victorian Britain

professionals – with a nationally systemic over-reliance on inexperienced and sometimes unqualified assistants. Those who chose to ‘sign up’ with the poor law thus tended to be the time-poor and/or financially harassed general practitioner. Neither doctors nor the authorities were prepared to lay aside private practice and have the medical officers become full-time ‘State doctors’.90 Instead, they worked part-time, attending to their workhouse or district duties at pre-arranged times and intervals – with additional attendances for emergencies and for district domiciliary care. This, it cannot be overstated, was the greatest impediment to welfare reform (under any guise) in the nineteenth century. It was also a key component in poor law medical negligence, to be explained fully in Chapters 4, 6 and 7. Put simply, the policy of part-time doctors worked where a private practice was successful and a medical officer could therefore afford drugs (and his time), but it was catastrophic in places where practitioners struggled to make ends meet. Given the financial constraints, the motivations of doctors under the poor law remains a moot point, described well by the welfare historian, Steve King: Medical historians are split on how we should regard the engagement of doctors with the poor law under these terms – were they doing loss-making work to stop somebody else getting a foothold in the local medical marketplace and to enhance their status by doing what was essentially charitable work? Or should we regard doctoring the poor as evidence of a profession under economic pressure? Answering this question, and more widely uncovering the economic position of doctors, is beset with problems of source and interpretation.91

The main ‘problems’ with studying the extant records of ‘negligent’ poor law doctors would seem to be that it is unrepresentative – e.g. the extremes of lax or bad practice. In contrast, inquiries into medical negligence left a variety of penetrative contemporary views of what was acceptable practice (and what was not) in the Victorian period. Professional associations, government inquiry documents and journals, for example, took an active interest in negligence. As such, their appraisals of the ramifications of negligence have left rare imprints of what various Victorians expected from the poor law medical services. As argued in Chapter 1, the shape of medical negligence is formed by a variety of external pressures (e.g. professional groups, political parties and legal definitions of acceptable medical practice). It is clear that financing medicine lay at the heart of controversies within the legislation and policies exerted on poor law medicine. In turn (for a number of reasons, explained below) economics was also at the core of most charges made against medical officers for negligence or neglect of duty. A poor law appointment could provide a steady income for a doctor in uncertain times. Nineteenth-century doctors would carry out their work and then wait some time for the payment. Chasing payment was a source of anxiety. Debts could mount quickly, which was exacerbated if bailiffs and court proceedings were needed to recover their fee. King’s research into medical practice in Lancashire is worth considering when weighing the balance of doctors’ claims of economic hardship: ‘In

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37

Lancashire even more than elsewhere, income came in spurts, leaving some doctors with cash flow problems at the same time as others had more money than they knew what to do with.’92 He argues that for many, the income from a poor law appointment may have been the deciding factor in financial survival. Just as some medical officers were content to provide their services for free to the poor laws – thus getting free publicity for their practice and keeping out medical interlopers – others were consistently operating on a knife’s edge of economic ruin. The stresses and strains of medical practice are reflected in the abnormally high numbers of suicides, depression and madness in the Victorian medical profession.93 As the historian, Alannah Tomkins, has said of their mental health, ‘Success received plaudits, and failures … encouraged complicity and silence, an absence of prurient inquiry and a willingness consciously to gloss misfortune.’94 Medicine, as discussed below, was intensely competitive. As a result, the poor law patient suffered from the whims of a ruthless medical free market. The ferocity with which some medical officers fought for their superannuation (discussed in the next chapter), and the apathy of others stemmed from the wide-ranging – but unevenly distributed – incomes for general practitioners across England and Wales. This detrimentally affected standards of care and prevented the unity that Griffin and Rogers sought. The majority were not well off. It undermined their status, rendering them less influential and insecure in their professional standing (i.e. unlikely to upset their more established and powerful peers). Arguably, this was the average medical officer: a doctor seeking to establish his career and/or struggling to keep a small practice financially viable – consuming every penny of a meagre poor law salary and leaving them ill-equipped for their retirement. Small wonder, then, that attendances were missed and low-quality drugs were supplied to paupers by medical officers. Thus historians, such as Crowther and Vaughan, have rightly focused on pay as a central issue in the mid- and late Victorian era, but wrongly overlooked the importance of medical negligence to the stagnation of reform.95 Their low salaries were a key part of the rising numbers of medical officers charged with negligence from the 1870s, discussed in Chapter 4. Historians have argued that salaries improved towards the late nineteenth century. This is simply not the case. Just over 2,000 workhouse medical officers were recorded by the poor law central authority as beginning their employment in the nineteenth century. Of those, 64 per cent saw no improvement in their salary during their term in office. Increases in the average starting salary for workhouse medical officers, shown in Figure 2.1, crawled from a very low level in the 1840s to an average amount that remained far from adequate at the close of the century. The average growth of £3 for each decade would have been overtaken by rises in the cost of living, the increasing expenses of doctoring and the devaluation of a small salary increment when incorporating inflation over the period. Despite increasing responsibilities in the late nineteenth century, the salaries of medical officers – when incorporating declining national economic virility and exorbitantly increased workloads – stagnated at a considerably low level throughout the Victorian period.

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Medical Negligence in Victorian Britain 60 50

Salary in £

40 30 20 10 0

1830–1839 1840–1849 1850–1859 1860–1869 1870–1879 1880–1889 1890–1899 Decade

Figure 2.1 Average starting salary for a medical officer by decennial period Source: TNA MH9 Series

The social historian Harold Perkin described the complexities of national economics at this time: Just as the rising prices of the mid-Victorian period eased the struggle for income, making it easier for landlords to obtain and for workers to demand and employers to grant wage increases, so the falling prices of 1873–96 exacerbated that struggle, squeezing rents, profit margins and interest rates, and making it more difficult for landlords to resist rent concessions, business men to grant wage increases, and wage earners to defend themselves against wage cuts.96

Yet, Perkins saw the ‘Great Depression’ of the late nineteenth century as a myth. He argued that national income and purchasing power per head generally increased at this time, and that the quality of life for many rose.97 Perkin’s figures, though, show improvement in real national income levels from the 1880s, but a levelling out before this. He also conceded that national figures concealed the effects of ‘bad years’ in different parts of the country (and at different times) for different industries and trades.98 Furthermore, the financial health of certain professions, such as doctors, was particularly sensitive to local economic factors. This is important to consider when ‘weighing the balance’ of the causes and effects of doctors’ negligence under the poor law. A medical officer’s dependence on income derived from a private practice – with a local patient pool – outweighed their reliance on the meagre (nationally sourced) poor law salary. A private practice hinged on a Welsh coal-mining community, for example, was at the mercy of a different set of circumstances to one based in the agricultural south-east or the urban north-west of London. Their fortunes could thus vary greatly

Victorian ‘State Doctors’

200–299

300–399

39

400+

100–199

0–99

Figure 2.2 Quantification of start salaries (in £) for all workhouse medical officers, between 1834 and 1899 Source: TNA MH9 Series

from region to region (or, even, within districts). Furthermore, the average national salary disguised the true number of medical officers who were paid under £100 per annum (Figure 2.2). By far the greatest number of workhouse medical officers received a salary under £50 per annum (Figures 2.3 and 2.4) – not infrequently placing them on a salary less than the national norm for a workhouse master or matron, and similar to that of less-skilled workhouse staff, such as nurses, porters or instructors. Sometimes a district post (and its respective salary) was held in addition to the workhouse, but this was by no means the majority. The pejorative salaries for workhouse medical officers were also reflected in (the experiences of) district medical officers who, Chapters 5 and 7 will argue, came under distinct pressures in the 1870s and 1880s. Only anomalies, such as the English capital, paid high salaries and employed full-time doctors.99 Griffin was forced to address the (proportionately overly vocal) better-off in 1859: ‘any medical officer who desires to remain under the present regulations may do so … this clause has been framed to meet the wishes of those gentlemen who are well satisfied with their present remuneration’.100 Appeasing a loud and powerful minority was a bad strategy – indicating, perhaps, Griffin’s experiential ivory tower. As Figure 2.4 illustrates, the majority of medical officers were paid too little to be effective, and this continued, with only slight redress, until the turn of the twentieth century. Throughout the nineteenth century, doctors continued to take up poor law appointments on salaries that were too low for them to practise with impunity within the bounds of their professional obligations (detailed in Chapter 4). According to the BMJ, ‘The grievances of the medical officers lie in a nutshell, and may be summed up in two words, “inadequate remuneration”; double their salaries, and they would put up with all the other inconveniences.’101 Despite the clear suppression of salary levels, as reflected in Figures 2.1 through 2.4, belief

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Amount of workhouse medical officers

400 350 300 250 200 150 100 50 0 0–9

10–19

20–29

30–39

40–49

50–59

60–69

70–79

80–89

90–99

Salary in £

Figure 2.3 Quantification of start salary for entire period for salaries under £100 Source: TNA MH9 Series

100

Number of medical officers

90 80 70 60 50 40 30 20 10

0 10 –9 – 20 19 – 30 29 –3 40 9 – 50 49 – 60 59 – 70 69 – 80 79 – 9 89 10 0–9 0 9 11 –10 0 9 12 –11 0– 9 13 12 0 9 14 –13 0 9 15 –14 0 9 16 –15 0 9 17 –16 0 9 18 –17 0 9 19 –18 0 9 20 –19 0 9 21 –20 0 9 22 –21 0 9 23 –22 0 9 24 –23 0 9 25 –24 0– 9 26 25 0 9 27 –26 0 9 28 –27 0 9 29 –28 0– 9 29 30 9 0+

0

Salary range in £ 1830–1839

1840–1849

1850–1859

1860–1869

1870–1879

1880–1889

1890–1899

Figure 2.4 Distribution of the ‘start salary’ for workhouse medical officers throughout the nineteenth century Source: TNA MH9 Series

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in free trade and competition governed employment procedure. Salaries were influenced by free-market competition at a time when Victorians were somewhat obsessed with the international context of free trade. It was at the centre of British attitudes to governing the economy – a concept of minimal interference and a purist belief in capitalism: that the market should be allowed to follow its natural course.102

Competition: The economics of poor law medicine Time and again the poor law authorities defended their ‘free trade’ mind set. Competition existed in private practice and the poor law authorities wanted to replicate this in poor law medicine. One poor law president described this to Griffin’s deputation of medical officers in unequivocal terms: ‘My object will be to introduce amongst you a certain amount of competition which is the principle of private practice … I desire to introduce into the administration of medical relief to the poor exactly the same principle which is in existence with respect to private practice and I don’t wish to carry it one step further.’103 The BMJ therefore regretted that it was a ‘sad thing for our profession, that this competition should be so glaring a part of it … . One member of the profession undersells another, and the governmental hawk takes advantage of the competition’.104 This suited poor law employers, who – through the ‘natural law’ of supply and demand – could pay a low salary because there was an overproduction of doctors at this time. Members of the medical profession quipped that guardians ‘have only to ring the bell, and a dozen applicants will at once appear at their summons’.105 Guardians were also frequently blamed and paraphrased: ‘whenever a vacancy occurs, there are plenty of men willing to take the office, and therefore why should the Board increase the salaries?’106 This would have been acceptable to most Victorians. Sir John Trollope (poor law president in 1852) reasoned that ‘perhaps the medical gentlemen themselves are somewhat to blame for this state of things. Under the operation of excessive competition they have been induced to take contracts at a lower scale than they can afford to do’.107 Such notions prompted more liberally minded contemporaries to question governing motives: ‘why should [competition] stop at Poor-law medical officers, why should it not ascend even as high as the premier?’108 Others questioned the medical officers’ lack of cohesion against the principles of ‘free trade’. As the BMJ wrote in 1864, ‘It seems to us hoping beyond hope to expect that a free trade House of Commons will ever force ratepayers to pay more for the services of an official than the official himself demands for his services.’109 This was a view that all could see, but none was willing to resolve. Punch observed that guardians were bound by the ‘principle of parochial economy’ to buy in the ‘very cheapest possible market – particularly when buying in the Medical labour-market’. The prescient humour of Punch paints a vivid picture: ‘Some guardians may fear lest a Medical Men’s Union, like that of the Amalgamated Engineers, may by-and-by

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be formed to dictate wages and other terms to Poor Law Unions. But the Medical Profession happily contains too many knobsticks for that.’110 Who could disagree? The crowded field of nineteenth-century medicine ensured a constant supply of eager and qualified medical professionals, which, in turn, suppressed wages throughout the whole of the Victorian era. The 1858 Medical Act slowed the spread of dubious institutes, but the Victorians’ medical ‘diploma mill’ continued to overstock the profession.111 The medical historian, Irvine Loudon, noted this irony of Victorian capitalism and condemned the new poor law ‘for insisting on gross understaffing with medical officers and consequent neglect of the sick poor, at the very time when everyone recognised the profession was overprovided with general practitioners anxiously seeking employment’.112 Yet, Loudon understated the role of medical practitioners, whose lack of unity or foresight lay behind much of the atrophied poor law medical reform. Although Tomkins withdrew from a ‘retrospective allocation of personality type’, she has said, ‘The challenges of medicine per se may have been exacerbated, however, by the personalities of the individuals who made it their occupation.’113 Though broad-brushing can be bombastic, even the medical profession was tempted to caricature the individual poor law doctor as one whose ambition too-frequently trumped the Greater Good (for their own corporate aims and in the interests of their patients). Correspondence to medical journals argued for unity or mocked poor law medical officers. For example, one doctor wrote: ‘… in my neighbourhood, a small packed board actually turned out a gentleman of high standing during the absence from home of all the respectable members of the board; and a drunken pot-house surgeon was employed … Such is the system!’114 Another angry letter writer criticized the workload: Of all animals, considering the cheapness with which they are kept, and the amount of labour they are expected to perform, perhaps the very worst served are the poor man’s donkey and doctor. Of course, a donkey is admirably adapted to the purposes required of him; he does not cut a very brilliant figure, nor presume to rival ‘Toxophilite’; but with a few thistles, and many whacks, he is made to perform the duties imposed on him. Is there an analogy between him and the ‘officers’ attached to the medical department of the Poor-law?115

From the 1860s, some unions supplied expensive drugs; but, on the whole, paupers relied on the financial stability of the doctor. Inevitably, both doctor and employer were at the mercy of economic cutbacks. All of this had an impact on standards of care and charges of neglect against medical officers. Medical officers were on the frontline of providing paupers with relief. They put Victorian perceptions of effective welfare management into practice, treating the ‘deserved’ pauper or withholding treatment from the fraudulent or malingering poor. This ‘gatekeeper’ role, described by Digby, increasingly led to neglect of their duties or conflict with their union employers (evidenced in Chapter 5’s discussion of poor law policy).116 If doctors let the gate fly loose and gave out too much medication or medical extras, they were deemed an expensive liability; but if they

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held the gate too fast, paupers were exposed to extremes of sickness, stemming from want and need – not infrequently, starvation. Thus, Crowther made the well-known observation that medical officers had ‘divided loyalties’117 – they needed to please their own profession’s interests and the interests of their patients, but they were held to account by guardians (their employers). In turn, guardians had to satisfy the ratepayers and various poor law inspectors. Rogers and Griffin, therefore, argued for centralized payment of medical officers’ salaries, believing that it would provide greater protection from the whims of cost-driven ratepayers and guardians. The consolidated fund was a national tax pool (unlike the local poor law rates collected and administered by local boards), and it was for this centrally monitored fund that Rogers fought hardest: he pinned all his reform hopes on this elusive goal. Half of the salary of a medical officer came from the consolidated fund and Rogers recognized the protection that this afforded them. Due to this proviso, both the employment and dismissal of a medical officer could only be carried out with the sanction of the central Board. This shield – weak as it was – had been formed by the intersection of the consolidated fund, the legislative measures encoded in the General Consolidated Order of 1847, and the Consolidated Order of 1855, which bestowed life appointments onto medical officers (who had met the criteria in Table 2.1). In turn, removing a medical officer became a much more complicated affair; a drawn-out legal process of intensive inquiry (detailed in Chapter 4). The legal historian, Peter Bartlett, therefore saw the consolidated fund as a turning point, and implied that doctors gained an increased independence.118 Nonetheless, the effect of the fund remains questionable. The fund had provided medical officers with some protection, but it also served the goals of permanent officials who could order generous guardians to keep salaries and expenditure down. In essence, the fund had supplied the central inspectorate with the overall power to hire and discharge a medical officer and to supervise their salary levels. Nevertheless, as with all poor law orders and measures, the permanent officials of the Poor Law Board tended not to interfere with guardians unless absolutely necessary (such as public scandals, discussed in the next chapter). Besides, both guardians and the central Board had a vested interest in keeping medical officers’ salaries as low as possible. The funds voted by Parliament for contribution towards medical officers’ salaries consistently increased: £70,000 in 1848; £90,000 in 1858; £110,000 in 1868.119 This represented half of the amount paid, with the other half provided at the local level. In addition, there were ‘extra medical and surgical fees’ and the ‘cost of drugs and medical and surgical appliances found by the guardians’.120 For example, in 1868, those additions brought the total figure up to £272,341.121 Small wonder, then, that the poor law permanent staff kept a close eye on rising medical officers’ salaries. Hence, when guardians were ‘disproportionately’ generous with salaries or superannuation for medical officers, the Board stepped in to reduce the amount.122 Although permanent contracts were underpinned by the fund, which gave some security (and boosted their longevity), as a whole, they were meek and fearful of their employers (both guardians and inspectors). Independence remained limited. The fund may have provided some limited protection from guardians’

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more tempestuous or whimsical decisions, but it did not significantly underpin professional independence. Gains in medical or professional territory, which were made against the backdrop of guardians’ resistance, could just as likely have originated from individual personalities. Independence, such as it was, came from the part-time contract – a further reason (why) doctors did not fight for full-time posts. Moreover, the Select Committee for Poor Relief demonstrated its aversion to their independence in 1864: ‘It is evident to [the] Committee that many of the changes advocated by Mr. Griffin … would unquestionably increase the expenditure for the relief of the sick, and diminish to a serious extent the control and responsibility of the Guardians.’123 Griffin had requested to remove medical officers’ remuneration from the ‘incompetency’ of guardians throughout the 1850s.124 The poor law president’s reply had been categorical: ‘I do not think there will be any chance of obtaining the whole amount from the Consolidated Fund. I think it much more likely that the half which you now receive from the Fund may be withdrawn than the other half paid.’125 Despite Griffin’s failure, Rogers felt that all was lost unless the medical officers could secure their entire salaries from the consolidated fund. In 1874 he described his motives: … unless we obtain this concession, it is, in my judgement, hopeless to expect any alteration of the country parish doctor’s pay or position. It would be necessary for three or four generations to pass away, and for a wide extension of the blessings of education to take place, ere a majority of the English farmers, or urban tradesmen, who form our guardian boards, would learn that any possible benefit could arise from placing our medical relief system on a better footing.126

The Association under Rogers’ leadership argued that it was in the nation’s interest to pay them entirely from the consolidated fund on several grounds. First, it argued that the ‘unequal and limited incidence’ of local taxation was no longer applicable to a national system. Moreover, this led to a second line of argument that the migratory character of pauperism had ceased to be merely parochial. This was as a result of restrictive changes to the laws of settlement and removal, which largely ended the practice of taking people from their parish of residence back to their place of birth, if they became dependent on relief.127 Therefore, a third ‘ground’ was that sickness among the poor should be a national charge and it should not have been localized: epidemics began in the poorest districts and frequently spread across the country. Fourth, the Association claimed that if the country could accept an emergency tax in the crisis of the cattle plague, it should, at least, have considered the poor equally to cattle – a point frequently and emotively made by Rogers. This was a valid and humane premise, but (unlike sick paupers) cattle evoked the self-interest of landowners, farmers and gentry. The cattle plague had also gained the medical profession’s full attention, whereas the poor law had not: the disease had helped to crystallize the advance of ‘germ theory’ at ‘a pivotal point in the history of British pathology’.128 The Association’s fifth point continued to appeal to the Victorian’s universal fear of disease: ‘illness in one part of the country needed the same highly skilled

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labour and outlay in medicine’ to treat it successfully nationwide. The Association’s reasoning was that such nationally relevant work meant that, with the ‘principle of part payment having been conceded’, the full salary of medical officers should be paid completely from the consolidated fund. They therefore proposed in a sixth objective, that all expenditure should be ‘equal and from one source … especially as uniformity of treatment can be secured only by the pecuniary provision being placed on a recognised scale’ and drawn from a common source. The Association argued that ‘local opposition to legitimate expenditure would be at an end’ if the ‘whole community contributed equally, upon a basis determined by a central authority’.129 Predominantly, if accomplished, those goals would have increased expenditure from the central fund – which no government at this time would have wanted – and upset the balance of liberalist centre–local relations. It was also pushing the pen towards an overt national system of health services – which, despite the piecemeal development of the poor law medical services, was well beyond the raison d’être of the workhouse system. Unsurprisingly, the poor law authorities dismissed all of the Association’s proposals. Victorians were generally against State intervention in order to diminish the national prevalence of poverty-based sickness (even New Liberalism deliberated over the quandary of State-made pauperism). Indeed, throughout modern history, economics and ideology have tipped the scale over ethical considerations in policy decisions. As the sociologists, Daniel Fox and Rudolf Klein, have argued, ‘Health policy is deeply affected by whom a government taxes (and the tax burden on different groups) and by how it prioritises health services and improvements in health status in comparison to, for example, economic growth and employment, infrastructure, and national security.’130 The British welfare historians, John Stewart and Steve King, have therefore noted that both doctor and pauper were caught in ‘a regime of strict cost control and implicit opposition to the expansion of medical welfare’.131 In spite of a reluctance to spend more on the medical services, Victorians overloaded the workhouse system with chronic cases of ill health, disability and mental illness. As a result, medical negligence began to occur with increasing frequency along the expanding fault line between medical treatment and medical expenditure under the poor law. In turn, a lack of legislation dovetailed with contemporary faith in unadulterated free trade, detrimentally affecting the employment of medical personnel and driving down the standard of care provided under the new poor law. This is also reflected in the punitive records of medical officers held in the United Kingdom’s National Archives. Over a third of workhouse medical officers in the nineteenth century had some type of disciplinary action against their name – a significantly higher proportion than has been previously recognized by historians.132 As Chapters 5 and 7 will demonstrate, there were also high numbers of disciplined district medical officers, especially after the mid-Victorian period. The majority of medical officers, though, were not attempting to make improvements. Instead, they were too busy covering-up the neglectful practice that was systemically caused by low pay and was part of their everyday working practices. Given the situation portrayed in this chapter, it may come as no surprise that many

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Medical Negligence in Victorian Britain

complaints and charges against medical officers had little to do with clinical negligence as it is defined, today. They represented, instead, power struggles between medical officers and masters, relieving officers or guardians over the union’s expenditure on the infirmary and medical regimen. Conflict became inevitable during times of extreme cost-cutting, such as the ‘crusade’ to reduce expenditure on outdoor medical relief in the 1870s and 1880s (detailed in Chapters 5 and 6). Thus, inspectors were frequently adjudicating between union officers. For example, in 1876, Leighton Buzzard Union backed the workhouse master against Dr Bothwell, the workhouse medical officer, despite him assaulting Bothwell. The master and Bothwell were continually disagreeing – a friction that had gone on for many years until there was open conflict between the two officers. Bothwell recorded in the workhouse medical report book the moment that it came to blows: ‘When visiting the workhouse on the evening of the 24th June the master was most insulting in his language and manner toward me [and] he struck me twice [:] first on the side with his hand and afterwards under the chin with his stick.’133 Among other dubious charges, Bothwell was accused of drafting inmates to the infirmary unnecessarily and therefore needlessly mounting expenses. Under Bothwell, the infirmary cost £134 17s 4d a quarter, whereas the previous medical officer had run the infirmary on £85 4d for the same period. Though this medical officer hired a solicitor and began legal proceedings against the master, the union backed the master. Bothwell was charged with eight offences – mostly stemming from disputes over medical expenditure and rows with his employers – and then forced to resign or be dismissed ‘for neglect of duty’. By the 1860s, the workhouse ‘deterrent’ system was fast developing into a mixed collection of State hospitals – in turn, forcing the medical service to provide a level of care that was beyond its capabilities. Griffin described the national situation idiosyncratically: ‘frequent resignations, between 200 and 300 annually, prove that [medical officers] soon become disgusted with their underpaid offices … they soon throw up their appointments, hence the great number of vacancies which annually occur … ’.134 Calling for higher salaries, however, did not attract support – whatever the motive. It was apparent to many in the mid-1860s that the medical officers would be more successful if they adopted a different approach. Joseph Rogers discussed this in a letter to the Lancet: It is satisfactory to find that the general public are disposed to take so much interest in [reform]; and I am perfectly satisfied that the position of Poor-law medical officers would not be so bad as it is if we were to keep back somewhat our own individual grievances, and study to show prominently the evil result of the present system on the poor.135

Rogers was onto something. In December 1864, the moment arrived to reveal the extent of systemic negligence while – crucially for doctors – distancing the medical officers from responsibility for it. The next chapter will discuss the importance of scandal in defining negligence in the public’s eye. If negligent practice was an inevitable by-product of the

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new poor law’s Raison d’être, some Victorians began to insist that the system needed to be altered. The next chapter will argue that ‘scandalous’ neglect was the motor for change in both the 1840s and 1860s. The fallout from the ‘Scandal at Andover Workhouse’ famously ended the Poor Law Commissioners’ reign, in 1847, but the subsequent chapter will argue that this changed little in regard to workhouse medicine. The latter years of the 1860s, though, ushered in one of England’s most public spirited and spectacularly successful episodes of reform in health care. Even so, that chapter will ask, what did the famous Lancet enquiry mean for negligent care under the poor law and what happened, nationally, after London’s Metropolitan Poor Act of 1867?

3

Negligence: The ‘Psychological Moment’

Background The medical officers’ fight for reform remained a largely self-serving affair until the passing of the mid-nineteenth century. After this, Rogers (in his new role as leader of their association) intentionally set out to gain public support. Moreover, Rogers recognized that neglectful care was at the heart of public opinions about poor law medicine. The political shakedown of the Andover scandal in the 1840s reverberated through subsequent decades, and, arguably, this influenced the latter reforms to London’s landscape of medical welfare in 1867. However, this chapter will argue against the conventional view of national progress from that point. The collective voice of the medical officers – apparent in their association’s activities – was but one in a Victorian cacophony. After 1867, their fortunes waned. They were part of a vibrant, partisan and ongoing debate over the shape of welfare (as we would now call it) in the Victorian era. This was most eloquently described by David Eastwood, a historian who has argued that this period should not be limited to a history of ‘reformers’ and ‘anti-reformers’.1 As such, Eastwood said: ‘What we see in early nineteenth-century Britain, then, is not a contest between poor law reformers and anti-reformers, but rather a contest between different strategies for reform.’2 The pursuit of humanitarian causes, however, rarely gained agency in public and political debates about the poor law’s medical policy. The Andover scandal, which was publicized between 1845 and 1847, was therefore notable both for its political impact and for its united public outcry against negligent care. The starvation of inmates in Andover workhouse and the unrelenting criticism of the Poor Law Commissioners by The Times, described below, brought structural reform. Though not strictly medical negligence, questions were asked pertaining to the ‘disgusting’ condition of the Andover inmates. An inquiry was instigated, but the assistant commissioner’s report was ‘smothered’ and he was forced to resign; leading the Provincial Medical & Surgical Journal to remark: ‘No wonder, then, that the Union medical officers should have been treated with so little consideration … Assistant Commissioners dare not see, on pain of being dismissed … .’3 In turn, public agitation forced Parliament to investigate the Andover scandal. People wanted to know how this neglect had developed under the collective gaze of a doctor, guardians and poor law inspector. The exposure

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of Andover by The Times led to the overthrow of the Poor Law Commissioners, but this impressive public-spirited campaign was to be overshadowed by the Lancet’s investigation into London’s workhouse infirmaries – the main focus of this chapter. As Peter Bartrip suggests, ‘it is hard to point to an example of a campaign, such as the Lancet’s on metropolitan workhouses, which made [such] a political impact’.4 The Times and the Lancet wrought change by effective use of their public platform to voice concerns over negligence under the poor law. As such, their respective famous campaigns of 1845–1847 and 1865–1866, together, form the central foci of this chapter. The chapter will demonstrate that combating negligence was central to reforms in poor law medicine. The starvation and neglect of paupers in Andover caused the downfall of the Poor Law Commissioners. Likewise, the negligence of sick paupers in London’s workhouses led to radical legislative reform to State-provided medical welfare in the capital. Public pressure was the common denominator and the most successful motor for driving forward changes to health care in Victorian Britain. The campaigns of the Lancet and The Times show that negligence – whether real or imagined – was at the heart of Victorian debates over standards of care in the poor law.

Publicity and negligence Before sequentially analysing the scandals of care in Andover and London, it is useful to consider the backdrop of publicity and negligence in the early and midVictorian period. On the whole, the egalitarian aspect of a health system for all was not a motivation for nineteenth-century legislators. Though a compassionate view of the poor could interplay with diverse ‘strategies’, debates on poor law medicine were mostly centred on managing economics. The view of the poor and of paupers (and how medical welfare was affecting them) took some time to enter the vocabulary of the medical officers, as reported through their vibrant meetings and in the pages of medical journals. As such, improved salaries and contractual arrangements were the leitmotif of the poor law doctors’ reform movement until the end of the 1860s. Crowther has therefore observed that it is ‘hardly surprising that they were unable to resolve their generation’s confusion on the subject of poverty, but it is more surprising that historians have persisted in seeing them as singleminded reformers’.5 The early- to mid-Victorian public lacked awareness of the challenges that medical officers faced on a daily basis because doctors were slow to publicize the effect of this on standards of care (probably from fear of blame and reprisal). The profession’s viewpoint, however, was described with increasing vividness in mid-Victorian medical reportage – such as ‘The Song of the Union Doctor’ – and relayed to other outlets, including the occasional satire in Punch. Apart from the ‘In-House’ limitations of this type of publicity, professional unions and selfinterested reform goals did little to ingratiate medical professionals to a wary public.

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Medical officers – as an entity – struggled to gain public trust and support. For many years, the voice of the ‘humane’ medical officer – who focused on higher standards of care for the poor – was in the minority. The jobbery of their profession undermined their powers of persuasion. In turn, the protests of dedicated medical officers (such as Griffin and Rogers) were drowned out by the din of more pressing issues for Victorians. As a general rule of thumb, the broad-brush snubbing of medical officers’ reforms by governance had a negative effect on the quality of care. This impact, however, is hard to measure on a national scale because of the diverse range of proponents in Victorian Britain who could limit or expand medical relief according to local custom, practice and objectives. Consequently, the English workhouse system was a regionally varied product of the push–pull relationships between central guidance and local boards of guardians, and the pressure leveraged by public and professional groups – a regional ‘patchwork’ character, which will be discussed further in Chapter 4. In short, the varied results of mixed reactions to reform had shaped the new poor law from its beginning. On the one hand, some unions had buckled under the force of public insurrection and riots against the 1834 Poor Law Amendment Act. On the other hand, it could be argued that many districts had welcomed the reform of 1834 with a united front of working- and middle-class ratepayers who joined with members of the political, elite and upper classes. In 1865, therefore, the Lancet accurately described the workhouse system as ‘a thing of shreds and patches, which has slowly grown up to its present form with all manner of miscellaneous additions and alterations from time to time; and the buildings in which the in-door paupers are housed, together with all the arrangements for their care, partake of this patchwork character’.6 This may well have been an editorial by the celebrated medical journalist, Ernest Hart, whose time with the Lancet is discussed below. A year later, he published a damning report in the Fortnightly Review, which was reprinted as a pamphlet – 50,000 copies were circulated. Hart argued that workhouse wards and infirmaries had ‘outgrown the original anticipations’. As a result, he said: ‘… the negligence or the inefficiency, whether of construction or management, which prolongs the sickness, aggravates the consecutive disablement, or costs the life of a patient, has its own direct money cost’.7 Hart added that, for most London workhouses, ‘… the term able-bodied is a mockery when applied to any considerable section of the inmates’.8 For examples, he gave Clerkenwell, where 530 out of 560 inmates were sick or infirm; and Shoreditch, which had 700 inmates: 220 were infirmary patients, 140 were ‘insane’ or ‘idiotic’ and ‘seven-eighths of the remainder were chronically infirm’.9 Hart’s anger almost screams from the page: There is no uniformity; there is a general meanness of administration; frequent examples of neglect amounting to extreme cruelty; many instances of gross mal-administration; and a prevailing ignorance on the part of the authorities of the principles on which what are in truth great hospitals should be managed,

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Hart’s colleague and friend, Rogers, decried the ‘shame’ that a national increase in wealth ‘beyond all former parallels in world history’ was directly ‘associated with an ever-increasing host of pauper dependents’ ignored by the general populace.11 Despite these moving words, and those of more famous Victorian health reformers, extreme poverty – and large numbers of working class living close to the poverty line – was consistent and grim features of Victorian life. The physically emaciated and under-fed poor of England’s most ‘advanced’ and industrialized cities repulsed those who ventured away from the affluent suburbs. Apart from poor law and public health officials, charities and medical men, most middle-class people kept a wide berth from the poor and their residential areas – leading to William Booth’s analogy of ‘Darkest Africa’.12 After cholera epidemics had ravished inner-city populations in the 1830s and 1850s, suburban homes became popular with professionals. From the mid-nineteenth century, the demography of good health and cleanliness (as much as social status) had visibly separated the middling classes from the working poor, the destitute and the down-and-out pauper. To many middling Victorians, the slums were a foreign, diabolical land. A mid-nineteenth-century doctor described the stigma of paupers: ‘The filth of their dwellings is excessive, so is their personal filth. When they attend my surgery, I am always obliged to have the door open. When I am coming downstairs from the parlour, I know at a distance of a flight of stairs whether there are any poor patients in the surgery.’13 There was little empathy for the poor, who were held in contempt and feared because of their appearance and their unsanitary and diseased bodies. They were an economic and biological threat that transmogrified into the eugenicist’s rationale at the end of the nineteenth century (gaining in global ascendency from then until the Second World War). When Jack London descended into the East End ‘abyss’ of London, he described people eating rubbish from the drains, ‘and this in the evening of August 20, year of our Lord 1902, in the heart of the greatest, wealthiest, and most powerful empire the world has ever seen’.14 London was voicing philanthropic concerns, but he cloaked them in the pervasive eugenic phraseology that emerged in the wake of Darwinism. To him, the capital’s paupers were ‘gorillas … the slum is their jungle and they live and prey in the jungle’ – ‘an anaemic and sickly progeny’ – ‘people of the machine and the abyss’.15 Long before the dawn of eugenic rhetoric, though, Victorians were proselytizing about ‘wasting’ resources on the weak and undeserving. As a result of such sentiments, philanthropy was consistently entwined with the religious and moral deservedness of the impoverished recipient. Selfpreservation and self-serving ideals were also pervasive motivations at the heart of public health and welfare reform. Most often this was tied in with ideas of national economic efficiency or the protection offered by prophylactic sanitary measures. In mid-nineteenth-century London, there was a genuine fear of contagious disease, which spread rapidly through the classes. Few families escaped epidemics, no matter what their social standing. Medicine, sanitation and health were thus

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national obsessions, cropping up in ‘other settings’ – an ubiquitous subject that was woven into most genres of the Victorian press.16 The medical historian, Ruth Richardson, described the era’s obsession with health: ‘Victorian interest in health matters, and campaigning journalism in the area of health care, were by no means confined to the pages of the medical press … . Medical controversies and high-profile campaigns, such as Thomas Wakley’s inquests and elections for coroner, gained considerable attention in the popular press.’17 The idea of medicine as a formidable pillar of society took time to grow in potency, but according to the historian, Michael Harris, the notion of health and medicine ‘formed part of the continuous interchange between producers and readers’.18 Notably, after the Andover scandal (described below), the Lancet detected a ‘change in public opinion’ and a developing conception of responsibility towards pauper sickness during the 1850s and 1860s: ‘Society in England has undergone many important changes of late years, but in no respect is it more remarkably modified than in regard to the exchange of sympathy and kindly feeling between the higher and middle classes and the poor.’19 Therefore, when the Lancet revealed widespread negligence, in 1865, there was a broad and united public insistence to reform poor law medicine. Legislative reform was, in turn, forced by a powerful network within the public sphere that gained popular support by bridging humane and economic motivations. Prior to that, reformers of the freshly minted new poor law had faced an uphill battle. By the 1840s, the Poor Law Commissioners had settled into an ongoing conflict of leadership at the centre, described in Chapter 1. They were unpopular and the three Commissioners played out a bitter and jealous feud with Edwin Chadwick. Notwithstanding the Commissioners’ desire to act within the letter of the law, their priorities were the efficient management of pauperism through the mandate of the Poor Law Amendment Act of 1834. Accounts of negligent care became a regular feature of the ‘Bastille’ workhouse image under the Poor Law Commissioners, but were generally ignored or dealt with at a local level. Chadwick and a handful of assistant commissioners carried out most of the work, investigating administrative issues and accusations of neglect, as well as visiting unions to inspect or carry out investigations. They were overstretched and could not possibly enforce policy, even if there was a will to do so. Instead, their objective was to advise and guide guardians on effective economic management. In the 1840s, this took the form of pushing forward the strict application of the workhouse test. In 1840, for example, the Bromsgrove Union guardians removed two lunatic paupers from the asylum and interned them in the workhouse. The two patients were moved to save the cost of their maintenance in the asylum. The certification of the medical officer leant this action legality, but the doctor seemed to have acted under duress. Nonetheless, when one of the lunatics died, the legal process was questioned. An assistant commissioner, Edmund Head, was sent to investigate. Head advised that the guardians’ actions were ‘… to say the least of it very questionable and I should hesitate to establish a precedent of the kind’.20 Yet, he did not force the guardians to remove the surviving pauper. Head merely ‘advised’ and ‘urged’ the guardians to reconsider the suitability of this lunatic (who was prone to violent outbursts) for

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workhouse care.21 This was reinforced by Chadwick, who backed the removal of the two cases from the asylum, with the caveat that if proven violent, the surviving ‘lunatic’ could only be held in the workhouse for the legal limit of fourteen days (mental-health patients are discussed in Chapter 6).22 The Commissioners deflected broad calls for medical reform, such as those from medical officers, essentially because it was not part of their original mandate. Medicine had been entirely left out of the Amendment Act of 1834 because it was supposed to be a separate issue. Rogers remarked that ‘it is a remarkable fact’ that there was no enquiry into the ‘growth of pauperism’ from sickness: ‘It is therefore no matter of surprise that the report [of the Royal Commission of 1834] contained no reference to this subject.’23 Victorians, such as Rogers and Hart, observed with anguish a system built to house the able-bodied, haphazardly evolving into a loose network of pauper ‘hospitals’. Medical professionals may have been ignored by the Commissioners, but other dissenting voices were also rebuffed. In the early years of the new poor law, guardians, masters and relieving officers had found it difficult to fulfil their duties without breaking the right to relief that underpinned their work. They objected to neglecting the poor under their care and some were vocal in their discontent. In Ipswich Union, for example, the guardians followed their central dictates to the letter throughout the 1840s. Instead of successfully managing and resolving local problems of poverty, the guardians found themselves perpetuating the downfall of some of its poorest citizens. They complained repeatedly to the Commissioners of the false economy in their orders.24 The Ipswich guardians were not guilty of purposeful cruelty, but perhaps a lack of backbone in the face of mass poverty. As local historian, N. R. Saunders, said: ‘… throughout the early years the [Ipswich] guardians wilfully conformed to “Chadwick’s insane instructional circulars” ’.25 In 1840, they pleaded with the Commissioners to rescind their orders to prohibit outdoor relief. They argued that such indiscriminate measures were exacerbating Ipswich’s poverty crisis: [We] are fully convinced that [the Amendment Act] has failed to accomplish the objects of its promoters, in as much as in forcing able-bodied applicants with their families into the Union workhouse … [which] deteriorates the condition of the poor and increases the expenditure … that your petitioners having been accustomed to consider the honest and industrious labourer when in distress from no fault of his own, as an object of compassion, and that to administer relief to such a person, in the least irksome manner is a duty enjoined by the laws of nature, and divine revelation cannot but view with feelings of much pain the operation of an order which militates against those … guides, and which treats poverty as a crime.26

Although appearing magnanimous, the Ipswich Board had initially approached the restriction of relief with gusto and now attempted to backtrack, while remaining obsequious to the Commissioners. Across the nation, there were contrasting poor law experiences and the Commissioners orders were repelled by some, while they were as likely to be welcomed with open arms by others.

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The Andover precedent, 1845–1847 The infamous Andover Union provides one of the best-known examples of guardians who followed the spirit – if not the letter – of the new poor law. When the Poor Law Amendment Act of 1834 signalled a tougher regime, this was welcomed at Andover. The historian, Ian Anstruther, said that Andover’s guardians enthusiastically applied the workhouse test to all applicants of relief. After 1834, they made an immediate saving of 35 per cent from expenditure on poor relief (though it is unclear from Anstruther’s research whether this was inclusive of the costs of paying staff and building a workhouse).27 Andover has become the most iconic symbol of the Victorian workhouse system: a name synonymous with neglect and cruelty. Though Andover’s ‘scandal’ was not ‘medical’ negligence per se, the public attention that it received, between 1845 and 1847, was a critical step in the march towards the medical reforms that the Lancet Commission would usher in two decades later. Andover was a small town in a region known for wealth; but it was an area long-recognized for significant pockets of deprivation, which rose exponentially with the off-seasons of agricultural work. The local labouring populace had therefore reacted angrily to industrialized farming methods (such as threshing), which robbed them of an already Spartan lifestyle. In turn, Andover played a lead role in the labourers’ revolts that preceded the Poor Law Amendment Act.28 In 1830, farmers around the town had lost crops and property to arson; Andover was mobbed by hundreds of violent protestors; and there were many thousands of pounds worth of damage to industrial and farming equipment. Only a military intervention had quelled the insurrection.29 Nearly one hundred people were sentenced to transportation to Australia. Two were hanged.30 After the riots, there was little sympathy for the struggle of the poor at Andover. In contrast to Ipswich’s protests to the Commissioners, no matter what the means, the Andover guardians were pleased with the savings on the rates. In 1837, they expressed their approval in a meeting and wrote to the Commissioners to congratulate them on the new poor law: ‘… in every District of this Union there are favourable symptoms of returning Industry and good Conduct as proofs of which many Parishes have had no cause for Magisterial interference since the Law came into operation … these great advantages have chiefly sprung from the Workhouse System’.31 Not surprisingly, they were on good terms with the assistant commissioner for Andover, who used the union as an exemplary model of the cost-saving workhouse test. In 1837, he proudly recorded that between September and December – the hardest time of the year for seasonal workers since threshing machinery had reduced the need for labour – out of 400 applicants who were offered the workhouse or nothing, only seven had accepted indoor relief.32 Andover workhouse also offset their costs by setting the inmates to ‘bone crushing’ (for use as fertilizer and glue). A special box had been designed to contain decomposing bones, while a large hand-held mallet was used (like an oversized pestle and mortar) to pulverize the contents. It was back-breaking work, but income from selling the powdered produce saved the union 28 per cent of the cost of relief.33

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By 1845, stories were circulating Andover about their union’s workhouse. It was said that paupers were being starved and cruelly treated. To stave off their hunger, it was rumoured that pauper inmates had resorted to eating the green and rotten flesh off the bones that they were supposed to crush. Some of the paupers’ faces had been scarred by the flying bone chips; and children, as young as thirteen, were being made to carry out the work.34 An even more ghoulish account described cannibalism. It was said that inmates had eaten the flesh off human bones that had been mixed in with those of animals. Later, it was claimed – but not proven – that this was the result of alterations to a local church that had unearthed bones, which had been collected and sold by ‘poor children’ to the workhouse.35 The scandalous gossip eventually spread to Hugh Mundy, farmer, guardian and member of an old and well-respected Andover family. Mundy interviewed some inmates and found that the rumours were based on fact – after extensive enquiry, only cannibalism remained unproven. Mundy recruited the support of Ralph Etwall, his local MP, and Thomas Wakley, MP for Finsbury (and the founder of the Lancet, discussed below). The most important agitation, though, came from the proprietor of The Times, John Walter, who was also MP for Nottingham. Walter had been set against the new poor law from its inception,36 and it was his unstinting and unrelenting reportage that hammered the nails into the Commissioner’s coffin. The Times had a circulation of 38,141 in the mid-nineteenth century – double the combined readership of its five main metropolitan rivals.37 Anstruther said of his powerful support: ‘In twenty-nine dramatic reports, the longest series ever published, every aspect of the Workhouse System as conceived in theory by the Poor Law Commission and administered in practice at local level was stripped, at last, of cant and stood revealed.’38 The Commissioners must have recoiled in horror as fact-after-fact from Andover chimed out their destruction and (what was to be) their final moments in office. For many years, the master of the workhouse (ex-Sgt Major) Colin McDougal had kept the paupers on a diet that was below the legal minimum dietary allowance; an amount already dangerously low in nutrition. This was made worse by his fraud and embezzlement, which siphoned off further rations for his personal gain and further reduced the pauper’s provisions.39 Parliamentary enquiries revealed a tyrannical regime under McDougal. The disabled were also made to work, including a one-legged man who had been made to crush bones. Under oath, the inmate added that he had also eaten candles to avoid hunger pains. Another pauper had children in the workhouse who were kept alive by giving them the raw potatoes and scraps thrown out for the chickens. The master was also violent; on one occasion, beating a three-year-old child with a cane so severely that the cane broke.40 The father successfully sued McDougal for assault with the help of a local clergyman. Two women also provided accounts of sexual abuse and molestation by the master.41 As Chapter 1 explained, this was crime and ‘violation’ – the ‘deliberate deviation from procedure’42 – not negligence, as it would be framed in Victorian or present-day legal guidance. McDougal’s abusive and criminal behaviour was beyond the ambit of medical negligence. Nevertheless, the political shakedown that came in the wake of Andover is worth noting, not least because McDougal’s regime had been conducted in a workhouse with a medical officer who had done little to prevent it.

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Initially, the Home Secretary dismissed the reports, but he persuaded the Poor Law Commission to send one of their assistant commissioners, Parker, to investigate. His report was not meant to see the light of day. The Home Secretary, Sir James Graham, attempted to quash the enquiry. It was later revealed that, on reading Parker’s report, Graham had said, ‘Now what am I to tell the House about this business? It will never do to produce Mr. Parker’s Report and these depositions … . This Report must not be produced. It must be treated as if it had never been made.’43 The Home Secretary, however, was held to account and forced to hold a painful open enquiry. As an astonished BMJ reported, ‘Mr. Parker’s report was an inconvenient one … and Mr. Parker himself, not possessing the requisite blindness, or pliancy, or being too upright, to see one thing and report another, is dismissed from office.’44 In his defence to the House of Commons, Graham denied the severity of the Andover Scandal: ‘I confess, Sir, I cannot help thinking that it is melancholy, at the present juncture, and in the existing state of public affairs, so much of the precious time of this House should have been consumed in a matter which after all is only, I was about to call it, a workhouse squabble in the south of England.’45 The calm overtures were contrasted uncomfortably with his initially bitter, and (as he had thought at the time) private, reaction to Parker’s inquiry. There was no escape from the attention brought upon the case by The Times and various prominent members of Parliament, such as Wakley and Walter. A select committee oversaw further investigation, but it was clear from the outset that the Commissioners’ time was up. The only question that remained was what would replace them? The Provincial Medical and Surgical Journal wrote that at this timely juncture it was crucial to memorialize the Home Secretary, and persuade him to place the ‘entire department of medical relief in competent hands’.46 This could have been the fanfare for change that many agitators had been waiting for; but it was not to be. Wakley made an emotional appeal to the House, seeking changes in the system of medical relief in the aftermath of the Andover inquiry: The disappointment out of doors would be very great when it was found that, after the inquiry that had been made, and all that had been said about the administration of the poor-law under the former system, no change whatever was to be made under the new system – that everything was to be maintained in its integrity, and that there was no prospect of a remedy to those evils which had been so much complained of. It appeared that the Poor Law Commission had been abolished, to relieve certain persons; but that with respect to the administration of the law itself not the slightest alteration was to be expected.47

The Poor Law Board replaced the Commissioners, but it was a weak and somewhat apathetic (and, as stated in Chapter 1, essentially non-existent) body of governance. Yet, Andover had exposed negligence. Moreover, the cause of that neglect had been traced from the active criminal negligence of McDougal to the guardians and, from there, to the highest authority: the Commissioners. In turn, the storm had enveloped Parliament for two years, passing only after the Poor Law Commissioners had been toppled from power in 1847. Wakley and Walter had set themselves against the poor

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law. They did not achieve their ultimate goal of the repeal of the ‘new’ poor law, but they both died in the knowledge that their exposure of negligent care had led to legislative reform. Walter learned of the Commissioners’ demise on his death bed. If there is such a thing as ‘resting in peace’, it was a timely and rewarding moment for this personal closure. Wakley died in 1862, but he passed on the flame of reform to his son, James, who realized his father’s ambitions. Under his editorship, the Lancet was almost singularly responsible for revealing the extent of negligent care in London and, in turn, forcing radical reform of medical relief in the capital.

The Lancet Commission, 1865–1866 In the midst of the 1864 Christmas festivities, wealthy Victorians and working class alike were horrified to learn of ‘dreadful neglect’ in Holborn workhouse. A working man, Timothy Daly, had fallen on hard times and contracted typhus fever. He was admitted to the workhouse infirmary, where he remained for six weeks, placed in a child-sized bed. He developed large sores, which ate into the muscle around his upper legs, leaving him essentially crippled. He had been left for weeks, cramped, and saturated in his own perspiration and urine. He discharged himself at the first opportunity, but later died.48 Most of the periodicals, journals and newspapers carried some type of reporting of the Daly case. The public were outraged. Just as Andover had come to represent the arrogance and indifference of the Poor Law Commissioners, Daly’s name became synonymous with the Poor Law Board’s neglect of their medical services. On the strength of this incident, Florence Nightingale was able to convince the poor law president, in 1865, that there was need for change. She later wrote, ‘I was so much obliged to that poor man for dying.’49 The medical officer was held responsible and charged with neglect – but he was later exonerated by the findings of an official inquiry and the pressure exerted by consequent and unwelcome publicity. The BMJ typically used the situation to prioritize professional issues: ‘as far as we can judge from the case as it stands, this is just another of the instances in which the doctor is made a scapegoat when a too striking example of the hardships – we may say, in some cases, of the cruelties – of the Poor-law system, comes before the public’.50 The Lancet also backed the medical officer, but, less idiomatically. It focused its attention on the sick poor (and, thus, public interest): ‘There was a strong case against our union infirmary system. The typical faults of that system were laid bare; to the mind of the guardians of unions and of the Poor-law officials they are no faults at all; to our mind, and, as we believe, in the eyes of the public they are grievous.’51 This was the legacy of Wakley who had backed the BMA Convention (for poor law reform) in the 1840s and consistently criticized the new poor law. His son, James, was now wearing the mantle of reform and steering the Lancet towards a head-on collision with poor law governance. The public furore was therefore rekindled in early 1865, when a second case of neglect hit the headlines of The Times. Richard Gibson had fallen into destitution and taken himself onto the parish as a pauper. He had a ‘bad leg’, so he was admitted to the workhouse infirmary for the united parishes of St Giles in the Fields and

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St George, Bloomsbury. He was neglected; essentially ignored, left to waste and then to die. Gibson’s body was covered in bed sores and a suppurating rash from typhus fever – it was also caked in excrement, sweat, blood and urine. His condition was recorded by a constable who was called to the scene after a complaint was made by one of the inmates of the workhouse about the condition of the man. Gibson died the day after the constable saw him.52 The Lancet was quick to utilize this event and strike a chord with public sentiment. In 1865, James observed a turn in public opinion and chose the moment to strike for a more ‘humanitarian’ reform of the poor laws. His timing was impeccable. According to Sir Samuel Squire Sprigge (who became editor of the Lancet in 1909), the journal had ‘seized on the psychological moment and instituted an inquiry’.53 This was the fanfare for one of the Lancet’s most successful ventures in the nineteenth century. It was also to become one of the most – perhaps the only – successful political and structural reform of State medicine, enacted as a direct reaction to public protest about negligent care. It is historically important and fundamental to this book because it set a precedent for public agitation about substandard medical care that has not yet been matched in British history. In April 1865, the Lancet announced its ‘Commission to Inquire into the State of Workhouse Hospitals’: This state of things cannot continue. It is necessary that public opinion should be fully enlightened and deliberately directed. We propose to supply, as far as we can, the more immediately necessary materials for such a deliberate judgement. We shall appoint commissioners well acquainted with the details of hospital management, and whose ability and discretion are beyond doubt, who will make it their duty to compare the present system in workhouse hospitals with that which prevails in the public hospitals of the metropolis.54

Looking back, Joseph Rogers’ brother recounted the momentous events: ‘a scandalous case of neglect led to an inquest, to an exposure of the facts, and to very severe comments by the press. Shortly afterwards the proprietors of the Lancet newspaper … resolved on investigating the condition of the London workhouses and their hospitals’.55 ‘Poor Richard Griffin’ had suffered from bad timing and a lack of public interest. In contrast, the medical historian, Joan Lane, described how the public and medical profession were better prepared for the Lancet Commission: ‘By the 1860s there was considerable pressure for reform. The medical profession was undeniably stronger after the 1858 Act and the Medical Register and, following the well-publicised deaths of two paupers in a London workhouse and general terror after the 1866–1867 cholera outbreak, public opinion was in favour of change’.56 The political and public spheres of London were also aware of an issue surrounding unequal expenditure on poor relief. Certain unions, such as those in the East End, had many more relief dependents than their richer counterparts in the West End and South London districts. Pauline Ashbridge has argued that for a decade (1857–1867), the ‘Rate

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Equalization Association’ networked and raised public awareness of this problem, fighting in Parliament for a more equitably shared burden of poor relief. In so far as the Metropolitan Poor Act of 1867 enunciated that association’s goals, though, Ashbridge understated the role of health and sickness in gaining publicity and cementing political support for the bill that led to the Act.57 Crucially, redistributing health costs under rate equalization met with the more dynamic and calculating exposure of negligent care. Put succinctly, preventing negligent care was more persuasive to Londoners. On one level, it met with humane sensibilities and a belief in a legal right to relief. In a more self-oriented capacity, the reduction of negligent care also meant reducing the ‘false economy’ of sustained unemployment through lack of medical treatment (i.e. the cost of supporting this and familial dependents on relief). Perhaps less consciously, as Lane observed above, health also appealed to the more personal instinct of self-preservation. Diseases, such as cholera, spread rapidly through the city without class distinction. In mid-nineteenth-century London, there was a genuine fear of contagious disease. Medicine, sanitation and health were therefore national obsessions by the mid-nineteenth century and most genres of the Victorian press reflect this. According to the medical historian, Ruth Richardson, ‘Victorian interest in health matters, and campaigning journalism in the area of health care, were by no means confined to the pages of the medical press. Advertisements for remedies for every medical complaint festooned newspaper pages. Medical controversies and high-profile campaigns … gained considerable attention in the popular press.’58 As historians have observed, health issues continued to ‘crop up in other settings’.59 Health – at least, one’s own – it is fair to say, was a national obsession in the Victorian period; other people’s health (especially that of the poor’s) only became an increasing concern to the residents of urbanized and industrialized areas. Here, people of all classes could come into contact in the street, hospital, transport or even in the home (with the to-ing and fro-ing between ‘upstairs and downstairs’). Londoners, in this respect, were more predisposed to the idea of improving the health of their poorer neighbours (and thus preventing their susceptibility to chronic sickness) than other parts of the country. From the outset, the idiosyncratic mix of medical and sensationalist social reportage of the Lancet captured the public’s attention with Dickensian panache.60 According to Rogers, the Lancet reports were copied and reproduced across most of the contemporary press in ‘Sunday, daily, and weekly journals, and gradually produced a feeling of intense public indignation’.61 Speculatively, it is likely that the medical journalist, Ernest Hart – who later became editor for the BMJ – wrote most of the colourful diatribe. He and two other doctors stepped forward as Commissioners: Anstie (Westminster Hospital), Carr (medical officer for Blackheath) and Hart, who was also a staff member of St Mary’s Hospital. They visited almost all of London’s workhouse infirmaries, making detailed reports of their condition. Their paths also crossed with Rogers’, who was the medical officer for the Strand Union workhouse. He allowed them full access to the infirmary and played the role of a consultant to the Commission, helping them to gain admission to London’s workhouses.62

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Rogers, as described in Chapter 2, was a rising star in the poor law medical officers’ reform movement – and soon to become the leader of their national association. The Commissioners were therefore confronted with an enthusiastic, fearless and like-minded medical officer, who held nothing back from the Lancet – an openness that was to lead to his subsequent persecution by the Strand guardians. It was the Strand report, and Rogers’ role in its publicity, that was to prove the hammer blow for poor law reform in the capital. Moreover, Rogers had entered the political stage. He was to play a pivotal role in the Lancet Commission and the successful passage of the subsequent Metropolitan bill. Besides being a leading figure in Griffin’s association, in 1865, he had already gained considerable experience as a doctor and workhouse medical officer in London. Rogers had become the medical officer for the Strand Union Workhouse in 1856, after cholera had decimated his private practice by causing his wealthier patients to move to ‘healthy’ suburbs of the capital. A vibrant mix of classes was replaced by poverty and slum dwellings. Prostitution, crime and sickness mushroomed. Another cholera epidemic spread through London ten years later, and consequently Rogers stated that the city’s health between 1862 and 1865 was so bad that there was widespread ‘distress’, causing an influx of sick poor into the workhouse infirmaries and constant overcrowding. Rogers complained to the guardians, but they accused him of being ‘too squeamish’ and of causing the inflated numbers by ‘being too indulgent to the sick’.63 His attempts to bring reform to the workhouse were consistently rebuffed by the guardians. In August, 1865, he had his revenge when the Lancet published their fourth report into the condition of London’s workhouse infirmaries: ‘The Strand Infirmary’. It was one of the Commission’s most damning reports. They criticized almost every aspect of the accommodation and care of the sick at the Strand workhouse. Only Rogers escaped their wrath: ‘It has never in the whole course of our inquiries fallen to our lot to observe a more pointed instance of hard and bitter service by a faithful officer … .’64 The commissioners laid the blame for the neglected ‘frowsy’ condition of the patients squarely at the feet of the guardians. Above all else, the woeful condition of the Strand was blamed on the inadequacy of the buildings and accommodation. There were 288 inmates. Of those, the commissioners estimated that only 8 per cent were considered able-bodied.65 Originally, the workhouse – in common with most others – had provided a couple of wards (with sixty-four beds) that were supposed to be sufficient for housing the mixed bag of patient categories, such as midwifery, sickness, disability or mental health patients. This had proved woefully inadequate. Over the course of three decades, the sick had come to occupy the lion’s share of the house. At times of distress (such as recession, epidemic disease or winter) the corridors and halls of the workhouse would be crowded with occupied beds. Under normal circumstances, wrote the Lancet Commissioners, ‘The extent of this hospital-accommodation (or rather hospital-occupation) may be estimated, on the most moderate reckoning, to amount to seven-eighths of the sleeping accommodation afforded by the entire establishment.’66 Hart was to later write, ‘At the Strand workhouse, perhaps, the buildings are more ill fitted for the purposes of an infirmary than in any of the London unions … .’67

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There is no doubt that Rogers provoked the guardians with his prolific and unrestrained public criticism of ‘their’ medical provision. The Strand report in the Lancet held nothing back.68 Hart was later to write an article for the Fortnightly Review, which repeated the facts, but with greater publicity (50,000 copies were distributed) and echoes of Andover: at the Strand workhouse, not only are the buildings in themselves thoroughly unfitted for hospital occupation, but they are closely encircled by workshops, mews, &c, and the Guardians have had the inconceivable stupidity to raise a nuisance of their own, by establishing and carrying on for years a large carpet-beating business, which is transacted in the yard immediately below the windows of the sick wards, so that the patients are choked with the poisonous dust and stunned with the perpetual noise of this offensive trade. Although many remonstrances have been made, the Guardians have proved so blind to a sense of their duty as to persist in this noisome nuisance to the sick of whom they have the care, because the business is profitable.69

Rogers had taken a great risk when he opened up the doors of the infirmary to Anstie and Carr. It defined his career. Conflict with ‘ignorant’ guardians became the leitmotif of Rogers’ working life.70 Initially, he escaped persecution from the Strand guardians. However, his continuous public agitation kept the Strand in the spotlight. Following further enquiries at Strand, and the official reports of two inspectors (Farnall and Smith), the Poor Law President, Charles Villiers, censured the guardians. He publicly blamed them for the condition of the workhouse. Villiers demanded that the Strand Union ceased overcrowding in the workhouse and halted the employment of pauper nurses.71 The professional nurse that was subsequently employed lasted barely six months. Yet, her public criticism of the Strand was to prove both timely and crucial to the movement for legislative reform, discussed below. Rogers had thus played a key role in publicizing the Strand’s condition. Over the next two years, Rogers’ relationship with his employers soured. In 1868, he was forced to resign, after a majority of the Strand guardians charged and suspended him for publicly deriding them in newspaper articles (a charge that is further discussed in Chapter 7). Rogers’ supporters on the board of guardians wrote to the poor law president requesting him to reinstate Rogers: ‘… this gentleman has received great provocation repeatedly from several of the guardians … the antagonism which he has met with at various times from members of the Board has mainly been excited by the great exertion he has made to bring about reform in the treatment of the sick poor, and which helped the passage of the Metropolitan Poor Act’.72 By then, Rogers had spent over two years propelling poor law reform into the public eye and aiding the Lancet Commissioners. There were common complaints across the Lancet reports (1865–1866), such as the lack of bedpans and toilets; no cleaning facilities in workhouses where patients were forced to wash themselves with water from toilets and bedpans; pauper nurses who were incapable or unwilling to carry out their job (or, worse,

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abused the patients); vagrancy wards which were so repellent that on one occasion a commissioner vomited; and severe overcrowding, unsanitary conditions and understaffing on a scale hitherto unknown by the general public. For example, St Pancras had two resident medical officers to treat 1,112 patients in an overcrowded infirmary. The report contained an appalling account of an unsanitary and overcrowded children’s ward, where thirty-two children were washed one after the other in a single tub.73 Although there were a few exceptions, such as the Camberwell Imbecile Ward and Chorlton Pauper Hospital, these were rare.74 The commissioners condemned most infirmaries, frequently recommending that it was essential to erect or convert alternative premises. As a result of the Commission, the Lancet was able to report in 1866 that ‘a great many masters have recently retired, since we began to look into workhouse matters, through resignation or dismissal’75; indeed, it was discovered that many, like McDougal, had amassed personal wealth through embezzlement and irregular business.76 Above all, the public were made aware that workhouse populations in London were mostly comprised of the sick and infirm. Londoners (and the reading public) were gripped and onside. After momentous clamour for reform, in 1866, the Poor Law Board sent out a questionnaire to London’s workhouse medical officers. Rogers – with good reason – felt this was a ruse to catch medical officers out by exposing different levels of opinion and taking advantage of their insecurity of employment. He seized the mantle and arranged a meeting at a London tavern. Most of the London medical officers attended, ensuring that the completed returns did not undermine their objectives (thus avoiding the mistakes of Griffin’s association). For example, on the issue of overcrowding and its remedy, one medical officer argued for 1,200 cubic feet of air for each patient, while another said that 500 cubic feet was adequate.77 It would have been obvious to most medical officers that the latter would result in overcrowding. Although this was loudly dismissed, they were in a difficult position: effectively, the questionnaire was asking them to openly judge their employers.78 The meeting was a success, however, and it resulted in the inauguration of the Metropolitan Poor Law Medical Officers’ Association. Rogers was elected as the first president. The Lancet advertised a follow-up meeting to decide their rules of conduct.79 From then on, Rogers referred to Griffin’s fading association, perhaps rather derogatively (under Victorian metrosnobbery) as the Provincial Poor Law Medical Officers’ Association. Within a year, Griffin had retired through ill health. Rogers was at the helm. He merged the two Associations and formed the Poor Law Medical Officers’ Association (PLMOA).

The zenith of reform Concomitantly to his increasing professional responsibilities, Rogers was at the vanguard of a growing body of reformers who sought to revolutionize medical welfare in London. Rogers felt indebted to the Lancet Commissioner, Anstie, who he felt had ‘worked to protect him’ from the Strand Board of Guardians. He arranged a dinner party in Anstie’s honour at his home in December 1865. Anstie was accompanied by Hart, and it was at this rendezvous that the three

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men conversed and struck upon the formation of an association ‘for the purpose of thoroughly enlightening the public’.80 The Association for the Improvement of London Workhouse Infirmaries (hereby shortened to Improvement Association) was formed. Meetings were held at Hart’s house, and according to Rogers, ‘the Association prospered beyond our widest anticipations’. It was ‘speedily joined’ by many famous Victorians, including Florence Nightingale, Charles Dickens, Louisa Twining and John Stuart Mill.81 There were also aristocrats, leading clergy and twenty MPs among its seventy members. At its first meeting a letter from Charles Dickens was read out, which could have helped raise the Improvement Association’s status: ‘few anomalies in England are so horrible to me as the unchecked existence of many shameful sick wards for paupers, side by side with a constantly recurring expansion of conventional wonder that the poor should creep into corners to die, rather than fester and rot in such infamous places’.82 Publicity was undoubtedly the greatest aim and accomplishment of the Improvement Association – ‘aided by the full force of the Medical Press, the great work was commenced’.83 This was ultimately the reform of London’s workhouse infirmaries, but the Association proclaimed ‘its precise aim is to bring clearly before the public mind, an impressive and summary form [of] the terrible shortcomings of the present system’.84 Mass public attention was rapidly achieved through an energetic mix of networking and what we would now term media spin. In early 1866, the Lancet reported that the press was following the Improvement Association and the Commission with keen interest. Among others, The Times, Morning Star, Sunday Gazette and Daily News were reporting on the Commission as an important current affair. This included the Pall Mall Gazette, which praised the Association: ‘… a more charitable work, a work less liable to abuse, and more emphatically deserving of every kind of support, has not been set on foot for years’.85 The Improvement Association built on the Lancet Commission, and speedily became a considerable force in the Poor Law reform movement, using its high-profile members to put constant pressure on Parliament. In this respect, Florence Nightingale’s pressure on the poor law president, Villiers, was its most successful and famous endeavour. Nightingale used Daly’s well-publicized case to illustrate the terrible shortcomings of workhouse infirmaries. Largely as a result of her persuasiveness, in 1866, Villiers sent two inspectors – Farnall and Smith – to follow in the footsteps of the Lancet Commissioners. They found only four resident medical officers in the entire city. The rest were part-time officers who resided away from the workhouse and visited it irregularly. According to Gwendoline Ayers, a historian who focused on the Metropolitan Act, Farnall was especially influenced by Nightingale.86 His report was unsparing and placed him at odds with most of his colleagues at the Poor Law Board. Farnall openly supported the medical officers, who, he argued, ‘… appear to me to do their duty to the best of their ability; but I am obliged to add that, in many instances, their duties are very arduous, and their salaries inadequate’.87 Farnall listed the huge amount of duties expected of a medical officer in one day, arguing that part-time officers could not meet the demands of the job. He provided apt case studies, such as that of a West London workhouse medical officer who had an annual salary of £110. Drugs cost him £45 per annum. He visited 152 patients a

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day, prescribing medication to more than a third of them. The medical officer claimed he spent four hours in the workhouse on a daily basis – Farnall insinuated that he would have struggled to balance his finances and time between his workhouse duties and private practice.88 By necessity, he would more than likely have neglected poor law duties. Farnall recommended that all drugs be supplied by guardians and that salaries should be raised to meet the job specification. Moreover, and to Nightingale’s delight, he called for the abolishment of pauper nursing – something that Chapter 6 will explain – did not happen for a further three decades. Most importantly, Farnall, controversially (and fearlessly) concluded that there was no means to improve care under the present Metropolitan infirmary system because the Poor Law Board had ‘no legal powers vested’ in them to compel guardians to build infirmaries, pay for drugs or employ resident medical officers.89 This report had seemed sure to bring extensive reforms to national health care, but it was not to arrive in the form envisaged. Shortly after Farnall’s report, there was a change in government. The Poor Law president, Villiers – who had warmed to Farnall – was removed. Rogers felt that when the ‘Derby–Disraeli conservative government’ took over from the Liberals (in 1866), there was a distinct change in the reception of reform.90 When Gathorne Hardy took the reins of president of the Board from Villiers in 1866, he essentially broke off ties with Nightingale. He also ostracized Farnall from his London set, by sending him to a northern district. Additionally, Hardy appointed two new inspectors, less disposed to reform. Initially, Hardy had one goal in mind: to steer through the bill that led to the 1867 Metropolitan Poor Act. Whether this was from benign intent or a need for the Conservatives to produce it in their own form is difficult to conjecture, because there are so many intersecting factors. According to Ayers, though, Hardy had no intention of following in Liberal footsteps.91 For a moment, the momentum for reform was slowed. The turning point came after the publicized ‘whistle-blowing’ of Matilda Beaton, the nurse who had resigned after six miserable months at the Strand Infirmary in 1865. Rogers and Hart persuaded her to provide evidence to the Poor Law Board. Beeton described her experiences of working at the Strand and Rotherhithe workhouses with courageous frankness. She listed acts of cruelty to the sick poor that she had felt unable to prevent, and her story reignited public debate: Beaton spoke of ‘patients dying on the floor of the ward [and] being dragged to the closet in the stage of illness; of brutal violence inflicted by pauper nurses; of systematic neglect and filthy dirt; of the refusal of the nurses to attend to the patients unless bribed; of robbery of the food and stimulants of the sick and infirm’.92 Her descriptions of neglect and cruelty tipped the scales of public opinion in the health reformers’ favour. The ‘whistle-blowing’ of Beaton, and the subsequent official enquiry, pushed Hardy into rapid response. Within months, a bill had been rushed through Parliament. Arguably, the medical and public press had created a storm of public fury, which politicians of every ilk were keen to extinguish. Without doubt, it was a remarkably fast passage for a nineteenth-century ‘welfare’ bill, which under normal circumstances would have taken several years to progress through Parliament. Most of the Improvement Association’s aims became enshrined in ‘Hardy’s Bill’, with the exception of one important clause that was withdrawn.

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Some medical professionals and politicians advocated the adoption of interns at workhouse infirmaries, just as they were in the charity and voluntary sectors. Rogers advised Hardy, and a student clause had initially been drawn into the bill. However, the bill had not proceeded far before autocratic elements of the medical profession interceded and the workhouse medical students’ clause was withdrawn. The Lancet criticized the waste: ‘… they allow a mass of the most valuable materials for the clinical instruction of medical students to lie unused. With proper management, what magnificent clinical hospitals might our workhouse infirmaries become’.93 In short, workhouse interns would have been too competitive for the established London teaching hospitals and, arguably, threatened the power of some of the more autocratic physicians.94 There may also have been fears of Statefunded medicine interfering with private enterprise and the free market of medical practice. The bill could thus have ushered in a new era in clinical medicine within poor law infirmaries, but the medical profession’s own internal hierarchy had overcome progress. Nevertheless, by 1867, Parliament and Lord Derby’s Conservative government had been left with little choice but to pass the rest of the bill. Hardy introduced the Metropolitan Poor Bill that included the ‘establishment of workhouse hospitals and dispensaries, and the supply of all medicines and medical appliances at the charge of the guardians’.95 According to David Green, historian of London’s poor law, the subsequent Metropolitan Poor Act of 1867 had provided the means to ‘finance a wave of workhouse and hospital construction that took place from the 1870s onwards’. In turn, this created an ‘entirely new framework with which to redistribute the cost of relief across the metropolis as a whole’.96 At the time, Rogers, the Improvement Association and the Lancet Commission were all acknowledged by Hardy as forcing the issue into the public and political arena.97 The Metropolitan Board met for the first time in June 1867, signalling a reduction in parochial powers and guardian autonomy in the capital. For the first time, the Poor Law Board had the power to remove or change guardians. Local Acts were abolished. The ability to hide in legal loopholes and defy the Poor Law Board’s directives had been significantly diminished. The Board had a jurisdiction of 118 square miles and a population of over 3 million – the same area that was later to become that of the London County Council. The sick, at least ostensibly, were to be finally separated from able-bodied poor: a new direction in philosophy and practice. There were to be city-wide dispensaries offering free treatment to the poor (in order to prevent further declines into pauperism, preserve the economy and disrupt the spread of communicable disease). Above all, the Common Poor Fund would now draw from a common pot of money and halt the high expenses of pauperism in certain districts. The high costs of poor relief in the East End unions would no longer be confined to those areas – all ratepayers in London were now their brother unions’ keeper. Costs, such as medical officer salaries, drugs, institutional care of the insane and maintaining patients in new hospitals would, in theory, no longer be withheld because of parsimonious Parish-pump attitudes. Nonetheless, while a new ethos of shared responsibility between the rich and poor seemed to be emerging, the impact

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of these reforms was inevitably felt in the ‘ratepayers’ pocket’ – spawning a keener interest in poor law expenditure from this time.98 As a result, expensive reforms after 1867 became less popular; a reaction explored in Part Two of this book. Yet, there is no doubt that the Metropolitan Act had changed the course of medical welfare in London. Negligence had been used to grab the public’s attention. Furthermore, it led to effective agitation from a united public sphere in London that had sought better standards of care.

Post-1867: ‘A disastrous and ludicrous failure’ After the success of the Metropolitan Act, medical officers, for a time, sought dramatic reform of the national system of ‘State medicine’ that went beyond salary increases. The PLMOA became ambitious under Rogers. They agitated the Poor Law Board and Parliament for a national hospital and dispensary system – that was not unlike a crude form of the NHS – modelled on London and Ireland. This went far beyond the motivations of their poor law employers and the wishes of local ratepayers. As Part Two will demonstrate, their objectives were political dynamite, but destined to implode in an English nation that became increasingly hostile to rising welfare costs. By seeking to prevent the spread of disease, medical officers had also entered the domain of public health, which was a central plank of their reform agenda until the mid-1870s. Ultimately – and detrimentally – public health was phased out of the role of medical officers in Rogers’ greatest strategic error. From the late 1860s, the BMA and medical profession together with some public and political reformers were pushing for a complete overhaul of the sanitary laws of England and Wales.99 The culmination of this was the Public Health (or Medical Officer of Health) Act 1872, which made it compulsory for all sanitary districts to appoint a Medical Officer of Health, and the Public Health Act of 1875, which largely re-articulated the proviso of the previous Public Health Act. Several bills preceded the Public Health Acts and, until shortly before the 1875 Act, medical officers were a key part of the public health bill. Consequently, Rogers wrote a regular feature for the BMJ, entitled ‘Public Health and Poor-Law Medical Services.’100 After 1875, the bifurcation of Poor Law and Public Health was part of a steady decline in the fortunes of medical officers. Unofficially, they continued to perform public health duties en masse – but in addition to their poor law job. Before 1875, the natural course had seemed an amalgamation of public health duties and poor law medicine – and many medical officers were receptive to this idea. The PLMOA proposed that there should be a system whereby ambitious medical officers could rise up through the ranks to Medical Officer of Health, going on to become inspectors and chief inspectors. In the event, the famous public health acts of 1872 and 1875 did not insist on more medically trained inspectors at the centre of health governance. A general inspector, Herbert Preston-Thomas, observed that staffing was ‘flagrantly inadequate, as there were not enough medical inspectors to visit more than about 3 per cent of the sanitary districts of England annually, and

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thus the supervision was so slight as to be futile’.101 Most of the PLMOA’s objectives of 1870 recognized the importance of public health to an efficient State medical service. At this time, medical officers proposed that: 1. ‘… medical relief and the sanitary care of the poorer classes, with which the registration of disease is indissolubly connected, are questions which ought not to be treated independently of each other, and that they require to be settled on improved principles by a connected and consistent scheme of legislation’; 2. A national system of district dispensaries was needed urgently; 3. Statutory regulation should enforce a ‘uniform basis’ for district sizes and the salaries of medical officers – with ‘no local exemptions being permitted’; 4. The terms of medical officers’ employment (e.g. tenure, qualifications and duties) should be officially regulated through a code; 5. A general registration of disease should be created, whereby all ‘new cases of sickness coming under treatment at public cost, in workhouses or in public and charitable institutions’ are completed in a ‘uniform system’ of ‘nomenclature’; to be returned each week – or more often ‘in times of pestilence’ – and that medical officers be ‘fairly remunerated’ for the additional work; 6. Consequently, those ‘returns of disease’ be collected and compiled, and forwarded at ‘stated intervals to the central authority’ by a ‘registration medical officer’; 7. Poor law medical officers ‘act as deputy health officers’ to perform ‘preventative duties’ – paid on a scale determined by the central authorities; 8. Medical and sanitary care of the poor in districts and workhouses should be periodically inspected ‘to rectify and prevent abuses’ – the inspections carried out by either ‘chief officers of health debarred from private practice’ or by medical inspectors under central authority, or by both; 9. All of the above is embodied in public health legislation.102

In the end, nearly all of those aims were withdrawn. The PLMOA insisted that the proposed joint poor law/public health medical officer role was dropped from the final public health bill. The poor law medical officers’ official role in public health ceased.103 In the main, this had been motivated by fears that further involvement would give an impression to a cynical central Board that medical officers could shoulder a greater workload. It was a risk no one wanted to take. Rogers’ selfdefeating achievement at Parliament was to successfully establish that medical officers could not take on increased responsibilities. The Poor Law Board’s assistant secretary wrote desultorily that the final public health bill made ‘no reference to the medical officers’.104 Yet, it is worth noting that there would have been substantially more charges of negligence against medical officers in this period had they remained the lynchpin of both public health and poor law reform. Rogers described a well-founded anxiety that the perpetrators of public health crimes – industrial polluters and landowners of unsanitary slums – were, in fact, often guardians, themselves:

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I saw it would not work, as medical officers would hesitate in affronting their Board of Guardians, many members of which would be found to be the principal offenders against the contemplated Act, and that in the few cases where the parish officers would faithfully carry out the requirements, and thereby offend their respective Boards, they would be sacrificed to the resentment of their members, and if appeal was made for support to the Central Department, such honest men would be called on to resign for not exhibiting sufficient courtesy, &c., and working with their Boards.105

In this respect, history has exonerated Rogers’ decision.106 A decade later, Hart (as Chairman of the BMA’s legislative division) was proposing radical changes to local governance. The medical officers of health were, to him, representative of the localized failures and wastage in public health policy: ‘Officers have been dismissed for speaking their minds with truth and freedom as to the sanitary evils they found around them … .’ In turn, said Hart, their lives were ‘made so intolerable’ that – like the unsatisfied medical officers of the poor law – ‘there was no course open to them but resignation’.107 Just as the poor law medical officers had fought to halt the ‘tyranny’ of annual contests for contract renewal, medical officers of health faced the same uphill battle.108 Hart opined that it had become the ‘fashion for local authorities to re-elect their officers only on the condition of their accepting a diminution of pay’.109 They were part-time, too, so the ‘perpetual conflict between private interest and public duty’ impeded any momentum for change.110 For Rogers, the first years of public health were a ‘disastrous and ludicrous failure’.111 For the national dispensary system he desired – to emulate those of Ireland and London – this turn of events signalled inevitable defeat. Without their official participation in public health, the PLMOA could no longer be effectively involved in public health reform. Moreover, Rogers said the demotion of public health, which lost out to a strengthened poor law administration, was a ‘most disastrous act of policy’. According to him, it ‘subordinated’ public health under the poor law department, ‘who had always been obstructive, and had neither carried out, nor permitted anyone else to carry out, any reform whatever’.112 Rogers was a New Liberal and he celebrated the small successes that Sir John Simon (Chief Medical Officer) had made with public health. Rogers’ ‘new’ liberalist outlook embraced the ability of the State to bring positive improvements where liberal determinism was left wanting.113 When he accompanied the first deputation of the PLMOA to the LGB president, he was therefore appalled to see the public health department and Simon delegated ‘to distant seats in the room’ – adding, that they ‘were the only intellectual element of the new Board’.114 One general inspector of the time was later to write that Stansfield, the first LGB president, was blind to the health, economic and social gains to be had in public health prophylactic measures.115 Put succinctly, the LGB was English liberalism writ large, and set on reducing State expenditure. They had more powers than the Poor Law Board, but their role was to facilitate the balance of localism over centralization and ensure value for taxpayers’ money. They sought to provide a centrally organized system of ‘guidance’ – a Victorian political system that was typically permissive, but with

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a subtly coercive power to ‘nudge’ guardians towards their policies. Given this mandate, the medical officers’ next battle was ill-timed. Concomitant to their back-pedal from public health, medical officers focused on reforming their pension rights. The PLMOA’s petitions to Parliament portrayed an ageing and jealous medical officer population: ‘Many aged and infirm persons now feebly hold on to office simply from having no other means of subsistence … many aged officers quite unfit for the work still clung to office, because they had no alternative but starvation.’116 In 1870, the Association sent an MP, Dr Brady, to Parliament with a bill to gain pension rights for medical officers of the poor law.117 Once again, it was ‘negligence’ that forced the poor law’s hand: without superannuation provision, many medical practitioners were clinging to poor law appointments long after they were capable of carrying out their duties. Brady argued to Parliament that medical officers were forced to work beyond a reasonable age, which caused unnecessary age-related medical mishaps. A comparison of the regulations of the poor law, contemporary debates and the time frame of Brady’s Bill, indicates that a greater number of medical officers than normal were beyond or approaching retirement age in the early 1870s.118 The ‘superannuation’ issue had been raised on several occasions from 1850, when it ‘was accounted worthy of the consideration of the Poor-law Board itself, which framed a bill for the purpose, but subsequently abandoned it’.119 The bill sought the sanction of Parliament to obtain a contribution from medical officers’ salaries towards their superannuation. Again, it was the doctors themselves that prevented progress: some argued that their salaries were not high enough to provide a contribution, while others recognized the need to contribute. Division stymied the bill’s advance and ultimately led to defeat. Subsequent attempts were also blocked because medical officers were deemed ineligible to come under the Superannuation (Union Officers) Act of 1864, because of the part-time nature of their work.120 Rogers argued: ‘Now, and admitting fully that such is the case, I would submit – 1st, whether the salaries are based upon the supposition that they do [work part-time]? – 2ndly, I would ask at what period of the day or night is the medical officer considered off duty?’121 The second point was particularly persuasive, the claims and certification procedure meant that legally a poor law doctor was, to use the modern idiom, ‘on call’, twentyfour hours a day for all seven days of the week. The image of an ageing and negligent doctor underpinned the bill’s success. Rogers celebrated its safe passage to an Act in 1870, but it was a hollow victory. When Parliament enacted the Medical Officers’ Superannuation Act in 1870, it was – as with most acts, orders and circulars regarding poor law medical welfare – optional. The result was that some unions continued to refuse superannuation to officers and others bestowed lavish pensions on favoured medical officers. The failings of the 1870 Superannuation Act were akin to other diluted reforms. Within three years of the Act, Rogers described his frustration: ‘… although they had congratulated themselves that the Act passed last session, it was eminently unsatisfactory. Its opponents succeeded in throwing the whole cost of superannuation on local funds, which, with its permissive character, had rendered the measure a farce in many rural unions and country towns’.122 Nevertheless, the act had allowed unions to give superannuation,

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when previously the Poor Law Board’s regulations had disapproved it. In 1880, Rogers pressed his brother, a professor and MP for Southwark, to gather statistics from Parliament about the granting and refusal of superannuation. The return showed that from 122 applications, seventy were granted and fifty refused (leaving two unaccounted). Not all unions responded, and therefore this is probably not an entire cohort of English and Welsh unions, but it provides an indicative estimate. Roughly half the unions gave superannuation and half did not.123 Despite the passing of the permissive Superannuation Act in 1870, the BMJ was littered with articles and features describing unions who had refused to pension off a medical officer after thirty or forty years of service.124 Some of those may have been forced to resign as an alternative to an expensive pension or as a result of age-related negligent practice. This seems to be reflected in the records of poor law employees held in the United Kingdom’s National Archives. According to the central records for England and Wales, just over 2,000 workhouse medical officers were employed under the poor law between 1834 and 1899.125 Almost one-quarter of those died while still in employment. Officially, 43 per cent of workhouse medical officers who were disciplined (for any reason) voluntarily resigned. Comparatively, 54 per cent of those that were never disciplined during their career voluntarily resigned. This may be an indication that some of the latter group were, in effect, pushed – concealing a number of coerced resignations. Those that died in the job also dropped – from 24 per cent of those without disciplinary notes to 19 per cent of workhouse medical officers who had some type of disciplinary proceeding on their record. Perhaps some of the disciplined doctors were pushed into a resignation before they were old enough to ‘die’ in the job. The contrasts, here, may suggest that some of those disciplined were forced to resign without receiving recognition or superannuation. The figures may also conceal the counter-strategies of some doctors. Most medical officers were in private practice. Many would pass their practice on to their sons, and perhaps some of these were aware of the charges of negligence that dogged the profession. Effective nepotism meant retaining a good local rapport and reputation; therefore, charges of negligence (and also slander and libel) were best avoided. Digby studied the economics of general practice at this time, observing that poor law posts were an important element of their ‘pluralist’ work-life. A general practitioner sought to monopolize a territory and ensure the security of their private practice.126 Sometimes it was safer, and perhaps less costly, to resign voluntarily if the practice remained in family hands. For the rest of his life, Rogers and the PLMOA protested to Parliament for compulsory pension rights. This was finally achieved in 1896 when pension rights were given to all officers of the poor law.127 The funds were allocated from a combination of medical officers’ contributions – the very thing that medical officers had refused thirty years before – and a centrally monitored fund. The establishment of this act brought great benefits to the system, inter alia preventing medical harm caused by medical officers who were working when they were clearly incapable. The Act had further gains at this time because it coincided with contemporary scientific advances. By the late 1890s, medical science was finally fulfilling its promise. Bacteriology and its antecedents had displaced miasma, heralding a new era of

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medicine. There were developments in pharmacy, technology and treatment that may have been beyond the capabilities of ageing medical practitioners, who had settled into the accepted but outdated (and questionable) medical practice of just twenty years before. The late nineteenth century, then, had heralded a reversal in the reformers’ fortunes. By the end of 1877, the Council of the PLMOA announced their objectives, drastically reduced (from their bold list in 1870) to a meagre list of three: the continued agitation for compulsory superannuation for doctors; the adoption of the dispensary system ‘in all large towns and rural districts’ where possible; and the promotion of medical officers’ interests – ‘defending, if necessary legally or otherwise, its members against oppression on the part of the authorities’. The first and second objectives were unsuccessful. Despite a few regional successes, the dispensary system was not nationally implemented in the Victorian period. The third goal has been overlooked by historians, but it is critical to explaining negligence under the new poor law. The poor law was archetypical of a health care environment riddled with hazards, failures and latent conditions. After the 1867 Metropolitan Act, medical officers were in an ever-more strained relationship with their employers and held responsible for negligent conditions beyond their control. Charges of negligence against them rose in the 1870s, but the reasons for this can be linked with the expanding fault lines in poor law medicine at this time. Chapter 4 will therefore define the legal apparatus used for investigating and managing an incident of neglect under the Victorian poor law – and examine the questionable motives that led to heightened numbers of medical officers charged with negligence or neglect of duty.

4

Controversies: The Poor Law of Negligence

Background In spite of the laissez-faire characterization of the poor law by historians, the permanent staff had broadened their power base and increased their number by the late-Victorian period. After the demise of the Poor Law Commissioners in 1847, the poor law was run almost entirely by permanent officials. Under the Poor Law Board, assistant commissioners were rebranded poor law inspectors, but little changed in the bureaucratic structure of managing the poor laws. Most historians are in agreement that the Poor Law Board ‘lacked a guiding hand’.1 Presidents of the poor law were too temporary in nature to create a major impact or lasting impression. Furthermore, there was no actual board that met to appraise and administrate the developing complexities of a diverse poor law system. Instead, the ‘remarkably long-serving’ clerks, inspectors and secretaries dominated the centralized aspects of governing the poor law. 2 The LGB absorbed the poor law department in 1871, but the new, more powerful Board lacked an effective mandate. The economic historian, Christine Bellamy, argues that after the first ten years, it had become a tool of the ‘treasury’ in all but name. It was forced to mediate the ‘demands of the local government system on rate payers, the money markets and the exchequer’.3 The LGB had the difficult task of stimulating local administrative growth at the same time as it was also obliged to control expenditure.4 According to Bellamy, the LGB’s growth was thus inhibited, not only by the inevitable clashes with local authorities, but also by the ‘quasijudicial culture of the Local Government Board, its paternalistic attitude [and] its detachment from professional networks … ’.5 Such tensions ensured that public health and medicine were relegated beneath broader concerns of constricting expenditure. Senior medical inspectors, such as Simon, were therefore restricted in their actions. Indeed, the LGB’s poor law inspectorate remained largely composed of non-medical gentleman and men from a socially elite background. As Crowther suggests, ‘Their social status made it difficult for them to understand the problems of workhouse officers’.6 Despite this social barrier to comprehending the daily challenges of a medical officer’s life (or indeed those of a sick and pauperized person), it was the inspectors who defined – more than any other body of centralized governance – the form that poor law relief would take in the late-Victorian period. As the previous chapters

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have demonstrated, the different motivations of permanent officials and medical practitioners placed them at odds with each other. They were therefore frequently in opposing camps for reform. This chapter will argue that, in terms of arbitrating cases of negligence, the adversarial nature of that relationship had an overbearing and negative effect on the outcomes of official inquiries into medical negligence. In turn, this had a significant impact on the practice of medicine under the poor law.

The inspectorate Historians often refer to poor law inspectors, but generally this is done with ephemeral citation and, almost always, with little or no empirical research. Arguably, this has been due to the developmental historiography of the poor laws. Theoretical, political and philosophical approaches to writing the history of the poor laws dominated the literature of historians working in the twentieth century, with good reason – the workhouse system was, after all, one of British welfare’s most controversial ideological experiments. Historically, it also remains Britain’s longestrunning legislative structure for providing aid to the destitute and sick. As such, there has been a trend to explain the treatment and management of pauperism in terms of its political, social and cultural significance to the history of welfare in Britain.7 With equally persuasive reasoning, the same historiographical tides have pushed historians away from the ‘cult of personality’, in order to avoid the superficiality of Whig-type narratives that portrayed an overly positive march of progress. Unfortunately, the resultant residual history has been dehydrated, missing the lifeblood of the lateVictorian poor law: the inspectorate. Crowther has written more about these men (there were no female poor law inspectors in the Victorian period) than most, but underestimated the effects of their individual personalities and beliefs. Perhaps this was because Crowther did not engage with the crusade against outdoor relief, discussed in Part Two. With the exception of Hurren’s research, poor law historians have overlooked and disregarded the extent of the inspectorate’s influence during the crusade years.8 Such a recasting of the late-Victorian poor law has discounted their considerable influence on national and regional policy after 1871. As a result, there has been limited explanatory research into who these inspectors were, what they did before their appointment, their politics, their views, or their associations and allegiances – all of which would be beneficial in exploring national and regional policy implementation. In short, it is remarkable that the vast literature on the English poor laws contains relatively little about them. The historian, Jeanne Le Brand, has written extensively about the medical services of the poor law, but made only superficial reference to the inspectorate. In common with most poor law historians, Le Brand concluded that they were too small in number and, as such, largely ineffectual: ‘With a more adequate professional inspection service the quality of medical care provided to the poor under these over-all regulations might have been better.’9 In spite of Le Brand’s lament, a greater number of general inspectors would have been no guarantee of raised standards of

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medical relief. Undoubtedly, their number and powers were limited, but it is wrong to assume that there was a desire at the centre of poor law bureaucracy to raise standards in a humanitarian form that is agreeable to us today (or was desired by many Victorian social critics, such as Hart). In contrast, while the LGB may have outwardly pushed for raised standards, their goals were skewed towards efficient management; which was not necessarily the same as better medical care. The internal priority of the LGB inspectorate was effective economic management of the poor laws. Thus, the desire for humanitarian reform of some medical officers aligned them with the best intentions of the LGB, but also brought them into conflict with the inspectorates’ need for pecuniary reforms in welfare provision. The inspectorate, as a body, was not looking at progress in the same way as reformers, such as Rogers or the Wakleys. Furthermore, the LGB took an altogether different view of medical welfare management to the PLMOA’s objectives, described in the preceding chapter. Although they carried out an extraordinary number of official inquiries, conferences and inspections, the LGB’s poor law department were seeking efficient administration of the medical services. This boiled down to micro-management of the economic dimensions, with an approach that was set against raising expenditure on medical care. The expensive but humanitarian reforms achieved in London’s Metropolitan Poor Act of 1867, were therefore in stark contrast to the LGB’s national cost-saving measures after this. Instead of rolling out similar legislation for the nation, the inspectorate played a key role in the subsequent crusade against outdoor relief, discussed in the next chapter, which overtly limited expenditure on poor law medical services. Standards of care were generally a priority only when entwined with matters of cost-saving and efficiency. As such, there were fifteen general inspectors for the provinces (Tables 4.1 and 4.2), supported by assistant inspectors and a large number of clerks and legal advisors. This was a threadbare provision of medical authority and expertise across England and Wales. Despite the obvious importance of medical inspectors to regulating standards of care, there were almost no inspectors trained in medicine: ‘a small attempt’ at medical inspection was made in 1865, with the appointment of Dr Edward Smith as a poor law inspector ‘with special reference to medical relief ’.10 However, in 1872, Smith’s office was abolished. During his tenure, Smith gained notoriety among medical officers and reformers for his lack of accomplishment. Furthermore, what little success he did have was largely confined to London. Medical professionals were therefore unimpressed with the situation. A Lancet editorial, for example, was scathing of Smith and a temporarily employed medical inspector (probably Markham). Both of them, it was argued, were ill-suited to their posts: ‘In their hands the profession has been like Paddy, when he was conveyed from place to place in the sedan that had no seat and no bottom. But for the name of the thing, he might as well have walked.’11 For a moment, at the end of the 1860s, there was a political will to place medical inspectors on a better footing, but it was stifled by the ever cost-conscious permanent officials. While a Poor Relief Bill was being passed in the House of Lords, in 1868, members of both Houses had vocally pronounced the need for the bill to include the provision of medical inspectors. Hart had presented the interests of a BMA

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Table 4.1 Inspectors and their respective districts in decennial periods, 1846–1876 District

1846

1856

1866

1876

1

vacant

R. Hall

H.B. Farnall

R. Hedley and Dr Bridges

2

R. Hall

G.G.W. Pigott

R.B. Cane

J.J. Henley

3

W.H.T. Hawley

R. Weale

R. Weale

W.A. Peel

4

vacant

Sir J. Walsham

Sir J. Walsham

H.B. Farnall

5

E. Carleton Tufnell

W.H.T. Hawley

W.H.T. Hawley

H.R. Courtenay

6

A. Austin

E. Gulson

E. Gulson

E.H. Wodehouse

7

Colonel Wade, C.B.

J. Manwaring

J. Manwaring

U. Corbett

8

Sir J. Walsham

A. Doyle

A. Doyle

A. Doyle

9

R. Weale

J.T. Graves

J.T. Graves

F.T. Longe

10

–

H.B. Farnall

W. Corbett

R.B. Cane

11

–

N.E. Hurst

N.E. Hurst

G. Calley

12

–

–

–

B. Fleming

13

–

–

–

–

14

–

–

–

–

15

–

–

–

–

Source: TNA Geographical Finding Aid

Table 4.2 Inspectors and their respective districts in decennial periods, 1886–1900 District

1886

1896

1900

1

R. Hedley and Dr Bridges and Major Lutley Jordan

H. Lockwood and H. Lockwood and Dr Downes and N. Herbert Dr Downes and N. Herbert

2

E.H. Wodehouse

J.S. Davy

3

J.J. Henley and H. Jenner-Fust T.L. Murray Browne

T.L. Murray Browne

4

W.A. Peel

J.W. Preston

J.W. Preston

5

H. Lockwood

H. Preston-Thomas

P.H. Bagenal

6

B. Fleming

B. Fleming

B. Fleming

7

H.R. Courtenay

H.R. Courtenay

H. Preston-Thomas

8

F.D. Longe

F.D. Longe

E.B. Wethered

9

R.I. Dansey

R.I. Dansey

R.I. Dansey

10

C.L. Dashwood

H. Stevens

H. Stevens

11

J.J. Henley and H. Stevens

H. Jenner-Fust

H. Jenner-Fust and W.M. Moorsom

12

J.S. Davy

H.G. Kennedy

H.G. Kennedy

13

W.E. Knollys

C.A. Dawson

C.A. Dawson

14

T.L. Murray Browne

F.T. Bircham

F.T. Bircham

15

F.T. Bircham

–

–

Source: TNA Geographical Finding Aid

J.S. Davy

Controversies: The Poor Law of Negligence

77

petition and a Select Committee endorsed their views.12 The only opposition came from the Poor Law president, who was ‘in a minority of one alone’ – as an indication of sentiment, the Pall Mall Gazette reported, of the ‘formidable obstructiveness of the department’.13 Despite both Houses agreeing to a resolution for medically trained inspectors, it was reported that they were misled into passing a bill that included no statutory requirement for this to happen. The permanent staff were blamed and criticized for their ability to satiate public opinion by ‘seeming to grant something, while in reality it leaves the status quo untouched’.14 Instead, the Pall Mall Gazette wrote with Rumsfeldian eloquence that general inspectors were to seek advice from a list of recognized medical practitioners: In other words, the gentlemen who have proved that they could not see in years what medical eyes have seen at the first glance, are, by an official inspiration, to know when they cannot see what they ought, and what it is that they have not seen; and by this mysterious intuition to take ‘when necessary’ counsel upon matters as to the existence of which they have already proved themselves utterly blind.15

Unsurprisingly, there were periodic questions as to the power, motives and background of general inspectors. With an understandable sense of persecution, the Lancet (1869) said that the ‘perversity’ of ‘appointing barristers rather than medical men shows the deep hatred to the profession which has existed at the Poor Law Board’.16 Whether ‘perverse’ or not, the approach did not alter significantly during the Victorian years of the LGB. In 1895, a medical officer wrote to the BMJ, and asked if inspectors were required to have medical knowledge (or training), ‘sanitary skill’ or if they had training or experience in medical welfare implementation. The BMJ’s answer was emphatic: ‘They acquire their knowledge as assistants. The President of the Local Government Board stated in the House of Commons that special knowledge in medical and sanitary matters was not considered by him to be essential!’17 In the same year, Hart wrote that, without medical inspectors, publicity was the only way to protect paupers from the worst aspects of workhouse care.18 Nevertheless, highly paid medical experts were not a priority for the LGB’s poor law department. It was opposed to any expansion of the medical services that warranted financial investment. Given John Simon’s antipathy to the general inspectors, it is not unreasonable to assume that further medical authority could also have been perceived as a threat to the cost-cutting goals of the poor law department. Besides, Simon’s medical department consisted of experts in public health and medicine, who could be called on for free. On the whole, when medical professionals were necessary for the complicated and quasi-medico-legal investigations of official inquiries (discussed below), doctors were drafted in from the LGB’s medical department. These were disease and sanitary experts more experienced in ‘public-health’ inquiries and reports – with experience in neither poor law medical practice nor medical jurisprudence. The public health historian, Roy Macleod, discussed the medical department of the LGB and its

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occasional overlapping duties of public health and poor law medicine.19 In common with most historians, he concluded that there were two medical poor law inspectors: one for London and one for the provinces. However, even this minimalist medical expertise has been commonly overstated. It was not until the 1890s that two ‘medical inspectors for poor law purposes’ were named (A. H. Downes and A. Fuller), and both of those posts were subordinate to the general inspectors. At best, the medical expertise of the Victorian poor law hinged on one doctor for London and another drafted in from time-to-time for the provinces. The most effective and ubiquitous of those was Dr F. J. Mouat. Tellingly, his tenure spanned the crucial years of the crusade. Though initially employed as part of Simon’s medical department, he attended more official inquiries into poor law medical negligence than any other medical professional at the LGB. Even so, Mouat rarely carried out an official inquiry without one of the district inspectors, who were the figure of authority for their region.

Regional inspectors The sliding rule of poor law policy – the verisimilitude of legislation’s interpretation in local practice – was relatively malleable in the hands of a poor law (district) inspector.20 The poor law historian, Derek Fraser, noted the regional aspect to inspectors’ policy implementation, and concluded individual personalities were to a large degree responsible: ‘As with the factory inspectorate, much depended on the personality of the individual inspector.’21 Undeniably, the intermediate role of the inspectors – detailed in the next chapter – was crucial to poor law policy implementation. In spite of its clear importance, though, there has been little research into the passage of political ideas from inspector to union. Fraser was conservative in his appraisal: ‘the weight of opinion indicates a failure at the macro level of policy. On the other hand, at the micro level of petty regulation the central authority was much more successful.’22 Nonetheless, at the fundamental level of policy creation, inspectors had direct access to Parliament through the Poor Law president, who was a member of Cabinet. They could thus be influential on the direction of central objectives. Furthermore, Part Two of this book will demonstrate that the effects of that influence and ‘petty regulations’ have been grossly underestimated by historians. On a micro level, they played a critical ‘bridging’ role between Board policy and practice in the unions.23 In contrast to the traditional image of an impotent central authority, Hurren also concluded that individual personalities – both that of inspectors and guardians – were instrumental in the regional implementation of the crusade.24 Yet, most historians agree that there were limitations to their role (such as the constraints of limited legal powers and those of time and travel). In order to appreciate this aspect, Tables 4.1 and 4.2 provide the name of each inspector and their respective district number, which links with the maps in Figure 4.1. The beginning and end year for each inspector is not precise because of the decennial nature of the collected data – for example, R. B. Cane ceased

Controversies: The Poor Law of Negligence

3

79

11

10

6 8

7 7

1

7

3

8

9

3

8

4

9 2

2

4

6

5

5

4

1846

1

5

1856

11

11

10

10 8

8

7 3 9

4

2

9

2

1

1

5

6

5

1866

4

3

8

5

6

12

7

8

3

5

1876

13

14

13 11

11

11

12

14

14

12 12

10

9

10

9 5

15

7

5

4

8

3

14

7

6

1886

1896

Figure 4.1 Inspectors’ districts by decennial period Source: TNA Geographical Finding Aid

3

1

2

6

4

8

1

2

6 6

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Medical Negligence in Victorian Britain

employment somewhere between 1876 and 1886. Nonetheless, the information provides useful insights. The size of districts is readily apparent. Figure 4.1 clearly shows that their districts were too large for a single inspector to visit every union in his district with any regularity. Thus, many unions would have gone for long periods of time without seeing an inspector – a notable hindrance to central policy implementation, discussed below. Moreover, before the 1870s, inspectors had no longevity, with the majority employed for about ten years or less. From 1846 to 1886, there was an incremental increase of the inspectors, after which they were employed for a longer duration. Only at the end of the Victorian period did most of the inspectors continue in office. Furthermore, it seems that the hard-line crusaders, Henley, Longe and Fleming (together with Cane whose retirement came earlier than the others), were essentially the permanently retained staff at this time. The trend could have lessened the influence of the crusade in certain regions, where inspectors were less attentive, or increased its overall impact by endowing the enthusiastically crusading inspectors with seniority. In either case, the piecemeal regional policy resulted in a contrastive nationwide pattern, composed of the subtly metamorphosed unions (most likely to slip under the radar of poor law historians) to those who had openly rejected or embraced it. The hyperactivity of the 1870s is also visible in the extensive reconfiguration of districts at this time, shown in Figure 4.1. Wales became one gargantuan district, this time with parts of her border counties – Monmouthshire, Radnorshire and Montgomeryshire – partitioned into Districts 7 and 9. The large size of the Welsh unions was part of this reasoning, feeding into the district’s scale and indicating some idiomatic reasons for negligent practice in Wales (explained in Chapter 7). Furthermore, almost every English poor law district was altered at this time, from the Marches up to Cheshire and from Kent up through the Midlands. Perhaps the most important district changes occurred in the north, where three distinct districts (numbers 10–12) of relatively equal geographic size were created. Added together, Districts 10–12 are just under one-third of the land mass of England and Wales. Until 1896, there is an apparent chaotic switching about of inspectors from one district to another. This may have occurred with more frequency when the years between the decennial catchments are considered. Although much of this reflects their rushed existence, the discussion of the crusade in the next chapter will explain why some inspectors, in particular, moved to certain regions and were particularly busy in the 1870s. There was one exception: as described in the preceding chapter, Farnall was moved from London as a ‘punishment’ for his role in the Metropolitan infirmary reform movement that preceded the Metropolitan Poor Act (1867). Anne Digby also said that ‘the troublesome’ Farnall was ‘exiled’ to the ‘geographical remoteness’ of the Eastern Counties’.25 Rogers mistakenly claimed that it was to a ‘northern district’ and that the distance from Farnall’s family caused him ‘hardship’. Yet, he had formerly been the inspector for District 10 – Yorkshire West Riding and Lancashire (see 1856); he then moved to District 1 – London, which is apparent in the map for 1866, before moving to District 4 – East Anglia and part of Kent in the late 1860s. Although his removal from London was undoubtedly to undermine

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and punish him, his relocation seems not untypical for an inspector in the pre1870s administration of the poor law. The switching of inspectors tends to reflect the somewhat frantic and chaotic nature of their overextended routines. The lack of continuity and the apparent absence of an effective organizational direction, seen in Figure 4.1, perhaps reflected an unsettled political turbulence – a poor law affected by the swings between Liberal and Tory governance. The apparent slapdash mode of administration reflects their peripatetic lives, but belies a growing bureaucratic efficiency and power in the 1870s. Nonetheless, in many ways, theirs was less of a systematic approach and more an exercise in bespoke damage limitation (attending to individual union matters where and when it was needed). They communicated with each other by using hastily scribbled annotations and notes, which are today visible in the borders and reverse-sides of extant correspondence and inquiry documentation (held in the National Archives). The sheer density of those notes – with questions, replies and annotated commentary – implies that this was a common mode of communication between Board inspectors and officials. Thus, Crowther surmised that permanent officials ‘responded fitfully to pressure from charities, from progressive guardians, and from public opinion’.26 This seems to have been the case at the high point of ‘crusading’ in the 1870s, when the inspectorate focused their energy on the regions that were the most ‘lax’ and indiscriminate in their administering of outdoor relief and medical services. For example, in 1876, the hawkish Fleming was administrating District 12 – Yorkshire West Riding, Lincolnshire and Nottinghamshire – but within a year he was the inspector for District 6 – Dorset, Wiltshire, Hampshire and the Isle of Wight – where he remained until at least 1900; R. B. Cane was District 2’s inspector in 1866 – Buckinghamshire, Oxfordshire, Berkshire, Surrey, Sussex, Kent and Middlesex – before moving to District 10 – Cumberland, Westmorland, Lancashire, Derbyshire and part of Yorkshire West Riding. Between 1846 and 1900, at least eighteen of the inspectors were moved up and down the country in an animated mosaic of altering districts. Arguably, this could have been a knee-jerk reaction to contemporary regional problems; sending their ‘best’ men to regional hotspots, as and when they appeared. Perhaps as a further indication of the inspectorate’s interest in the crusade, three new districts were created in 1886, and there were also four promotions from the assistant inspectors of the decade before. T. L. Murray Browne, R. I. Dansey, J. S. Davy and F. T. Bircham became general inspectors in the 1880s, and all four were still inspectors at the turn of the century. However, the majority of nineteenthcentury inspectors were not trained ‘in-house’ – only between 1886 and 1896 was there a stabilizing of the districts and consistent inspector allocations. Moreover, in the same time frame, there were only subtle changes to a few districts. Wales was changed, returning to a single Welsh district running along the border with England – with only part of Montgomeryshire in another (English) district. The Lancashire-centred north-west district was expanded to include Cumberland and Westmorland. After 1896, almost all districts remained the same until the end of the period.

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Medical Negligence in Victorian Britain

To return to the problems of policy, noted above, the maps in Figure 4.1 also demonstrate that the challenging geographical extent of most districts continued unabated throughout the Victorian period. They clearly show that almost every district was consistently of a scale beyond the capabilities of any single inspector. At a time when the train was barely beginning to snake across the country, when travel by foot, horse or carriage was the main way to get from place to place, these maps conclusively show that the inspectorate were vastly overstretched. It is a wonder that inspectors were able to visit each union with any regularity. Writing of the 1890s, when the inspectorate had reached the height of its numbers, and travel was much improved from previous decades, Inspector Preston-Thomas bemoaned the size of his district and described the frustration: ‘Of the ordinary inmates of workhouses it is difficult to get any intimate knowledge in visits which rarely take place more than two or three times a-year. The Inspector is naturally more or less of a stranger to them.’27 Before that time, it was more difficult to travel and – the further you go back – inspectors were less in number. How did they manage to traverse the mountains of Wales or the moors of the north and south-west of England? Their job must have been largely seasonal, having to avoid inclement or severe weather conditions.28 Perhaps that is why the south-west and north-east of England were neglected in comparison to other regions where they had more of a presence. As Chapter 6 will show, the wellpublicized whistle-blowing of a nurse at Newton Abbott Union’s workhouse revealed that in the final years of the Victorian era there remained negligent care and lack of advancement in the south-west. In 1896, when Preston-Thomas succeeded Courtenay as inspector for the Western District (Somerset, Devon and Cornwall), it was a backwater of poor law development. According to Preston-Thomas, ‘… no means had previously been taken to let the Guardians know the badness of their administration or the extent of their pauperism’.29 Interestingly, he argued that there was a great problem of pauperism in south-west England, owing to the region’s population demographic, which contained a relatively large amount of the aged poor. He claimed that there were seventythree in a thousand people over the age of 65, which compared unfavourably with ‘manufacturing’ districts, such as Lancashire, with thirty-three in a thousand.30 In turn, this contrasts with the charges of negligence against doctors, which were much more frequent in the north-west than the south-west of England (indicated in Figure 5.1). Furthermore, Preston-Thomas said that, in his experience, the workhouses of the south-west were of a lower standard than those of the Eastern Counties, and ‘the sick were generally lodged in old-fashioned and ill-ventilated wards, without the appliances which modern practice requires’.31 Until 1876, the south-west district had remained unaltered, making it the most geographically consistent district partition. The north-east of England was also relatively consistent in marking out its inspector’s jurisdiction over the course of the nineteenth century. Perhaps indicatively, those two districts were also the least active areas for official inquiries into medical negligence or workhouse administration. This agrees with opinions at the time.32 Arguably, then, the widespread charges of negligence against medical officers in other areas were indicative of something more than the implicit connotations of negligent practice.

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They mark places, not only of medical mishap, but also of an overt willingness to investigate and charge officers with negligence. Moreover, charged doctors may indicate places where the tensions between policy and practice were especially heightened. Certainly, during the 1870s (when the crusade peaked in its popularity), doctors found themselves the subject of official inquires more frequently in the northwest and a central swathe of England that spanned from the Midlands to the Welsh coastline (shown in Figure 5.1). Historically, the assumption has been to consider charges of medically oriented negligence under the new poor law as a common denominator of medical neglect and mishap; but measuring increased charges of negligence against medical officers will not necessarily serve as a barometer for low standards of care among unions and regions. As the next chapter will argue, the inspectors were actively pursuing a crusade agenda, which included extreme cuts to medical expenditure, and this interplay shaped the demography of charges of negligence against medical officers. For example, district redistribution on a large scale occurred again between 1876 and 1886, with concentration in the heavily industrialized regions in and around Lancashire and the Midlands, where the worst effects of economic depression had been experienced in the 1860s and 1870s.33 The consequent high levels of poverty may explain why Lancashire became a distinct district in the same decade that the crusade encouraged cuts in poor law relief outside of the workhouse – causing a widespread strain on medical services, discussed in the next chapter. Arguably, the formation of a single Lancashire administrative district would have aided the LGB to focus their efforts on a costly and rebellious region. As Steven King described, Lancashire guardians could be ‘difficult’: ‘Once created, Lancashire unions elected some of the most grudging and obstructive poor law guardians, who were those least likely to respond favourably, or at all, to central initiatives.’34 In spite of the harsh and tough stereotype of northern unions, the late nineteenth century saw a transition in some Lancashire unions. According to King, Bolton was a prime example of developments in some north-west unions at this time, from ‘reactionary, backward and spendthrift’ to ‘pace-setters’.35 In turn, this may indicate a further reason why Lancashire was attracting the attention of a ‘reactionary’, crusade-minded LGB after the 1870s. Moreover, scandals and publicly fought charges of negligence were an important element in shifting the opinions and political allegiances of fractious northern guardians, such as those at Bolton.36 King also observed, in this late nineteenth-century Lancashire transition, that a ‘new impetus was thrown into the melting pot in the form of coalitions of prominent local women who sought to extend their philanthropic and public roles into the area of social welfare’.37 Indeed, the north-west altered its course and was far ahead of the pack in raising standards of institutional care in the 1890s and reducing the region’s reliance on pauper nurses. It would be wrong, though, to assume that the inspectorate were behind the pathbreaking investment in nursing staff at this time. Chapter 6 will show that it was, once again, bad publicity, public pressure and public-spirited reportage that forced substantive change on a busy and distracted inspectorate. This section has shown how difficult it would have been for inspectors to impose policy on rebellious and disparate unions, which were clearly spread over a great

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distance within a vast inspectorate jurisdiction. Official inquiries were therefore a reason – an excuse – to make an unusually time-consuming and stringent examination of a union’s medical services and the guardians’ provision of medical relief. An inquiry could therefore be a powerful motor for change or an effective means to reel in overspending guardians and medical officers. It was an exceptional arena for conflicting ideological approaches to play out between administrators or for likeminded guardians and inspectors to crush an opposing officer’s will for unwelcome reforms. Official inquiries into negligence therefore had a great effect on the working lives of medical officers, but were perhaps less influential on the broad national thrust of poor law practice in the Victorian period. As such, inspectors and their official inquiries have received less attention from historians who, for the most part, have focused on the poor law’s political character. Crowther thus described the inspectorate as consistently conservative, ‘wedded to traditional solutions to pauperism’.38 This was true, but it underplays their active role in the crusade. A low medical standard was no indication of a ‘weak’ body of inspectors. The LGB did not fail to press for reform.39 Returning to Englander’s multiplicity of reformers, from 1871, inspectors pursued extreme measures in economizing welfare that set them at odds with the PLMOA’s objectives. As Part Two will discuss, the permanent staff were very effective in facilitating the spread of reforms embedded in the crusade. As such, medical inspectors were not a priority – legal expertise (which the LGB had in abundance) was the most valued vocation in the permanent officials and civil servants of the poor law.

Law and ethics for a doctor and medical officer With the arrival of the new poor law, the State had provided the means of mass corporate employment of doctors. Yet, it also provided a system that was heavily bureaucratic by Victorian standards, and not designed to be a health care system. As a result, it contrasts profoundly with the exponential growth in the legal protection afforded to doctors under the subsequent NHS.40 After the revolutionary changes to London’s health care provision in 1867, the poor laws were an opportunity for doctors to come under the wing of a major aspect of national health policy, and (ostensibly) ensure improved medical welfare. In spite of this, the LGB does not seem to have taken this course. The rules of 1871, written by William Golden Lumley, are the most explicit indication of the LGB’s intention, from that time, to stamp down on the medical officers’ association, which was growing into a counter-movement to their objectives (symbolized by the crusade). Lumley was one of the longest serving permanent officials of the poor law. He served from the early years of the new poor law until the 1870s as Assistant Secretary, after which he moved to Counsel. He may be characterized by a notable ambivalence towards the medical profession and their push for more influence, contextualized in Chapter 2. Arguably, Lumley was conservative in his ideas on paupers and the provision of medical services for them. Lumley’s tone of reference to medical officers is ambiguous to say the least. He was well versed in the successes

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of reformers in the 1860s, and the continued medical officers’ agitation for reforms in medical provision, conditions of employment and remuneration. Lumley was therefore keenly aware of the growing influence of Rogers’ reformed association at this time. According to Lumley, the medical profession was backed by ‘considerable political influence’ and there was an ‘energetic [and] intelligent association of medical officers earnestly engaged in furthering the interests of their order’.41 He pointed out that their association was supported by the press and that ‘much success [had] attended these various efforts’.42 Expanding medical power, knowledge and – albeit slowly – curative ability, were motivating the profession to have more influence on public life, including poor law administration. Lumley seems unimpressed, though; almost defensive. He pulled a few punches in the preface to the 1871 rules of employment, where he issued a stark warning: Men do not seek for that which they do not consider it to be for their advantage to possess. No one is compelled to be a medical officer. The salary and duties are clearly disclosed to every candidate before he obtains the office, and he ought to consider calmly and cautiously whether the remuneration is compensatory for the services; and if he accept the office he ought not complain if he finds he is mistaken. He should in that case take the earliest opportunity of retiring from his position.43

Though somewhat inflammatory and divisive, Lumley’s opening salvo is representative of the times. Chapter 2 argued that the rising status of the medical profession was in direct contrast to their lowly position in the poor law (reflected in their appallingly low remuneration). Negative attitudes to medicine at this time were largely – and somewhat justifiably – born of its ‘trade’ characteristics, questionable treatments and long history of charlatans, fakers and quacks.44 It was thus explained that, though doctors sought individually to claim a moral and ethical high ground, they struggled to escape the strictures and image of a trade. Moreover, a lack of convincing medical science underpinned a limited curative ability, which helped to sustain an ongoing ambivalence towards the medical profession. This underpinned the attitudes of many high-ranking poor law officials in both governmental and local administration, such as Lumley, who was also addressing the issue of their salaries and the ongoing conflicts over their status.45 Lumley issued a further warning: ‘[medical officers] are liable to be dismissed for incompetency or unfitness, or for disobedience of the orders of the commissioners, and must submit to the various consequences which attend upon dismissal’.46 In other words, ‘bite the bullet or else’. The rules of 1871 reflect the motives of a department whose prime directive was to make cutbacks in welfare expenditure. After 1871, it became all too easy to set the medical officers up as the nation’s ‘fall-guy’ wherever and whenever poor law medical ‘scandals’ and neglect occurred. As explained in the previous chapters, poor law doctors found it hard to unite and improve their position. The medical profession may have commanded the debates over the NHS in

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the early twentieth century, but, in the Victorian period, the LGB’s permanent staff of non-medically trained inspectors, clerics and lawyers dominated the ‘State doctor’. Historians have tended to note the broad political backdrop of their defeat, but the detail of their employment strictures was fundamental to the LGB’s domination of the medical officers’ counter-movement. The General Consolidated Order of 1847 (and its root in the statutes of the Poor Law Amendment Act of 1834) was the main legal device that underpinned contracts, and poor law legal proceedings, from its inception to the early twentieth century.47 The Medical Orders of the 1850s, described in Chapter 2, added to it by ‘allowing’ permanent contracts for medical officers. This dovetailed with the Medical Act of 1858, which provided the means for guardians to verify the credentials of doctors (Table 2.1).48 The part-time nature of medical officers, though, placed them in a difficult position with regard to their duties and obligations. Their contract differed from other poor law officers because they held a certain modicum of independence. As Lumley explained, ‘Hence, not being wholly dependent upon his employment, their engagement preserves for the most part the form of a contract.’49 The legal structure was thus described by Lumley as similar to the contracted obligations under the old poor law, when doctors had often been employed on a case-by-case basis. Legal proceedings under the poor law were thus based on an agreement made between governance (local and central) and an individual medical professional. In terms of the strict application of law, medical officers were disciplined by reference to their breached duties, which were part of their contractual obligations. Although the language of ‘tort’ (negligence) law is recognizable in inspectors’ judgements, it was usually adopted by them – somewhat misleadingly – to emotively describe a doctor’s neglect of a pauper. In contrast, investigations into negligence under the new poor law were akin to disciplinary (contract-based) tribunals. Proceedings were conducted by adherence to contract law, and enforced by the powers of the permanent poor law officials, which had been bestowed by statute in the Poor Law Amendment Act of 1834. This is interesting in the context of English law and international medical jurisprudence. Giesen describes the law of contract – widely adopted in Civil Law countries – as existing primarily to ‘vindicate an individual interest’, to enforce or compensate for an unfulfilled promise.50 This description also applies to the dominant use of contract law under the new poor law. Yet, scholars of English medical law, such as Mulcahy, have specified that contract law is rarely used in the context of modern State medicine in England because it is ‘an unwieldy regulatory tool and is not well suited to dealing with minor and moderate transgressions’.51 Medical jurisprudence under the English poor law therefore seems anomalous to the modern legal history narrative. Despite the apparent parallels with Civil Law, described in Chapter 1, the poor law was not based on a contract made between patient and doctor. Yet, it has a great deal in common with the ‘flirtation of malpractice law with contractual language and doctrine’ described by US historians, Kenneth De Ville and James Mohr, for midnineteenth-century North America.52 Nevertheless, it contrasts with this because the poor law was not a private agreement between doctor and patient. In this way it could be compared with France and, what Giesen calls, the ‘anachronistic immunity from

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liability’ in their public hospitals.53 There, the implied contract of English common law – between public patient and hospital-employed doctor – does not exist. A patient cannot bring an action against a doctor in the described French scenario, but it is also difficult to hold a hospital authority in France to account for the actions of a doctor. Similar to the poor law, it is normal for administrative tribunals to deal with negligence.54 Even so, there was a fundamental grey area in the poor law’s relationship with court actions that had stemmed from neglected paupers. Giesen conceded that national and social health care schemes were problematic in the sense that ‘arguably a contract is made’ when a patient registers with a health care provider.55 Giesen meant a tax- or insurance-based system, which would seem to discount paupers. Nevertheless, a similar controversy sits at the juncture of contract and tort law under the Victorian poor law. Moreover, there are familiar elements of modern negligence: obligation, duty, a right to be treated and the legal situation that arises from ‘want of skill and attention’.56 Although this would seem to eliminate paupers, Lorie Charlesworth, a legal scholar, has argued that there was a legal right to relief (including sickness) that predated the Victorian era and underpinned the poor laws.57 This claim has led to some considerable controversy among historians.58 As Peter King argues, there is danger in ‘conflating the existence of a legal ruling with the separate question of its operation, mediation, and enforcement in practice’.59 The vast bulk of archival evidence demonstrates that local variables consistently trumped statute under the new poor law. A legal right to relief would not have guaranteed its receipt on the ground. Paupers had to apply for it, and be appraised, before relief was given or refused. As such, defining need (culturally and legally) was at the hub of converging Victorian controversies in paupers’ rights, the process of assessment and contemporary efforts to inhibit the ambit of ‘needy’. Medicine fed into those complexities. Legal scholars have yet to fully engage with this subject in this period and, as such, is not clear what rights (if any) pauper patients held by ‘implication’ under the contract between LGB (through guardians, its local representatives) and doctor. Notional rights of State patients, their rising expectations (and those of their representatives) and vicarious liability may be surprising elements in the crossovers from poor law to court action. There were some rare moments when the negligence of a poor law doctor led to complaints and, in turn, to a court trial for gross negligence or manslaughter. These have been largely ignored by legal historians. English courts had recognized that a patient was legally covered by contract law when the contract was made by a third party on their behalf in 1862,60 but how this would have affected poor law patients remains unexplained. A notionally implicit right (as exists in most third-party contracts) would have been further complicated by the proviso of the Medical Relief (Disqualification Removal) Act of 1885. From then, people who were sick and poor (but not paupers) could be treated in a workhouse infirmary, retaining both their nonpauper status and voting rights.61 Certainly, the notion of a pauper’s (or a non-pauper patient’s) rights would be central to actions of negligence in the courts. Historians should consider the process for dealing with negligence under the poor law, though, as a contract. It was neither made between patient and doctor nor recognized as such by the law. Instead, negligence under the poor law was legally (but

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not socially and politically) defined by the employer’s right to exert certain obligations from the employee by reference to his contracted duties. Those obligations included duties that were aimed at treating and attending to the medical needs of the poor within the constraints of a contract. This did not mimic the duty of care that is implicit in the tort of negligence (and is prevalent in most countries today). There was no complex ‘medical’ appraisal of the desired ‘reasonable care’, discussed in Chapter 1 (nor a litigious linking of cause, injury and compensation). This was contract doctrine, seeking ‘skill and attention’. Inspectors were thus keen to ensure that a contract was binding – between them and a doctor – because it formed the basis of their legal powers. Their inquiries gave the air of a thorough investigation, but the way that the LGB used contract law implies that doctors’ fees, attendance and disobedience were their predominant concerns. Despite regular orders, circulars and (occasional) legislation throughout the nineteenth century, the contractual basis of official inquiry judgements continued and doctors bore the brunt of failings in poor law medical practice. In this context, whether or not a doctor was motivated by the ethics of beneficence (in his capacity as a professional doctor) was not legally relevant.62 A medical officer was, however, compelled by the law to attend to his contractual obligations to the poor law. It is clear that neither the LGB nor the medical profession was seeking or placating anything that resembles the patients’ rights that evolved from the mid-twentieth century in Britain. Medico-ethical considerations under the poor law can consequently be misleading if skewed by a modern notion of patients’ rights. Ethical considerations in medicine were centred on self-interested factors, not the patients’ rights-centred doctor/patient narrative we are familiar with today.63 Professionalization, ‘custom standard’ and intra-professional etiquette were what the medical practitioner sought in the nineteenth century. As the medical historian, Mary Fissell, has said, ‘from the Renaissance well into the nineteenth century, no ethics particular to medicine governed the patient-practitioner relationship in Europe and North America … medical interactions were largely structured by the rules of commercial interchange’.64 Medical professionals in the early- to mid-Victorian era were more concerned with the establishment of trust than philosophical precedents in ethics. Without that, there was no patient and therefore no business income.65 As such, the historian, Ivan Waddington, concluded that medical ethics, until the end of the nineteenth century, was not concerned with the doctor–patient relationship at all; it was primarily about doctor-to-doctor working relationships.66 The competitive, over-crowded medical market, described in Chapter 2, was the primary motive for this. Until the end of the nineteenth century, ethics – both within and outside of the poor law – was thus about formulating a framework for the division of labour and a code of ‘etiquette’ between working practitioners.67 The theoretical basis of medical law reflected the strong market values of medical practice. Medical ethics was thus described by The Medical Practitioners’ Legal Guide (1870) as ‘a code of etiquette, upon the due observance of which the profession most properly relies for the cultivation of a high tone of character among its members’.68 Most of that code constituted, or proposed, proper etiquette between

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medical practitioners in an increasingly jealous and territorial profession. Doctors were warned to avoid ‘officious intercourse in a case under the charge of another’ and ‘impeaching the professional skill or knowledge exhibited in the primary treatment of [a] case, though such treatment may have been unsuccessful’.69 Moreover – as Chapter 2 described – physicians were gentleman, those with social status, and they lorded over the rest of the medical profession. They could exercise authority over the diagnosis and dispensing of (more lowly) general practitioners – despite them holding dual qualifications as surgeons and apothecaries.70 Less senior doctors were advised to keep disputes in-house, away from public scrutiny, arbitrated by ‘higher’ members of the profession: ‘The adjudication should not be made public, but submissively acquiesced in and accepted con amore.’71 Notwithstanding a robust and widespread loyalty to the profession, there were regular public disputes and wrangles between medical practitioners over fees and practice jurisdictions in the nineteenth century.72 These were missed neither by the public nor by the poor law permanent staff. Indeed, the Poor Law Board demanded a much more egalitarian practice of medicine than was the norm for the times or was expected between the lowly medical officer and his higher-ranking poor law employers. From 1849, special rules were created for the employment and regulation of medical officers: Considerations of professional etiquette must not interfere with his official duties. If a physician be called in, and direct the discontinuance of the Medical Officer’s medicines, and the pauper act upon the advice, there may be good ground for considering that medical relief is not wanted, but this the Guardians must decide. In any such case the Medical Officer would not be bound to supply any medicines which might be prescribed by the physician.73

Though understandably set to minimize outside interference, this was tantamount to setting medical professionals against one another. It also handed the ultimate ‘medical’ decision over to those least qualified: the guardians. A medical officer was a general practitioner and disobeying the advice of a physician meant breaking from professional etiquette (or ‘ethics’). The Poor Law Board thus cared little for the medical profession’s limited and self-interested ethics. There was no ethical basis for the duty of care, so the specific duties of the contract became a critical part of the contract’s legal usage. Despite the duties of a medical officer being reasonably clear in their objectives, they were open to abuse because of the contradictory and sometimes ambiguous rules governing their practice. The Medical Practitioners’ Legal Guide (1870) warned medical officers to be wary of the ‘complex character of duties … more especially as red-tapism is an inexorable taskmaster’.74 The ‘red tape’ of orders for attendance was the central issue in most charges of negligence or neglect of duty against a medical officer. As such, Chapter 7 will focus on the details of this fundamental contractual obligation, explaining how the interrelatedness of orders, duties and fees could frequently entwine doctors in a catch-22. Duties seemed simple in appearance, but a medical officer soon discovered that they led to obligations, which were not so straightforward.

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Delineating between the duties of a workhouse and a district medical officer is somewhat irrelative to the underlying issues of negligence, except in regard to emergency treatment (and fees), discussed in Chapter 7. The rules governing both stations were similar, but the institutional duties of the workhouse led to some exceptions. Article 207 of the General Consolidated Order outlined the duties for both the district and workhouse medical officer in the nineteenth century. In essence, they were parallel roles, but there were some institutional additions for the workhouse medical officer: No. 1. To attend at the Workhouse at the periods fixed by the Guardians, and also when sent for by the Master or Matron. No. 2. To attend duly and punctually upon all poor persons in the Workhouse requiring medical attendance, and, according to his agreement, to supply the requisite medicines to such persons. No. 3. To examine the state of the paupers on their admission into the Workhouse, and to give the requisite directions to the Master according to Articles 91 and 92. No. 4. To give directions and make suggestions as to the diet, classification, and treatment of the sick paupers, and paupers of unsound mind, and to report to the Guardians any pauper of unsound mind in the Workhouse whom he may deem to be dangerous, or fit to be sent to a Lunatic Asylum. No. 5. To give all necessary instructions as to the diet or treatment of children and women suckling children, and to vaccinate such of the children as may require vaccination. No. 6. To report in writing to the Guardians any defect in the diet, drainage, ventilation, warmth, or other arrangements of the Workhouse, or any excess in the number of any class of inmates, which he may deem to be detrimental to the health of the inmates. No. 7. To report in writing to the Guardians any defect which he may observe in the arrangements of the Infirmary, and in the performance of their duties by the nurses of the sick. No. 8. To make a return to the Guardians, at each ordinary meeting, in a book prepared according to the Form (Q) … and to insert therein the date of every attendance, in conformity with Article 205, and the other particulars required by such Form to be inserted by the Medical Officer, and to enter in such return the death of every pauper who shall die in the Workhouse, together with the apparent cause thereof. No. 9. To enter in the commencement of such book, according to the Form marked (R) … the proper dietary for the sick paupers in the house in so many different scales as he shall deem expedient.75

Workhouse duties remained the same throughout the Victorian phase of the poor laws. Although in appearance there are nine listed, essentially there are only four different categories being enunciated: attendance, examination, directing and reporting, and dispensing and dietary. The nine duties were not always clearly

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distinguishable from one another and, in essence, often amounted to the same type of duty or overlapping activities. In other words, a doctor guilty of breaching one type of duty, would find himself on a charge for failing to carry out several duties. For example, if a medical officer failed to attend to a sick pauper after receiving an order from a master, he may be charged under duties one, two and eight. If he failed to attend the workhouse and examine paupers, he may also be charged with breaking the same duties plus number three. The rules of attendance meant that doctors were supposed to fill out their part of the workhouse medical officer’s report book, noting their attendance times and dates; to which, the master was supposed to add his confirmation. A best practice guide (published for medical officers in 1890) said that the reporting was a complete failure, one of the ‘useless relics of the ancient Poor Law … . It is obvious that, under any conceivable circumstances, these checks must be utterly useless, and the sooner they are done away with the better’.76 The Board tried to enforce the documentation, but masters and doctors colluded to render the activity a farce. In practice, masters often ignored a medical officer’s written requests, and, whether because of this or not, medical officers treated paperwork as a waste of time. Frequently, both master and medical officer neglected to complete their attendance books, or filled them out en masse at the end of a quarter. Alternatively, a doctor may have completed his side of the forms diligently, only for the master to sign everything off without consideration. Doctors who did not complete their side of the report books, however, were frequently disciplined. The normal practice seems to have been to avoid paperwork wherever possible. Attendance, directing and reporting involved paperwork, however, and an obligation for a medical officer to give written information. Failing to carry out these administrative duties could result in multiple charges (for example, breaches of duties four, five, six, seven and eight). The medical officer for the Thetford Union Workhouse, for example, was found not to have been attending cases on his permanent medical list. Pembroke Minns’ negligence was discovered after he had delayed attending to a lunatic, named Borley. The case was only brought to light because the mentally-ill man committed suicide (publicly) by jumping down a well.77 For his non-attendance, Minns received only a warning. Death of a pauper, due to the non-attendance of a medical officer, was not a guaranteed charge of negligence. Nevertheless, friction between officials or vocal public protests would usually motivate the most reluctant of guardians into suspending a medical officer or bringing a charge of negligence. Within weeks of Minns requesting a salary increase, he was charged with neglect of duty on six counts: (1) (2) (3) (4) (5)

The Workhouse Medical Relief Book irregularly filled up. The Bed Tickets not filled up. The improper language of his assistant to the governor [master]. The Medical Relief Book does not correspond with attendances given. For refusing to see Inmates when required by the Governor and matron except in infirmary. (6) For taking 12 Old People off all extra diet from the very day he was ordered to attend before the Board to explain his conduct in the first three cases.78

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Behind Minns’ collection of charges is the circumstantial evidence that he (and his assistant) had fallen out with the master, and that Minns had requested an increased salary. Most of Minns’ six charges revolve around attendance and the administrative irregularities of his bookkeeping and the negative attitude of the medical officer and his assistant towards the master and matron. As such, he had refused to attend the chronic infirm and sick, who were dotted around the workhouse ‘able-bodied’ wards. Those types of patients dominated the workhouse caseload, forming the bulk of the medical officers’ routine with barely any recognition in pay or statistical returns. Yet, when reporting had been neglected, it allowed LGB officials to shift the blame for substandard infirmaries onto workhouse medical officers who were supposed to direct the master’s and guardians’ attention to areas that needed improvement or repair. This was an awkward proposition for a medical officer who relied on his employer’s cooperation, especially in the day-to-day payment of fees and, in some unions, the partial or whole supply of drugs and medicaments. In 1888, for example, Dr Edwin Roe took over from his father as workhouse medical officer for Barton-Upon-Irwell Union. He was paid a salary of £75 per annum, excluding the supply of medicaments and drugs. The father had served the union for over thirty years and was awarded a generous superannuation of £100 per annum. Despite obvious localized nepotism – and rewarding a ‘faithful’ doctor – the son was forced to resign after barely a year in his post.79 His obligatory departure was rooted in the employment circumstances explained in Chapter 2. Unreasonable guardians could place an unrealistic burden on a medical officer to equip and supply a workhouse infirmary. The LGB made some attempts to list items that guardians should supply, such as trusses, crutches and wooden legs,80 but it was a futile exercise. Advancing technology and pharmacopeia meant it was never exhaustive, and the LGB’s unwillingness to be authoritative meant it was all too easy for guardians to shirk responsibility. The son’s short tenure had less to do with medical mishap or ineptitude, and more to do with his unwelcome, ‘modernizing’ approach to poor law doctoring. His father, arguably, had accumulated a successful practice and was perhaps less than diligent in his duties for the poor law. When his son took over, there may have been a more thorough approach to the post, because Roe (junior) found the demands of the workhouse exceeded his expectations. He reported this repeatedly and tried to renegotiate his contract, which met with disapproval. Above all, Roe had found the toll of supplying drugs and medicaments unbearable and offered to lower his salary if the guardians took more responsibility: ‘To my way of thinking the whole cause of friction has arisen in my persistently asking the Guardians to supply me external applications and suggesting (seeing that there was some difficulty in deferring external applications) the advisability of altering the existing contract … .’81 He failed to accomplish this, despite repeated attempts and writing a letter of complaint to the LGB: As I understand my appointment I provide the necessary attendance on the in-door sick, internal medicines and a Dispenser. I find on referring to the attendance book that I and my partner have spent an average of one and a half

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hours per day in the hospital, and in the 90 days ending March 31st ult. I have supplied 1167 bottles of medicine, being a rate of two shillings an hour for time and rather less than 1¼ per bottle – last week the number of patients taking medicine was 74 [and] besides these there are others under treatment not taking medicine … . It is obvious that out of such payment, it cannot be expected that I should furnish the hospital with instruments, and it would be impossible to carry backwards and forwards every day, every instrument that might be required in so large an establishment.82

The guardians, though, had seen no reason to alter local practice: ‘the whole of Roe’s late proceedings indicate a desire on his part to coerce them into the adoption of a course, to which they are not inclined viz.: the abrogation of the contract into which Mr Roe voluntarily entered, after public advertisement in competition with other and competent medical practitioners’.83 In effect, the guardians ignored Roe’s repeated requests for essential medicines, citing his contractual obligations. The persistent pressure from Roe caused the guardians to suspend him on the ground that ‘the relations between the Guardians and the Medical Officer having become so strained, the Guardians feel they have no alternative but to suspend Mr Roe from the discharge of his duties from this day, pending the decision of the [LGB].’84 Initially, the guardians used the death of an infirmary patient, named Hannah Walton, to grab the LGB inspector’s attention. In turn, Roe had hoped to highlight Walton’s death from ‘bedsores’ as an example of negligence by the guardians – blaming her death on their refusal to supply him with essential equipment and medicines. The LGB inspectors, Henley and Downes, came down on the side of the guardians, who had successfully framed the doctor for being at fault in the drug supply. Roe was found guilty of exaggerating the need for medical appliances and pharmacopeia. It was said that his requests were ‘unusual and unnecessary’, that two-thirds were excessive and should have been supplied from Roe’s own costs.85 The inspectors also accused Roe of exaggerating the cause of Walton’s death; concluding, instead, that she had died from phthisis, not bed sores. Although they concluded that the guardians should have paid more attention to Roe’s requests, Henley nonetheless issued an order for his resignation. Reporting was thus a risky venture – accurately done, it could cause a rift between officers or bring unwelcome public attention to guardians who were remiss in maintaining acceptable standards of care. Charlesworth has also argued that unproven charges against an official could carry a hefty fine, but there appears to be no pervasive use of such fines reflected in the records of charged medical officers.86 Roe’s protests were motivated by his pecuniary losses, but many other doctors kept quiet and personally dealt with unexpected expenses in order to avoid conflict. Undoubtedly, many medical officers turned a blind eye to the low standards of care in their infirmary. Unless there was serious negligence and a public inquiry, a neglected infirmary may get by for many years before there was need for change. Yet, in the aftermath of a public scandal that had revealed a dilapidated workhouse infirmary, the LGB need only have pointed to a doctor’s lack of reporting.

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The ‘mockery of so-called Poor Law inquiries’ Crowther said that ‘strangely’ the medical officers ‘failed to become an effective pressure group’.87 The failure of a counter-movement to the crusade, and the deadlock over a national form of London’s 1867 dispensary and hospital ‘system’, were elements of this frustration – and are critical to explaining welfare history in this period. Lack of unity and public support are reasons for defeat that are recognized by historians, including Crowther; but charges of negligence and disciplining doctors have been overlooked. In weighing up the balance of causes, it was a defining factor in the paralysis of the medical officers’ professional movement. The mass effect of charges of negligence against them, whether intentionally or not, stymied medical reform under the late nineteenth-century poor law. Leading historians of the medical services of the poor law have missed or understated the combined effect of the crusade, contractual obligations and disciplining doctors. Ruth Hodgkinson underpins a great deal of historians’ literature on poor law medicine, but she gave scant regard to official inquiries and charges of negligence. Hodgkinson proposed that charges dropped in number from the 1860s, and assumed that (if this had of been the case) it had been due to symptomatic improvements in health provision. Few historians have questioned this a priori reasoning; none has argued with the inaccurate assumption of generally improving standards and a concomitant drop in charged doctors.88 Crowther, for example, argued that ‘the diminishing number of official inquiries’ was ‘no guide to the quality of the service’.89 The contrasted reality (Figure 4.2) has much to do with the history of medical negligence, itself, being neglected and – until recently – an accepted understating 60

Number of WHMOs

50 40 30 20 10 0

1860–1869

1870–1879

1880–1889 Decade

1890–1899

1900–1909

Figure 4.2 Peak in (known) forced resignations and dismissals of workhouse medical officers in the 1870s Source: TNA MH9 Series.

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of the extent of the crusade among poor law historians. In truth, standards of care in many unions went down at the same time that charges of negligence against medical officers rose inexorably. Despite a copious poor law literature, no historian has yet singled out charges of negligence against medical officers and the PLMOA’s shift in focus to ‘defending’ medical officers during the crusade years. In 1882, Rogers described the dire situation: ‘… within the last two years, in consequence of certain occurrences, he had made up his mind to abandon, so far as he was individually concerned, the idea of appealing to the Local Government Board, and had determined to endeavour to mould the Association into a Mutual Defence Association’.90 The rising tide of charges of negligence against medical officers in the 1870s (demonstrated in Figure 4.2) implies that Rogers was right to realign the association’s key motive: there was something unusual occurring within poor law medicine. If the decades of the 1860s, 1890s and 1900s are considered a reliably normal rate, the 1870s had well over 300 per cent more medical officers charged with negligence than should have been expected. The timing of the crusade was one aspect, explored in the next two chapters, but the core problems revolved around the system itself – the systemic problems that London had solved after 1867, and which reforming groups (such as the PLMOA) had sought to expand across the nation. Ever the opportunist, Rogers used the rapidly increasing numbers of charges of negligence against medical officers as a means to expose, and reform, the system. Official inquiries were obviously not a preferable option, but (used wisely) a welldocumented inquiry could provide free publicity and a means to expose the faults of the system. In essence, this became the chosen reform method of Rogers and the association during the 1870s and 1880s.91 A charge of negligence, however, could originate from almost anywhere (a subject returned to in the final chapter). Raising an alarm was not confined to authoritative figures or public representatives. Paupers (if literate) could write and complain or inmates of workhouses could make verbal complaints to officers and guardians (surprisingly, some brave souls did do this). Parish-level friends and representatives could also make a complaint on a pauper’s behalf, such as the case study in Chapter 6. It was not unusual for coroners to complain or charge a doctor with negligence themselves – though they would most likely action this through the courts. From the mid-Victorian period (as Chapter 6 explains), whistle-blower officers, such as nurses, sometimes alerted the LGB or public to seriously low standards of care or abuse. Nevertheless, it was guardians who brought the most pernicious and numerous complaints and charges against their officers. Their motives ranged widely, such as a reaction to an event of medical neglect or as punishment for disobedience, discord or violation. The LGB had the power, though, to remove an officer without sanction from any local official. They were empowered to hold an official inquiry by various provisos, granted under the combined effects of statutes in the Poor Law Amendment Acts of 1834 and 1842, and the Poor Law Board Act of 1847.92 Under the Poor Law Board, inspectors were compelled to conduct an official inquiry where an officer had disputed the ‘alleged grounds of the dismissal’.93 Despite this, there was no distinct rise in charges of negligence or official inquiries until the 1870s (Figure 4.2). Inspectors also

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had the authority to subpoena witnesses, but this power was limited to the ambit of the union – and paying the expenses of numerous witnesses could be costly. ‘Official inquiries’ were, therefore, important affairs. The LGB’s interest in negligence began immediately on its inception. In 1871, Lumley expanded the rules governing contractual obligations and official inquiries into a medical officer’s conduct. For the first time, ‘negligence’ and malpractice unambiguously entered the language of the rule books that underpinned their contracts: Where complaint is made against an officer and the same is not disposed of by correspondence which acquits or convicts the officer, the Board institute an open inquiry by examination of witnesses, on oath, before an inspector, either one of their staff or one specifically appointed [such as medical department inspectors]. The medical officer can procure any witnesses whom he may desire to have examined, and who can give testimony pertinent to the inquiry to be summoned by the inspector, and their expenses will be charged … but if he retain attorney or counsel … he must bear the charges himself, they cannot be borne by the guardians or the Poor Law Board … . The decision of the Poor Law Board is conclusive, and cannot be opened by any court of law … . The questions which are inquired into are such as relate to mala praxis, negligence in regard to the paupers whom he may be ordered to attend, either by not visiting promptly, or omitting to visit with regularity, want of sobriety, absence from his district or the workhouse, without adequate provision of a substitute, improper conduct towards pauper patients under his charge, insubordination in regard to the board of guardians, or wilful disobedience of their orders or those of the Poor Law Board.94

The list of charges was vague and far removed from today’s understanding of clinical negligence. Creative guardians – wishing to rid themselves of a troublesome doctor – could invent virtually groundless charges and distort the duties and rules of a medical officer’s engagement. Moreover, the LGB held all the cards and a judicial ace up their sleeve: their decisions could not be opened by any court of law and inspectors superseded and could overrule the decisions of guardians.95 The LGB had the legal jurisdiction to indict their employees, but, essentially, inspectors were also the judge and jury of an official inquiry. Rogers was scathingly critical of this aspect, which he described as the ‘existing mockery of so-called Poor Law inquiries’. He contested that no individual should ‘… be vested with the sole power of deciding what shall be the evidence that shall be taken when the inquiry shall close, nor that he shall be the sole judge of the value of such evidence’.96 Rogers was bemoaning the power bestowed on a single person, but the collective potency of those judgements had a wider effect. A publicized inquiry could advertise the direction of policy and demonstrate a willingness of the inspectorate to follow through words with actions. Arguably, official inquires had a ripple effect. They bolstered and cloned crusading across some unions,

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intensifying the clustering of charged doctors within a sympathetic inspector’s district (see Figure 5.1 and Table 5.1). Although the inspectorate may not have been able to force policies into practice, the semi-judicial process of an inquiry was an important crossing point for policy and practice. Even today, complaints about substandard care are recognized for their capacity to sound out differing expectations and perspectives.97 Negligence, on the one hand, has been unjustly maligned by poor law historians as a subject with little academic merit. Many local historians, on the other hand, have ‘discovered’ medical officers charged with negligence, but frequently and unwittingly embraced the bias of the inspectorate’s reports and judgements. In contrast to both of those portrayals, official inquiries were a key strategic element of the inspectorate’s will and means to put policy into practice. In so doing, they also created a rich – but underestimated – resource for academics in law and history to study the developmental history of medical negligence under State medicine in Britain. One thing is clear: official inquiries into medical negligence are an important – but hitherto missing – aspect of the ‘conflict and compromise’ in localized poor law practices described by historians. Figure 4.2 shows workhouse medical officers who were obviously dismissed or forced to resign. At just over 120, this cohort presents a low number, but it is – to borrow Klein’s metaphor – the tip of an ‘iceberg’ of less visible conflict and discontent.98 The LGB rarely dismissed a medical officer, preferring voluntary (coerced) resignation; in spite of this meaning that a medical officer could retain his backdated salary (no matter however long a suspension or inquiry had taken). Most doctors would therefore opt for resignation when under threat of dismissal. Others voluntarily resigned before an inquiry was held or before anything had been recorded against their name. Others have a full record of disciplinary proceedings, but resigned during or after an official inquiry. In spite of those barriers to a complete and accurate picture, of the 2,022 workhouse medical officers recorded in the government’s returns between 1834 and 1900, well over a third were disciplined. The great majority of these were for minor infringements, such as poor recording in the workhouse medical relief books. Of those that were ‘disciplined’ at some point in their career cycle, at least 15 per cent gave a clear indication in poor law files that they were forced into resignation. Officially, 43 per cent of those with disciplinary procedures ‘voluntarily’ resigned. Comparatively, 54 per cent of the doctors with no disciplinary notes ‘voluntarily’ resigned. This may be an indication that many did not leave ‘voluntarily’ and were, in effect, pushed, and that the term ‘voluntary resigned’ conceals yet more coerced resignations. Suspending an officer, though, was an expensive and time-consuming business, especially if they chose to fight against a charge of negligence. A replacement had to be found in the interim and if an officer resigned voluntarily, he received his salary in full, up to his final contracted day. Some guardians were not aware of the rules governing suspensions, and others wanted desperately to punish doctors who had brought unwelcome public criticism (like the Strand Union and Rogers). As a result, guardians’ belligerence sometimes went too far, which led to expensive (and

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unexpected) backtracking by the inspectorate. The LGB thus requested guardians to be less ‘hot-blooded’: ‘Unless the complaint be one which renders it dangerous or highly improper, or embarrassing that the medical officer should continue to act, the guardians should not suspend him, but should report the complaint to the [Board] for their decision.’ They explained the economic reasoning, and added: ‘the complaints made are frequently such as will not prevent the officer from discharging his ordinary functions, until the charge has been disposed of ’.99 Notwithstanding the LGB’s motives in disciplining medical officers for the reasons discussed above, it was nevertheless set against unnecessary expenditure on trivial complaints. Though guardians were repeatedly advised by the LGB not to suspend doctors in the first case, a suspension was normally their initial move in the disciplinary process. It was their legal right to do so under Article 162 of the General Consolidated Order (1847).100 As a result, it was frequently the first moment that the central Board was informed of a problem. By then, local or national press may have learned of the details and it was often too late for the LGB to intervene and prevent public curiosity and scandal. Thus, the attention and result of an official inquiry could impinge heavily on the work of the permanent officials – taking a toll on both their time and image. So, although the LGB would not traverse the country searching out medical officers to ‘blame’, they would certainly enter an official inquiry on the defensive and ready to do their utmost to avoid a public inquiry on the scale of Andover or the Lancet’s campaign. Furthermore, central policy could only work if there was willingness in the regions and a receptive body of local governance. Charges of negligence were the perfect tool for guardians to rid themselves of a recalcitrant and bothersome officer. They could also grandstand an inspector’s partisanship to the crusade. In so far as district inspectors were a factor in the verisimilitude of poor law practice, policies – such as the crusade – could not have been effectual, though, unless there was already a groundswell of receptive attitudes. As the historian, Alan Kidd, has argued, ‘Despite the intentions of the reformers, subsequent official policy was the result of compromises between central and local interests which varied between regions and, as had been the case before 1834, also varied within regions.’101 As the next chapter will demonstrate, the crusade was taken up in various unions because it was a policy with public support and the sanction of both local and national governance. Although not all unions endorsed the crusade, those that did had worked with the inspectorate and, for a time, this significantly affected the national scenario. Thus, claims for medical relief were increasingly scrutinized by lay ‘crusading’ administrators of the poor law, with the endorsement of crusade-inspired inspectors, such as Fleming and Henley. As this chapter has argued, their powers lay in a complex regulatory structure that effectively undermined doctors’ authority and provided the legal basis of charges of negligence against them. As a result of this, inspectors were able to publicly blame individual doctors for negligence, but avoid the fundamental latent failures of the poor law system. This has particular relevance for the period when crusading dominated the thinking and actions of permanent officials. The next

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chapter explores the intricacies of crusading and provides a penetrating exposition of the role of inspectors. It will show that the effects of crusading were extensive. Crusading lowered the health of people already suffering and on the margins of society. It also increased the number of individuals who could no longer be supported at home.102 As a result of this, poor law medicine buckled under the strain of intensified infirmary provision and severe cuts in medical relief to the poor beyond the workhouse walls.103 In spite of this, medical officers were held responsible for the systemic failures of a poor law medical service that was simply not fit for purpose.

Part Two OUT-DOOR RELIEF: A TRAGIC BURLESQUE (ADAPTED FROM A RECENTLY REPORTED MEETING.) SCENE: Board-room of a Wealthy Parish. Meeting of Guardians and Parochial Officials. Titled and Military Vestrymen thrown in – say a DUKE and a DRUM MAJOR. CHORUS OF GUARDIANS. Tra la la la, what a feeling comes rushing, Filling the heart of the guardian gay, When he reflects that his duty is crushing All the poor people who come in his way. Tra la la la, if the pauper is poorly, Why, let him hunger, consumed by his grief; To starve him to death is the cheapest and surely The best way of giving him proper relief. (Conclusion of chorus, and short interlude of sandwiches and sherry.) BOARD CLERK. Aw! Gentlemen, I grieve to say That since you met the other day Our parish doctor’s made a fuss And brought the papers down on us, Because a woman chose to die For lack of things we don’t supply. DRUM MAJOR. ’Twas turtle soup, I understood, He thought would do the woman good. Now, gentlemen, if paupers droop Because they can’t have turtle soup, Good gracious me, are we to blame?Shall penny prints our deeds defame? DUKE. Disgusting! Horrid! On my word, The thing is painfully absurd. I wonder folks can waste their breath About a paltry pauper’s death. On strong beef tea, the doctor said, And mutton chops she should be fed.

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If we’re to find such things as these, Why not blancmange and duck and peas? Ice pudding, too, we might supply, Chateau Yquem and Piper dry. Some cad might fancy with his wine, A slice or two of English pine. Beef tea, forsooth! The woman’s dead Because she wouldn’t swallow bread. I will maintain, in spite of clamour, We did our duty by her(The concluding words of the noble DUKE’S speech were inaudible, owing to the applause of his colleagues.) RELIEVING OFFICER. It’s all a knowing plant, it is, about this Charlotte Hammond, The Public and the Press as well are regularly gammoned. It’s only just a week before she’d half a loaf for dinner, And now we’re blamed because she died one day she’d nothing in her. COLONEL. The doctor who ordered beef tea for her food Was a ninny unfit for his berth: Beef is far too expensive a thing to be stewed For a pauper who cumbers the earth. CHORUS OF THE GUARDIANS. Let the world in its wickedness pelt us with dirt, We are kind to the poor, and they know it; Over-feeding would do the sick paupers a hurt, And encourage the lazy to ‘go it.’ What would ratepayers say if we squandered the cash, Buying meat and good liquor to fill them? We’ve much cheaper methods of cooking a hash, And yet ’tis by kindness we kill them. (General adjournment to champagne luncheon, kindly provided for the guardians and local magnates by the guardians and local magnates, at the expense of the ratepayers.)

‘Outdoor relief: A tragic burlesque’, Fun (June 14, 1876): 253.

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A Latent Failure: The Crusade against Outdoor Relief

Background The failure of the medical officers’ reform movement, described in Chapter 2, can in part be ascribed to the concomitant success of the crusade against outdoor relief, a campaign run between the 1870s and 1890s.1 This broadly meant a drive to withdraw non-institutional relief paid to the poor in their own homes from taxation; but outdoor relief was also a catch-all phrase for the panoply of medical aid and benefits designed to temporarily alleviate illness and distress. In so far as the poor law was one side of the crusade’s double-edged blade, charity was to be the lauded other face of the movement. Crusaders sought to investigate a claimant’s background more thoroughly, dividing the impoverished between charitable and State aid. Those that had clearly exercised thrift and led exemplary lives – the deserving cases – were to receive charitable care. Less deserving people were to be offered the workhouse or nothing. The crusade was never successfully implemented on the scale desired by permanent officials, but a large number of long-term relief dependents were affected, such as widows, single mothers, the infirm and the disabled. As this chapter will describe, the crusade was partly a reaction to economic pressures, but it was also a deeply rooted English ideology against welfare dependency that had found its voice. Therefore, Rogers’ reforms, discussed in Chapter 2, came up against a growing national movement and widespread crusade attitudes in the 1870s. He and the Lancet had captured the popular imagination in the mid-1860s, but, within a few years, mass appeal was against Rogers and medical officers because of their role in distributing (or withholding) outdoor relief. Despite their allegiance to some aspects of crusading, discussed below, it is easy to understand why the medical officers’ primary objectives – increased expenditure on medical services and medical autonomy – placed them at spectacular odds with the LGB at this time. Sidney and Beatrice Webb claimed in The Minority Report (1909) that a policy was conducted by the inspectorate of 1869–1886, and that it ‘included as one of its departments a tightening-up of the conditions on which Medical Orders were habitually granted’.2 In The State and the Doctor, the Webbs re-dated the crusade as 1871 to 1885, and described it as a ‘hostile’ movement against welfare reforms, such

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as national provision of dispensaries.3 Williams, though, defined the ‘formal’ end of the crusade as 1896, when a circular was issued, ‘which accepted outdoor relief for the deserving’.4 Notwithstanding the research of Hurren, this chapter will argue that the crusade philosophy was more nebulous, widespread and popular than historians of English welfare have hitherto recognized.5 Although there is an extensive body of research into the new poor law, it has tended to brush over the crusade years.6 There was an ‘early misrepresentation’ in historical literature for this period, described by Hurren as ‘a trend that was never fully reversed … . This is still a “Jack-in-theBox” experience; the reader gets to peek below the lid but the reality of the poor law remains hidden.’7 Robert Humphreys’ research into Victorian ‘organized charity’, by contrast, estimated that few unions adopted crusading measures. He claimed that 90 per cent of unions refused to make extreme cuts to outdoor relief.8 Arguably, this is an overestimate, but, in any case, such low numbers of crusaders would still have had a great impact on standards of care in – what amounts to – over sixty unions. Even so, this figure would have been higher for the 1870s. Such estimates have commonly overlooked the subtle cuts and changes in giving and withholding relief at different times and at different unions. The crusade was played out within hundreds of unions who were less extreme in cutting outdoor relief, but influenced by the policy nonetheless. The broad financial accounting of those years shrouds the many thousands of paupers who were affected by cuts in the 1870s and 1880s. This chapter will therefore extend Hurren’s research and build on the history of the poor law by exposing the importance of inspectors and by articulating their methods of crusading in this period. It will move the historical narrative towards the actual impact on medical practice under the poor law. It will argue that fears of rising numbers of paupers, dependent on ‘medical’ relief payments for destitution, had translated into a national reactionary political environment that underpinned the rising numbers of doctors charged with neglect in the 1870s. As this chapter will show, this was primarily because doctors were on the frontline of both issuing outdoor relief and treating the rising numbers of vulnerable patients in workhouses at this time. Ultimately, the main objective of this chapter is to provide an empirically based exposé of how crusading interacted between governance, doctor and pauper patient to weaken a system of health care that was riddled with latent failures, but ignorant of – or wilfully blind to – its faults.

Fertile ground By the time of the LGB’s inauguration, in 1871, economic concerns had reached boiling point.9 England had settled into a long recession that had some of its root causes in the cotton famine of north-west England, brought about by the American Civil War (1861–1865) and intermittent crop failures.10 In addition, international competition was reducing the supremacy of British manufacturing, leading to economic instability and declines in available work in some regions of Britain.11 Poverty had therefore increased in both industrial and agricultural areas. In turn,

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poor law relief payments had soared, particularly outdoor relief, which had risen to unprecedented levels in 1870.12 All of this had the effect of undermining the centrality of the workhouse test. Voicing the opinions of many ratepayers in the 1870s, The Morning Post wrote that outdoor relief was considered ‘parish pay’ by many of its recipients. It agreed with the LGB and guardians that outdoor relief should be withdrawn and the workhouse test applied to every type of applicant.13 The ‘new’ board had therefore joined with public opinion. The LGB instigated a policy to cut back welfare expenditure, with the objective – which had always been popular with ratepaying Victorians – to diminish reliance on poor law outdoor relief. In the first six years, the crusade was successful in slashing the cost of outdoor relief by 28.6 per cent, from £3,663,970 in 1871 to £2,616,465 in 1877.14 Yet, in both monetary and humane terms, there were important caveats that led Victorians to, ultimately, question the benefits of crusading. By the end of the 1880s, most unions were ignoring the crusade agenda. Nevertheless, numbers of relief recipients had dropped in the 1870s and this figure did not climb back to previous levels. It can therefore be argued that the crusade was representative of developing attitudes to welfare in the late nineteenth century. Elizabeth Hurren has led recent research on the crusade, and she has been at pains to explain that it was the spirit of the times writ large – that crusading was a popular ideology.15 Hurren closely analysed the practice of the crusade, using Brixworth Union as a case study. From this, she concluded that ‘there were in fact different types of crusaders, in different places, at different times and with different economic motivations. Numerous participants – the opportunistic, moderates and extremists – deployed crusading techniques’.16 Such national enthusiasm is crucial to understanding the crusade. Just as the law has an evolving, interactive relationship with society’s changing ideals, the poor law depended upon contemporary society for its modus operandi. The LGB had then essentially encapsulated and distilled the zeitgeist with calculated efficiency. In 1873, for example, Inspector Andrew Doyle was reported by the Pall Mall Gazette to have addressed the guardians of his district at a ‘favourable moment’, when the ‘tide of public opinion [was] at length full set against the demoralization of the outdoor relief system’.17 This ‘tide’ of public opinion, however, had been encouraged by the LGB. Their number one objective was to reduce the ‘scale’ of outdoor relief and bring more uniformity in its distribution by the substitution of ‘in-door for out-door relief ’ as far as ‘practicable’, whether relief was for sickness or unemployment.18 Inspectors sought to extend the workhouse test further than ever before – seeking (though never achieving) total withdrawal of support outside the workhouse and, essentially, an extension of the test to the sick, infirm and disabled. The crusade may have been the product of a top-down policy within the poor law, but it met with a groundswell of like-minded elite, poor law administrators and ratepayers in the regions. It was a popular attitude – a fashionable ideological stance – as much as it was policy rooted in the stratosphere of contemporary governance. The ‘seventh annual central conference of representatives of poor law guardians’, in 1877, described the crusade as a ‘movement’ in its ‘infancy’, but that ‘various unions were

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gradually waking up’.19 The handfuls of (mostly London-based) model unions, which are commonly and incorrectly referenced by historians as the limits of the crusade, were in fact prototypes – a Victorian pilot study.20 Their progress was monitored by the LGB. This was reported and observed closely by other unions, who, in turn, rejected or adopted the prohibition of outdoor relief. The crusade was therefore a nationwide movement. It was not confined to a minority of ‘model’ unions, but the subtlety of those who made less extreme cuts in the 1870s was not so visible in contemporary statistics and, in turn, has all but vanished from subsequent historical accounts. Across the country, different associations and groups with an interest in poor law matters (such as agricultural or labour associations) met with regularity in the 1870s to discuss the means of decreasing outdoor relief – there was a general consensus that outdoor relief created pauperism and dependence.21 The Essex Standard was typical of the times, when it reported that the ‘truth is’ that outdoor relief generated a ‘spirit of mean dependence, which has a most injurious effect in leading, not only to improvidence and thriftlessness, but to idleness and deceit, and their natural concomitants of vice and crime’.22 The labourer, wrote John Bull, ‘should be taught self-denial by not being encouraged to look to the Poor Law for his “pension,” as he termed out-door relief … wealth meant work and thrift, and poverty meant waste and idleness’.23 Medical clubs, self-help and charities for the deserving poor were seen as the best ways to deal with the sick poor. Historians, however, remain divided over the efficacy of medical clubs and societies at this time.24 Undoubtedly, some drew in funds, only to spend them on regular alcohol-drenched ‘meetings’ in a public house. If contemporary records (such as newspapers and the notes of guardians and medical officers) are to be believed, these ‘fraudulent’ clubs were widespread. They could disband at any time, leaving their members in crisis. The historian, James Riley, convincingly argues that the ‘narrow range of essential services’ covered by friendly societies were for the most part confined to those who chose to pay. Moreover, he concludes, societies and clubs were limited by low levels of funding (inhibiting what could be covered) and, in any case, ‘many men and women, among them those most in need of aid, did not belong to friendly societies’.25 For those beyond charity and self-help – or for those whose money had been squandered in unreliable medical insurance – the ‘improved’ institutes of the asylum and workhouse (appraised in the next chapter) were to be the cornerstones of relief.26 The crusade thus galvanized long-held beliefs in self-help and popular sentiments against welfare dependency. It was therefore hugely successful. It gathered momentum fast and frequently won against liberal reforms in the 1870s and 1880s. By 1876, there was a widely held belief that a poor law bill would lead to legislative restrictions in outdoor relief – but, despite the Longley Strategy (discussed below) there was no change in statute.27 This was probably due to the complexity and controversy of making drastic alterations to the historical legal basis of the poor law, which was underpinned by a legal right to relief.28 Arguably, succeeding governments were reticent to debate this after the social upheaval over 1834’s ‘new’ poor law. Despite the diversity of practice in poor law unions across England and Wales, described in Chapter 4, there were thus many who adopted practices similar to

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that of the crusading unions. Financial control and interference from guardians led to cutbacks in the issue of important drugs and the funding of expensive treatments – severely exacerbating negligent practice and, consequently, charges of neglect against doctors. Emergency attendance and treatment (including midwifery) was also affected by some boards’ reticence to pay expensive medical fees, which created problems in doctors’ attendance and is explored in Chapter 7. In effect, regular attendance was limitless to guardians – already paid for in the medical officer’s (low) salary – so the number of orders given out for regular attendance on the poor was not an issue for them. Some unions therefore ordered their medical officers to cut back on emergency attendance and medicaments, irrespective of the amount of sickness. In spite of a lack of legislative foundation, the crusade reached further than previous poor law initiatives. It affected poor law medical relief per se: good doctors, nursing staff, effective medicine and adequate medical facilities all cost money, and this was counter to the crusade aims. In terms of negligence, such an approach had far-reaching implications for systems and standards of care. It led to the economic being prioritized over the medical decision and exacerbated the pre-existent problems of financing poor law medicine described in Part One. A more humane treatment of the sick poor (than that which was coveted by crusaders) took time to take hold because of popular attitudes of the ratepaying electorate towards the causes of pauperism at this time.29 Ratepayers across England and Wales took a close interest in poor law expenditure from the late 1860s. After the expense of pauperism was evened out across a union with the Union Chargeability Act (1865), rates had increased for many people. The Act removed the liability from parishes with large numbers of paupers and spread the cost to those with relatively few.30 Although this created an opportunity to invest in workhouse care and improve institutional provision, liberally minded, humane, reforms in medicine, welfare and public health were effective but costly (such as those brought about by the Metropolitan Poor Act of 1867 and Sanitary Act of 1866). Instead of widening access, after the 1860s, the operation of the poor law became more cynical towards all applicants for relief and continued this way for at least two decades.31 Mary MacKinnon thus described the crusader reaction against liberalist reforms: The potential to increase expenditure was indeed created by union rateability, but there is considerable reason to believe that its introduction in fact encouraged restrictive changes in poor law policy. With the burden of rates shifted, a rather different (and wealthier) group of ratepayers would take the greatest interest in the level and components of expenditure, and this change could well affect the operation of the poor law.32

Within a few years, a further change in the political landscape empowered a new swathe of ratepayers who wanted to keep rates low and ensure only the ‘deserved’ poor received ‘their’ financial aid. The electorate was widened by the Reform Act of 1867, which extended the voting franchise into the working classes. This new group of voters was, arguably, formed of financially insecure ratepayers who had a more

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personal interest in poor law expenses.33 From this time – until the voting progression of the 1880s and 1890s – many of those ratepayers may have asserted their political acumen in terms of money, not rights: a backlash against further economic advances into their pockets from the growing poor law medical apparatus. Yet, historians of the English poor law have been partly blinded by the selfprotectionism of ratepayers, viewing the 1870s and 1880s crusade as a retrenchment of the edicts of the Poor Law Amendment Act of 1834. The new poor law, however, had no overt policy towards the sick poor because its original intention and use of the workhouse were meant to be aimed at the able-bodied. Although the Outrelief Prohibitory Order (1844) had been used on occasion as a legal directive for unions to withdraw outdoor relief, its usage was limited after the 1840s. In so far as a long list of exclusions, under ‘exceptions’ (such as sickness), had meant that it was a tardily and easily misused directive. From 1871, unions looking to the Prohibitory Order were directed to ignore the long list of ‘exceptional’ cases and seek to prohibit all outdoor relief – with a focus on the cessation of medical relief beyond the workhouse infirmary. Hurren has said that crusading attitudes would have extended well into the late nineteenth century: ‘Pauperism statistics show that at least until the 1880s most poor law unions acted in this manner; otherwise the large reduction in expenditure on outdoor relief recorded at the LGB could not have been achieved on a broad front … .’34 As such, until that time, the medical, legal and political environments of the Victorian period came together with devastating effect under the LGB’s Longley Strategy – a scorched earth approach to reducing all forms of outdoor relief.

An inspector calls: The Longley Strategy George Goschen, the last president of the Poor Law Board, claimed the poor had abused the system. He expressed the ‘reforms’ that set the crusade in motion in an 1869 circular, since known as the Goschen Minute.35 He called for strict delineation between the deserving and undeserving poor: ‘… an attempt should be made to bring the authorities administering the poor laws and those who administer charitable funds to as clear an understanding as possible, so as to avoid the double distribution of relief to the same persons’.36 He believed that charity should be for those close to pauperism, but not yet paupers. Furthermore, Goschen claimed the poor had abused the system; that there were paupers making multiple claims from charitable and poor law sources. To this end, Goschen worked closely with the Charity Organisation Society to diminish abuse and wastage of funds. The famed secretary of the London branch, Charles Loch, described the Society as a ‘new movement of thought and social reform’.37 The Society had itself been instigated to work closely with the LGB in ‘prohibiting’ outdoor relief. At its heart was a resistance to indiscriminate philanthropy: ‘Relief, as it is now administered, often produces pauperism. Under what conditions may it have the opposite effect? Our answer is, that it must be organised. By this we mean that it must be administered on some common principles

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and methods’.38 The Society caught the wave of sentiment, described above, that encouraged thriftiness and saw lack of self-help as a prime cause of pauperism. One of its most prominent founding members, Charles Trevelyan, wrote that poor law outdoor relief was the ‘main cause of inebriety and pauperism’. Trevelyan argued that charitable committees would be better suited than relieving officers to root out deception, sort the deserving from the undeserving, and – unlike poor law administrators – they would be unhindered by ‘any idea of right such as attaches to out-relief ’.39 Both the Society and the LGB were in agreement that pauperism should be defined by those in absolute want – only these were to be the jurisdiction of the poor law. Goschen, along with other prominent Victorians, therefore argued in Parliament and to the public (through meetings and publications) that there was a need for strict and discriminating provision of relief. The Charity Organisation Society and Goschen’s ideas took hold and inspired the aims of many administrators, including Henry Longley, who became ‘legal Inspector of the Board to hold Official Inquiries’ in 1870.40 Humphreys described Longley as one of the ‘most prestigious inspectors’.41 Indeed, four years after beginning this onerous role – a period when official inquiries into medical negligence had consistently shifted blame onto medical staff – he published the Longley Report, which set out and expanded Goschen’s aims in no uncertain terms.42 Longley went further, seeking complete withdrawal of outdoor relief and more stringent controls on medical relief. Longley had extensive influence over Board policy and he further extended the London minute in a circular from the LGB to all inspectors: ‘The large increase which has within the last few years taken place in the amount of outdoor-relief has been regarded by the Local Government Board with much anxiety … .’43 He advocated closer ties between the LGB and organized charity and recommended closer invigilation of applicants for relief. According to Humphreys, Longley had an ‘unshakeable’ conviction that the ‘lower orders of society lacked the integrity and moral strength of the better-off ’.44 His rather personal brand of welfare attrition was never ‘officially’ implemented across the nation, but Longley’s report (and his authority over other inspectors) had a profound influence on poor law practice in the 1870s and 1880s. Longley’s circular was the launch pad for the Longley Strategy, whereby inspectors were instructed to: invigilate guardians; ensure that there was stricter inquiry into relief applications; limit the range and diversity of outdoor relief practice; and reiterate to guardians that generous outdoor relief ‘removes every incentive to self-reliance and prudent forethought’ by the poor.45 An extension of the workhouse test lay at the heart of the policy, but with a fresh focus on medical outdoor relief.46 Hurren isolated eight different aspects of crusading that were usually identifiable in unions that were practicing a hard-line reduction in the distribution of welfare. Of these, four had a clear medical dimension: selling pauper cadavers to anatomists; withdrawing outdoor medical relief; claiming ‘lunatic grant-in-aid funding and then shifting paupers on to county asylums’ (discussed in the next chapter); and cutting staff costs, both in and out of the workhouse.47 Michael Rose has said of this circular, ‘Even the aged and sick, the Board advised, should have their applications for relief carefully scrutinised.’48 In contrast, the original creators of the new poor law had not

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intended relief examinations to be applied towards the sick poor. The Longley Report (and Longley’s authority) meant that the ethos became a distinct crusading policy with a profound influence on poor law practice and medical care. Between the 1870s and 1890s, inspectors either tacitly agreed with the policy or were instructed to ensure that the unions within their district followed Longley’s Strategy. In turn – and from a relief recipient’s point of view – this had a severe and detrimental impact on medical welfare at this time. Rogers saved his most vitriolic criticism for the inspectors and permanent officials of the poor law department. He argued that they had ‘usurped’ the poor law with ‘powers they were not entitled to’ and pushed forward their own agenda.49 By implication, this meant the crusade against outdoor relief. The Webbs may have agreed. They picked the inspectors out as the party most responsible for the policy of those years.50 Yet, Rogers also poured praise on Goschen, whom he felt had temporarily ‘checked’ the influence of permanent officials ‘who had always been obstructive, and had neither carried out, nor permitted anyone else to carry out, any reform whatever’.51 He argued that Goschen’s presidential stint with the poor law was too short, and his successor (Stansfield) signalled a long period of power and influence for the ‘permanent officials’.52 Nonetheless, it was Goschen’s famous circular that had signalled the beginning of the crusade. He had also blamed the rising poor law budget on indiscriminate relief and over-generous medical services.53 Essentially, from 1869, inspectors pressured guardians to hold back medical relief. Those applying for medical treatment or medicine were made to undergo the same examination as someone applying for normal relief.54 Williams noted that ‘the “crusade” was a campaign whose strategy was formulated and pressed upon boards of guardians by these peripatetic civil servants, each of whom was responsible for poor law administration in one region’.55 Yet, as argued in the previous chapter, there has been limited research into the instrumental careers, personalities and motivations of inspectors. They bought their ideals to English and Welsh regions and heavily influenced local – and, in turn, national – policy. Moreover, official inquiries – particularly into medical negligence – were a useful cog in the LGB’s plans to extend the crusade to the national stage from the model unions that had served as a prototype for the crusaders’ aims and objectives. An official inquiry into charges of neglect against a medical officer could therefore serve the two-fold purpose of getting rid of a troublesome officer and sending out a warning to others who were not stringent enough with outdoor relief or medical extras. As such, the Poor Law Medical Officers’ Association and the BMJ kept a close eye on crusade progress and the persecution of medical officers – informing their members, but also, unintentionally, providing a platform for LGB fear-mongering.56 The intermediate role of the inspectors, discussed in the preceding chapter, was therefore crucial to local cutbacks, and they were at the hub of policy implementation. In recognition of their key role, in 1872, the LGB president gave his assent to increasing powers of the poor law inspectorate. He also sanctioned the creation of a dozen new posts called ‘assistant inspectors’. At a time when most purse strings were being pulled tight, unusually, the president gave his blessing for an increase in the annual budget of £9,000 for their exceptionally high salaries.

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There were two reasons that this happened: first, the public health bill, discussed in Chapter 2, was soon to be passed. This was set to increase the remit and duties of general inspectors substantially. Second, the LGB were working closely with governance and the Charity Organisation Society to implement the goals of the crusade. The LGB were therefore ‘… quite convinced that such assistance is now urgently required for the additional special supervision by their Inspectors of the administration of Out-relief ’.57 The assistants were initially employed for a three-year period, but, at the end of that term, six were retained on a permanent basis. Their main purpose was to aid the virulent application of the Longley Strategy: The Board are now engaged, through their inspectors, in urging specially upon Boards of Guardians a more rigid administration of Out-relief; and in pursuance of this policy it will be necessary for the inspectors to give much more time and attention than they have hitherto been able to give the examination of the books and of the work of Relieving Officers. For these reasons the Board are strongly convinced that it is their duty to provide at once such assistance to their inspectors as may enable them promptly and vigorously to address themselves to their new work and responsibilities.58

The inspectorate’s policy dissemination was centred on a series of regional and annual national conferences throughout the 1870s, with one of the first held at the Social Sciences Association in London. These were reported in The Times and other leading publications of the day. Indicatively, in 1872, Longley was chief representative for the LGB at the ‘second central conference’ of chairmen and vice-chairmen of guardians. The Parliamentary Secretary of the LGB, J. T. Hibbert, proclaimed that much had already been achieved. His observations demonstrate the extent of crusading, the ways that statistics were used to bolster the movement and the ongoing encouragement to new adherents. The number of people in receipt of poor law relief, Hibbert claimed, had been reduced by 11.3 per cent, since 1870, and this had occurred ‘principally in the class of out-door paupers’.59 The meeting also examined the wide disparity nationally between unions in the provision of outdoor relief, such as Atcham, which had a stark 1:1 outdoor and indoor pauper ratio, and Llanelly (arguably, an example of Welsh generosity to the poor in their local communities), who proffered 31:1 outdoor to indoor paupers. Encouraging regional uptake, advertising the success of crusading unions and leading local implementation, thus became key issues for the inspectorate at this time. Figure 5.1 and Table 5.1 demonstrate that the inspectors must have had a significant impact on the practice of medicine in their districts. The clustering effect of doctors ‘forced to resign’ is indicated by four circles (Figure 5.1), centred in districts 10, 12, 9, 2 and 5 – and there are a number of charges in Wales that could widen the central circle. The most important aspect of Figure 5.1 is that certain inspectors can be isolated with those four circled areas: Henley, Cane, Fleming and Longe; and, to a lesser degree, Courtenay and Dashwood. Arguably, the maps in the previous chapter, together with the crusade policy discussed in

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10

11

8

12

7 7

3

8

4

9 2 1 3

4

5 6

Figure 5.1 Map showing charges of negligence against workhouse medical officers in the 1870s and 1880s (and numbered districts of Table 5.1) Source: TNA MH9 series and TNA ‘geographical finding aid for MH32 and MH33’

this chapter, indicate that inspectors played a more influential role in poor law practice than historians have acknowledged. Also, this implies that guardians looked further afield than their immediate locale for inspiration. Inspectors’ districts are notoriously difficult to track through time because the LGB frequently changed the inspectors, numbering and jurisdictions. Table 5.1 has therefore reshuffled the inspectors for 1886, in order to set the relevant inspectors for that year against the geographically corresponding district for 1876 (see Figure 5.1). Despite the alterations to districts throughout the nineteenth century, this comparison demonstrates that some inspectors were consistently conveying policy and retaining the continuity of personal influence.

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Table 5.1 Inspectors’ districts during the crusade District

Inspectors in 1876

Inspectors in 1886

1

Hedley and Bridges

Hedley, Bridges and Jordan

2

Henley

Henley and Jenner-Fust

3

Peel

Peel, Wodehouse (Kent)

4

Farnall

Wodehouse (Kent), Lockwood (East Anglia), Peel (Cambs, Harts)

5

Courtenay

Wodehouse (Sussex), Fleming (Dorset, Hampshire and Wiltshire)

6

Wodehouse

Courtenay, Longe (North Somerset)

7

Corbett

Dansey, Browne (Wales)

8

Doyle

Browne (North), Bircham (South)

9

Longe

Longe (Central and South), Henley and Jenner-Fust (Warwickshire)

10

Cane

Browne (North), Henley and Stevens (Central), Dansey (South)

11

Calley

Knollys (Central and North), Davy (South)

12

Fleming

Davy (North), Dashwood (South)

Source: TNA ‘geographical finding aid for MH32 and MH33’

J. J. Henley seems to have been one of the most zealous and busiest crusading inspectors. In 1872, for example, there was a district poor law conference organized by him in his capacity as LGB inspector for the central region. There were eighteen unions represented at this conference, with delegates from every county in Henley’s district, such as Warwickshire, Oxfordshire, Berkshire, Surrey, Middlesex, Northamptonshire and Buckinghamshire (and some from beyond). The proceedings of this conference were reported in the national and local press and sent to other unions.60 It was clear from this that Henley had organized the mass meeting of guardians to implement the aims of the Longley Strategy. The minutes of this conference unequivocally demonstrate the inspectors’ mode of transferring ideas, laying down policy and influencing practice in the regions. Henley had direct influence on the attendees who were comprised of guardians and officials. Many of those attending were from unions who enacted dubious ‘insubordination’ charges against their medical officers within a few years, such as Brixworth, Cambridge, North Aylesford, Potterspury, Newport Pagnell, Woodstock, Lutterworth and Leighton Buzzard.61 Notably, the delegates unanimously agreed that sick paupers were abusing the system, medical relief was the greatest drain on the rates and that expenditure on this should be curtailed. The main points of discussion hinged on cutting back outdoor medical relief and medical treatments: 1. The ceasing of out-relief for all able-bodied. 2. A strict application of the workhouse test, including the sick poor. 3. Thus, the use of workhouses as hospitals and the withdrawal of outdoor medical relief.

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4. 5. 6. 7.

The strict regulation and curtailing of medical extras. Medical officers must record and make reports about medical extras. Midwifery orders should only be given on loan. Women with illegitimate children should not receive medical relief during sickness. 8. There should be closer testing and checks on the widespread faking of sickness and ‘abuse of the system’ by the sick poor.62

The inspectorates’ enthusiasm for reigning in medical relief shines through this report. Henley regarded the ‘most important resolution’ of that day to be the guardians’ agreement to curtail medical officers’ autonomy: ‘… as the recommendations of medical officers for meat and stimulants are regarded as equivalent to orders for additional relief, they should, in all cases, be accompanied by a report from the medical officer setting forth the particulars of each case, ascertained by personal inquiry and examination of the pauper’.63 Guardians and inspectors were voicing the concerns of the time. Victorians had become increasingly irritated with expenditure on medical relief under the poor law because of a widespread perception that doctors were too ‘lax’ with issuing orders for medical extras. Medical negligence, though, frequently lay at the juncture where crusading policy impinged most heavily on the poor law medical services.

Subordinating medicine Longley’s condemnation of ‘lax’ outdoor medical relief underpinned the conflicting nature of poor law doctoring at this time.64 Williams’ seminal work on the crusade years described adroitly the process of medical subordination to economic ideals under Longley’s Strategy (paraphrased): Longley insisted that expert technical judgement should have a very limited place in the relief decision. There was to be no system of ‘doctors’ papers entitling individuals to certain benefits; the poor law medical officer might decide, for example, the medicines necessary in a particular case but ‘it is for the guardians, and for them alone, to determine whether or not the patient shall receive these necessaries from their hands’.65

From 1870, there was a growing anxiety among poor law officials that had transmogrified into a palpably obsessive perception of over-generous medical officers. Consequently, the 1870s and 1880s were a time when unions restrained public expenditure and there was extensive encroachment into medical matters from non-medical guardians. Brand described the objective of poor law officials as a ‘fear that the poor law medical officer, given free reign over medical extras, would send the costs of medical relief soaring’.66 Following conferences and meetings, such as those described above, medical officers came under severe pressure from boards of guardians to withhold or cut back their use of medical extras.

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It is difficult to define medical extras because, essentially, a doctor could order anything that would improve poor health or alleviate sickness. As Steven King has argued, medical extras spanned a wide-spectrum of relief.67 Impoverishment and malnutrition could benefit from dietary supplements and medicaments; but coal or clothing, for example, could be of equal value to the impoverished sick or infirm. This ambiguity resulted in quarrelling, which sometimes led to conflict, but the final authorization of a medical order was with laymen, not the medical officer. Medical provision therefore depended on a productive relationship between the doctor and other poor law officials, such as guardians, masters and relieving officers. It perhaps need not be spelt out that the miscommunication, friction and warring that ensued among poor law officers was a time bomb that waited for inevitable ignition. Doctors therefore rightly questioned their subordination to lay officers. For example, an experienced doctor wrote to the BMJ in 1879 to complain about attempts in his union to curtail spending on medical extras: In the scrofulous diathesis, can [lay officials] adequately estimate the importance of food and warm clothing, or the amount of evil that may possibly be prevented by a whole shoe or a warm sock … . Surely, when ordering milk and arrowroot in a case of organic disease of the stomach, or chopped meat in intractable diarrhea, I am as truly and perhaps more wisely practicing my art than if I were to prescribe chalk mixture in the former, or bismuth, hydrocyanic acid, or creosote in the latter case. It seems to me either the medical officer must wholly deny the curative and preventative power of ‘extras’, or he must retain the power of administering them in his own hands.68

The authorization of medical extras and drugs had always been a controversial issue, but this snowballed during the crusade into a major cause of discord between medical officers and their employers. Digby described the widespread tension: ‘Contests of authority between the doctor and guardians were found in unions [across the country], and centred on medical extras, which were suspected by lay administrators of being in aid-ofrelief, rather than in-aid-of-sickness’.69 Limiting the doctor’s authority to supply food and essential items for survival may have been motivated by a genuine fear of doctors’ misjudgement and greed, but it also led to cases of medical negligence that had stemmed from malnutrition and physiological need. The Victorian public were therefore interested in cases of neglect and starvation, which were related to withholding outdoor relief – the reporting of which was regular and predominantly spanned the crusade years.70 The poem, which forms the frontispiece to part two of this book, was published by Fun – a short-lived ‘liberal’ competitor to the more famous Punch – as a satirical criticism of the systematic withdrawal of outdoor relief under the crusade. It lampoons a meeting of guardians, but highlights the serious key issues of the time, particularly the resultant starvation of impoverished people, such as Charlotte Hammond (named in the fifth verse). It was claimed that she had died as a result of her refusal to enter a workhouse. Hammond’s family had some income and possessions, which divided

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contemporary opinion over the case. Her five-member family shared one room, but there were working adult children and Charlotte’s temporarily unemployed husband. They were, however, clearly impoverished. Given the restraints upon them, it seems that Charlotte made a choice to forego her own nutrition in order to feed the family and pay the rent. The Hammonds were exemplary of the social cost of crusading, brought about by using a narrow decision process to distinguish the deserving from the undeserving claimant. Crusading offered an asymmetrical dichotomy of giving and withholding relief, which ignored essential living costs (such as housing) and abandoned all but the most extreme cases of poverty. The LGB’s inquiry into Charlotte’s death, in a district of St George’s, Hanover Square Union, was reported in The Times and other publications in 1876. In defence of the St George’s Union, Mr Henry Hardcastle, the chairman of their Relief Committee, said: ‘He had been endeavouring, as a Guardian, to minimize outdoor relief, and the Guardians had reduced it from £5,000 to about £1,600 a year.’71 This was unsurprising; St George was one of the model crusading unions. It featured heavily in the annual guardians’ conferences of the 1870s. In 1872, for example, the ‘East End Guardians’ (such as those for St George, Lambeth, Poplar, Stepney, St Marylebone and Whitechapel) reported that their policies for outdoor relief had largely led to the ‘progress’ that had reduced the number in receipt of relief in the Metropolitan area by 38,000 from the preceding year.72 Indeed, between 1872 and 1876, Shoreditch and Whitechapel reduced their numbers of paupers receiving outdoor relief by a staggering 80 and 86 per cent, respectively.73 Outdoor relief was therefore at the heart of the Hammond case. Questions revolved around the ‘fraudulent’ nature of the Hammonds: it was claimed that Charlotte would have entered the workhouse if she had been truly poor. Yet, a guilt-stricken medical officer, Dr Fenton, regretted issuing an order for the workhouse. He had done this in line with his duties and in the belief that Charlotte could be better treated there: ‘… he could not cope with her disease unless she had outdoor relief or went into the house … . He spoke to her seriously of her condition, but she strongly declined going into the house’.74 Under oath, Fenton recollected: ‘… he gave the daughter a certificate recommending 2lb. of mutton and some tea and sugar to be given once a week for a month. Later in the day he visited the deceased and found that this relief had not been given; and she complained that, instead of food, she had got an order for the house’.75 The guardians defended the relieving officer: ‘The medical officer was the judge of a pauper’s state of health; but the relieving-officer had always a certain amount of discretion in refusing relief.’76 The workhouse test had been rigidly applied and, therefore, the LGB were unlikely to pinpoint their own policy as the cause of a latent failure within poor law relief. Instead, they focused on the active failure of individuals: the relieving officer, medical officer and, unusually, the patient – who, it was said, had chosen starvation over the workhouse. The relieving officer was commended by the guardians, but they called for Fenton’s resignation or dismissal: ‘… on account of the generally unsatisfactory manner in which he has performed his duties, and especially for his conduct in the case of the late Charlotte Hammond … it would be quite impossible to carry out

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the duties assigned to them with Mr. Fenton, who had studiously act their orders at defiance, and seemed to have gratification in causing sensational cases like that of Charlotte Hammond’.77 Squirming under the public gaze, such as that of Fun, one of the guardians warned, ‘… if the doctor erred it was upon the side of humanity, and in that would meet the support and sympathy of the public. He begged that the Guardians would not display anything like a vindictive feeling towards the medical officer, if they did they would be held up to opprobrium’.78 This was ignored. The BMJ, of course, came to the defence of the doctor. The journal agreed that the Hammonds were not destitute – and therefore undeserving of relief – but expressed no surprise that the guardians had been ‘exonerated’. The BMJ lamented the hierarchy of blame, which had led to Fenton as the ultimate scapegoat: ‘… a gradation of opinion which has arisen probably from the belief that the doctor, having fewest friends, may be kicked with impunity’.79 In the final judgement, both the relieving officer and medical officer were severely reprimanded by the LGB inspector – though, unusually, both officers kept their jobs. Cambridgeshire was another nexus of crusading ideals located by Hurren. Here, the poor were forced into the workhouse to receive any poor law relief from destitution, and their strategies of survival at home crumbled. Hurren speculated that the economy of makeshifts, and care in the community, was peeled away to such an extent that the paupers in Cambridge may have sold the bodies of their dead in return for funds from local college anatomists.80 If further evidence were needed of the Longley Strategy’s interlocution with the medical officers’ fortunes, Rogers attacked the Cambridge Union (among others) in an 1880 meeting of the Poor Law Medical Officers’ Association: As to Cambridge, he had known that, for the past twenty-five years, it had been distinguished as the worst managed union in the kingdom as regards its Poor-law medical relief. For years, it was at variance with its medical officers, and now treated them on the starvation principle, and the ratepayers had to pay for it. Cambridge had a population of 30,000 in 1871; and it provided no quinine, cod-liver oil, or other expensive medicines … . The result of his inquiries in Cambridge was, that every possible discouragement was given to the administration of proper medical relief to the sick poor. The districts were so arranged that the poor had to travel needlessly long distances for medicine. The guardians were too much in the habit of looking upon the poor as troublesome individuals, without thinking of the evil results that accrue in the way of pecuniary expenditure from such a course.81

Moreover, the workhouse medical officer for the Cambridge Union, Dr Ransom, had set himself at odds with the board of guardians by seeking local medical welfare reforms.82 Echoing Rogers’ experience at the Strand, Ransom was forced to resign. After seeking improvements in the workhouse, and his salary, Ransom had carried out a very public battle by writing letters to the local newspapers, giving candid criticisms of the Cambridge Union.83 Ransom was suspended and charged with neglect – essentially, because of the public embarrassment he had caused Cambridge Union.

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In the words of the guardians, Ransom was forced to resign because of ‘his public comments upon the conduct of the Board of Guardians (whose officer he was and whose lawful directions he was bound to obey) through the medium of the public press [and] that such comments and proceedings are so highly improper … ’.84 Yet, many doctors – within and beyond the poor law – were in agreement with, or were themselves, cutting outdoor relief. As a professional mouthpiece, the BMJ outwardly criticized attacks on medical autonomy. Editorials, however, tended to tally with Longley’s viewpoint – as did most of the Victorian press. For example, the BMJ wrote that ‘a large proportion of pauperism notoriously originates in relief granted for sickness’ and thus a ‘general increase of pauperism may be in a great measure attributed to laxity of administration in this respect’.85 Whether it was willingly or reluctantly, poor law doctors’ ‘gatekeeping’ (e.g. Fenton) consistently involved them in tests and checks for malingering and ‘abuse of the system’. Digby has said that ‘attempts to restrain public expenditure meant that the doctor was but one amongst several gatekeepers’,86 but their bifurcated role stands out as a direct route to conflict and negligence during the crusade. If medical officers held the gate too fast and paupers died from need, they were blameworthy. If they let the gate fly loose and gave too many medical extras, they were over-generous and held in contempt. Examining paupers for sickness in some unions could thus develop into the reverse during the crusade. For example, at Stow-on-the-Wold Union, the district medical officer was accused of neglecting a pauper. In his defence, he questioned the pauper’s status and claimed that his services were only wanted by this patient for the ‘purpose of ordering meat and wine’.87 Unsurprisingly, given the Union’s status as a Victorian proto-pilot study, Brixworth was testing rigidly for ‘malingerers’.88 In 1874, the BMJ quoted the union’s committee, which had met to consider medical relief: ‘A very large proportion of cases obtained relief in the first instance through medical certificates for some illness, either feigned or only of a temporary nature … .’89 The Brixworth Union medical officer agreed with this and ‘confessed that there is a strong tendency on the part of the poor to feign disease’.90 Victorian doctors saw no contradiction between their own crusading sentiments and their battle against the withdrawal of medical outdoor relief. Rogers may have railed against unfavourable aspects of the crusade, but he had seemingly crosscurrent loyalties. Rogers spoke highly of Trevelyan and worked with him on – what he called – a ‘public movement’ that they were both involved in. Given the timing, this was possibly the Charity Organisation Society.91 Hurren has said of the joint objectives of crusaders in the poor law and Charity Organisation Society, ‘… the drunk, the idle and the profligate should be rejected on moral grounds because they drained resources and hoodwinked charities and guardians’.92 Doctors were frequent and willing participants in searching them out. Rogers and Adam Simpson were two of the most respected members of the Council of the Poor Law Medical Officers’ Association, but this did not preclude them from carrying out malignant tests of deservedness. Both of them were involved in what, to twenty-first-century observers, seems questionable medical practice – but, to them, were acceptable tests for weeding out ‘malingerers’. Two LGB official inquiries were carried out against Simpson (in 1882 and 1886) before he was

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dismissed from his post as medical officer for Birmingham Union’s workhouse infirmary. Simpson had been accused (and found guilty) of ‘punishing’ mentally ill patients and subjecting ‘refractory patients’ to blistering and shower baths.93 Rogers was infuriated by the lay accusations against Simpson, and wrote a scathing tract in the BMJ: ‘… no one who has not held such an office can be at all aware of the amount of malingering and deception that one has daily to encounter … . To such impostors, mustard poultices, blisters, the galvanic battery, or the shower bath, appear to me to be the most fitting treatment.’94 Victorian doctors were therefore not above reproach. They agreed with, and put into dangerous practice, some elements of the pseudo-philosophy of the crusade. At the height of the crusade, in the 1870s and 1880s, there was an increase in deaths of paupers who had been treated in the wrong way for their condition – dying from starvation or neglect, due to ‘malingerer’ tests. For example, in 1877, a drunken man was admitted to the West Derby workhouse. Despite having breathing difficulties, he was placed in the padded room after he became ‘difficult’. The next morning he was found, ‘in a crouching position, dead’.95 In 1872, the workhouse medical officer for Nottingham, William Dunn, put an inmate into the lunatic ward even after realizing that he was sane, and left him there for ten days as punishment.96 Whether willing or coerced cohorts of the crusade themselves, medical officers in certain unions, such as Brixworth and Cambridge (with a predominantly crusading board of guardians), found themselves under pressurized working conditions from 1871. Thus, a majority of workhouse medical officers who resigned under threat of dismissal during the crusade years, such as Fenton and Ransom, had experienced clashes with their employers in the preceding months or years before a charge was made against them. The intense workload of poor law doctors is reflected in the standard of care provided at workhouses and their infirmaries, which buckled under the strain of a more stringent workhouse test. Dr Langston of North Aylesford Union was typical of the workhouse medical officers who experienced a growing workload as numbers of patients (inmates) increased under the crusade’s impact. The Union followed the practice of severely cutting medical outdoor relief in the 1870s and targeting medical autonomy. Langston, was thus inundated with paupers and an unexpectedly high infirmary workload in the early 1870s. He requested a raise in his workhouse salary but it was refused. Instead, the guardians forced him into resignation for ‘gross insubordination’ and subsequently rearranged his former district to make further savings on medical welfare expenditure.97 Across the nation, however, initial savings from withdrawing outdoor relief were to be eclipsed by the spiralling costs of indoor relief. Crusaders had unintentionally ‘replaced the lenient system of outdoor relief with the more expensive one of institutional care’.98 As contemporaries observed, the ‘absolute’ numbers of paupers may have decreased, but the ‘relative expense’ of welfare had increased. The National Federation of Employers of Labour examined the fifth annual report of the LGB, for 1875–1876. The Federation reported that pauperism as a whole had been reduced by 23 per cent, when that year’s figures were compared with 1870–1871 (which, at 1,037,360, was said to be the highest ever noted).99 Yet, the Federation also observed

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that the cost of maintaining a workhouse pauper had almost doubled between 1851 and 1876, though the numbers had only risen from 114,367 to 146,800.100 Furthermore, workhouses may have been improved in their size, structure, amenities and ‘cosmetic’ (civic pride) appearance, but the lavish expenditure had brought no investment in staffing. This became visibly apparent in some unions, when patients were piled into already overcrowded workhouse infirmaries during the crusade. Historians wishing to chart the course of the crusade, or map its implementation, would do well to examine the records of the poor law medical officers in the 1870s and 1880s. Charges of neglect against them can serve as a divining rod for identifying crusading unions. National and local employment records of thousands of medical officers indicate a widespread reactionary stance to medical welfare in the 1870s and 1880s.101 The crusade does not explain all cases of negligence at this time, but it was a major factor in the increased quantity of charges of negligence against poor law doctors and nursing staff. The medical services of the poor law became more heated where and when crusading permeated attitudes to medical welfare. The policy was an excellent example of how cultures (of practice and society) and latent failures (set within a system) can interact with individual active failures to shape – one might argue, to create – medical errors, substandard care and negligence. As medico-legal academics, Richard Baker and Brian Hurwitz, describe, ‘Active failures are the immediate causes of the safety incident … . The latent failures rest in the systems, procedures and culture’ of organizations.102 Thus the crusade was itself a latent failure that was set by the ‘upper echelons’ of poor law administration. It relied on sick people’s self-sufficiency in the home and a reasonable standard of care in workhouses (that was not the norm for the time). As a result, when put into practice, the crusade also interacted with the active failure of individuals, such as relieving officers and doctors who were faced with untenable obligations. In turn, latent failures worked in tandem with the rules and contractual duties, described in the previous chapter. ‘Outcome bias’ is a modern health and safety term, but it can be equally applied to the poor law, where negligent practice was ubiquitous but only dealt with when it led to catastrophic or ‘scandalous’ outcomes. The ‘Swiss Cheese’ model of accident causation, exemplified by James Reason, is a useful way to consider the complex interaction of systemic, latent and active failures that underpinned the sharp rise in the number of medical officers forced into resignation or dismissed in the 1870s and 1880s.103 In this image, multiple slices of hole-ridden ‘Swiss’ cheese can represent the multiplicity of factors that go into creating a health care space. For example, layers may relate to the administrators, cleaners, managers and lawyers that crowd out the medical practitioner, influencing and shaping medical practice: the ‘strangers at the bedside’, described by the medical sociologist, David Rothman.104 In the ‘Swiss Cheese’ model, medical mishap is more likely when the different aspects (layers) of that medical provision – from the personal failure to the administrative or clinical mistake – are ‘lined up’. Thus, the different components have come together to create an unintentional, but unhindered, pathway to neglect through the ‘holes’ in adequate care. Arguably, the protections against negligence in poor law medicine were threadbare. As a result, numerous holes were all too frequently

A Latent Failure: The Crusade against Outdoor Relief

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Table 5.2 Reasons for leaving for all workhouse medical officers between 1860 and 1909 Reason for leaving

1860–1869

1870–1879

1880–1889

1890–1899

1900–1909

Voluntarily resigned

75

182

168

194

132

3

10

2

7

5

Retired or ill health

23

78

68

90

96

Died

55

99

98

76

68

Indication of forced resignation

14

48

19

15

10

2

4

5

1

2

172

421

360

383

313

Transferred to another government position

Dismissed Total Source: TNA MH9 Series

presented and ‘lined up’, contributing to a high-pressure environment and the general increase in medical officers who ceased employment in the 1870s (Table 5.2). In part, the increased numbers for all categories from the 1870s may have been a by-product of the Union Chargeability Act in 1867, discussed above. The Act may have brought about higher numbers of workhouse medical officers recorded in the central records. It could also have led to higher numbers of resignations, due to dissatisfaction, after the Act’s impact on ratepayers had signalled an increase in the medical officer’s day-to-day workload. From 1871, the LGB may also have insisted on more accurate recording of their employees than had gone before. In addition, the right of superannuation from 1896 (discussed in Chapter 2) seems to have affected numbers of doctors who resigned and those who died while holding their post: the former figures rose from the 1890s, while the latter number fell. In spite of those confounding factors, the crusade undoubtedly interplayed with the high numbers of resignations (forced or otherwise) shown in the 1870s (and to a lesser extent in the 1880s) in Table 5.2. Of the 1,649 workhouse medical officers recorded as leaving employment between 1860 and 1909, 120 (over 7 per cent) had done so through dismissal or a clearly indicated enforced resignation. Table 5.2 shows that over 63 per cent of the cohort of 120 was forced to do so in the 1870s or 1880s. Voluntary resignations, arguably, rose and fell in line with the crusade because this category conceals an array of reasons for leaving. The numbers of ‘forced’ resignations would be higher still if the hidden numbers, the ‘iceberg’ discussed in Chapter 4, were to be considered. Many of those concealed a ‘leap before pushed’ scenario, such as dissatisfaction, stress or employer coercion. These were medical officers who resigned rather than continue an untenable position; or left their post after an accusation of neglect, in order to avoid an official inquiry or negative publicity for their private practice. There was a rise also in the 1890s, which may be an indication of the Superannuation Act’s impact – perhaps some pension awards or payments were wrongly recorded as voluntarily resigned or other doctors resigned after an application was refused. Table 5.2 also provides an indication of the figures that may be expected for the thousands more

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district medical officers, whose interaction with crusading was more overt – which is explored in Chapter 7. In the short term, the crusade had reduced the number of paupers, but it had also cleaved a schism through poor law medicine – steeped in welfare attrition on one side and low standards of institutional care on the other. It was a crushing blow to delicate micro-economies outside of the workhouse and contributed to an ‘exodus’ of vulnerable cases into workhouses during this period.105 The next chapter will therefore first appraise the standard of care across the workhouse medical services, and then use a case study to reveal the human story of paupers who were interned at this time. The intricate details of the official inquiry will, in turn, expose the double-edged effect of the crusade on standards of care in both institution and home.

6

Survival of the Fittest: Indoor Neglect

Background At the beginning of the crusade, in 1869, the House of Commons had sought an explanation for the rising cost of the poor law. This was reflected in the increased rates at this time. As the previous chapter described, this had attracted attention across the political and public spheres. When answering questions from the House, the Poor Law president, Goschen, blamed the public’s insistence on higher standards of care in workhouses. He alluded to the events that had led to the Lancet inquiry of 1865–1866 and described a forceful ‘public conscience’ that had become dissatisfied with the treatment that the sick poor received in workhouses. According to Goschen, ‘The consequence was that every kind of improvement in the sanitary and general condition of the workhouses had been demanded from that time to this, and the expenditure had increased accordingly … we could not expect the rates to be kept down at the same time that we were establishing a higher standard of treatment for the poor’.1 In spite of some questionable evidence, Goschen’s financial concerns drew on an exaggerated image of the improved workhouse hospital as a national norm, a view which was accepted by a broad section of the crusading Victorian public. Humphreys’ research into the Charity Organisation Society has shown that, beyond London, charity did not provide the hallowed net to catch the ‘deserving’ cases of vulnerable and pauperized people: ‘… nationally the categories of outdoor paupers who suffered most from the crusade were not the able-bodied groups … . In reality by far the greatest fall in out-relief numbers were among disadvantaged categories of pauper, including the aged, the infirm, the disabled and widows with their dependent children’.2 Though the crusade sought to target ‘idlers’ and ‘undeserving’ cases, the withdrawal of vital payments for familial carers drove up the number of institutionalized and vulnerable patients.3 Once interned, they faced an uncertain future. The poor law infirmary offered the legal promise of ample diet and appropriate medicaments; however, these were of little use if a patient needed frequent assistance to eat or if they were dependent on carers for round-the-clock care. Survival in a ‘provincial’ Victorian workhouse depended on your condition Parts of this chapter were originally published in a slightly different form in: K. Price,‘ “Where is the fault?”: The starvation of Edward Cooper at the Isle of Wight Workhouse in 1877’, Social History of Medicine 26, 1 (2013): 21–37. Reprinted with the kind permission of Oxford University Press and the Society for the Social History of Medicine.

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matching the sparse care. Workhouse infirmaries were notoriously short-staffed. As a result, dependent and vulnerable patients were particularly prone to physical emaciation and neglect. Despite using workhouses as the nexus of medical relief, many poor law infirmaries were providing a level of care that was almost half a century behind equivalent services in voluntary hospitals.4 There had been no investment in medical staff, and the majority of those who actually carried out the care (and medical) work were untrained and unqualified. This chapter will show that a low nurse-to-patient ratio, and the continued use of pauper nurses, interacted negatively with the rising numbers of vulnerable cases in workhouses during the crusade. While the Longley Strategy was being backed by such a strong majority, the dependent, vulnerable and sick poor (including those with disabilities, mental health problems or learning disorders) saw their options dwindle. In spite of the crusade dominating the latter decades of the Victorian poor law, historians know little of how it interacted with the care of the poor ‘on the ground’. The central motivation of this chapter is therefore to reveal the experiential history of provider and recipient of workhouse care under the Longley Strategy.

The workhouse funnel The central tenet of the crusade was to withhold outdoor relief payments, thus forcing the poor to turn to work, self-help, charity or, as their final choice, enter the workhouse. Crusaders argued that workhouses and their newly built infirmaries were fully capable and rejuvenated institutes. After the Metropolitan Act of 1867, a genuine belief in improved conditions was understandably widespread. Reports from the capital city described ‘neat and trim’ workhouse infirmaries – a world apart from the Lancet reports of a mere few years before.5 Moreover, after London’s reforms, a few workhouses from across the nation had followed suit. Most of those were in large urban unions, such as Birmingham, Liverpool, Manchester and Halifax.6 The guardians there equipped their infirmaries in line with contemporary thinking – providing cleanliness, space, light, air and humane care – and staffed their ‘State hospitals’ with dedicated doctors who were assisted by professional nurses and a new breed of ‘probationer’ nurses (trained in and for the workhouse infirmary). Nevertheless, it is important to recognize that this was not an orchestrated national policy. In 1894, the BMJ argued that, nationally, the few localized improvers had resulted in a misrepresentation to the public: ‘… reading of these things, and quite ignoring the fact that these are altogether exceptional institutions, they go their way thinking that after all the lot of the poor is not so very bad’.7 The extent to which London’s dispensary system rolled out across the nation was a cause for debate, then, and has remained so ever since.8 A study such as this – focused on ‘negligence’ – must adopt a cynical view of improved standards of care nationwide. There is simply too much evidence to suggest that the majority of provincial workhouse infirmaries continued as they had before the Metropolitan Act. Except for those of large towns, most guardians outside of London maintained

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a makeshift workhouse infirmary, staffed in the main by paupers. Although the civil servants and inspectors of the Local Government Board (LGB) discouraged the excessive use of outdoor medical relief, they did pressure guardians to employ paid nurses, but with mixed results explored in the next section. The LGB also pushed them to build bigger infirmaries and ‘improve’ indoor medical services. Yet, this was expected to be achieved at the same time as miraculously reducing investment in medical services. Ultimately, responsibility for the standard of care in the infirmary devolved onto a distracted medical officer with little funds at his disposal and impotency in terms of power. Official sanction was given in clause (7) of Article 207 of the General Consolidated Order, which outlined the duties of a medical officer in the nineteenth century: ‘To report in writing to the Guardians any defect which he may observe in the arrangements of the Infirmary, and in the performance of their duties by the nurses of the sick.’9 As Chapter 4 detailed, the General Consolidated Order provided the legal elements of a medical officer’s duty to treat the poor. It also underpinned their ‘obligation’ to ensure that infirmary conditions were up to scratch. On the one hand, this could mean a fight with boards of guardians over standards of care; or, on the other hand, it might have resulted in avoiding quarrels but allowing substandard care – by any contemporary yardstick – to continue. Doctors, such as Rogers – who were clearly reforming and dedicated to raising standards of care – mostly, came up against severe difficulties and time constraints, whether their guardians were supportive or not. A small rural union workhouse with few patients was no guarantee of high standards, but nor was a progressive city location with too few medical staff. As a result, the patchwork character of the poor laws pervaded workhouse infirmary practice too. For example, a rural union’s ratepayers, such as those of Falmouth, may battle against expansion of a small workhouse infirmary;10 whereas in a large town, such as Oldham, they may pitch one medical officer against hundreds of medical cases.11 Improvements, such as they were, came from a managing perspective. Curative and preventative medicine was not yet seen as a worthy brake on spiralling sickness-related poverty. Hart was at the forefront of the Lancet campaign in 1865, before becoming the editor of the BMJ (from 1867 to 1898). Three decades later, he berated the LGB for the ‘false economy’ of not insisting on healing the poor – arguing that if all the infirm ‘were medically treated’ as they were in London, there would have been more recoveries and, therefore, ‘important savings on the rates’.12 As described below, Hart continued to attack the poor law until his death; particularly the negligent care in workhouses caused by pauper nurses. A further brake on improved standards of care remained in the unions that adapted workhouse accommodation blocks into hospital provision for the poor. The switch from the wheel-spoke design of the early workhouses (built in the 1830s and 1840s) to pavilion workhouses, from the 1860s, brought some benefit to many infirmaries. Yet, this was limited. Williams described the architectural process (advanced by prodding from the LGB) as ‘a second best solution’ of ‘adding pavilion blocks’ to already existing workhouses: ‘In this context, perhaps the fatal weakness of the pavilion system was that it lent itself so well to the piecemeal modification of existing institutions with the addition of extra pavilions.’13 Although an improvement

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on the old workhouses, pavilions were somewhat of a stopgap, an opportunity, used by guardians who had recognized that sickness occupied the lion’s share of the workhouse, but were unwilling to make radical – expensive – alterations to medical provision. Though pavilion blocks sometimes brought better separation of the sick in some unions, others were pushed for decades before they distanced their medical wards from the main workhouse building. Even when compelled to do something by a genuine concern for the inmates, guardians could be held back by local ratepayers or unwilling to go down the route of London’s expensive reforms. Looking back to the crusade years, the Webbs observed that ‘the two fold policy’ – of cutting outdoor relief and increasing indoor paupers – ‘… emanating from the Local Government Board has been reflected in the medical administration of the boards of guardians up and down the country, in an irregular manner and to a varying degree’.14 They added that the ‘great majority of unions’ had been ‘equally impervious to both sides of the advice and injunctions of the Local Government Board’.14 Consequently, the contradictory programme of workhouses (built to deter the feckless) had evolved ‘willy nilly’ into hospitals for the poor.15 Yet, historians have understated both the dangerously low level of care that was sustained under the crusade and the impact of publicized cases of negligence on the Victorian conscience. The reaction and agitation against substandard care would eventually lead to the reforms (discussed below) that were to come in the 1890s. Before then, workhouse medical officers in crusading unions observed an increase in the numbers of sick poor and a backwash against humanitarian-type (expensive) medical reform. In turn, there was a funnelling of greater numbers of the sick, infirm and disabled poor into workhouses, which led to overcrowding – and overstretched staff. For example, Henry Coleman, the workhouse medical officer for Lutterworth Union, thus described the unsuitable infirmary wards and his increased workload between 1870 and 1874: The union workhouse as it now stands contains as inmates, imbeciles [and] the aged and infirm – scarcely one of the inmates can be considered as able bodied. The accommodation for the sick is inadequate to supply the demand. The male infirmary is too contracted and close, and between that and the lying-in ward a lattice plaster partition only exists which allows everything to be heard on both sides. The nurses are not competent to attend to the absolute and almost hourly emergencies of the sick, the imbeciles being composed of such a class as to require constant watching.16

Coleman resigned after regular disputes with guardians over pauper nursing and, as such, the low medical staff-to-patient ratio. His was a typical scenario in the 1870s. Nationally, the workhouse system was understaffed, ill-equipped and totally unsuited to cater for mentally ill or disabled patients. The workhouse was supposed to be, in essence, a safe house for the chronic ‘imbecile’ or ‘idiot’ – those with physical or mental disability or learning disorders.17 After the 1860s, however, there were greater numbers of chronic cases in workhouses than the medical staff could cope with. Historians of disability, such as Wright and

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Borsay, have argued that many county asylums were overcrowded from then.18 As such, the chronically mentally ill poor were, in over-stretched counties, returned to the workhouse. This, together with tightening economics and the crusade, conflated numbers of institutionalized poor law patients under various contemporary mentalhealth categories.19 The commissioners of lunacy did inspect amenities but their powers were limited.20 The BMJ said the ‘inspection of the insane in workhouses by the Commissioners in Lunacy was a mere farce [and] there is one subject which, somewhat to our surprise, the commissioners pass over in silence, and that is, the obvious insufficiency of the medical staffs … ’.21 Despite some workhouses employing nurses and wardsmen, there tended to be a very low standard of care. The physically or mentally disabled were frequently left with patients with learning disorders or serious mental-health illness – housed in wards for ‘lunatics’, ‘imbeciles’ or ‘idiots’. Accidents were frequently caused or ignored by fellow patients. The limited care provided for the disabled and mentally ill patients (detailed below) was a key nexus for the ‘active’ neglect of pauper nursing to interact with the ‘latent’ failures of the system. The problems that underpinned negligent care during the crusade were not new – overcrowding, understaffing and underfunding had always been there – but pre-existent latent failures were exacerbated, which propelled negligent care to a more dangerous level. In short, there were many workhouses (arguably, the greater proportion) which were unable to cope with the net result of the policy to prohibit outdoor relief. Oldham workhouse, for example, was the subject of scandal in 1894 when a mental-health patient committed suicide in the nocturnal hours by jumping from one of the windows. The problems escalated, however, when in the same evening a nurse mistakenly fatally poisoned a sick inmate, inadvertently revealing problems in the provision of care. The nurse had reached into a cupboard to fetch a dose of whiskey, but got the wrong bottle. Instead, she had given the patient a spoonful of atropine solution (poison, derived from deadly nightshade). A jury found that she was overworked and her actions had been accidental – and thus it was ruled ‘death from misadventure’. During the court hearing, it had emerged that she was the only nurse for three blocks of buildings and over 200 beds.22 Thus, even where there was a paid nurse, it was no guarantee of a good standard of care. The absentee part-time doctor, described in Chapter 2, was one part of the problem in workhouse care, but – as Coleman had said – inadequate nursing intensified the situation.23

Pauper nursing In effect, workhouse infirmaries were predominantly staffed by the inmates and patients themselves, as ‘pauper nurses’ and attendants. The care that was provided by them created a general standard of care that was far below the expected level for the time. According to Hart, it led to an extreme situation: ‘… few days pass but that in one country newspaper or another news is given of a catastrophe that has resulted from the want of trained nurses … ’.24 This was recognized by the LGB who, from time to time, sent out circulars with the aim of encouraging the uptake of paid

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nurses. Dr Arthur Downes, medical inspector for the London Metropolitan district, thus released a circular to all unions in 1892, advising guardians to halt their reliance on pauper nurses. The circular, though well informed, did little to compel guardians to cease this practice. Instead, it reiterated an earlier circular of 1865. It reminded guardians that, though cheap, inmates were a bad investment: ‘Where pauper nurses are directed to act as assistant nurses there is no stimulus to exertion, no test of capacity, and no responsibility for negligence.’25 Nevertheless, this type of advisory circular had little effect. Downes tried to prod guardians by appealing to the ‘false economy’ of using paupers to staff the infirmary. On one hand, he agreed, trained nurses were costly – in terms of salaries, uniforms, rations and quarters. Yet, Downes argued that they were an efficiency saving on the rates. Under their care, ‘curable cases’ would recover more quickly; food and drug wastage decreased; and ‘malingering’ was detected. Trained nurses knew how to use medical appliances properly, added Downes, which limited costly misuse and breakage. They could also ensure an economically viable future by their ability to train probationers. In spite of LGB guidance, numbers of professional nurses under the poor law remained extremely low throughout the nineteenth century. As such, most workhouse infirmaries were reliant on pauper nurses and wardsmen. Whether or not some of those were caring or capable, they were renowned among Victorians for their frequent negligent actions. According to some historians, such as Peter Ardern, pauper nurses were mostly ‘alcoholic prostitutes’26; but this harsh stereotype belies a wide range of inmates that were used as nursing staff. They could be drawn from the disabled, and those with learning disorders, to the old, convalescing or able-bodied paupers.27 Most often they were paid with extra rations and alcohol or rewarded with other forms of privileges. Alfred Sheen’s almanac for medical officers thus described a common problem of recruitment: ‘Competent and willing patients are selected from time to time for these offices, but they are constantly changing, as patients are never detained specially for this work.’28 The revolving door of the workhouse meant that residual pauper staff were likely to be aged, chronically ill or disabled. This resulted in pauper nurses and ward attendants, who were illsuited to manual work and – what we now call – ‘people handling’. Notwithstanding the odd, anomalous union, it is important to recognize that professional nursing in the poor law was not implemented with any clear strategy until the 1890s – after Hart’s campaign in the BMJ, described below. This was for a number of reasons, but two tethers were particularly inhibiting to growth: on one hand, professional nurses were expensive; on the other, the demand outstripped the supply. Numbers of professional nurses remained far from adequate until after the First World War. It has been estimated that by the turn of the twentieth century, there were 69,000 nurses in total. Of these, somewhere between 12,500 and 25,000 were trained or qualified.29 Moreover, the mushrooming of numbers of professional nurses, from the late nineteenth century, often obscures the true picture before then. Furthermore, the broad figures – which cover all sectors – skew the reality for nursing in Victorian workhouses. In 1861, for example, there were less than 1,000 women employed as ‘hospital’ nurses across the entire voluntary,

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charitable and ‘State’ sectors – a figure which would shrink drastically for numbers of nurses in workhouses only.30 It is impossible to precisely state the figure, but in 1902 it was estimated that there were 1974 ‘probationers’ spread thinly among the poor law institutions of the entire nation. Of those, only 925 were in the provinces – the rest were in London.31 Given that there were nearly 600 unions beyond the capital city (if those probationers had been shared equally), there would have been approximately 1.5 paid nurses to each one. In contrast, Table 6.1 shows that the patchwork poor law resulted in unions with ‘good’ levels of nursing, such as Withington (with 50 paid nurses), and others, such as Bath, that used ‘paid nurses’ as a misnomer for one trained nurse and a number of employed inmates.32 As a result, there were various schemes adopted across England and Wales to combat the shortfall in professional nurses in workhouse infirmaries. London (after the Metropolitan Act) led the way in hospital provision and the training of nurses.33 By 1894, Mile End Infirmary, for example, could boast of thirtyseven nurses (including probationers) under the authority of a trained superintendent nurse.34 Training and certification was also taking place in the majority of workhouse infirmaries in the capital city. Outside of London, there were some similar initiatives, but the broad sketch is one of limited development. Recognized training and qualifications in nursing remained a moot point throughout the nineteenth century. Lengthy work experience, good character, obedience and maturity formed the benchmark of a good workhouse nurse.35 Nevertheless, some unions, such as Leicester’s, did begin to train their own nurses.36 Interestingly, after decades of reactionary practices in workhouse medicine, the north was far ahead of the south and east of England in introducing higher standards of nursing.37 It was a hotbed for the training of nurses in workhouse infirmaries. Much of this activity had stemmed from the Workhouse Infirmary Nursing Association, which began in 1879 and was a pervasive force in the north for almost two decades.38 The association’s mandate was to publicize the plight of pauper nursing in workhouses and to train and supply nurses to workhouse infirmaries; with a subsidiary objective, to agitate for the compulsory employment of matrons trained in nursing.39 The association reported that each year there was a steady increase in the number of requests from guardians for trained nurses. By 1897, the association claimed that it had received 1,225 applications from unions for nurses; 805 had been appointed. Of those, 321 had been trained by the association at a total expense of £3,700 (each nurse cost £12 to train for a year). In the same year, they had 105 nurses at work in fortyeight workhouse infirmaries. Yet, the decision was made to dissolve the association because it ‘had not been able to meet the demand’ for nurses. As such, they had been forced to accept that the situation could only improve when ‘training and supply of nurses’ had been successfully brought to a ‘larger scale’ and ‘undertaken by a state department’.40 The Nursing Record reported another stumbling block for the Workhouse Infirmary Nursing Association (and for all nurses with similar trainee backgrounds): some guardians objected to the requirement for a nurse to serve the ideals of their training provider before that of the guardians. The association had invested greatly in the training of these nurses and, as such, it insisted that they sign a contract to

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Table 6.1 Extracts from the BMJ’s investigation of fifty provincial unions Union

Hatfield

Number of beds

Trained nurse (Day)

Trained nurse (Night)

Accommodation (General wards)

General remarks

36

1

0

‘Very crowded’

‘Sanitary arrangements bad’

58

2

0

‘Crowded’

—

Bishop Stortford

112 (including fever hospital)

1 midwife

0

—

‘Very fair but for pauper nursing’

Haverfordwest

32

0

0

‘Crowded’

‘Bad altogether’

Bath

230

1 (+2 trainees)

0

‘Crowded’

‘Bad’

Bishop Auckland

115

1

0

—

‘Nursing staff inadequate’

247 (including ‘imbeciles’)

2

1

‘Only one day room for men’

‘Nursing staff wholly inadequate’

Aberystwith

18

0

0

‘Women’s ward crowded’

‘The best made of inadequate arrangements’

Chester

Wrexham

138

1

0

‘Sufficient’

‘Tone and management good’

Darlington

72

1

0

‘Sufficient’

‘Very fair except for insufficient staff ’

Wakefield

130

2

1

‘Sufficient’

‘Insufficient nurses’/‘ “dirty cases” badly located and neglected’

Lanchester

49

1

0

‘Sufficient’

‘Very fair infirmary’

Liskeard

54

—

0

—

‘Structure old and bad’ (Continued)

Medical Negligence in Victorian Britain

St Albans

Union

Trained nurse (Day)

Trained nurse (Night)

Accommodation (General wards)

General remarks

Plymouth

184

2

0

‘Scattered wards’

‘Hopeless structure’

Festiniog

26

0

0

‘Ample room’

‘Master and matron the only officers for all purposes’

Keighley

98

1 (+2 probationers)

1

‘Sufficient’

‘Insufficient staff ’

Truro

78

0

0

‘Small scattered wards’/‘no day rooms’

‘Unsuitable structure and no nursing’

Stockport

300

3

2

‘Very crowded wards’/‘no day rooms’

‘Wholly bad’

Falmouth

34

0

0

‘Sufficient’

‘Old and inconvenient structure’

Barton Regis

586

4

0

—

—

Swaffham

26

0

0

‘Sufficient’

‘Plenty of room, slovenly nursing, etc.’

Thetford

57

0

0

‘Sufficient’

‘Plenty of room, slovenly nursing, etc.’

Yarmouth

282 (including ‘lunatics’)

0

0

‘Sufficient room but unsuitable’

‘Bad structure’/‘no nursing’

E. and W. Flegg

16

0

0

‘Plenty of room’

‘Old style’/‘few patients’/‘infirm in house’

Brofield

18

0

0

—

‘Squalid’/‘in every way unsuitable’

Reading

—

Sister (+2 probationers and 4 assistants)

—

—

‘Good throughout’

750–800

52

7

—

‘Good throughout’

Withington

131

(Continued)

Survival of the Fittest: Indoor Neglect

Number of beds

Trained nurse (Day)

Trained nurse (Night)

General remarks

Downham Market

28

0

0

‘Sufficient, but inconvenient’

‘Bad structure’/‘untrained nurses very capable’

Mitford & Launditch

72

2 (+1 probationer)

—

‘Sufficient’

‘Very fair’

Durham

49

0

0

‘Crowded’

‘Unsuitable buildings’/‘nursing by paid attendants’

Sedgefield

14

0

0

—

‘Very small’/‘humane treatment’/‘makeshift arrangements’

Blackburn

256 (including infirm in general wards)

9

2

‘Hospital standard’

‘Sick department good’/‘infirm and lock patients in house much worse off ’

29

0

0

‘Comfortless and bare’

‘Quarters very unsuitable’

Exeter

121

0

0

‘Rather crowded’

‘Insufficient nursing’

Oldham

327

‘Charge nurses’/ ‘professionals’

—

‘Ample’

‘Children’s block insufficiently nursed’

Totnes

—

3

0

—

‘More nurses, baths, etc., wanted’

Crediton

70

1

0

‘Crowded’

‘Very bad every way’

S. Thomas

72

0

0

‘Sufficient’

‘Defects mainly structural’/‘trained nurses wanted’

Portsea

466

2

0

‘No day rooms’

‘Nursing by paid inmates’

Forehoe

24

0

0

—

‘Patients not ill and kindly treated’ (Continued)

Medical Negligence in Victorian Britain

Number of beds

Okehampton

Accommodation (General wards)

132

Union

Union

Number of beds

Trained nurse (Day)

Trained nurse (Night)

Accommodation (General wards)

General remarks

Aylsham

17

0

0

‘Sufficient’

‘Sanitary appliances’/‘structure above average’

Honiton

28

0

0

‘Ample’

‘Fair on the whole’

29

0

0

‘Crowded’

‘very bad all round’

Braintree

30 (others ‘scattered’ around workhouse)

1

0

‘Crowded’

‘Nursing fair’/‘structure unsuitable’

Warwick

96

2

0

‘Insufficient’

‘Fair as to arrangements’/‘insufficient nurses’

200 (in two hospitals)

0

0

‘Sufficient’

‘No nurses’

Tonbridge Nottingham

500

5

0

978 (in two buildings)

Yes (but no number given)

Yes (but no number given)

Bedford

70

1

Smallburgh

—

0

Liverpool

Source: ‘On Nursing in Workhouse Infirmaries’, BMJ, 26 September 1896: 858–9.

‘Crowded’

‘Structure bad’

‘Ample’

‘Good’

0

‘Sufficient’

‘Slovenly’

0

‘Ample’

—

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prevent them from taking work beyond a workhouse infirmary. Nurses had to take any post offered by the association for three years or repay the funding of their training. At a cost of £10, few would have been able to afford this. In 1894, the Nursing Record therefore wrote of Nurse Harcourt who had ‘expressed her distaste to certain portions of her duties’, which led to the termination of her contract with the Bedford Union. Yet, it was Harcourt’s loyalty to the Workhouse Infirmary Nursing Association that had irritated the Bedford guardians. When they asked her to break off ties with the association, Harcourt rightly replied that she could not, because she was under a bond.41 Moreover, there was discernible distaste for workhouse employment across the profession of nursing. Nightingale’s in-road into workhouse nursing, such as Agnes Jones and the Liverpool Infirmary, are well documented; but such well-trained nurses provided isolated successes in workhouse infirmaries (see Table 6.1). Many professional nurses, including Nightingale’s, were unwilling to enter service in a workhouse because of the conditions, and the unwelcome authority of the nonmedical master and matron.42 In turn, professional nurses could also present a threat to the fragile status quo of the workhouse institute. This was not confined to the insecurities and fears of guardians, masters and matrons. While medical officers had fought for improvements in workhouse infirmaries, their ‘medical gaze’ tended to overlook their own substandard care. A well-trained professional nurse could not only bring a high standard of care for the patients, but she also had the opportunity to impart her own opinions, attitudes and, importantly, use her senses. In the early years of probationary nursing, their prime motivation was care, not treatment. When done well, however, this was meeting a fundamental need in the patient pool of a workhouse. Although most workhouse medical officers, who expressed an opinion, seem to have realized the usefulness of professional nursing staff (and promoted this), some were undoubtedly threatened by the encroachment of a female authority in ‘their’ workhouse infirmary.43 Nurse Beaton’s whistle-blowing in the mid-1860s (described in Chapter 3) had provided impetus at a key moment in the campaign to reform London’s workhouse infirmaries. Other Victorian nurses were equally spirited, making effective (and fearless) whistle-blowers, even though this led to clashes with guardians or medical officers.44 These nurses generated vital publicity and made their collective presence felt in the poor law. They revealed neglect or abuse to local newspapers or via a complaint to influential local people or the LGB. For example, in 1894, Knaresborough Union initiated an inquiry into the workhouse medical provisions – solely on the complaints and witness statements of the nursing staff.45 Nurse Osler gave a damming report of the conditions in Knaresborough Union’s workhouse infirmary. She complained about the workhouse management, especially the matron, who had allowed soiled linen to be washed in cold water and then put back on the beds when it was still wet. Osler said the beds – including her own – contained fleas and that the patients were compelled to wash in dirty chamber pots. The inquiry found the master, matron and medical officer guilty of neglect and all three were forced to resign.46 The Victorian matron was a different entity to the chief nurse role that was to come in the early twentieth century.

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Throughout the Victorian period, matrons were not expected to have training in nursing or medicine. On the whole, they would have been the master’s wife, but an employee in their own right. Nonetheless, if a master died or was forced to leave or resign, the matron’s contract was immediately brought to an end. Matrons were expected to help run the infirmary: looking after the laundry, nursing and general provisions. In general, they did not work well with doctors. Dr Rhodes wrote a letter to The Times in 1898, which was discussed in the BMJ: ‘[He tells us] the old story of the difficulty of obtaining satisfactory nurses for Poor-law service, especially in some of the smaller unions. The reasons for this difficulty he states to be the low rate of wages offered, the meddling of incompetent matrons, and the bad food … .’47 Sour working relations between medical staff and the master or matron were a considerable factor in charges of negligence against both doctors and professional nurses under the poor law. For example, in 1873 Margaret Wild, an ‘imbecile’ died from injuries acquired in the Oldham Union workhouse. She fell down some stairs, fracturing her skull, but was left unattended for nearly four hours. An assistant nurse bandaged her head and laid her down, but it was the matron’s opinion that there was no need for a doctor.48 On further inquiry, it emerged that the master and matron were not on good terms with the medical officer, Samuel Jackson. They had been avoiding him and had consistently refused to supply Jackson with requisite orders for attendance – arguably, this probably also occurred because emergency attendance was due a fee. The working relationship between matrons and doctors improved gradually at the turn of the twentieth century, when nursing grew into a fledgling profession and matrons began to move from masters’ wives to senior nurses with medical training. Nursing reformers, such as Nightingale and Twining, had kindled a fire in workhouse nursing, but it did not ignite fully until probation nurses entered the poor law en masse in the 1890s. Thus, at the turn of the twentieth century, there was a leap to 700–800 properly qualified nurses being turned out each year, but this had been institutionalized with painstaking slowness throughout the second half of the nineteenth century. Rosemary White, a leading historian of nursing, has said that the costs of employing nurses ‘quadrupled in the 30 years between 1860 and 1890’;49 nonetheless, this can in part be explained by the low starting base in the midVictorian period. A more widespread impact on the poor law only occurred from the 1890s.50 Until then, when guardians did seek to employ trained nurses, they found that they were costly and in short supply. The 1890s thus marks a turning point in State nursing history that has been overshadowed by the subsequent reforms of the early twentieth century.

Newton Abbott and the BMJ campaign against pauper nursing When Newton Abbott Union hit the headlines, in 1894, most Victorians would have been unsurprised at the extensive use of pauper nurses in its infirmary.51 Many people, though, would have been unsettled by the revelations. Nurse Hinton was a professional nurse, but had left the Newton Abbott workhouse infirmary after trying and failing to

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bring improvements. She graphically described the negligence and the abuse that she had witnessed being committed by untrained pauper nurses and attendants. She went to a magistrate and made a sworn affidavit, which was well publicized at that time. According to Hinton, the mentally ill were left alone for most of the day, resulting in constant injuries from accidents or acts of violence on one another. It emerged that, to save time and ‘prevent’ injury during nocturnal hours, the elderly and disabled had been stripped naked and put into a sack, called a ‘jumper’. There were six strings attached to the sacking, so that inmates could be fastened tightly and tied down to their beds. Hinton had seen ‘black marks’ around the throats of elderly women put through this ordeal (one presumes, after a night of straining against the binding). She also knew of at least one death as a result of this practice. Hinton claimed that one of the ‘ward women’ had violently abused a paralysed elderly patient because she had defecated herself. As punishment, the ‘ward woman’ had also stuffed a handful of faeces into the struggling patient’s mouth and left her bound in a ‘jumper’. She died in this condition during the night, unattended. Newton Abbott’s workhouse infirmary was also infested with fleas and lice because inmates had been (illegally) forced to bribe the pauper nurses and attendants for laundry. The unkempt appearance of patients was made worse by a lack of sanitary items, such as one towel between fourteen people and no bathing facilities. Paupers had resorted to washing in their chamber pots. Sexual and ‘immoral’ abuses were also rumoured. The BMJ observed that the reports from Newton Abbot were reminiscent of those that had motivated the Lancet campaign, thirty ‘eventful’ years before. Hart, who had led the Lancet Commission before becoming editor of the BMJ, therefore wrote with conviction that the public had been ‘confronted with a statement of abuses in a country workhouse which, almost word for word and certainly fact for fact, are practically identical with those which so many years ago produced such indignation’.52 After decades as a medical journalist, Hart was fully aware of the national scale of the ‘pauper nursing’ problem. An official inquiry was called for at Newton Abbott, but, as one correspondent pointed out, ‘… it was held by one of those partly responsible, in an official sense, for the condition of things which is there alleged to have existed’.53 As Chapter 4 argued, the inspectors’ use of contract law meant that they were likely to seek to blame individuals and unlikely to point a finger at their own department. Nonetheless, the widely reported negligence, there, had fixed the public’s attention on pauper nursing. Hart may have been biding his time until a well-publicized case, such as this, grabbed the public’s attention. As his obituary in the BMJ noted, Hart sought publicity to ‘arouse local sympathy or even local hostility’ by using ‘well-authenticated instances of maladministration or positive neglect’.54 In so far as Hart was seeking publicity for negligent practice under the poor law, the national reliance on pauper nurses became the key thematic element of the subsequent BMJ commission. After the ‘scandal’ at Newton Abbott workhouse infirmary had entered the national press, the BMJ – under Hart’s direction – introduced a series of ‘Reports on the Nursing and Administration of Provincial Workhouses and Infirmaries’.55 Two strong thematic arguments run throughout the fifty reports that were published between 1894 and 1897: first, as a rule of thumb, poor law infirmaries

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were staffed by pauper nurses most of the time; second, that the LGB’s weakness was to blame for the negligence that had resulted directly from this situation.56 The reports also exposed the threadbare – frequently non-existent – nursing that was provided during the night in workhouse infirmaries (Table 6.1). Downes’ circular, described above, had recommended that the ratio of paid nurses and assistant nurses to patients’ beds should be between 1:15 and 1:10.57 Clearly, the ratios of the nurses to beds, shown in Table 6.1, were in stark contrast to the LGB’s own guidance on the matter. For example, in Bishop Stortford’s infirmary, the sick and infirm were locked up for the night with no medically trained attendants and no access to proper ablutions. The supply of able-bodied was so small that the matron ‘did not know where to turn’. As a result, the nursing staff of the infirmary was almost entirely composed of ‘sick’ inmates.58 In Bath, the professional nurse’s day-to-day routine echoed the problems of medical officers: ‘… by the time she had looked at the serious cases, made her notes, issued her orders to her subordinates, filled the medicine bottles, and looked through the wards, the time was gone’.59 The guardians of Bath assured the BMJ that they were engaging a night nurse, to which the BMJ retorted, ‘one night nurse to 230 beds!’60 Despite the obvious importance of those reports, historians of medicine and nursing have given scant attention to the BMJ Commission. This is surprising because it played an important role in forcing the LGB to fully open the floodgates to probationer nurses in workhouse infirmaries. Hart had blamed the LGB administration from the outset and aimed to harass the inspectorate: ‘The Local Government Board appears for a long series of years to have regarded these sad conditions and cruel neglects with silent complacency or gentle chidings at cases of scandal; it needs to be awakened from this supine satisfaction.’61 According to Hart’s BMJ editorials, the permanent officials had allowed or ignored ‘non-progressive board of guardians’, who sought to save money by employing inmates to nurse the sick. Whether or not Hart’s pressure played a major part is debatable, but the LGB did issue an order to ban pauper nursing in workhouses after three years of unrelenting criticism from the BMJ.62 The journal announced the Nursing in Workhouses Order (1897) with ‘feelings of no small satisfaction’. To the BMJ, it was the ‘ultimate victory in the war which we have waged for many years’. Few could argue that it was not (as they described) ‘a great step in the right direction – the preliminary, in fact, of a humane revolution’.63 State nurses may have taken time to arrive en masse, but the wave of ‘probationer’ workhouse nurses, from then, was the defining step forward into the modern era of nursing. This was to be the swansong of Hart. He died (with considerable personal satisfaction, one hopes) four months after the LGB’s nursing order.64 The BMJ commission had, however, highlighted and publicized a further endemic problem of workhouse staffing that took much longer to resolve: a lack of night nursing was leading to negligence in workhouse infirmaries. Table 6.1 demonstrates that, on the whole, there were no night nurses employed in unions. As Coleman, the medical officer for Lutterworth, had identified (above), epileptics, the mentally ill and the disabled were prime subjects for neglect – especially during the nocturnal hours. If it was difficult for one nurse to look after hundreds of patients in the day, night nursing was therefore a formidable challenge.

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This was a critical latent failure in workhouse infirmaries, but it had been brushed under the carpet by successive poor law authorities. Newton Abbott had adopted the ‘jumper’ as a cruel salve, but most patients were simply left to their own devices at night. Epileptics and the disabled were left alone for long periods of time (often, locked up at night) with patients with learning disorders or serious mental-health problems – housed in wards for ‘lunatics’, ‘imbeciles’ or ‘idiots’. For example, in Newton Abbott workhouse, epileptics and the disabled had remained without adequate care provision in an ‘idiot’ ward. According to the local coroner, one epileptic’s death was entirely preventable: During the night he (the deceased) had an epileptic fit, the noise of which aroused some of the occupants, but there was no one in the ward in authority whose duty it was to give assistance to the epileptics in any way, and during his struggles, whilst in an unconscious state, he turned on his face, and, his head being buried in his pillow, he was suffocated. There is no doubt that had any person given him the slightest assistance by turning him round, the death would not have occurred.65

Severely disabled or vulnerable people, no matter what age or pathology, were therefore more likely to suffer in the workhouse, which was understaffed and illsuited to the time-consuming and close care that they needed. Even if a workhouse did employ nurses, they were likely to be overstretched and heavily reliant on a handful of untrained wardsmen and pauper nurses.66 Day-to-day care work, such as assistance with eating, bodily excretions and ablutions, were therefore regularly carried out by fellow inmates. This situation was a consistent factor in Victorian workhouse negligence. The injury or death of an ‘imbecile’ or ‘idiot’ (including preventable deaths of epileptics) is a recurrent theme in records of workhouse neglect.67 One such tragedy, gained notoriety in the Hampshire region, before it was reported in the national press and mentioned in Parliament. The remainder of this chapter will extrapolate the circumstances of that death, in order to demonstrate the interaction of crusading and workhouse negligence in practice.

The starvation of Edward Cooper in the Isle of Wight workhouse On the 26 February 1877, Edward Cooper, a severely disabled (but otherwise ‘healthy’) 23-year-old man, was admitted to the Isle of Wight Union workhouse as an ‘idiot’.68 One month later, he was dead. A letter was sent to his mother, Mary, informing her of the death. Her son-in-law, Francis Munns, came to the workhouse to receive Edward’s corpse. Munns said to the staff that ‘it wasn’t fit to be seen’: the body was contorted and naked, the jaw hung slack and the eyes were not closed – Edward was emaciated and there were visible injuries.69 Munns paid for a calico shirt and to have the jaw bound up and the eyes covered. He placed the body in a coffin – made

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and sent by Edward’s uncle – and brought the body home. Mary insisted on seeing Edward one last time and was devastated by his condition. She contacted her eldest son, Henry, a corporal in the telegraph department of the Royal Engineers. He came from London immediately. Henry’s description of the corpse was almost identical to that provided by the subsequent coroner’s inquest: My brother was laying in a front room of our home. I took a light & removed the lid of the coffin. The body was very emaciated. Mouth was open – chin dropping very much. Eyes open but very much sunken. The cheek bones seemed to be almost protruding through the skin, just covered. I then noticed his mouth. The bottom lip had marks as if the teeth had been tightly compressed upon it. I forced his upper lip up & saw that his teeth were gone – looked as if they had been broken off & the stumps turned inwardly as if forced off by some hard substance. I noticed the right knee was drawn up & the right knee joint swollen. I noticed then a very large sore on his right hip, it had a very black appearance. I took him in my arms & turned him on his side – I found a very large sore at the bottom of the back bone & the flesh eaten away with a yellow appearance. I found both hips about equally sore & looking about the same. His privates were in a shocking condition. The skin was off the testicles & they looked as if there had been a discharge from them. There was another sore between the left ankle & the heel about 1½ inch long; that was apparently healing. I decided then I would have the affairs investigated as I believed he had been thoroughly neglected.70

After Henry had viewed the body, he went to Colonel Atherly, a local dignitary who had previously helped the family. He referred Henry to a local medical practitioner, Dr Barrow, who assisted in their complaint against the union. Barrow examined Edward’s body, made out a certificate for Henry to take to the police and arranged a coroner’s inquest. Henry then hired ‘legal advisers’.71 Local and national press followed the case. The guardians, unable to reach a decision, panicked and requested an official inquiry from the LGB. Two inspectors, Baldwyn Fleming and Dr Mouat, arrived on the island and held an inquiry on the 8th and 9th of May. The previous chapter argued that Fleming was one of the most active crusaders in the inspectorate. Herbert Preston-Thomas, an LGB inspector, described him as a ‘curious old beau’ with the nickname, ‘The Flea’ – a metaphor, perhaps, for an irritating and unrelenting character.72 As described in Chapter 4, Mouat was a medical inspector with the LGB’s medical department. He was drafted in to assist with poor law inquiries when the case had been framed as ‘medical’ negligence. Mouat is difficult to appraise. His professional opinion was freely given, but it was aligned with best practice for the time. This sometimes damned a medical officer for events that were beyond his control – and appraised the medical officer in a manner that was a far cry from legal prescriptions of the ‘reasonable’ skill level. Yet, as Rogers described, Mouat also defended medical officers against obstinate masters and guardians.73 In any case, both Mouat and Fleming focused on the ‘active’ neglect of the doctor and

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overlooked the glaring and sentient systemic faults that had led to Edward’s death; in particular, the interaction of the crusade with low standards of institutional care. The workhouse medical officer, his deputy, a nurse and a ward attendant were all dismissed or forced to resign. Detailed cases of neglect, such as this, can prise open and lift the lid on pauper experiences of poor law medicine. They can provide the ‘carefully contextualised analyses’ that some historians have argued is missing from the history of the patient’s view.74 The Coopers were the ‘deserving’ poor and should have received the cream of charity and voluntary aid.75 Instead, they slipped through the gaping holes of a welfare net stretched wide by a recession and the withdrawal of outdoor relief (noninstitutional benefits paid to the poor in their own homes).76 They were typical of the labouring classes, weathering economic downturn and hardship by negotiating a ‘mixed economy of care’ and residual paternalism.77 This family knew their rights and the duties of officials, and their desire to do ‘battle’ with the guardians feeds into recent poor law history.78 Surprisingly, it also meets with and pre-dates today’s patient-centred medical complaints systems. There was no mechanism for compensation payments under the poor law, yet the Coopers sought retribution for Edward. Henry’s search for knowledge and truth resonates with the primary motivations of health care complainants in the twentyfirst century, eloquently described by the law academics, Alan Merry and Alexander McCall Smith: … the urge to see coherence in the events of our lives and to resolve the unresolved is very powerful. Even if the knowledge that we acquire as to what has happened were to have no practical value – in the sense that it would not alter how we conduct our affairs or even how we deal with them legally – it may still be important to us for its own sake. The truth is always important to people, whatever other motivations may also contribute to the search for the facts.79

Perhaps the ‘search for the facts’ is an indication of a visceral and historical motivation – an atavistic reaction to human tragedy.80 The fight to rehabilitate Edward from a dehumanized pauper ‘idiot’ to a patient – with rights – pitted the Coopers against the medical profession and poor law authorities, leaving a rare and rich account of disability and care in the community – from a lay perspective.81 Vague definitions of idiocy sometimes led to diagnoses that drew heavily from the testimonials of family, community and lay officials.82 In general, the permanence of idiocy – a congenital condition – was contrasted with lunacy, which was characterized by sudden onset (from previous sanity) or chronic lunacy with moments of lucidity.83 Cases, like Edward – who received relief payments for disease of the spine, not idiocy – were not so easily categorized. His alleged ‘memory’, ‘understanding’ and ‘recognition’, should have legally prevented him from being classed as an ‘idiot’.84 His physical condition, though, made him appear the ‘perfect idiot’ to many, including the Isle of Wight poor law doctor. In an era that pre-dates medical supremacy, Edward’s case is an extraordinary example of a pauperized family successfully fighting for a disabled patient’s rights.85 Contrary to the historical

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stereotype of poor people shunning, abandoning or stigmatizing disability, Edward is a prime example of those who were accepted and cared for, in surprising numbers, by family and local community.86 Despite this, in 1877, after 23 years of a dependent but rich and nurtured life, Edward was incarcerated. This was not an isolated incident and his death in the workhouse is intimately linked with contemporary policy, medical practice and notions of disability.87 Edward’s incarceration stemmed from the altered landscape of welfare between the 1870s and 1890s. As the previous chapter demonstrated, it was a time when civil servants and local health and welfare administrators encouraged a crusading mentality against what they and their contemporaries considered to be wasteful and undeserving welfare recipients.88 It was a period which embraced a cynicism towards welfare recipients, shrunk access to vital benefits and scrutinized claims for medical welfare: ‘The crusading experiment drove those in deepest poverty to enter a system in which they were shuffled about to save costs.’89 As a sign of the times, The Hampshire Advertiser appraised the ‘cost’ of outdoor relief, by comparing that county’s figures for in- and outdoor relief between 1874 and 1875. Out of 26 unions in Hampshire, the Isle of Wight was one of the five unions with a conflation of rising expenditure on the workhouse at the same time as cuts in their outdoor relief; the others were Ringwood, New Forest, Southampton and Alton.90 There were also 16 unions in Hampshire that had succeeded in cutting both outdoor and indoor costs; in contrast, Alverstoke and Havant were the only unions with increases in both. Over the same 12 month period, the neighbouring, infamous Andover Union had managed to cut £105 from indoor expenditure, while expending £465 less on outdoor relief. The Isle of Wight, meanwhile, had cut £370 from the costs of outdoor relief, but rose its spending on indoor relief by almost 31 per cent (£961) – a considerable increase. In 1877, when Edward entered the workhouse, the union was arguably under pressure to shave expenditure and match the financial savings of local unions, such as Andover. The last chapter argued that workshops, meetings and conferences were the centrifugal spokes of the crusade wheel – a place to insist both on policies being put into practice and to propagate crusade ideals. In this way, unions all over the country were influenced by the energetic work of LGB inspectors and the publicity of success stories. By the mid-1870s, there was an almost universal belief that welfare was a loophole for over-generous and indiscriminate relief. The crusade had fed into the nation’s wider concerns about welfare expenditure, and inspectors ‘encouraged guardians of the poor to think of themselves as medical experts, using “sound business sense” in both welfare and public health administration’.91 Thus the Lancet was quick to defend the Isle of Wight workhouse medical officer and blame the LGB: Guardians are permitted to practise a paltry economy at the expense of the poor, and when an accident occurs inspectors hold an inquiry, censure what they previously sanctioned, supersede certain of their approved agents, and, in this pleasant way, appease the clamour of public opinion … . We are strongly of opinion that the case which has just occurred at Ryde is not only a typical but a publicly important instance of systematic mismanagement and neglect.92

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The contradictory programme of adapting deterrent workhouses into ‘State hospitals’, described above, had resulted in frequent cases of neglect that reached its apotheosis in the 1870s.93 The Coopers’ experience is thus historically important and Edward’s fate contrasts the crusade rhetoric with the pathos of its enactment. The Coopers first applied for poor relief in 1874 when Edward’s father was sick and temporarily hospitalized. In addition, his sister had married and was pregnant and could therefore no longer share the greater burden of care with their mother. The loss was keenly felt in the Cooper household and lowered their earning potential while both parents were not working. The guardians did not consider this a case for outdoor relief, which is reflected in the conflated numbers for relief, shown above. Mary was able-bodied and could work. Edward was thus a prime candidate for the workhouse ‘idiot’ ward. Mary described his experience in 1874: My husband was off work for the day & I asked him to stop & see the boy. He came home & began to crying ready to break his heart. He said the poor boy was fell away to nothing & had sores all round the lower part of his body – the dry skin was hanging off his back & he had like boils round him. We then made up our minds to take him out … . His mouth was dry & turned up hard - & his body had got very thin – all round the lower part was in these large wounds, more especially one on the hip … His other parts were all but dropping from him. He had been then in the W.H. 10 clear days … .94

On this occasion, the family did not complain. Instead, Colonel Atherly helped the family to bring the case before the guardians. A grant was arranged of one shilling a week, which continued until Edward’s incarceration in 1877.95 Possibly, this was hush money to appease the family and prevent them from bringing unwelcome public attention or a latter-day paternalistic gesture. Atherly was a respected island dignitary, guardian and chairman of the workhouse visiting committee. Corroborative statements in the inquiry indicated the family had received other types of aid from various local people – helping with Edward’s care and transport or by paying for important goods. Such support would have formed a critical element of a fragile economy of makeshifts; providing a survival net that, when it was withdrawn, left a gaping hole in household finances and care strategies. After 1870, few such cases were able to ‘maintain their independence outside the workhouse’.96 The previous chapter demonstrated the popularity of the crusade – Edward’s would not have been an isolated case. In 1870, there were 843,000 claimants of outdoor relief; six years later, the number had dropped to 567,000.97 Moreover, between 1850 and 1890 the proportion of ‘insane’ on outdoor relief fell from approximately 25 to 6 per cent.98 Mary’s decision to place Edward in the workhouse was a traumatic but commonplace one, ‘predicated less on an acceptance of a medical approach to idiocy than on practical issues of household economy and life-cycle poverty’.99 When Edward’s father died at the height of the crusade in 1877, it was made clear to Mary that poor law relief for Edward meant the workhouse.100 Widows were one of the prime targets of the crusade and within weeks Edward was incarcerated while Mary went to work.101

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Historians have tended to highlight the shortcomings of community care and rightly focus on the numerous cases of familial abuse and neglect reported by the Lunacy Commissioners.102 However, Edward was clearly not better ‘in’ than ‘out’ – he was not shunned by the community, abused by his family nor hidden away. Edward was remarkably well accepted and cared for by his family and the local community. An extensive ‘kinship network’ had helped the family to keep Edward in relative comfort. His life experience goes against the familiar image of disability and domiciliary care in the nineteenth century and weakens the ‘myth’ of declining familial care in the face of industrialization.103 Edward had survived in the Coopers’ home for 23 years. This provides a rare opportunity to compare standards of domestic care of the disabled with that provided in a workhouse. The inspectorate recognized a legal need for skill and attention in Edward’s care, but – as they sought to find out – what had he been accustomed to?

‘He was not an idiot’: Disability and care in the community It was clear that Edward had been accepted as a regular family member and the Coopers had fought hard to keep him alive.104 It is difficult to say how common this type of domestic care of the disabled was, because it has received far less attention from historians than institutional provision. As Wright has argued: ‘for individuals kept with relatives, there are no documents with which to judge the care, diet, treatment’ and that there is no ‘fair’ way for historians to compare institutional with community care.105 Notwithstanding Wright’s assertion that a dependence on government documentation has led historians to fixate on the experience of the institutionalized mad, inquiries into medical neglect under the poor law can provide an unusual comparison between workhouse and home care. An acceptable standard of care was a slippery concept under the new poor law – a system built on less eligibility and deterrence. Yet, a low level of care at home may mitigate subsequent neglect in a workhouse and shift attention elsewhere. Inspectors working in an official inquiry therefore tended to establish standards and expectations on a case-by-case basis and sometimes this entailed an assessment of both institution and community. In such circumstances, inspectors subpoenaed witnesses from a wide social range and asked questions pertaining to standards of care in the home and workhouse. Many official inquiries can therefore provide a vast untapped resource for social and medical historians seeking to make comparisons. Moreover, the extensive affidavits of an inquiry – drawn from diverse social groups – can restore voice to what Peter Mandler has described as the ‘comparatively dumb’ poor of history.106 Though Edward could not speak for himself, the statements of the relieving officer, local officials, neighbours and family compose an impressive record of domestic care.107 Almost all of those interviewed at this official inquiry – including the deputy workhouse medical officer – argued that Edward would have survived at home if funds had been provided for Mary.108 The Isle of Wight Chronicle agreed and blamed the guardians’ adherence to the crusade ideals: ‘Had an amount

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of out-door relief proportionate to the peculiar requirements of the case been afforded, there is no doubt, judging from the almost heroic affection displayed by the widowed mother [that] she would have much preferred to have kept him beneath her own roof.’109 This would have been no mean feat for any family, let alone one struggling with poverty. Edward’s severe disability occupied a space within nineteenth-century ‘lunacy’ aetiology that was neither strictly idiocy nor imbecility but was open to interpretation. With shrunken feet and hands and little control over his limbs, he was almost completely dependent on other people. According to Mary, Edward’s head had been injured during the birth process ‘and he was never able to speak, but he had very quick hearing. He knew what was said to him and I never considered him an idiot’.110 Emma MacMahon was a neighbour who had seen Edward almost every day for four years. She thus described his ‘wholesome’ appearance – ‘like a lad of 16 or 17’ – and his disability: ‘he used to make a funny kind of noise like a person who can’t talk – I don’t think he was deaf. I know he was very quick at hearing – he would turn his head if you called to him.’111 This was also corroborated by another friend of the family, James Walker, who said that Edward was mute but not deaf.112 Despite the medical diagnoses of idiocy – documented by poor law doctors in 1874 and 1877 – the Coopers refused to accept or describe Edward in those terms.113 In addition to his mother, Edward’s sister, brother, aunt, uncle and neighbours all testified that he was not an ‘idiot’. The facts that he could cry and respond if his name was called from out of sight – that he warmed to or recoiled from people – were all touted as evidence. Non-medical protagonists, such as the coroner’s jury and LGB inspectorate, were also interested in Edward’s emotional and cognitive range and had sought the opinions of family and community. For example, questions were asked, ranging from his ability to feel emotional pain and joy to whether or not he could recall people, establish relationships and recognize his surroundings. Wright has said of this push–pull method between medical professionals, lay and family, ‘one senses a process of negotiating the meaning of disability in which, if anything, the family had the stronger say’.114 Moreover, their combined affidavits do indicate that Edward may not have been mentally impaired. He was well aware of his surroundings. It is possible that his starvation in the workhouse could have been purposeful self-harm or suicide. Mary’s description of Edward indicates limited physical abilities, but mental awareness and processing: He did not make much noise during the day, unless a stranger came in – then he would throw his arms about in an excited sort of way – or perhaps smile – take it in different manner – some strangers he was pleased to see – some he didn’t like to see … . He was very pleased at seeing his father come up the garden. He would jump up & make a pleased noise whenever he saw him coming in sight … . He could not speak at all, but he could make anyone used to him understand what he wanted … . He would have allowed a stranger to feed him. He would have allowed you to feed him if he liked your appearance. He would make a little

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pleased hallo out, if he was glad to see you. If there was anything peculiar in appearance he would seem timid like.115

Edward had the ability to recognize and form emotional bonds. Therefore, he was not an ‘idiot’ to the Coopers, who seem to have interpreted idiocy as a condition with no emotional or cognitive interaction.116 His inability to work or perform any household duties meant Edward was a fulltime prospect in an impoverished family. Nonetheless, he was loved and endearingly referred to as ‘Teddy’ by his primary carers – his mother and sister. In addition to them, a father, uncle, brother and male friend of the family also contributed. They were (historically) unusually caring, describing Edward in openly empathetic and compassionate terms.117 Mary described the help Edward had received from others and detailed Edward’s daily care regime to the inquiry. He had specially made flannel shirts of which ‘the sleeves were sewn up to keep his hands from the cold’ and made with double flannel on the arms, chest and back. During the day, he remained in a bespoke chair made by a relative, which reclined and performed as a commode. At night, he was carried upstairs to a bed with a comfortably adapted mattress. According to Mary, ‘He was generally very quiet at night’ and ‘never cried’. Critically, someone was always with him and Edward never slept in a room alone. Moreover, Edward could not eat without assistance. It took between fifteen and twenty minutes to feed him: He always had his meals when we had ours. We generally breakfasted between 8 & 9 he had nothing before that – He used to take bread & butter dipped in tea. He could not feed himself at all – he was powerless. I used to feed him, or my daughter. He used to move his mouth as if he masticated, but I always fancied dry food seemed to hang in his throat as if he could not swallow it … . Generally he took his food well … .118

Crucially, for an inquiry into starvation, it was confirmed that he had a healthy appetite. The inspectors concluded that Edward had a reasonable to high standard of care at home and that he was capable of eating, though he could not masticate well and needed assistance to eat. Almost from the moment Mary became a widow, she was physically and financially unable to continue caring for him: ‘He was very heavy for me to lift – hurt my back very much. I had to bring him down stairs in morning and my husband took him up at night … . After my husband’s death I found I couldn’t manage him. I had no means of supporting him besides the 2[s] a week.’119 She had battled for years to keep the family’s finances afloat, only to have chance and tragedy defeat her best laid plans.120 The Coopers joined with an unknown number of working class families whose experience of bereavement during the crusade was to set their disabled or mentally deficient children ‘on the road to the asylum’ or workhouse – literally and figuratively.121 Mary borrowed a wagon from Colonel Atherly and, together with her daughter and a neighbour, she took Edward to the workhouse.

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‘He was a perfect idiot’: Disability and the workhouse system Edward’s mother and sister visited the Isle of Wight workhouse once or twice a week – and were accompanied by family friends on two occasions. They observed his physical and mental condition rapidly deteriorate. Despite bringing him food and bribing the nurses with extra food and money, Edward starved to death. Whether or not he was having difficulty eating due to depression and trauma from the loss of his family and home environment, it was obvious that Edward needed assistance to eat. The overstretched and uninterested workhouse staff were unable or unwilling to invest their time in managing Edward’s meals. According to the one paid nurse, it took half an hour to feed him. Contradictory statements from the nurse, nursing assistant and pauper attendants imply that Edward was left to starve for most of the time that he was in the workhouse. The busy, distracted work in the infirmary left his need for nutrition frequently overlooked or forgotten. It is also possible that the inmates who were assigned to feed him had stolen his food. His starvation was made more appalling to Edward’s family because during his short stay in the workhouse his body became covered in ‘wounds’ and ‘sores’ and he lost several teeth. Several accusations were made about the lost teeth (including violent force-feeding), but, from the statements, a fall from his chair seemed the most probable cause. Mary had taken Edward’s own chair to the workhouse, which had been used part of the time, but he had been left in it for long periods of time. He had spent much of this time tied to a bed by sheets or slumped in his chair, causing deep bedsores. These were exacerbated by Edward soiling his linen and lying or sitting in urine for long periods of time. This situation was worsened by the exchange of Edward’s regular nightgown for workhouse attire: a shirt and heavyweight woollen trousers which were wholly unsuited to his sensitive skin and physical condition. The medical officer, Dr John Beckingsale, was present at the Coroner’s postmortem and attempted to subvert the final judgement of starvation and neglect by making claims that there were other causal factors. Although Beckingsale remained silent throughout the autopsy, he subsequently claimed it was flawed and constructed several alternative ‘medical’ reasons for Edward’s death: ‘pining’ for his mother, ‘malassimilation of food’, ‘ulceration of the stomach’ and ‘disease of the liver’. Yet, he had originally certified Edward’s death from ‘debility and imbecility of the mind’.122 In his defence, Beckingsale stated: ‘I thought from the time I first saw him that he was wasting, & he continued to get weaker till he died – I think his life was shortened by separation from his mother, & I consider that he died from debility – He was a perfect idiot … ’.123 In direct contrast to Edward’s family and friends, guardians and other lay witnesses at the inquiry, the doctors did not use Edward’s name and only referred to him by his condition: idiocy. Beckingsale was backed by his son (a medical student) and Dr Charles Meeres, the poor law medical officer for the Coopers’ district. They tried to destabilize the Coopers’ statements by insinuating that Edward was starved before entering the workhouse and that Mary was somehow culpable. The medical officers argued vehemently that Edward was an ‘idiot’ and therefore his death was

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timely and expected and that ‘he could die from pining because he wasn’t normal’.124 Whereas family and friends had described a disabled but communicative patient, the doctors focused on his visual deformities and portrayed a degenerate creature that made incoherent ‘animal noises’.125 When asked about Edward’s bedsores, Beckingsale said that he did not think of using water beds – the common nineteenth-century remedy – and claimed, ‘besides they were broken’. He was unrepentant of his lack of attendance – it was, after all, the way that he had practised poor law medicine for three decades. When asked how he decided which patients to see, Beckingsale said that he asked the nurse: ‘If there was anything she wished me to see? & if she says not I rely upon the nurse – Having confidence in the nurse I have always thought that sufficient.’126 In turn, the nurse was distracted and relied almost entirely on paupers and untrained ward attendants. She was unaware of Edward’s emaciated condition until shortly before his death. Thus a complete reliance upon an absent medical officer and inadequate nursing led to Edward’s starvation. As Beckingsale said, ‘It never struck me that it was desirable that I should myself see him fed – notwithstanding the representations of his mother & his failing state – I understood he took all the food ordered.’127 Edward had starved because despite being severely disabled, he had been left to fend for himself. At the official inquiry into Edward’s death, Inspector Fleming noted: ‘No record of state of body at death … No other record of the treatment of lunatics and idiots. As a matter of fact there is no record where Cooper was visited by himself or deputy whilst in the workhouse.’128 In common with other LGB inquiries into neglect at this time, the inspectors pointed the finger of blame at the medical officer’s (lack of) attendance: Neither the Medical officer nor his substitute took trouble to see that the instructions they say they gave as to pillowing for the relief of the sores were carried out and in fact instructions were never acted on. The medical officer never saw Cooper fed or examined his evacuations though he believed the rapid wasting and death to be due to mal-assimilation of food.129

Fleming found that Beckingsale left the workhouse duties to his son, Daniel, who had worked as his assistant. In turn, Daniel had barely attended the workhouse himself and had not properly examined Edward. He had missed all of the salient points of the case: ‘the Board cannot avoid the conclusion that both those gentlemen gravely failed in their duty’.130 The medical officer was subsequently forced to resign, while Daniel, who was not actually employed by the poor law, was initially banned from holding future poor law appointments. Later, this was overturned on appeal by his father and the guardians. The Lancet responded on behalf of the medical men, arguing that the LGB had been quick to attribute blame but slow to take responsibility themselves: ‘… an inspector is the officer responsible to the Central Board for the arrangements he may be called to condemn … . The result must necessarily be a grotesque absurdity,

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and it is almost inevitable there should be injustice inflicted somewhere when the whitewashing process begins.’131 Indeed, throughout most of the 1870s, the public were hoodwinked into blaming doctors for systemic faults. The medical profession themselves could be damning of the poor law medical officers. Sick Paupers and Their Medical Attendants was a pamphlet written by ‘C. H.’, which was the surgeon, Charles Holmes, who had previously served as medical officer at Chipping Norton.132 In spite (or because of) this experience, he was moved by Edward’s death to publicly condemn poor law doctors who used assistants.133 Nonetheless, as the next chapter will demonstrate, the use of assistants was permitted and Beckingsale had not acted illegally (except for bad bookkeeping, which was ubiquitous among poor law medical officers). The Isle of Wight was exemplary of the poor law’s systemic negligence of vulnerable patients. Edward’s death had stemmed from an over-reliance on doctors, such as Beckingsale, who operated a high-risk strategy of attending workhouses for the bare minimum and relied on unqualified workhouse staff and pauper nurses. This was a pattern repeated haphazardly across the nation and sanctioned by the LGB until it led to neglect and public scrutiny. The Hampshire Independent thus asked, ‘Where Is the Fault?’ … It is obvious that faults, inherent in the system, are chargeable, in any given case, to the central power. And if a department be so crippled by want of resources that a failure is at any time imminent, it is manifestly unjust to visit subordinates with condign punishment when such failure occurs. To attempt to allay public indignation or divert it into a false channel by making a scape-goat of helpless officials is a practice which we had hoped to be obsolete. Anyhow, we believe it will fail in its object, and serve only to direct the public attention more closely to the actual working of a department that resorts to such vicarious atonement.134

The fault, however, was more subtle. It lay in the interweaving of policy with ‘latent’ and ‘active’ failures in the organizational structure of poor law medical provision (both in and out of the workhouse).135 The conflation of inmates during the crusade had buckled a strained and widely varying system of workhouse care for the disabled. This interacted negatively with the part-time employment of doctors who, in turn and par for the course, neglected their duties regularly. Such top-down and systemic (‘latent’) failures, though, translated into the outcome bias of individual (‘active’) culpability: staff were blamed when their neglect ended in tragedy, but the environmental causes that underpinned this continued. The crusade against outdoor relief may have been the igniting spark, but the ‘free-trade’ sentiments of the poor law had created a tinder-dry system of welfare: the system was primed for this type of neglect. Patients suffered, as Edward did, because of the split prerogatives of doctors, who were frequently blamed and lambasted for their infrequent attendance, and this suffering was intensified by the subsequent reliance on unqualified assistants and pauper staff in the infirmary. Beckingsale had followed the same course that he had

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adopted for 30 years as a medical officer of the Isle of Wight workhouse – during which time the poor law authorities (and Lunacy Commissioners) had regularly inspected and condoned his practice. The next chapter will take this argument one step further. It will demonstrate that, although the LGB publicly claimed that doctors should personally attend to all poor law duties, their rules and regulations gave clear authorization for the use of assistants. Moreover, under the crusade, the temptation to cut costs affected doctors’ fees and the orders for their attendance. Medical officers increasingly found themselves trapped in a catch-22.

7

A Catch-22

Background Overall, the previous chapters have presented a detailed and nuanced exploration of poor law medicine, with an emphasis on the impact of economically set latent failures on charges of negligence made against Victorian poor law doctors. Systemic faults, it has been argued, morphed with ease into the active neglect (and blameworthiness) of individuals. This chapter will directly examine that pathway. Building on the previous chapters, it will demonstrate how the duties and obligations of the district medical officer interacted with the policy environment of the crusade years, contributing to the heightened number of doctors charged with negligence in the 1870s and 1880s. The previous chapter pinpointed staffing and ‘care’ as a major issue throughout poor law institutes. This chapter will explain how and why the rules and regulations of employment fed into the quality of care provided by district medical officers, creating a catch-22 for them to navigate. It will be argued that the untenable aspects of medical attendance worsened during the popular years of the crusade. The regulations and duties that governed doctors’ attendance on the poor placed them in an obscure catch-22 that tightened its grip at this time. In the 1870s and 1880s, it became more difficult for poor law doctors to claim fees for supplementary and ‘sudden and urgent’ (emergency) attendances. As this chapter will demonstrate, this had far-reaching implications for poor law medicine. The inability of district medical officers to ably meet their contractual obligations was a consistent and systemic failure in the Victorian poor law. When under financial pressures, such as the crusade, this catch-22 became deadly for the sick and poor. In effect, part-time district medical officers – with one eye on private paying patients and the other on their contractual obligations – made ill-informed decisions about which pauper patients to attend and which to neglect. The Longley Strategy had placed guardians and relieving officers – together with a number of other non-medical officials – at the heart of its directives. As a result, medical authority and independence (such as it was) withered. The medical officers were important gatekeepers – releasing and withholding relief – but their limited authority could be brought into question if it counteracted the aims of crusaders. The allocation of resources, therefore, consistently underpinned the neglect

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of outdoor poor patients. As a result, both pauper and doctor were embroiled in disputes over medical extras and missed medical attendances. As Chapter 5 demonstrated, regulations and contact law were used to hold medical officers in check. This ensured that their employers maintained authority. Obviously, such a situation created tensions that historians have been keen to point out. Notwithstanding a broad acknowledgment of the poor law’s esoteric claims procedure, these accounts have tended to miss the obscure nature of claims for medical relief. A consequent lack of detail has presented a distorted view of the problems that paupers experienced in claiming and receiving medical relief – and of the reasons for doctors being charged with negligence. This chapter will therefore provide a counterpoint to this distortion by giving a detailed extrapolation of the outdoor medical relief claims process. The emphasis will be on the impact on the neglect of the sick and poor patient.

Denial, local resolution and sustained latent failures The superficial interface of pauper and doctor concealed a bureaucratized system that heavily influenced their interactions – and underpinned the neglect of patients. As Digby has said, ‘Driven by a cost-cutting engine and informed by a deterrent social philosophy, the system set up under the 1834 act loaded the dice against the development of an adequate system of medical care … .’1 The extent of this impact on standards of care, though, remains understated by historians. In Chapter 5, Reason’s model provided a persuasive description of the pathways that can open to negligent care when there are insufficient checks on unsafe procedure.2 It is useful to return to Reason’s analyses of organizational hazards, accidents and errors in order to fully comprehend the interaction of latent failures and active negligence under the new poor law. There are, of course, many discrepancies between Reason’s research into present-day dilemmas in hazard prevention (such as highly technological and safetyconscious organizations) and the controversial, un-technocratic, past bureaucracy of the Victorian poor law. Reason was also describing errors and mistakes, not medical negligence. Yet, the explanatory rhetoric that Reason employs in hazard analyses can be a useful comparative tool.3 His framing of error causation in organizations has much in common with the latent failures and systemic factors that led to the active neglect of poor law patients. Victorian Britain obviously did not prioritize and reflect on industrial safety with the sophistication of today’s systems analysts, but the poor law authorities had an acknowledged responsibility towards the paupers placed under their care. Furthermore, the Poor Law Board and the LGB were seeking to avoid negative publicity about the neglect of paupers. The inspectorate was keenly aware of their need to save money at the same time as being seen to provide adequate care in and out of the workhouse. It is therefore worth holding in mind Reason’s description of such tensions, while appraising the motives and actions of the LGB: ‘All organizations have to allocate resources to two distinct goals: production and safety. In the long term, these are clearly compatible goals. But, given that all resources are finite, there are likely to be many occasions on which there are short-term conflicts of interest.’4

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Reason argues that the division and allocation of resources (e.g. money, time and equipment) are fundamental to errors and violations of acceptable working practice. Accordingly, there is a balancing act between resources and the pressures levied on ‘production’ – or in the case of the poor law, the distribution of relief and medical care. The crusade against outdoor relief and the restrictions set on poor law funding by the treasury are therefore central to the overbalance of prerogatives under the LGB’s Longley Strategy. From the permanent officials down to the local poor law medical officer, certain hazardous practices became embedded in the poor law system. Pathways to neglect were therefore created by the interaction of numerous latent and active failures, such as the circumstances that led to Edward Cooper’s death in the Isle of Wight workhouse. As Reason argues, organizations have a ‘memory’ – ‘Their thinking is a strong indicator of the ability to generate or eliminate hazards.’ As a result, he has said, organizational responses to hazards and safety data can be split into three groups: denial, repair and reform.5 In consideration of Reason’s three categories, the strongest correlation for the LGB’s response to negligence appears to be with actions of ‘denial’ and ‘local repair’. Reason explains that organizational denial leads to punishment and dismissal of observers; their ‘observations expunged from the record’ or ‘the validity of their observations is disputed or denied’.6 Instead of observing the calls for reform to systemic problems, the LGB’s consistent reaction to problems was to deny structural issues and to attempt to provide stop gaps at a local level. These involved official inquiries – but local as opposed to national – and the common scapegoat figure of a poor law doctor charged with negligence. In line with Reason’s description of the limitations of local patch-ups, the ‘wider implications’ of the neglect of patients were ignored or denied. Thus, in this respect, as David Green has demonstrated, the prescient reforms to London’s system of medical welfare (described in Chapter 3) were a normative response to a local problem.7 In so much as the Metropolitan Poor Act of 1867 was a large-scale, relatively comprehensive system of welfare, it had to be in order to deal with the London-centric problems of welfare provision in that particular area of England. Through its lack of engagement with national needs, the act was nonetheless in keeping with a history of ‘Localised Action’. As previous chapters have argued, the permanent poor law officials were ineffective in raising standards because their mandate was value for money and cost reduction. Expanding medical services on a national scale conflicted with the pressures put upon the poor law department by the treasury. In short, the LGB’s leadership encouraged the inspectorate and guardians to focus on blame, but avoid penetrative appraisal and costly reforms. In this way, the poor law administration was not unlike Reason’s ‘pathological’ model of organization: Pathological organisations are ones whose safety measures are inadequate even under normal conditions. These organisations sacrifice safety goals in the pursuit of production goals, often under severe economic pressures, and actively circumvent safety regulations. Information about hazardous conditions is suppressed at the source … .8

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Reason’s research was centred on modern, highly technical organizations with strong safety elements, such as the nuclear power and aviation industries. But it is interesting to note that the will to deny cause and effect is a strong human instinct in stressed organizations. Paul Ekman, an expert on the psychology of lying, has said, ‘The fact that someone interprets matters in a way that reflects well upon her, a way that allows her to engage in actions she finds desirable, does not mean that she is necessarily lying rather than misinterpreting.’9 Ekman says that a broken promise or a failure to remember are not lies. All poor law officials, from inspector to medical officer, were operating under tight budget constrictions with limited resources at their disposal. Poor law doctors would have been prepared to make difficult choices, but their job frequently placed them in a double bind (Crowther’s ‘divided loyalties’). Yet, they knew that any successor to their post would be faced with exactly the same dilemmas. There was no incentive from the LGB to provide quality of care and, in turn, long-serving medical officers could make a continuum of choices that diminished over time any sense of moral ambiguity. Furthermore, the guidance for medical attendances allowed the perception of responsibility towards the pauper to be passed about between officials like the proverbial hot brick. For example, in 1888, Samuel Hope, medical officer of the Petworth Union Workhouse and for ‘Number Two District’, neglected to attend a case of emergency midwifery. The case is a tragic example of the problems of the nineteenth-century claims system and how its failings could directly result in negligence. James T. Woodcock (a Pauper) wrote to the Petworth Board of Guardians complaining of Hope’s conduct. On three occasions, Woodcock or his sister had called upon Hope’s residence to alert him to the unfolding circumstances of Woodcock’s wife’s difficult labour (her name was not noted). As the evening progressed, Woodcock’s wife began having fits; as the pain increased she became faint and then unconscious. Her labour continued in this way from approximately 8.00 pm on 14 August until the following midday, when she died. At some point during the labour, the baby had also died – partially born.10 The circumstances were obviously traumatic for Woodcock (the pauper) who was passed around between three different medical practitioners – and fatal for his wife and stillborn child. Hope had initially accompanied Woodcock and examined the woman for ten minutes, before leaving a vial of medicine and returning home. As the labour became more serious, though, Woodcock again sought the doctor. Twice more, the anxious Woodcock returned to Hope’s residence. Hope was said to have ‘stood at the foot of the stairs in his dressing gown and told [Woodcock] not to worry’. On the third visit (at midnight), Hope stood at the top of his stairwell, ‘leaning on the banister’, and refused to come down; repeating to the indignant Woodcock that ‘there was no danger’.11 The difficult labour, however, continued. Woodcock was given money by his sister to go and find another doctor. He called on a private practitioner, Dr MacDermott – but this doctor refused to attend, saying: ‘I don’t wish to interfere with Mr Hope’s business.’12 MacDermott’s wife, it was claimed, leaned out of a window and told Woodcock to go to another doctor named Pearse. Fearing his wife’s condition, Woodcock did not want to waste more time. He offered money to MacDermott, who turned it down, replying that it was not about money but ‘life’ – presumably, meaning

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the quality of his own. Dr Pearse’s attendance having been secured, he arrived at Woodcock’s house at 3.00 am. Pearse immediately diagnosed a blood clot and gave the woman twenty-four hours to live. She died nine hours later. Looking back, Pearse said that he could not give an opinion as to whether or not the mother and baby would have survived if they had been seen earlier by a doctor. Hope showed no remorse. He had treated Woodcock previously as a private patient and doubted his eligibility for poor relief. Hope hinged his defence on this. Woodcock said, in contrast, that he had been attended by Hope since the former union medical officer had died, and so he had gone to Hope’s residence when his wife’s condition worsened. Under oath, and in answer to a question by Petworth Union’s clerk, he defended his actions: ‘On the third occasion he considered that Dr MacDermott having been called in he was relieved of further attendance … . It was not till the morning that I became aware that she had had fits. This was about 9am[.] I went down out of curiosity not to a private or a Union patient. I considered myself entitled to fees as a private patient in this case.’13 His brazen approach to payment crossed a line when, during the same examination, he asked the clerk for a rise in his salary of £20 per annum.14 Needless to say, Hope was asked to resign and immediately tendered his resignation for the district, workhouse and public vaccinator. Despite the surprising frequency of complaints made by paupers, discussed in the next chapter, inquiries into neglect did not bring significant reforms to the process of claiming medical relief. Denial was apparent throughout the poor law administration. Inspectors, doctors, guardians, masters and relieving officers were prepared to deny their own part in the neglect of pauper patients, but ready to point the finger of blame at one another. The most likely to be blamed – and, in terms of proximity to the event (both spatially and systemically), the easiest to hold responsible for negligent care – was the poor law doctor. Even with the hindsight of history, the actions of medical officers like Hope appear indefensible. Yet, the variant factors of their employment, described in Chapter 4, necessitated regular thwarting of contractual regulations, if not outright breaching of their duties. As Reason explained, the final realization of systemic latent failures frequently lies in the actions of individuals: ‘Everyday observation shows that if the quickest and most convenient path between two taskrelated points involves transgressing an apparently trivial and rarely sanctioned safety procedure, then it will be violated routinely by the operators of the system.’15 He adds that ‘operators’ (e.g. medical officers) are the ‘inheritors of system defects’ – sustained by ‘poor design’ and ‘bad management decisions:16’ ‘Their part is usually that of adding the final garnish to a lethal brew whose ingredients have already been long in the cooking.’17 In effect, that is a perfect analogy for the myriad problems in outdoor medical attendance under the Victorian poor law. The scenario of a man running around the town in the middle of the night seeking medical care for his dying wife – and being shunted between doctors – does not seem to indicate a poor law that had progressed substantially by the end of the 1880s. It also indicates that historians have tended to place too much emphasis on a popularized image of the relieving officer withholding relief. The simplistic image of the victimized poor, traipsing to-and-fro in order to make a claim, has held water though because this did happen. It was not unusual for the sick and poor to go through an arduous

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and testing experience, such as the Woodcocks’, to gain (or to be refused) relief. Charles Dickens was a famous source of such sentiment (e.g. Our Mutual Friend);18 but, since such portrayals, the relieving officer’s role in supply and demand has hardly been readdressed in subsequent years. The claims process for medical attendance was far more nuanced and, as Hope demonstrated, it contrasts with the broad view of a willing doctor and reticent relieving officer. This is apparent in Thomas Wakley’s protests to the House of Commons in 1848: The relieving officer gave an order to anybody who applied, and they thus created a wholesale pauperism, the most profligate system ever adopted. They would not pay the medical officer an adequate salary; but they compelled him, at an inadequate salary, to attend to all for whom he received an order from the relieving officer. In many districts, in the great majority of cases, when he visited a destitute person, he found him in a state of disorder, arising, not from any positive disease, but from want of food. The duty of the medical officer, then, was not to give bark or quinine, or any tonic medicine, but to order proper nourishment … . If the medical officer was what was called ‘liberal’ of these orders for nourishment, he speedily lost favour with the guardians; and the right hon. Gentleman would recollect, according to the rules of the late and of the present Poor Law Commissioners – for it appeared the system was too perfect to be changed – that before the poor person could receive the food required, the order had to be confirmed by the relieving officer; or, in other words, the relieving officer stood above the medical officer in reference to an order given medically, and given, too, for food.19

Wakley’s words seem to form a contradiction. He begins by saying that relieving officers gave out too many orders, but then goes on to insinuate that medical officers were unable to get orders that they needed. This is because not all orders were equal. The poor law authorities encouraged distinctive reactions to certain forms of need. This was apparent in policy, particularly during the crusade, and in the construction of the rules governing medical attendance. In terms of regular medical relief, the local poor law relieving officer was unlikely to refuse certification. The attendance of medical officers, especially the majority that supplied medicine from their own means – was value for money. They were contracted as part-time employees, but they were on call for twenty-four hours a day, seven days a week. Even conscientious doctors, such as Alfred Fleischman of Cheltenham Union, found it impossible to attend to all the regular and ‘sudden and urgent’ attendances that were required. Fleischman worked for one year as a workhouse and district medical officer for Cheltenham Union. He claimed that he had become a medical officer in order to publicize their reform movement. This seems plausible. He served from 1866 to 1867 and consistently referred to the Lancet Commission and the successes of London. He also made regular, verbose reports, pointing out the problems of the workhouse infirmary. Indicatively for this chapter’s themes, on one occasion Fleischman wrote in the Porter’s book: ‘What did I come for?’20 He had attended the workhouse gratuitously but could not keep up with the

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sheer scale of medical orders. He asked a fellow medical practitioner of Cheltenham to cover the hours from 1.00 am to 5.00 am, but still Fleischman missed attendances. During his short tenure at the workhouse, Fleischman found that over-generous orders for attendance were the practice, but orders were withheld when it came to the supply of drugs, medical extras or emergency attendance – all costs that unions, such as Cheltenham, wished to keep down in this period. The result of this was an over-abundance of medical orders – not a withholding of relief. Too many orders had thus created a situation where medical officers ignored calls for aid, or came when it suited them – delays that could result in a fatality and a charge of negligence against a medical officer. Unlike the district medical officer, workhouse medical officers’ received no fee for ‘sudden’ and ‘urgent’ cases – except in childbirth (Table 7.1). Yet, they could still be ordered to attend outside of normal contracted hours. This could be at any time of day or night. Alfred Sheen’s best practice guide for workhouse medical officers noted his personal experience of receiving too many orders for emergencies: ‘A late Master of our workhouse was in the habit of repeatedly, almost daily, sending for me after my usual visit, and in nine cases out of ten, quite unnecessarily. Matters eventually reached a climax. I was sent for, but did not attend, and the patient died without my seeing him.’21 These were the actions of a well-respected medical officer. Sheen was given a warning but defended himself successfully without recourse to the LGB inspectorate. Returning to Wakley’s statement to Parliament, there are elements of several key organizational issues that opened up pathways to the active neglect of pauper patients at a local level. First, malnutrition and undernourishment are interwoven with the causes of declining health, the onset of morbidity, and, in extreme cases, mortality. Victorians did not agree on the links between poverty and ill health and the role of this in unemployment. Therefore, the controversial role of sickness in the sliding scale between being pauperized, poor or in paid work meant that the recognition of ill health (as previous chapters have demonstrated) placed the medical officer into the position of a key gatekeeper; a decisive figure in the allocation of ‘resources’. Furthermore, the poor law’s mandate of less eligibility meant that it was difficult to square the circle of providing adequate nutritional relief – in the form of medical extras – while not going above the lowest standards of living for the working and self-sufficient poor. In this way, medical officers were held to account (such as Fenton in Chapter 5) for decision processes that were largely out of their hands. As the Medical Officers’ Vade-Mecum described, ‘In regard to the supply of “extras” it may be stated generally that any Certificate or Order given by a Medical Officer for the allowance of extra nourishment to any of his pauper patients, can only be regarded as a recommendation, or statement of his opinion as to what is required.’22 Just as effective medical welfare contradicted the original purpose of the new poor law, regular nutritional and dietary supplements (under the guise of medical aid) was a step too far. After 1871, Longley wanted to go as far as removing all outdoor relief to the sick, ‘except when they are incapable of removal’. This was a popular sentiment, reflected in crusaders’ rubbishing of outdoor medical relief as a ‘back-door of pauperism’. As one

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Table 7.1 Permitted fees for medical treatment and attendance Fee

District

Workhouse

(a)

Treatment of compound fractures of the thigh. A fracture was called compound ‘when the end or ends of the bone or bones have penetrated the soft parts so as to come in contact with the external air’.

£5

yes

no

(b)

Treatment of compound fractures or compound dislocations of the leg. Dislocation of the ankle falls under ‘leg’, whereas, a fracture of the foot did not.

£5

yes

no

(c)

Amputation of a leg, arm, foot or hand.

£5

yes

no

(d)

Operations for strangulated hernia. Reductions of hernia without the use of a knife were not due a fee. Neither was removal ‘of a stone from the bladder’.

£5

yes

no

(e)

Treatment of simple fractures or simple dislocations of the thigh or leg. A fracture of the malleolus externus (or ankle) was a simple fracture of the leg. A dislocation of the patella was not applicable. The hip joint was considered a dislocation of the thigh. Fractures of the foot were not included.

£3

yes

no

(f)

Amputations of fingers or toes.

£2

yes

no

(g)

Treatment of dislocations or fractures of the arm. This included the shoulder and wrist. ‘Care should be taken over dislocation of the radius and ulna – it should be ascertained if it is a simple dislocation of the bones of the hand, in which case it does not receive a fee. A fracture of the arm thus includes the humerus, radius or ulna, but not the scapula, acromion scapulae, clavicle or collar bone. A compound fracture of the metacarpal bones of the hand is not within the order. A dislocation and compound fracture of the thumb and finger are not covered by a fee’.

£1

yes

no

(h)

Treatment of a dislocation of the arm, accompanied with a fracture of the shoulder and ribs.

£1

yes

no

(i)

Attending to midwifery cases after receiving an order from a person legally qualified to issue one.

10–20 shillings

yes

yes

(j)

Midwifery cases ‘under circumstances of difficulty or danger’, with a legal order for attendance or where a doctor has attended without an order. The latter was permitted if the confined patient was in receipt of medical relief, or was one ‘whom the guardians may subsequently decide was in a destitute condition’.

10–20 shillings

yes

yes

(k)

In midwifery cases of ‘great difficulty’ in the delivery, long subsequent attendance or ‘in respect of some puerperal malady or affection’.

£2

yes

yes

Source: Lumley, Manual (1871): 22–33

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crusading zealot, John Pretyman, wrote in his treatise, Dispauperization: ‘… it opens the door to a variety of fraudulent devices; tempts medical officers to court popularity, or exercise a cheap benevolence, by recommending stimulants and nourishment; and induces, we are told, much feigning of ill-health on the part of their patients’.23 As Chapter 5 described, medical extras and fees for certain types of medical attendance therefore intermittently came under attack throughout the Victorian era, with the crusade providing the most sustained period of cuts.24 Nonetheless, the fundamental aim of the poor law was dispauperization – discouraging pauperism and dependence on relief, and cutting expenditure. The LGB inspectorate operated under a highly pressurized environment where the focus was almost entirely on cutting and shrinking expenditure. During the crusade, this pressure was diverted onto medical relief in a way that had not been experienced previously. Guardians and relieving officers looked at ways to make severe cuts to expenditure on their medical services. The centrifugal influence of resource allocation tipped the balance of prerogatives away from patient care in an extreme manner in the 1870s and 1880s. Poor law doctors faced too many orders for regular attendance (which was covered by their salaries), but the required certification for fee-paying services (e.g. obstetric emergencies) attracted localized obstruction. As ugly as Hope’s actions may seem, his case encapsulated the obscured pathway from latent failures to active negligence. This had been sustained by localized resolutions that regularly charged individual doctors, but ignored systemic failings. The crusade brought all the elements of this pathway together with unintended precision.

Dilemmas: To be there or not to be there Notwithstanding the attuned focus of crusaders, medical officers had always attracted criticism because of the extra fees that they could earn in addition to their salaries. Although guardians were decisive at a union level, the payment of fees was ultimately authorized by the LGB under a pay scale dependent on the type of treatment (Table 7.1). This pay scale became more complex and obscure as nineteenth-century medical knowledge expanded.25 In turn, the Poor Law Board and then the LGB wrote complex guides to the eligible medical treatments. The initial fee guidelines were provided under the Order of 1842, but this was retracted after problems.26 Fee directives were then reissued under the far-reaching General Consolidated Order of 1847.27 Nonsettled and the settled poor were covered by fees – there was no distinction.28 There was no extra payment for incurred costs (e.g. splints, apparatus and drugs). Although, in surgical cases not listed in Table 7.1 (e.g. lengthy assistance, technical need or particular difficulty), the guardians could make a bespoke ‘reasonable’ payment, subject to LGB approval. If there were several qualifying fee-paying treatments or operations for one patient, stemming from the same cause or incident, medical officers were due a single payment of the highest qualifying fee. The failure of an operation to prevent death was no bar to payment, providing the patient survived more than thirty-six hours. In such cases, the medical officer was due half the fee, but was also required to prove that he had made ‘several’ attendances on the patient before morbidity.29 Given the low

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salaries of medical officers, described in Chapter 2, the extra fees were a welcome and needed nominal income for many. In the early years of the new poor law, doctors dealt with a wide range of surgical cases and the flexibility of fees they could claim reflected this. As medical knowledge expanded, the rules followed trends. On one hand, trepanning and homeopathy, for example, slipped from vogue;30 while, on the other hand, surgical procedures became more specialized, time-consuming and costly.31 The fee guidance had originally ensured some extra payment for the diligent doctor, but the unintended constrictions of set rulings was that guardians could become more restrictive in the extra fees that they were prepared to allow. Furthermore, the rising costs of the incumbent medical fees led to fears that procedures were carried out for their pecuniary interest rather than necessity. As a result, it became more difficult for medical officers to carry out amputations without the second opinion of another qualified doctor. Only in exceptional ‘cases of sudden accident immediately threatening life’ could a medical officer perform an amputation without a second opinion. In all other cases, before carrying out the operation, the medical officer must have – at his own cost – first obtained the advice of a member of the Royal College of Surgeons, London, or a Fellow or Licentiate of the Royal College of Physicians, London. Payment was not made unless a certificate had been supplied from the medical practitioner who had sanctioned the operation.32 While some medical officers may not have welcomed the restrictions, this was an unusually clear directive. Other ‘sudden’ and ‘urgent’ cases continued to be a chief cause of problems with attendance. The confusion over emergency obstetric procedure, for example, caused frequent conflict between poor law officers and officials. The procedures for childbirth were a key element in the pathway from latent failures to the active neglect of pauper women (and, arguably, their unborn foetus). The obstruction that doctors faced over fees was experienced by both workhouse and district medical officers in matters surrounding childbirth (see Table 7.1). Dr Joseph Rogers – renowned reformer and leader of the Poor Law Medical Officers’ Association – withheld treatment in an obstetric emergency because of interference from the master, and because the guardians refused to pay his fees. As workhouse medical officer of the Strand Union, Rogers was continually denied orders to oversee ‘sudden cases’ in childbirth: ‘I was debarred from attendance on [them], and could not claim any fee. The master and clerk arranged that no order should be given until nine days had elapsed, when it was held that I was bound to take charge … as in an ordinary case of illness.’33 When Rogers attended emergency cases without an order, though, he was repeatedly refused the due fee. He brought the disputes to a conclusion by refusing to attend an obstetric emergency unless a written order was provided. It created a standoff. Rogers waited for the appropriate order, but, he said, ‘… although both of these officers knew of the poor woman’s condition, they had maliciously allowed her to remain without proper attendance, and would not give any order, so that I should not be paid a fee’.34 Another doctor’s attendance was purchased, though, and Rogers was charged with neglect. As Lumley stated clearly in his manual of legal directives, medical officers of the workhouse were not entitled to fees for delivery in the workhouse, unless they had received an order from the master or matron ‘in circumstances of difficulty

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or danger’.35 Nonetheless, Lumley’s own directions for Article 182 of the General Consolidated Order contradicted the need for an order and made it clear that emergencies could be treated without one.36 Rogers was well aware, though, that payment for autonomous attendance relied on the guardians’ goodwill. The nine day lag was extreme, but it had clearly been set to avoid disputes over the time frame for emergencies, which had to be ‘in or immediately after childbirth’.37 The LGB’s meaning of ‘immediately’ was unclear: ‘… it has been considered that an attendance several days after the delivery is not sufficient’.38 Nine days must have seemed a sure bet. The circumstances surrounding Rogers’ charge and forced resignation are often traced to his activities as a reformer.39 Whilst his involvement with the London reform movements, described in Chapter 3, soured his relations with his employers, the active negligence of Rogers came about because of latent failures that affected all medical officers. The translation of those problematic features in the subsystem of obstetric orders into his individual neglect was emblematic of the poor law's ineffectiveness in dealing with the issue of pauper childbirth. In disputes between guardians and medical officers, the LGB would adjudicate; but they ‘declined to lay down any precise rule as to what were to be considered as cases’ of ‘great difficulty’.40 Their guidance only served to further muddy the water: Where delivery of the child had taken place, but the placenta was retained, and the umbilical cord having been ruptured, the patient’s life was in danger, the case was considered to be within this article. So where there was a hand presentation, and the foetus required to be turned. So where there was an arm presentation, and the woman had been long in labour before the officer arrived. Where a woman had been nearly three days in delivery, and was ultimately delivered by means of instruments, the case was also within the order.41

Problems thus stemmed from an obscure nomenclature – especially for the lay personnel appraising the doctor’s fee – and the Board’s lack of defined meaning. While some medical officers may have welcomed guides to fees, most recognized that it was unworkable. It led to disputes, such as those experienced by Sheen and Rogers, described below. A clearly defined fee structure also implied to administrators that anything not listed as attracting a fee was covered by the medical officer’s salary. Thus, while the range of prescribed fees may have nominally increased in the mid-nineteenth century, the orders for salaried attendances would have risen exponentially at the same time as the fee-paying guidance became more inflexible, bureaucratic and open to abuse during the crusade years. In Bridgnorth, for example, a medical officer was called by the pauper family to assist a birth in 1885. He discovered an emergency that could not proceed without his intervention. He feared another refusal by the guardians to pay his fees and sent the expectant mother’s husband to a relieving officer to obtain certification, ‘who referred him to the Board, which happened to be sitting that day. [The] Board refused an order … stating that if the man had applied to the [relieving officer] before coming to me, he would have given him an order’.42 Yet, the expenses of ‘sudden cases’ – or rather, the doctor’s fee it incurred – had led to localized interference from

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guardians and cutbacks in emergency treatment. Relieving officers at Bridgnorth were directed to withhold medical orders for emergency childbirth involving forceps, because guardians argued that it incurred a fee of two pounds. However, the use of instruments did not in itself guarantee payment.43 Such misunderstandings or wilful misreadings were a frequent cause of fierce debate between guardians, permanent officials and doctors. A fee of two pounds was supposed to apply to births with ‘great difficulty’ or with ‘long subsequent attendance’.44 But Table 7.1 (j) and (k) show that ‘circumstances of difficulty or danger’ were indistinguishable from those of ‘great difficulty’. ‘Peculiar circumstances of difficulty’ was the benchmark for the £2 fee, but – as with all childbirth fees – only for ‘circumstances arising out of the delivery’.45 Thus sickness and disease (e.g. scarlet fever) after confinement were discounted, but puerperal maladies were included. Further exceptions were given, but these were inadequate for the range of possible obstetric complications; such as the ‘mere retention of the placenta, the woman having been delivered by a midwife’ and a ‘knee presentation of a dead child, where only manual assistance was rendered’.46 All childbirth-related fees were confined to situations where the ‘child may be born alive’. Premature delivery of a baby at seven months, the LGB directed, was thus due a fee. It made no difference if the baby died in utero; a fee was still due. Furthermore, a medical officer who followed an order but found ‘the woman dead on arrival’ remained entitled to a fee.47 The LGB were neither conclusive nor decisive in their approach to the emergency claims procedure. They produced confusing guides, such as the Medical Officer’s Vade-Mecum, which did little to alleviate systemic problems and warned doctors against dangers ‘arising from ignorance of complex official regulations – the unintentional neglect of duties imperfectly understood’.48 Yet, when approached for help, their correspondence was equally obtuse. For example, in Stratford-on-Avon Union, the workhouse medical officer wrote to the Board, complaining about the non-payment of his emergency fees in a case where rapid intervention was needed to mend the dislocated bone of a pauper child. In the words of the LGB, the doctor had ‘reduced the dislocation without having previously received any order’ and was not, therefore, due the nominal fee. Although they accepted that there were subsequent orders for his attendance, those were ‘merely applied so as to require [his] subsequent attendance on the child’.49 The LGB recommended that the guardians pay a ‘reasonable remuneration’ for the medical officer’s attendance, but made it clear that this was a gratuity. The neatly framed role of overseers in this complex legalconstruct was clear in the LGB’s closing words to the doctor: ‘you remark as to the difficulty experienced in obtaining the order of the relieving officer, the Board would remind you that, as [this case] was one of sudden and urgent necessity, it would have been competent for a churchwarden or overseer of the Parish to have given an Order for your attendance’.50 Guardians, however, could refuse to pay that type of order and the doctor would then be forced to write off or pursue the payment in court from the parish official. Doctors, such as Hope, were at the whim of lay decisions about complex medical needs and emergencies. The relieving officer, overseer, assistant overseer, master and matron were all empowered to give orders in cases of ‘sudden and urgent necessity’.

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Yet the guidance in Table 7.1 raised more questions than it answered, leaving fee payments open to widely varying factors in local interpretation and consequent practice. The Overseers’ Manual described the importance of emergency cases: ‘Overseers cannot give any relief out of the poor rate, except in cases of sudden and urgent necessity, and then only temporary relief, in kind, and not in money.’51 It made no difference whether the applicant was the casual or settled poor – ‘… in either case, the duty of the overseer is to administer relief at once in articles of necessity, if the case be really sudden and urgent; and, if it be not, to refer the applicant to the relieving officer. If the overseer neglects or refuses to give such necessary relief to any person, not settled or usually residing in the parish, a justice of the peace may order such relief to be given’.52 The Manual added: ‘A justice of the peace may also make an order for medical relief in cases of sudden and dangerous illness.’53 The local officials, though, had no clear guidance on distinguishing between a case of serious but regular sickness and one that was ‘sudden and dangerous’. When in doubt, an overseer could seek a medical officer’s attendance and, similar to relieving officers, be reasonably sure that they were shielded by the ambiguities of the rules for emergency attendance. Although guardians did issue orders to medical officers (via their officers), the rules stated that ‘neither the guardians nor the clergyman of the parish nor any other officer of the union or parish is so entitled’.54 This did not stop the local vestry, church wardens or clergy from calling on the medical officer – and it was not uncommon for the medical officer to be called out by members of the public. Given this range, the medical officer had the right to retrospectively claim a fee for emergency attendances without an official order from the relieving officer: ‘He must then give credit to the party who calls him in, or must trust to the guardians recognising the destitution of the patient, after he has rendered his services.’ Yet, the LGB neither required nor compelled the guardians to make this type of payment55: The 11 & 12 Vict. C. 110, s. 2, enacts, ‘that it shall be lawful for the guardians of any union if they think proper, to pay for any medical or other assistance which shall be rendered to any poor person on the happening of any accident, bodily casualty, or sudden illness, although no order shall have been given for the same by them, or any of their officers, or the overseers’. Hence a medical officer may render his aid promptly without an order, relying upon the due acknowledgement of his services by the board of guardians; but he must remember that he has no absolute legal claim upon them, as they are to make compensation in any such case only if they think proper to do so.56

As a result of this flexibility, guardians could, and frequently did, veto payments for medical officers who had attended an urgent case, or treated paupers without an order. Contemporary guides for doctors, such as the Medical Officer’s VadeMecum, cautioned the reader to ‘attend first and raise the question afterwards; otherwise … he might be placed in a situation from which he would find it difficult to extricate himself, however unknowingly his neglect had arisen’.57 District medical officers were thus frequently faced with the decision of whether or not to attend some cases.

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The problem was compounded by the fact that a parish overseer could give an order for a medical officer to attend an emergency, but that guardians were able to legally refuse to pay the doctor for his attendance. The LGB advised that if guardians refused to pay, medical officers should try to recover their fees from the overseer in the courts. This was expensive and time-consuming. Most general practitioners were unable to afford legal costs, or unwilling to lose time chasing claims in court. This aspect of the medical welfare system left little room for manoeuvre. The rules legally covered the LGB and guardians from all directions. Officers and overseers, even paupers, could request the medical officer without paperwork in an emergency. In practice, this meant that medical officers could ignore or cherry-pick ‘requests’ for their attendance. Yet, if they did not heed an overseer’s order, and the outcome was unfavourable, then the absentee could be charged with negligence. As the Medical Officer’s Vade-Mecum warned, ‘In case of the Medical Officer’s refusing or neglecting to afford such attendance, it will be incumbent upon him to prove that he was justified in the course he may have adopted.’ Contemporaries acknowledged the regular missed attendances, but investigation was heavily reliant on outcome bias – those cases of non-attendance that had led to negligence, complaint, official inquiry or death of a pauper. In effect, the doctors were caught-up in a contractual ‘catch-22’ that echoes Joseph Heller’s black-humour military conundrum. Such a view of the emergency system was clearly described in a letter to the BMJ: The poor must be given to understand that in all sudden cases they must go at once to the medical officer, without an order. If the latter attend to the case, and then claim the regulation fee, he is politely asked for the order, and having none, is told by the board to go about his business. If, on the other hand, he decline to go to a case before the order is obtained, he is held to do so at his own risk; and should such a case terminate fatally, down comes the coroner upon the medical officer like a hatchet. The board follows suit, in a state of virtuous indignation, and the local press takes good care not to lose the chance of airing its rhetoric at the medical officer’s expense … . The medical officer has to choose between being made a social Aunt Sally or doing the required work for nothing; and, in general, he chooses the least of two evils, and the Board gets the work done and saves the price of it, thanks to the dread of an enlightened public opinion.58

The reality of doctors choosing which cases to attend resulted in avoidable morbidity and mortality that had resulted from negligence. A further example of obfuscation was embodied in Mr Buck, a district medical officer for the Newport Union. In 1878, Buck had been treating a pauper family of a labourer named Wright. The children were on the union’s medical relief list (those entitled to relief); as such, when Wright’s son fractured his leg, Buck duly attended to set the fracture. In line with regulations, Buck did not wait or apply for an order for his attendance. He was clearly in the right: this was an emergency and the family were already on the list of permanent paupers. In spite of this, his subsequent request for the regulatory fee was refused because he had not obtained an order from the relieving officer:

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Mr Buck wrote to the Local Government Board, giving the facts of the case, and inquiring whether, having ordered his attendance on the family in April, the guardians could refuse an order in December. He received for answer that the guardians were the sole judges when an order for relief, medical or otherwise, should be granted; that if an order for medical relief were granted, such order only remained in force so long as the illness continued; and, therefore, an order for relief given in April would not apply to a fracture of a leg of one of the children in the following December; but expressing no opinion on the fairness of the guardians towards him. Now, we can have no hesitation in expressing our decided opinion that Mr Buck has been most meanly used by this Board of Guardians; for it will be noticed that, when medical relief pure and simple is ordered for Wright’s children, no objection is raised; directly, however, that an accident occurs, the treatment of which involves a fee of £3, then the order is refused. Our readers will also not fail to observe that the Local Government Board do not give any opinion on the merits of the case, beyond stating that the guardians are the sole judges when relief should be afforded.59

The General Consolidated Order of 1847 was an attempt at clarity, but in essence the ‘opinion’ of the LGB had remained open. In turn, ill-defined caveats broadened the choice of payment vetoes. Thus, in the example of fractures, ‘treatment is not only the setting of the fracture but the attendance on the patient until recovery or death’.60 Therefore, setting the limb, without subsequent treatment, could be deemed ineligible for a fee. Being sent to a hospital or workhouse after the setting of a fracture was also not due a fee; nor was discontinuing attendance where there had been no ‘cure’. Much depended on the goodwill of guardians towards ‘their’ doctor. Months of procrastination and debate could follow a ‘sudden and urgent’ attendance. After such an experience, one medical officer complained to the BMJ: ‘From a humane point of view, it is impossible for a medical man to refuse to attend an urgent case until an order is first procured, although this conduct of the guardians would almost drive one to it.’61 It should be recognized that a great number of doctors did forgo fees and attend paupers without the legal payment. As Digby observes, though there was a balance between self-interest and philanthropy, ‘Credence must be given to genuinely idealistic, charitable, religious and humanitarian impulses … .’62 This had changed by the mid-nineteenth century. Attitudes to the poor had hardened and the competitive field of medicine meant that fees were needed and expected by most.63 Those that sought their legally recognized fee, under the poor law, could face a protracted wrangle with guardians. Thus, to ensure payment, some did take a risk (in terms of neglect, job security or negative publicity), and withheld ‘urgent’ treatment until authorization was received. In 1897, for example, a man called David Overall had arrived at the private surgery of Dr Coombe, who was also the district medical officer in Maldon Union. He was refused treatment. Overall had a broken arm and was in great pain, but he had been waiting for an hour before Coombe arrived. He offered to give the doctor part of his fee (as a private patient) and settle the balance the next day. Coombe was adamant that, without payment of the fee or an order from the relieving officer, he would

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give no treatment (on loan or otherwise) to anybody from the district of Maryland Barracks. He maintained that residents, there, had repeatedly refused to pay his fees, and that guardians had not honoured ‘urgent’ fees without an order. As a result of this exchange, a man named Ridgewell was sent to William Read, the district relieving officer, to get him to come and see Overall (who had realized he had little choice if he wanted immediate treatment). When the relieving officer arrived, he pressed the medical officer on his ‘inhuman treatment’ and asked why he would not treat Overall. He was told that Overall had not applied for an order, himself, because he did not want to be pauperized. He bemoaned the fact that he had not visited an alternative doctor in the opposite direction. Read then stated that ‘Seeing the case to be one of great urgency I at once gave an order on loan … .’64 A few days later, he called at Overall’s house to inform him that the matter had been reported to the guardians. Overall informed him that, in accordance with his ‘promise’, he had returned to Coombe and settled the fee. Although he agreed with Read that he had been neglected and that the doctor should be ‘showed up’, Overall, however, was more disgruntled with his unwanted temporary pauperization and did not pursue a charge of negligence.65 The doctor got wind of the proposed charge and threatened legal proceedings against the relieving officer. He claimed to have treated the arm immediately after Ridgeway had been sent to Read. At the heart of his defence lay his right to question the pauper’s ability to pay and to appraise his status – which the LGB endorsed. In spite of a belligerent and ‘hard’ attitude towards the poor, Coombe’s vigorous defence of his actions paid off. With apparent misgivings, the LGB saw no need for an inquiry and held up his defence: ‘Having regard to the former inquiry [into previous charges against Coombe], I do not think the present case reflects any credit upon Dr Garton Coombe, but he was undoubtedly within his legal rights in demanding an Order before he attended the man.’66 The guardians were forced to backtrack from a ‘complaint of negligence’ and reframe their dissatisfaction as one of a recalcitrant and bothersome officer.67 The relieving officer therefore mentioned three further cases. From these, it is apparent that the role of fees in the attendance catch-22 had been at the heart of repeated charges and complaints against Coombe. One of those had involved a pauper named Bridge (also from Maryland Barracks). According to Read, Coombe had arrived at the relieving officer’s house one evening. The doctor had ‘said he had been called in to see [Bridge’s] Wife who was Expecting her Confinement, and as he would never get his fee would I give him an Order. I said can’t the man apply. I know nothing of the Case’. Again, the grey area between the private patient and the pauperized medical relief claimant was a cause for conflict. Read refused to give an order for a loan without application.68 The next chapter will return to this grey area, formed at the juncture where the fee-paying working person morphed in and out of fee-worthy pauperism. The Clerk of the Maldon union wrote to the Board for their direction and questioned Coombe’s suitability as a medical officer: In a large and scattered district like the Southminster Relief District, all parts of which have to be visited by the Relieving Officer, it may often happen that in a case of accident or other serious emergency, there might be considerable delay

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and difficulty in getting an Order from him or from the Overseers of the Parish to which the sufferer belongs for the Doctor’s attendance, and this Board asks the advice of the Local Government Board as to the steps they should take to provide against the serious consequences which may arise if Dr Coombe should insist on having an Order before attending to the Case.69

The emphasis in the catch-22 had been shifted, here, in an attempt to push the doctor into consistently attending without orders – which they were not legally obligated to pay for – and in order to underline that the responsibility for neglect would lay firmly with him if he did not. Attending emergencies could throw out the careful balance of a doctor’s resources (in terms of time and money). Cases that occurred at great distance from the doctor’s home or surgery would result in lost time; additionally, there was the possibility of loss of earnings from a private patient who may go elsewhere in the interim. A busy doctor, struggling to make ends meet in the competitive sphere of private medicine, was therefore unlikely to have been receptive to repeated requests for attendance in what were, to many medical officers, unnecessary circumstances. Given those caveats, the Petworth medical officer’s behaviour towards the Woodcocks becomes understandable, if no less abhorrent. The financial prerogatives of medical officers undoubtedly underpinned their daily interactions and thus it was unsurprisingly a key element in the decisions and actions that led to their neglect of patients.

Assistants: Negotiating the double bind In addition to the emergency attendances, described above, medical officers were expected to treat and supply necessary medication to all paupers on the relief list – those possessing a certificate or ‘ticket’ for medical relief (issued by a relieving officer). In regard to their surgery or dispensary, they would have maintained a horse and carriage, had servants to pay and carried the expenses of medicaments and pharmaceutical stock. Most doctors would also have been responsible for their own family’s finances. The limitations on time and money are obvious. As a result of the poor law authorities’ refusal to acknowledge the dangers of employing them under a sustained double bind, assistants became the norm for the district medical officers. They were a necessary bulwark that kept in check the pressures brought to bear by the finite resources of both time and money. Edmund Cockey provided a typical account of those stretched resources. He claimed to have ‘ridden or driven for 10.5 miles daily for 246 days’;70 incurring the costs of a manservant and ‘horse and gig’, which cost him £87 6s on a salary of £62 a year.71 Excluding drugs, tax and tolls, Cockey’s list of expenses were already beyond his annual Poor Law wage: ‘during the winter, it is one horse’s work to take me through the district; so that after paying for medicine, gates, etc., in addition to wear and tear, you will see that very little can be left … no one can undertake the constant trouble and anxiety attending such an office with satisfaction’.72 The BMJ reported that

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a Penistone medical officer, Dr Gruggen was being paid £26 a year, but the union only supplied cod-liver oil and quinine. Thus, his salary (supplemented with a privatepractice income) was considered enough to treat the needs of a population of 5,213 in a district of 8,830 acres. Gruggen recorded that he made 828 visits to treat patients in one year – with more prescription and diagnosis work carried out at his practice and in his home. On average, Gruggen had officially treated thirty poor law patients each fortnight. According to the BMJ, Gruggen applied for an increase of £10 a year: ‘Although his application was supported by the Chairman, it was, after a not unusual exhibition of ignorance and bad feeling on the part of the assembled guardians, unanimously refused.’73 To counter these financial limitations, and the failed state of their fight for improved remuneration, medical officers en masse turned to the regular use of assistants. Following Edward Cooper’s starvation and neglect in the Isle of Wight workhouse, several newspapers turned their attentions to the use of assistants. It sparked considerable debate but nothing was done at an official level to halt the practice. In 1878, an ex-medical officer (and fellow of the Royal College of Surgeons of England), Charles Holmes, published a damning indictment of the use of unqualified assistants to carry out poor law work: In many cases the Sick Pauper is visited once at the commencement of his illness by the Medical Officer, and if his Assistant is sufficiently intelligent to detect symptoms of approaching death, a second visit is made; certificates of the cause of death are, however, in many instances, given by the Medical Officer when he has not seen the deceased pauper for a long time before death occurred, and in such a case the fact is carefully kept from the friends, and also from the Coroner of the District, that he has been attended by a person without medical education.74

The General Medical Council, Holmes said, had held a meeting in 1878, where a proposition on assistants was moved by Sir Dominic Corrigan, ‘That while the Council cannot undertake the duty of prosecuting unqualified practitioners, they nevertheless think it their duty to call the attention of the Local Government Board of England, to a practice which it appears exists in England, of practitioners in charge of Medical Relief Districts, of employing Unqualified Assistants to act for them in the treatment of medical and midwifery cases, tending to the detriment of the public, and other evils … .’ 75 Arguably, the historical view of poor law medical services is one that has largely overlooked and underestimated the extent of this mixed-bag workforce of assistants. This gap, in part, has been caused by the occasional muddling of the terminology between three different entities: substitute, medical officer’s assistant and assistant. Every medical officer was required to name a legally (as described in Table 2.1) qualified substitute – and this substitute would appear within the terms of their contract.76 They were supposed to cover periods when a medical officer was taken ill or was away from the union. In Holmes’ experience, agreements were reached between doctors merely to satisfy the paperwork: ‘The writer is acquainted

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with cases where the Sick Paupers are frequently left for a week, or more, to the sole charge of an Unqualified person, the substitute not being even aware of the absence of the Principal.’77 District medical officers sometimes made arrangements among themselves to perform the role of substitute. According to Holmes, this was with the ‘understanding, implied or agreed, that they shall never be called on to act’.78 The main point here is that a substitute was a medical colleague and clearly not an assistant. The occasional names listed in central employee archives as ‘medical officer’s assistant’ were also qualified medical practitioners. This sub-group of medical officers were contracted and paid officers. Towards the end of the nineteenth century, roughly at the time that probation nursing grew, there was a limited move towards using workhouse infirmaries for training medical students and newly qualified medical professionals. Thus, the records of some larger infirmaries, such as Birmingham, began to list paid medical officer’s assistants. For the rest of the country, throughout the entire Victorian period, the unofficially sanctioned assistants meant something quite different. They are unrecorded in the central employment records because they were independently employed or interned to medical officers via private arrangements. They could range from a recently qualified medical practitioner gaining experience, such as Beckingsale’s son in the last chapter, or the under qualified or unqualified medical student, to the unqualified drug dispenser, hired hand or servant. Some were clearly unequal to the tasks that were set them and the level of unmeasured neglect nationally can only be guessed. Just how numerous they were and how regularly assistants carried out medical work remains controversial, but the records of official inquiries, medical journals and newspapers point to an almost ubiquitous presence in district medicine. Holmes argued that if there were to be a ‘Parliamentary enquiry’ and that if questions were asked pertaining to who actually carried out the visitations upon the poor, it would have been revealed that district medical services (e.g. attendances, treatment, observation, monitoring and dispensing) were regularly carried out by unqualified assistants: ‘… it would, we believe, show that the poor are largely, and in many Districts almost exclusively, attended by men with little medical education, and that the existing scheme of PoorLaw Medical Relief as now practised is a COSTLY SHAM, by which the Ratepayer suffers much, and the Sick Paupers profit little’. 79 The medical officers were part-time, still struggling to meet even minimal attendances. The impact of their absences must be considered. When the social historian, Joan Lane, argued that the medical officer was the key figure for medical care under the poor law, the words had unintended implications.80 In some unions, it would be no exaggeration to claim that they performed as a figurehead or consultant – offering advice and guidance at infrequent intervals – which was clearly not what they had been contracted to do. The previous chapter argued that untrained nurses sustained a large portion of the workhouse infirmaries, carrying out the lion’s share of ‘care’ across England and Wales. The same problem of absent doctors plagued the quality of district medical care, but with assistants regularly carrying out primary care work. The large districts in some poor law unions hint that assistants would have been used often as a coping mechanism.

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The legal limit of a district was 15,000 acres, but Wales was exempt from this ruling. Even so, the neighbouring English counties (and beyond) seemed to have emulated their Welsh counterparts with large, but illegal, district sizes. The problems that beset large districts thus did not stop at the Welsh border. Table 7.2 shows that Herefordshire had districts over 60,000 acres, which was four times the legal limit for England. This deliberate lawbreaking spread beyond the border unions – at least as far as Staffordshire, where one district was over 54,000 acres. Perhaps this blasé use of illegally large districts reflects other patterns in the poor law. Stewart and King said that the ‘West of England broadly defined was amongst the harshest of English subregions when we judge attitudes towards the poor.’81 In general, though, districts in Wales far outsized those in England.82 Arguably, the Poor Law Commissioners (and then the Boards who did not overturn the ruling) had not envisaged the expansive Welsh districts that became the norm in the nineteenth century (Table 7.2). Bearing in mind the legal limit for English unions – which the PLMOA considered too large in itself – it is clear that these were insurmountable distances for one medical officer to cover.83 The end result was non-attendance and use of assistants. Welsh unions did not employ more medical officers per district or build more workhouse infirmaries. Welsh-based poor law doctors therefore had to cover greater distances than those of English unions.84 Moreover, this distance would have applied to the general practitioner and the distance from his residence or practice to the homes of his private patents – providing less time for poor law patients. Historians, such as John Stewart and Steve King, have seen this as a direct Table 7.2 Representative large districts in Wales and England Union name (Wales)

District size in acres

Union name (England)

District size in acres

Abergavenny

32,848

Atcham

29,922

Aberystwith

41,261

Bromyard

60,664

Bangor and Beaumaris

19,582

Cheadle

54,172

Brecknock

76,184

Chester

22,415

Carnarvon

28,457

Clun

22,625

Gower

46,251

Dore

30,946

Llandovery

77,640

Droitwich

15,427

Llanrust

55,849

Ledbury

29,797

Merthyr Tydfil

24,615

Leominster

39,519

Narberth

39,588

Penkridge

20,721

Ruthin

36,549

Solihull

17,883

Source: TNA MH9 Series

Stow-on-the-Wold

22,453

Tarvin

22,765

Upton-on-Severn

16,651

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conduit to the continuing use by Welsh paupers of alternative medicine throughout the nineteenth century.85 As Chapters 2 and 3 argued, until the mid-Victorian era, some of this medical treatment (e.g. bonesetters or traditional remedies) may have been equally effective to some of the limited medical provisions of poor law welfare. The Welsh experience meant that medical practice per se was a challenge: ‘A good road network was always a significant factor in the siting of an eighteenthcentury medical practice, enabling patients to reach the surgeon-apothecary, and the practitioner to make domiciliary visits as easily and quickly as possible.’86 This would not have been the case in much of rural, nineteenth-century Wales. For example, a Narberth Union medical officer (see Table 7.2) wrote to the BMJ in 1871, explaining why he had to give up his appointment. He averaged 200 poor law ‘attendances’ each year, scattered over sixteen parishes in a huge district: ‘This entails the necessity of travelling on horseback a distance of ten or twelve, and frequently fourteen, miles through a mountainous country, in many parts inaccessible to every kind of vehicle, in addition to supplying all medicines, for the munificent salary of [£]35 per annum’.87 The doctor explained that he accepted the low salary because there was no place ‘suitable’ for him to live within the district, so he was contracted annually. Thus, by the residency loophole – discussed in Chapter 4 – he had to go through the process of annual competitive re-election each year. In Bangor and Beaumaris, Dr Jones resigned from his post for workhouse and recounted the reasons: ‘one being the excessive amount of work, and the other the worry and petty annoyance I have had to endure … . By the former I meant that the duties and responsibilities attached to the post were out of all proportion to the salary’.88 The Brecknock workhouse medical officer, Thomas Armstrong, was only contracted to attend to patients at the infirmary twice a week (as well as emergencies), but still could not manage those minimal duties. At 76,184 acres, Brecknock Union had one of the largest districts in Victorian Britain. Such a huge district meant crossing difficult terrain and traversing time-consuming distances were necessary, but had limited financial incentive. Unsurprisingly, skipping attendances was the result. Armstrong was forced to resign after repeated attempts to make him attend more regularly. His non-attendance became unacceptable after a pauper was left in the infectious ward for ten days without examination. The guardians had been forced to send for (and pay) another medical practitioner.89 The practice of having large districts in Wales was more hazardous – in terms of ability to provide medical welfare – because the topography of Wales was one of great hills, mountains and valleys. The stereotype of the weather-beaten district medical officer, portrayed eloquently in the Song of the Union Doctor, was closer to the reality in Wales. Nonetheless, given the choice, not all doctors would have battled the Welsh countryside or the inclement weather, and scaled a mountain to visit a sick pauper who may or may not have needed medical treatment. The picture of an overstretched medical practitioner, needing his private practice for its income, and prioritizing those duties, was therefore equally accurate. Furthermore, Welsh paupers were likely to have been in need of effective nourishment, not medical treatment. Arguably, many doctors in Wales embodied the wider problems of the poor law system; finding their obligations distasteful and doing as little of it as possible.

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The catch-22 meant that, by necessity, the majority of medical officers in England and Wales prioritized their attendance on private patients. Irvine Loudon described well the importance of travel and its impact on a successful private practice: ‘The round of visits was the essence of medical practice.’90 Private patients expected a visit from the doctor – that was part of the payment. On top of this, a successful private practitioner would need to look the part and maintain a horse and gig. Those in the wildest rural regions (e.g. North Wales) would have needed more than one capable horse – lameness was a constant and time-consuming expense.91 An 1890s’ description of the general practitioner’s horse reads like a romanticized analogy of their owners: … there is no doubt that the typical doctor’s horse, the horse of a hard working general practitioner, has a trying life … his work is never done, and he must be exceptionally sound and robust to stand the wear and tear of day or night … . He may not look so well as the animal driven by the country medico, who generally takes a pride in his horseflesh, but he costs quite as much and does not last so long. Six years work is as much as can be expected of him.92

Even the arrival of rail travel brought little change to the practice of poor law medicine in the nineteenth century. As Loudon explained: there were few stations and a doctor would have needed a horse or gig ready at the station. He therefore argues that the age of the rail saw a boom, not a decline, in the use of the horse.93 The cycle age would have received an ambivalent reaction in the more challenging rural areas and its impact must be doubted – the horse would have remained the staple transport throughout the nineteenth century. According to Loudon, it was the ‘motor car’, and the accompanying increase in roads, that changed the face of doctoring in the early twentieth century.94 Given these constraints on time, money and ability (to ride, walk or generally get about), the decision to attend becomes paramount. A day spent trekking a Welsh mountain may be better spent elsewhere if the case was thought to be a pointless journey. Undoubtedly, the use of assistants propped up untenable day-to-day attendances for district medical officers with a challenging district or pauperized population size. As inexcusable as it seems, the greater portion of medical officers had to have an assistant in order to negotiate the double bind of their obligations to poor law and private patients. In spite of the LGB’s pontification on the subject, and their misleading of the public with guff and bluster, they did allow the use of assistants and were fully aware of the extent of their use: ‘… the Board are not prepared to say that in ordinary cases the medical officer may not employ, under his own superintendence, his assistant or apprentice to visit the sick paupers under his care … ’. 95 The Medical Officer’s Vade-Mecum thus said: ‘In regard to the frequency with which a Medical Officer should visit cases in which he has received an order to attend – especially chronic cases – much doubt has been entertained.’96 It described the books that district medical officers were required to use, in order to record and report their personal attendances, and those that were carried out by an assistant. Red ink was supposed to be used to highlight where they had not personally attended the case but had sent a ‘substitute’ or ‘other person’ (meaning an assistant) instead.97 The

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Medical Officer’s Vade-Mecum further advised that in order to accurately report the case, the medical officer should attend more than once before documenting details (presumably related by an assistant): ‘Unless this be done he will not only be unable to certify to the condition of the case as it actually exists when the Report is made, but he cannot state whether the “necessaries” which he formerly ordered are still required; or, if required, whether in greater or less quantities.’98 Public concerns about the overuse of assistants therefore seem well-founded, but there is very little research by historians to accurately appraise the efficacy or extent of their work. The highly pressurized system, and the double bind of medical officers, would have resulted in an over-reliance on inexperienced and unqualified nurses and assistants. It has thus been argued, throughout this book, that there was a continuing crisis of care in the nineteenth century under the poor law that reached its apotheosis under the crusade. The narrative has, however, been moved away from the hyperbole of ‘scandal’. Instead, negligence has been viewed as the important legal mechanism that it was under the poor law – a serious charge in the eyes of inspector, guardian, doctor and pauper patient. Each one, it has been argued, had different expectations of poor law medical care; in turn, they thus had contrasting views of neglect and how to deal with it. The final chapter will complete this analysis and put public reactions to neglect into the limelight. It will examine a surprisingly potent factor in the creation and framing of negligence under the poor law: the verisimilitude of pauper complaints about negligent care.

8

Conclusion: The Patients’ Voice – Seen but Not Heard? Looking back In contrast to the accepted history, charges of neglect against poor law doctors did not go down after the 1860s. The role of negligence (and official inquiries) in paralysing the reform movement of the PLMOA has thus been overlooked. This book therefore opened with a repositioning and expansion of the medical officers’ history, in order to reveal the nature and extent of their failures on the national stage. Instead of the Metropolitan Poor Act of 1867 leading a reforming wave across the nation, there was a reversal in the political tide and the momentum vanished. Standards of care dropped at the same time that charges of negligence rose against poor law doctors. Considerable evidence links this to the high water mark of crusading in the 1870s and 1880s. Concomitantly, Rogers’ two decades at the helm of the PLMOA were marked by failure. In spite of a peripatetic and exhausting lifestyle, spent speaking at public events and conferences, he failed to galvanize public support for the national medical reforms that he sought. Successive medical officers found themselves negotiating an impracticable medical welfare system. It became clear to Rogers that the association was fighting a losing battle for the nationwide reforms that it sought. Instead, he moulded the PLMOA into a quasi-defence union. He used the forum of charges of negligence against medical officers to highlight the problems that were feeding into their active neglect – in so doing, he also described many of the latent failures that sustained the crisis of care. Thus, throughout the late-Victorian period, medical officers were positioning themselves as a counter-movement against the LGB’s economic goals. Exposing negligence and low standards of care – but explaining this in terms of the system, not medical officers’ culpability – was a dangerous but calculated gamble that did not always pay off.1 The LGB pushed the crusade forward like a prodigal son. Blind to its faults, official inquiries used pauper complaints as the basis to blame medical officers for the undesirable effects of crusading; likewise, the various political and public interests that had embraced those experimental cuts seem to have been ignorant of its latent faults but wise to the active negligence of doctors. Medical officers and paupers, in different ways, therefore bore the brunt of the crusade’s impact on standards of care. Still, integrating their parallel interests in reform was a malignant social and economic circle that could not be squared by Victorian doctors – many of whom

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looked down on paupers and were ideologically disposed to crusading. Besides, the patients’ voice (where it was heard and documented) could express discontent at medical officers or make demands of them, negotiate and push for costly extras or medicaments. The disgruntled and dissatisfied pauper patients (or their bereaved relatives) could also complain about low standards of care. Medical negligence, such as Hope’s, led to seemingly avoidable deaths and a palpably blameworthy doctor to hold to account. The success of a complainant, though, depended on the strength of their evidence (most often provided by witness testimony), the severity of the negligence and the likelihood of public exposure. Thus, pauper complaints appear to rise during the crusade when systemic faults interplayed more frequently with the active neglect of individual doctors. Starvation cases, like Edward’s death in the Isle of Wight, or the cruel aspects of care seen in Newton Abbott, became more prevalent under the hazardous atmosphere of the crusade. In turn, there was greater scope for publicity. In this way, the pauper voice (as an individual, but not as a group) was heard, but their interests were taken up and blended into the heterogeneous political interests in the management of the workhouse system. Patients’ interests were thus ‘voiced’ as causes by inspectors, medical officers and the political classes, but always entwined with, and thwarted by, the self-serving aims of those groups. As a result, medical officers were blameworthy subjects, held to account by employer, public and patients. For two decades they were an ideal scapegoat for the systemic faults that repeatedly interacted with their own active neglect. The latter-Victorian poor law was therefore an ideological battleground in which negligence was a consistently politicized phenomenon. As argued throughout this book, the broad economics of poor law doctoring – and the role of free-market competition – formed a significant part of this backdrop.2 A doctor’s income was at the hub of those issues. Successive poor law authorities encouraged salaries to be at the minimum, occasionally capping guardians who offered too much. This did not attract public criticism because most medical officers worked part-time and the majority of them were also engaged in private practice. As such, it was argued that they had a substantial private income. Doctors nonetheless relied on the (metaphoric and physiological) health of their local business. Medical fortunes could vary greatly from town to town, or between regions. Not all practices were thriving and even those that were doing well went through fluctuations and delays in their income. Their budgets were at the mercy of local events and recessions. As a result, the medical market was replete with financially insecure and struggling practitioners who were willing to accept poor law vacancies on dangerously low salaries which, in turn, inevitability led to neglect.3 The cost-minded central authorities, from Commissioners to the LGB, nevertheless had no intention of interfering with the free market by setting salary levels or increasing the cost to the Treasury. This, and medical officers’ own inability to resolve the full-time/part-time conundrum of their employment, had a detrimental effect on the standards of care that they could provide. During the Lancet commission one medical officer had confessed ‘that the whole business was a ghastly joke; that to

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save himself from the pecuniary ruin which the neglect of his private practice would have involved, he was obliged to make his attendance on the sick paupers a merely perfunctory business’.4 As a result of those ‘divided loyalties’, doctors’ low salaries were also at the heart of nationwide issues with their supply of medicaments and their attendance on pauper patients.5 To get round the double bind of their employment in private and public medicine, doctors commonly used assistants to carry out a great deal of the poor law work. The latent faults of systemic double binds could not have been sustained without reliance on assistants for attending to the outdoor poor and the use of pauper nurses (and an army of pauper wardsmen and women) for the indoor poor. Holmes claimed that pauper patients were regularly treated by doctors’ assistants: ‘The systematic evasion of duty by many – we had almost said a majority – of Poor-Law Medical Officers, has for a long time past excited feelings of indignation in the breasts of their more conscientious brethren, who, although they whine, and cry for help, one to another, yet hesitate individually, to bring charges of misbehaviour affecting another of their own order under the notice of the Local Government Board, and demand his censure; thus the grievance has hitherto run its course unchecked, and the evil-doers have remained unadmonished.’6 The use of unqualified or inadequately qualified assistants reached epidemic proportions, leading the GMC to issue mandates on this and warn the profession that it was not to be tolerated.7 The LGB mimicked the GMC’s public denouncement of the use of assistants in the (public) arena of an official inquiry, but they also published rules that allowed this practice – and there can be no doubt that inspectors knew that it was widespread. This contradiction was typical of the tensions of medical officers’ employment arrangements, and the recurrence of those themes in the conflicted zones of official inquiries. This historically important non-court legal setting provides an important but overlooked aspect of the conflict and compromise described by poor law historians. Official inquiries were important affairs, but to doctors, such as Rogers, they were a ‘mockery’ of the law. In effect, this was a quasi-judicial setting, in which the rules and duties of their employment could be used to hold a medical officer to account with little legal recourse for defence. Crucially, there was no penetrative investigation of the systemic causes. Denial therefore found an outlet in the local resolution of official inquiries, which systemically sought individual blame – most often this was aimed at the doctor. There were also no patients’ rights in any systematic way, and the legal scenarios of official inquiries were underpinned by contract law, not the duty of care in modern tort law. In this way, contracted obligations were essential, but duties were complex and overlapping. A doctor could thus be charged with a multitude of offences that most frequently boiled down to conflicts over their attendance, the payment of their fees, or their disobedience. As such, doctors were seriously undermined by failings created by their employment arrangements. The ease with which charges of negligence could be brought against them also held in check their attempts for unionized power. Likewise, inquiries are the tip of an ‘iceberg’ of patient neglect under the poor laws that has remained hidden from view largely because the active (blameworthy)

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neglect of a localized medical officer has distracted attention away from the national extent of systemic negligence. Poor law doctors, and the workhouse infirmaries that employed them, were constituent parts of a reluctant system, which was attempting to provide a range of medical services that was beyond its capabilities. This was understandable because those provisions ran counter to the purpose of its design. Permanent officials and the public (and some medical professionals) were consensually, therefore, against expansion of the medical services. Doctors and patients were caught in a regime of strict cost control, which resulted in a system in which negligence was widespread and occurred on a day-to-day basis. It was a by-product of the common local responses to national cost-cutting pressures, and the somewhat inevitable result of a system that was flawed because it was mismatched with its daily work. The traditional notion of a linear development of State health care, making piecemeal progression towards the NHS is, at best, only tenuously linked with what was being practised across much of late-Victorian England and Wales. The patients of the poor law were stigmatized and this was wrought into the inherent limitations in their care at almost every level. Poor law doctors, such as Rogers, sometimes fought for their patients’ rights to better treatment, but, at this time, this did not improve their own cause – and could even damage it. There was a popular view that medical welfare was a loophole for undeserved, over-generous and indiscriminate relief. This fed into the concerns of Victorians about welfare expenditure and their fears of a rising number of pauperized people, dependent on poor law relief. The Webbs claimed that ‘objections’ were made, after 1871, to any extension of poor law outdoor relief that moved from acute relief to investment in prophylactic long-term welfare measures: ‘The Poor Law Officials, who took the lead in the new department, had, in fact, come, after Mr Goschen’s transfer to another office, under influences hostile to the forward movement which had been in view.’8 Preston Thomas, a government inspector, also noted that Goschen had been handpicked in 1870 to take the ‘helm of the LGB’ and guide through the legislation that was to bring poor law and public health under one governing body, but he was called to the admiralty.9 Similarly, the Webbs (and Rogers) argued that the permanent officials had thwarted Goschen’s aims and ‘made no exception for domiciliary medical attendance and the supply of medicine’.10 Whatever the political cause, the permanent officials – the inspectors and permanent secretaries – solidified their powers of influence and dominated the administration and management of the poor law from 1871. Ten years later, when Rogers addressed the National Association for the Promotion of Social Science, he was clear about who was responsible for systemically low standards of care and why: ‘The Local Government Board has never seriously attempted to enforce their own orders and regulations, and consequently, in large portions of England and Wales, Poor Law Medical Relief is reduced to an absolute sham … .’11 Outwardly inspectors encouraged humanitarian reforms, leaving records of inspection and guides to better (seemingly more humane) treatment of the poor, but they were focused on mediating the economic problems between central and local administration of the poor law. Broadly speaking, they sought good management, which equated to financial efficiency and savings. As such, they played an important

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bridging role, between policy and practice, during the crusade. Somewhat unsurprisingly, the longest serving Victorian officials also seem to have been hardline crusaders. From the 1870s, nationally, medical cases came under increasing scrutiny and, as Hurren argues, inspectors ‘encouraged guardians of the poor to think of themselves as medical experts’ across the spectrum of welfare and public health provision.12 In turn, this book has revealed a more extensive, more national, crusade than contemporary British government statistics express; whereby specific inspectors’ districts, and certain regions, indicate higher levels of negligence that have interplayed with crusading. As such, charges of negligence against medical officers seem to be laid over areas where there were conflicts over medical provision, but there was an overt willingness to investigate and charge a doctor with negligence (such as central England, the North West and Wales). In exploring medical negligence, the book has also demonstrated some major aspects of the localized impacts of that cost-cutting agenda and exposed more of the human cost of the Longley Strategy. At this time, standards of care were only a priority when entwined with costs saving and efficiency. The crusade’s attack on medical relief was part of an ideology of welfare attrition that is unequalled in modern British history. Pointedly, crusaders seem to have had no recognition or concern with alleviating the impoverishment caused by localized events, such as commercial and industrial boom and bust, and the effect of this on unemployment and sickness. Most were blinded to the causes of pauperism by fervour for self-help and dispauperization by any means. The cutbacks in outdoor relief ignored the starving condition of the poor because the system was not meant to offer subsistence support above the level of the lowest working poor. Those at risk of starvation could be directed to the workhouse. Given the impact of withdrawing outdoor relief on makeshift household economies, the crusaders’ denial of basic nutritional needs became a ‘Tragic Burlesque’. It led to the screw tightening on medical extras in a period when some people were already feeling the financial pinch. For example, after the death of Charlotte Hammond, discussed above, the doctor’s defending solicitor asked: ‘If a doctor tells the relieving officer that a woman is dying of starvation, and that a pint of beef tea would save her life, would the relieving officer be justified in refusing relief?’ To which, one of the guardians replied: ‘The relieving officer would be guided by circumstances, but if he found food in the place he would be justified in refusing.’13 Such a situation led The Medical Officer’s Vade-Mecum to advise that any continuance of extras should be accompanied by a personal visit so that the ‘extra’ provisions could be soundly defended.14 This warning was issued because charges of negligence frequently lay at the counterpoint where the medical services were most affected by pressure on costs, such as medical extras. Under the crusade, these pre-existent layers of faults – particularly those linked to funding – lined up to create unhindered pathways to negligent care. For example, inspectors ignored or denied the inherent problems of making a claim for and receiving emergency medical relief. As a result, the responsibility for ensuing negligence was passed around like the desperate pauper in Hope’s disturbingly callous case. Indicatively, childbirth was on the front line of those problems. It encapsulated the key features of

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the catch-22 that embroiled medical officers in a no-win situation. Interpretative grey areas, such as ‘sudden and urgent’, ‘Great difficulty’ or ‘long subsequent attendance’ were enflamed by complex guides, which did little to clear up matters. The range of people who could give an order for the medical officer’s attendance in an emergency was at the hub of delayed payments, which caused consistent conflict and doctors’ fees not being honoured retrospectively. In addition, most poor law literature has placed too much broad emphasis on the difficulty of getting hold of a relieving officer and in their withholding of orders for medical relief. In contrast, they tended to issue too many orders for doctors’ attendance but withheld or delayed orders that involved fees, such as emergencies, or medical extras. Unnecessary orders for attendance may seem like minor events, but – stacked up – they could easily translate into financial catastrophe for a doctor who was struggling to balance a private practice with a poor law post. As a reaction to this trend, doctors ignored and cherry-picked orders to attend or they sent an assistant. It was a catch-22 that left them solely responsible for neglected patients and wide open to charges of negligence. At the same time that outdoor relief was being cut, the understaffed infirmaries were strained by the more intense application of the workhouse test (and the removal of any ring-fenced outdoor medical relief). Most provincial unions had adapted their existing workhouse accommodation provision rather than build new hospitals. This had created care environments that were hopelessly inadequate and unsuited to the numbers of physically and socially disadvantaged pauperized people entering workhouses during the crusade. Furthermore, medical practitioners were not involved in the building or design of a workhouse infirmary. Medical officers made the best of the space provided to them. They also had no input into the staffing (such as nurses and wardsmen). They were supposed to report any defects and advise on reforms, but this was a pathway to conflict with their employers. Local records show that their medical advice was regularly ignored and pressing sanitary reforms could go unheeded for decades. In spite of this, the responsibility for quality of care in workhouses devolved to them and their impotent powers of enforcement. Edward’s death showed the reality of the crusade’s interaction with a medical service on the brink of crisis most of the time. The Lancet called the inquiry into his neglect an ‘absurd’ ‘whitewash’. Inspectors had regularly inspected the Isle of Wight union but had not found fault until Edward’s death. The finger of blame was then pointed straight at the medical officer, Beckingsale, who had no knowledge (and no documentation) of Edward. His guilt was nonetheless a ‘false channel’, which was not lost on the local press, who questioned the use of individual blame. Journalists argued that Edward had been neglected in the workhouse and that the crusade had interplayed with his mother’s need to institutionalize him. There can be no doubt from the evidence of the official inquiry that the quality of care that Edward received dropped drastically from familial domiciliary care to that provided by the workhouse infirmary. Edward was allowed dedicated time for routine tasks at home, but in the workhouse no one gave him the time that he required. Pointedly, one nurse in the workhouse had complained that it took half an hour to feed Edward. Moreover, Beckingsale relied entirely on the opinion of one trained nurse who was overworked

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and ignorant to (or ignored) Edward’s state until he was already dying. This was not unusual. The watershed in professional nursing came at the end of the period. Numbers of professional nurses were extremely low throughout the nineteenth century. There was a shortfall in trained nurses across England and Wales, which meant, even if a union wanted to employ more nurses, the majority had to resort to in-house training and paupers. As a result, workhouse nurses were mostly the aged, chronically ill or disabled – because these were the inmates that stayed in the workhouses longest. According to Hart, few days passed in the lateVictorian period when there had not been a scandal of neglect caused by the nursing staff.15 In 1894, Hinton’s whistle-blowing shocked hardened Victorians with graphic descriptions of nursing negligence at Newton Abbott. As the BMJ reported, though, the LGB official inquiry produced another ‘whitewash’ – the inspector who had conducted the enquiry, the journal argued, was the same person who had allowed substandard care to continue in the south-west.16 Nevertheless, the infamous episode of negligence was a spark for nursing reform in the 1890s. The BMJ’s subsequent commission into nursing was instrumental in this. It has not received historical prominence, but it was a big event in the mid-1890s. It highlighted three interrelated issues at the core of negligence in Victorian workhouses: first, pauper nursing was a nationwide problem; second, there was no effective night nursing or care provision; third, lack of central direction was to blame for recurrent problems. The Nursing in Workhouses Order (1897) signalled the ‘true’ dawn of professional workhouse nursing (as opposed to the false dawn of the mid-Victorian period). The impact of professional nurses from the 1890s is astonishing. Arguably, they ushered in an era of whistle-blowing in workhouses that propelled infirmaries into better standards of care under the Edwardians. To sum up, there was a continuum of (ir)responsibility in Victorian workhouses: the only medically qualified officer, the doctor, was contracted part-time. Even so, those minimal workhouse duties were too frequently missed, rushed or left to an assistant. In turn, medical officers and their assistants passed on day-to-day care work (and the decisions about who to treat) to nursing staff. Paid nurses were almost always overstretched, which meant that they redistributed the bulk of their care work onto pauper nurses and ward assistants (inmates and patients, themselves). Poor law infirmaries were therefore exhibiting an outward image of developing health care provision that concealed a different internal reality (Rogers’ ‘sham’). This book’s juxtaposition of policy and practice has exposed the disjuncture of the two. It has been argued that the LGB inspectors pushed the Longley Strategy but they were in denial of or blind to the systemic latent faults that interacted with the crusade and the active neglect of doctors. Local resolutions did not reveal the root causes, which were most often the hidden, subtle, aspects of latent failures in the national system. At the end of the period, Britons began to sense those faults, but doctors had made an ideal scapegoat for most of the nineteenth century. The persistent view of the Victorian poor law as a developing health care system must be revised to properly include contemporary socio-legal notions of negligence, which was as important to Victorian health care as it is today.

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A Janus-faced view Potentially, there are three interrelated directions of future research that could extend or repudiate the findings of this book: first, more research is needed into the permanent staff of the central poor law authorities, particularly those of the LGB’s inspectorate. The law was at the heart of inspectors’ professional motivations, but they could also be sympathetic to neglected paupers. There is little trace of the eugenicists’ rhetoric that was to seize social relations and influence social policy in the early twentieth century. As such, there is a contradiction in the inspectorates’ sympathetic approach to some neglected paupers that is hard to balance with their lack of compassion for the effects of crusading measures on the poor. To what extent were the legally minded inspectors galvanized by legal and social responsibilities to paupers? Why did LGB inspectors react so quickly to pauper complaints with an energetic, costly and time-consuming enquiry? Was it purely to project an image and stymie negative publicity? To what degree of consciousness were inspectors diverting attention from systemic faults by blaming doctors? Or was it legally more complex? The answers to those questions will throw more light on the themes of this book, such as the persistent historical importance of accountability in medical law. The second and third lines of enquiry, therefore, lay in the interrelated histories of patients and the law. Such research could better assimilate legal dogmas that emphasize Black Letter rights to relief with a well-documented need for pauper patients to negotiate and assert their rights to access State health care. The interpretative function of Victorian legislation has created conflicting views.17 More research is evidently needed into the intersecting issues of pauper agency and the medico-legal implications of their right to relief. The experiences of the Cooper family, in their defence of Edward’s rights, hints at a cultural history – a second pathway for research – that may be enriched by further knowledge of such sociolegal expectations. This could provide hidden, forgotten aspects of the medical encounter between pauper and doctor.18 As King has stated, ‘sickness was the pivotal experience of people on the margins’, but we know little of the interactions, the meeting points, between State and sick pauper.19 Future analyses may find a rich seam of hidden social history in the hundreds of official inquiries held in the poor law records of Britain’s national archives. There was clearly no self-conscious movement of patients’ rights in the poor law, and paupers were an unrepresented group, but there has certainly emerged from this book an idea, a notion, that individually (as opposed to a body politic) paupers had an expectation that they would receive medical aid. Negligence was not met with an accepting shrug of the shoulders. When their care fell below an acceptable standard, they were prepared to complain, seeking legal recourse through the local or national administration of the poor law. The crisis of care, described in this book, could also be described as a crisis of managing aggrieved patients (and public opinion) under the new poor law. The multiple hundreds of official inquiries provide evidence that paupers had a right to complain and, in some circumstances, to expect an investigation. The Medical Relief (Disqualification Removal) Act of 1885 removed the legal compulsion for some

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patients to be declared paupers. Yet, this seems to have had no impact on complaints about negligence, so it did not receive attention in this book. Within a few decades of that act, though, the State was incorporating a wider spectrum of patients (such as those covered under National Insurance from 1911). This raises questions about the legal ‘progression’ during the subsequent Edwardian era, particularly for complaints about medical negligence. At this time, the State’s patient groups diversified and expanded. Though pauperism continued, many of the treated sick were, then, citizens who no longer lost their rights – but what were those rights? Did those rights (or a fear of imagined patients’ rights) affect the legal and administrative shape of State medicine’s complaints procedures? Given the propensity for paupers to complain, revealed in this book, was the scenario of a medical litigation boom contemplated by Edwardians in the early twentieth century? How did the (at that time, recent) history of poor law official inquiries influence relations between the State and the medical profession? Did the ‘scapegoat’ culture of the crusade years underpin a collective, embittered, professional memory? Did this experience affect doctors and their noted hesitance to become full-time State employees in the early twentieth century? How would the answers to those questions, and the interlocution of relevant points raised in this book, feed into the progressive legal account of the history between the Victorian poor law and the Bolam precedent? What role did the State – the politicians, the civil servants and the inspectors – play in that ‘progress’? Legal historians need to better explain the role of poor law negligence in the broader development of law, and question its interplay with the subsequent, turbulent, pre-Bolam decades of the early twentieth century. A third direction of research, therefore, is desperately needed into the legal crossovers between the contract-based poor law and the broader, but connected, complexities of Victorian and Edwardian court actions. For example, towards the end of the nineteenth century, there were a small number of medical officers who were charged with negligence that had a parallel charge of manslaughter in the courts.20 Historians, such as Ian Burney and Pam Fisher, suggest that such a charge could emanate from the proceedings and powers of coroners’ inquests, but they both also imply that this was rarely executed.21 Without further research into the history of law, this slippage from a tribunal to court setting will be an enigmatic circle for poor law historians to square. There may be further legal complexities and contradictions to add to the socio-legal view of pauper patients. Despite the legal contrasts between tort and contract, described in the introduction, the poor law demonstrates that (for different reasons) blame was central to medical negligence in Britain before the twentieth century. Later, Bolam seems to have provided a court-based bulwark against ‘scapegoat’ cultures, which sought figures of blame, such as that experienced by poor law medical officers. Since then, comparatively speaking, the adversarial elements have shifted emphasis from lay managers’ powers over doctors, to patients’ powers to sue doctors (via their legal representatives). Without the historic ramifications and stigmatization of pauperization, a patient’s voice can be more vocal than it was a century ago. Yet – as a separate entity to medical professionals, politicians, analysts and health care managers – it remains disenfranchised and powerless. An aggrieved patients’

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voice is relatively isolated and only becomes empowered through independent legal representation. Seen through the lens of history, therefore, the collective voice of patients has been consistently muted, while lay and medical professionals have seesawed an exclusive power dichotomy. Alarmingly, despite the shifts in this dichotomy over the last century, the systemic causes of patient neglect were rarely tackled, until recently. Today, there are suggestions that health and welfare budget cuts have been a contributory cause of medical negligence, both in and out of NHS hospitals. In spite of the complex differences (and the intellectual pitfalls of comparing past with present), there are some striking parallels between medical negligence under the Victorian poor law and present-day analyses of the neglect of patients in Britain’s NHS. Although the modern Welfare State in Britain is clearly not the same as the poor law that came before it, twenty-first-century cuts to national welfare provision in Britain seem to have some basic antecedents in the crusade. The controversial removal of a range of benefits for the disabled and chronically sick, at the same time as sweeping budget cuts and reorganization of the NHS, has been vilified by critical observers across the political spectrum.22 The UK Government has responded to such anxieties with the Better Care Fund, a policy for ‘Integrated Care’. As such, £3.8 billion has been ring-fenced to ‘ensure a transformation in integrated health and social care’, and to alleviate some of the stress on acute services.23 However, there are no guarantees as to how this policy will unfold on the ground. The fund is spread thinly among local authorities, and there is neither central authority nor methodologically sound guidance to ensure that joined-up thinking will prevail. Vulnerable groups of people, such as the disabled and elderly, seem at risk from gaps between service providers and shortfalls in the funding of their care. The crusade appears to provide an allegory in its deep funding cuts to welfare provision as a reaction to national recession, and in its reliance on local variables in care services. The LGB’s failure to recognize the causes of substandard care, or to acknowledge its own part in a systemic spawning of negligence, lay in crusaders’ insistence that the withdrawal of outdoor relief could be covered by community-level assistance (through private, charitable and voluntary means) and State institutional provision. As a result, there were cuts to medical relief without an accurate assessment of local services and workhouse infirmary provision. Ideological wilfulness during the crusade either could not see or refused to acknowledge that there was a crisis of care unfolding. Notably, the recent conclusions of the Francis Report’s investigation of patient neglect in the NHS’s Mid-Staffordshire Foundation Trust have provided disturbing echoes of the revelations of patient neglect described by concerned mid-Victorians. In contrast to the public pressures of the nineteenth century, the Francis Report of 2013 was largely the product of campaigning by patient groups (such as Cure the NHS and AvMA), not medical professionals. The report was commissioned after considerable public pressure forced a response from the Houses of Parliament. Robert Francis QC chaired the enquiry, which, commendably, focused on the systemic faults of the NHS that were evident in the active neglect of patients at Mid-Staffordshire. Francis described an ‘unhealthy and dangerous culture’, where patients were ‘failed

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by a system which ignored the warning signs and put corporate self interest and cost control ahead of patients and their safety’.24 Disturbing echoes of poor law negligence were apparent in his damning conclusions; from NHS latent faults to the active neglect of overworked nurses and unsuitable care assistants: There was a lack of care, compassion, humanity and leadership. The most basic standards of care were not observed, and fundamental rights to dignity were not respected. Elderly and vulnerable patients were left unwashed, unfed and without fluids. They were deprived of dignity and respect. Some patients had to relieve themselves in their beds when they [were] offered no help to get to the bathroom. Some were left in excrement stained sheets and beds. They had to endure filthy conditions in their wards. There were incidents of callous treatment by ward staff. Patients who could not eat or drink without help did not receive it. Medicines were prescribed but not given. The accident and emergency department as well as some wards had insufficient staff to deliver safe and effective care.25

After such tragic revelations of negligence, provided by staff and patients (or their relatives), Francis argues for a cultural change in the NHS. He suggests that there should be a move away from blame and scapegoat culture; that openness and candour should be underpinned by statute and non-compliance with this enforced by criminal procedure.26 Yet, the recommendations do not seem to resolve the inherent tensions in the adversarial relationship between aggrieved patients and accused doctors, which creates a fear of reprisal (curiously, in both, for different reasons). The NHS culture of ‘blame’ has evolved from doctors’ fears of retribution from their State employers to the present-day panic about litigation from their patients. In comparison, patients have been historically hesitant to complain from fears that it may affect their quality of care or because it may appear ungrateful. The aftermath of a medical error can breed fear and loathing, a trend which seems set to continue unless the recommendations of Francis extend to a complete overhaul of the NHS complaints and compensation system. At present, there is nothing for patients in the overly bureaucratic procedure that can compete with the possible personal and financial rewards of litigation. As such, their use of litigation will expand, not diminish. Locating the act of negligence for clinical litigation, however, leads to figures of blame. In turn, while ‘accountability’ continues to underpin the attitudes of health care professionals, managers and patients, secrecy (and an adversarial culture) will remain an issue. Blame will continue to be a motivation for professionals to deny error, which problematizes the processes of resolving patient dissatisfaction and locating systemic faults. The billions of pounds set aside in the NHS budget for projected compensation payments will continue to grow exorbitantly.27 Francis noted the challenge of altering a legally oriented culture, but only recommended that ‘… the duties of the system to respond to complaints should be regarded as entirely separate from the considerations of litigation’.28 Unfortunately, walking this ‘tightrope’ and maintaining this dual consideration will be very difficult to manage with impartiality.29 A litigation-wary institution will be ill-equipped to fully

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engage with the mandate of whistle-blowing, openness and candour encouraged by Francis. History shows that whistle-blowing only becomes an effective tool for change if revelations are seized upon and pushed forward by a motivated and united public sphere – inclusive of patients and medical professionals. Expecting in-house reform (or consistent openness and candour) from a traditionally defensive organization may be clutching at straws. In common with the new poor law, the NHS has historically been an insular and restrictive beast when it comes to dealing with medical negligence. As the Francis Report observed, localized resolutions have been cumbersome processes under the NHS and slow to reform the complex structural issues that have created pathways of neglect from deeply riveted latent faults. The key traits that underpin Reason’s ‘pathological’ organization will therefore continue under a litigation-wary culture of the NHS. Despite its penetrative location of latent faults throughout the system, two major underlying factors for ongoing negligence and institutional denial were beyond the report’s ambit: first, the broader backdrop of health and welfare funding, and the joined-up pressures and impacts of this on different sectors of health care; second, the cultural and legal motivation for secrecy: fear of retribution. Likewise, the legal scholar, Alan Merry, suggests that the system of legal retribution and punishing doctors neither deters future offenders nor resolves the systemic problems that may have contributed to causation: ‘If it is accepted that many errors occur and produce harm largely through predisposing factors in the environment or system, then it seems obvious that punishing the doctors who make them without addressing these factors is unlikely to prevent a recurrence of the errors … .’30 Without wishing to make a naïve or simplistic comparison between now and then, those words fit hand in glove with contemporary Victorians’ critiques of poor law inquiries into medical negligence. Historically, it seems that blame has remained at the core of legal redress in health care, despite a consistent discord with the parallel needs of patients and health care providers to locate and reform systemic faults. These are historic problems, rooted in law, economy and patients’ disenfranchisement. The Francis Report has set a new tempo, but radical legislative solutions are needed. Economic short-termism, political ineptitude and professional interests may serve to continue the historical pattern of localized stop gaps and reactive policy fumbling in the dark.

Notes Chapter 1 1

2 3 4 5 6 7 8

9 10 11

12 13

14

15 16 17 18

D. Giesen, International Medical Malpractice Law: A Comparative Law Study of Civil Liability Arising from Medical Care (London: J.C.B. Mohr & Martinus Nijhoff Publishers, 1988): 9. Giesen, International Medical Malpractice: 9. Giesen, International Medical Malpractice: 9. Giesen, International Medical Malpractice: 7. Blackstone, quoted in: Giesen, International Medical Malpractice: 7. Giesen, International Medical Malpractice: 9–10. For example, see: H. Teff, Reasonable Care: Legal Perspectives on the Doctor-Patient Relationship (Oxford: Clarendon Press, 1994): 194. V. Harpwood, Negligence in Healthcare: Clinical Claims and Risk in Context (London: Informa, 2001): 1–27; A. Merry and A. McCall Smith, Errors, Medicine and the Law (Cambridge: Cambridge University Press, 2001): 46–211; J. Herring, Medical Law and Ethics (Oxford: Oxford University Press, 2006): 69. J.L. Montrose, ‘Is negligence an ethical or a sociological concept?’, The Modern Law Review 21 (1958): 260. See: M. Brazier and J. Miola, ‘By-bye Bolam: a medical litigation revolution?’, Medical Law Review 8 (2000): 85–114. P. Fenn and C. Whelan, ‘Medical litigation: trends, causes, consequences’, in: R. Dingwall (ed.), Socio-Legal Aspects of Medical Practice: The Royal College of Physicians of London Collected Papers (London: Royal College of Physicians of London, 1989): 12. Fenn and Whelan, ‘Medical litigation’: 12. Montrose, ‘Is negligence an ethical or a sociological concept?’: 259–64; Harpwood, Negligence in Healthcare: 43–64; Teff, Reasonable Care: 24–35, 180–7 and 192–5; Fenn and Whelan, ‘Medical litigation’: 12–6; Clifford Hawkins, Mishap or Malpractice? (Oxford: Blackwell Scientific Publication, 1985): 15; Herring, Medical Law and Ethics: 41–65. Harpwood, Negligence in Healthcare: 5; B. Knight, ‘The legal basis of medical negligence’, in: J.P. Jackson (ed.), A Practical Guide to Medicine and the Law. Foreword by the Right Honourable Kenneth Clarke, QC, MP (New York, NY: Springer Verlag, 1991): 277. Montrose, ‘Is negligence an ethical or a sociological concept?’: 260; Herring, Medical Law and Ethics: 41; Fenn and Whelan, ‘Medical litigation’: 12. Brazier and Miola, ‘By-bye Bolam’: 85. J.H. Baker, An Introduction to English Legal History. Third Edition (London: Butterworths, 1990): 394. Baker, English Legal History: 455.

188 19 20

21

22 23 24 25 26 27 28 29 30

31 32

33

34 35 36 37

38 39

40 41 42 43

Notes A. Ferguson, Should a Doctor Tell? The Evolution of Medical Confidentiality in Britain (Farnham: Ashgate, 2013): 35. K.M. Odden, ‘ “Able and intelligent medical men meeting together”: the Victorian railway crash, medical jurisprudence, and the rise of medical authority’, Journal of Victorian Culture 8, 1 (2003): 36. For an introduction to North America’s mid-nineteenth-century medical malpractice ‘crisis’, see: A. Spiegel and F. Kavaler, ‘America’s first medical malpractice crisis, 1835–1865’, Journal of Community Health 22, 4 (1997): 283–307. Baker, English Legal History: 468. Montrose, ‘Is negligence an ethical or a sociological concept?’: 261. Montrose, ‘Is negligence an ethical or a sociological concept?’: 261. The summing-up of an early-twentieth-century judge, from: Teff, Reasonable Care: 180. Ferguson, Should a Doctor Tell?: 40. Hawkins, Mishap: 15. Baker, English Legal History: 474–7. Hawkins, Mishap: 2–17. Hawkins, Mishap: 2–17; J.W. Brooke Barnett, ‘History, development and current position in the UK’, in: C. Wood (ed.), The Influence of Litigation on Medical Practice (London: Academic Press, 1977): 2–3. Teff, Reasonable Care: 17. R.G. Hodgkinson, The Origins of the National Health Service: the Medical Services of the New Poor Law, 1834–1871 (London: Wellcome Medical Library, 1967): 415–27; M. A. Crowther, ‘Paupers or patients? Obstacles to professionalization in the poor law medical service before 1914’, Journal of the History of Medicine and allied Sciences 39, 1 (1984): 40; Hawkins, Mishap: 15. Klein observed that potential complaints were ‘choked off ’; for every complaint there were 100 ‘grumbles’ and for each patient who publicly grumbled ‘there were four who changed their doctor’ (‘friction’). R. Klein, Complaints against Doctors: A Study in Professional Accountability (London: Charles Knight, 1973): 105–6. Klein, Complaints against Doctors: 60–120. L. Mulcahy, Disputing Doctors: The Socio-Legal Dynamics of Complaints about Medical Care (Maidenhead: Open University Press, 2003): 4. A. Merry, ‘How does the law recognise and deal with medical errors?’, in: R. Hurwitz and A. Sheikh, Health Care Errors (Oxford: Wiley-Blackwell, 2009): 75. For example, according to Mulcahy, ‘despite appearances, the medical profession had formidable control over the handling of complaints in the twentieth-century NHS’: Mulcahy, Disputing Doctors: 34. Mulcahy, Disputing Doctors: 4. T. Reader and A. Gillespie, ‘Patient neglect in healthcare institutions: a systematic review and conceptual model’, BMC Health Services Research 13, 156 (2013): passim. http://www.biomedcentral.com/1472-6963/13/156 [accessed 25 April 2014]. K. Price, ‘ “Where is the fault?”: the starvation of Edward Cooper at the Isle of Wight workhouse in 1877’, Social History of Medicine 26, 1 (2013): 21–37. The National Archives (hereafter TNA), MH10/92: Circular of 27th September 1866, Complaints of inmates, offering suggestions for guidance of guardians. Ferguson, Should a Doctor Tell?: 35. A. Brundage, The English Poor Laws, 1700–1930 (Basingstoke: Palgrave, 2002): 1–8.

Notes 44 45 46 47 48 49 50 51 52 53 54

55 56 57 58 59

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A. Crowther, The Workhouse System, 1834–1929: The History of an English Social Institution (London: Methuen, 1983): 1–53. D. Englander, Poverty and Poor Law Reform in Britain: From Chadwick to Booth, 1834–1914 (London: Longman, 1998): passim. D. Fraser (ed.), The New Poor Law in the Nineteenth Century (Basingstoke: Macmillan, 1976): 1–24. D. Green, Pauper Capital: London and the Poor Law, 1790–1870 (Farnham: Ashgate, 2010): 1–23. B. Harris, The Origins of the British Welfare State: Social Welfare in England and Wales, 1800–1945 (Basingstoke: Palgrave Macmillan, 2004): 1–14. L. Hollen Lees, The Solidarities of Strangers: The English Poor Laws and the People, 1700–1948 (Cambridge: Cambridge University Press, 1998): 1–77. A. Kidd, State, Society and the Poor in Nineteenth-Century England (Basingstoke: Macmillan, 1999): 8–64. S. King, Poverty and Welfare in England 1700–1850: A Regional Perspective (Manchester: Manchester University Press, 2000): 48–76. M. Rose, The Relief of Poverty, 1834–1914 (London: Macmillan, 1972): passim. N. Longmate, The Workhouse (London: Temple Smith, 1974): 13–33. For the old poor law, see: R.G. Cowherd, ‘The humanitarian reform of the English poor laws from 1782 to 1815’, Proceedings of the American Philosophical Society 104, 3 (1960): 342; E.G. Thomas, ‘The old poor law and medicine’, Medical History 24 (1980): 1–19; J. Walmsley, ‘Provision for the non able-bodied poor in the eighteenth and early nineteenth centuries: some evidence from three Bedfordshire parishes’, Local Historian 20 (1990): 17; A. Tomkins, ‘Paupers and the infirmary in mid-eighteenth-century Shrewsbury’, Medical History 43 (1999): 227; A. Tomkins, ‘Almshouse versus workhouse: residential welfare in eighteenth-century Oxford’ Family and Community History 7, I (2004): 56; L. Granshaw, ‘ “Fame and fortune by means of bricks and mortar”: the medical profession and specialist hospitals in Britain, 1800–1948’, in: L. Granshaw and R. Porter (eds), The Hospital in History (London: Routledge, 1990): 199–220; R. Porter, ‘The gift relation: philanthropy and provincial hospitals in eighteenth-century England’, in: L. Granshaw and R. Porter (eds), The Hospital in History (London: Routledge, 1990): 199–217 and 149–73. W.C. Lubenow, The Politics of Government Growth: Early Victorian Attitudes toward State Intervention 1833–1848 (Newton Abbott: David and Charles, 1971): 67. K.D.M. Snell, Annals of the Labouring Poor: Social Change and Agrarian England, 1660–1900 (Cambridge: Cambridge University Press, 1985): 118–37. R. Wildman, ‘Workhouse architecture’, in: N. Longmate (ed.), The Workhouse (London: Temple Smith, 1974): 286–91. D. Eastwood, ‘Rethinking the debates on the poor law in early nineteenth-century England’, Utilitas 6, 1 (May 1994): 102–3. N. Edsall, The Anti-Poor Law Movement, 1834–1844 (Manchester: Manchester University Press, 1971): passim; E.C. Midwinter, Social Administration in Lancashire 1830–1860: Poor Law, Public Health and Police (Manchester: Manchester University Press, 1969): 178; D. Green, ‘Pauper protests: power and resistance in early nineteenth-century London workhouses’, Social History 31, 2 (2006): 159. Lubenow, The Politics of Government Growth: 67. A. Brundage, England’s ‘Prussian Minister’: Edwin Chadwick and the Politics of Government Growth, 1832–1854 (London: Pennsylvania State University Press, 1988): 35–55.

190 62

63 64

65 66 67 68

69

70

71 72 73 74 75 76 77 78 79 80 81

82

Notes J. Parry, The Rise and Fall of Liberal Government in Victorian Britain (New Haven, CT: Yale University Press, 1993): 178; P. Harling, The Modern British State: An Historical Introduction (Cambridge: Polity, 2001): 70–3; P. Harling, ‘The powers of the Victorian state’, in: P. Mandler (ed.), Liberty and Authority in Victorian Britain (Oxford: Oxford University Press, 2006): 43–7. Lubenow, The Politics of Government Growth: 41–56. C. Bellamy, Administering Central-Local Relations, 1871–1919: The Local Government Board in Its Fiscal and Cultural Context (Manchester: Manchester University Press, 1988): 273; Harling, ‘The powers of the Victorian State’: 25–50, 84–7 and 71–111; Parry, The Rise and Fall of Liberal Government: 167–78; E.P. Hennock, British Social Reform and German Precedents: The Case of Social Insurance 1880–1914 (Oxford, 1987): 212–14; E. Higgs, The Information State in England: The Central Collection of Information on Citizens since 1500 (Basingstoke: Palgrave Macmillan, 2004): 99. Bellamy, Administering Central-Local Relations: 274. Lubenow, The Politics of Government Growth: 35. Bellamy, Administering Central-Local Relations: 273. Hollen Lees, Solidarities of Strangers: 2–55; M. Blaug, ‘The myth of the old poor law and the making of the new’, The Journal of Economic History 23, 2 (June 1963): 151–84. See: Kidd, State, Society and the Poor: 2; A. Brundage, The Making of the New Poor Law: The Politics of Inquiry, Enactment and Implementation, 1832–39 (London: Hutchinson, 1978): 184. M.W. Flinn, ‘Medical services under the new poor law’, in: D. Fraser (ed.), The New Poor Law in the Nineteenth Century (Basingstoke: Macmillan, 1976): 66; Rose, The Relief of Poverty: 30–1. F. Driver, Power and Pauperism: The Workhouse System, 1834–1884 (Cambridge: Cambridge University Press, 1993): 165. S. King, We Might be Trusted: Women, Welfare and Local Politics, 1880–1920 (Brighton: Sussex Academic, 2006): 8, 51 and 269. Hollen Lees, Solidarities of Strangers: 9 and 177. See: Driver, Power and Pauperism: 165. Lubenow, The Politics of Government Growth: 40–8. P. Bartlett, The Poor Law of Lunacy: The Administration of Pauper Lunatics in MidNineteenth Century England (London: Leicester University Press, 1999): 40. A. Digby, British Welfare Policy: Workhouse to Workforce (London: Faber, 1989): 32. Fraser, The New Poor Law: 17. R.G. Hodgkinson, ‘Poor law medical officers of England 1834–1871’, Journal of the History of Medicine and Allied Science 11, 3 (1956): 299. W.F. Bynum, ‘Ideology and health care in Britain: Chadwick to Beveridge’, History of Philosophy, and Life Sciences 10, supplement (1988): 76. ‘State hospitals’ and ‘State doctors’ are widely used terms from the mid-Victorian period. For example, see the consistent use in the BMJ and in publications: E. Hart, ‘An account of the condition of the infirmaries of London workhouses.’ Reprinted by permission, from ‘The Fortnightly Review.’ Printed for the Association for the Improvement of the Infirmaries of London Workhouses (April 1866); S. Webb and B. Webb, The State and the Doctor (London: Longmans, Green and Co., 1910). A. Digby, Making a Medical Living: Doctors and Patients in the English Market for Medicine, 1720–1911 (Cambridge: Cambridge University Press, 1994): 244.

Notes 83

84 85 86 87 88 89 90 91 92 93

94 95

191

J. Lane, A Social History of Medicine: Health, Healing and Disease in England, 1750–1950 (London: Routledge, 2001): 54; H. Marland, Medicine and Society in Wakefield and Huddersfield 1780–1870 (Cambridge: Cambridge University Press, 1987): 93. Poor law inspectors will be discussed at length in Chapter 4. Kidd, State, Society and the Poor: 8. Crowther, The Workhouse System: 156. Lane, A Social History of Medicine: 63. Crowther, The Workhouse System: 156. See: Digby, Making a Medical Living: 300; I. Loudon, Medical Care and the General Practitioner, 1750–1850 (Oxford: Clarendon Press, 1986): 231–46. See discussion and transcription in: M. Rose, The English Poor Law, 1780–1930 (Newton Abbot: David and Charles, 1971): 226–7. K. Williams, From Pauperism to Poverty (London: Routledge & Kegan Paul, 1981): 91–144. E. Hurren, Protesting about Pauperism: Poverty, Politics and Poor Relief in LateVictorian England, 1870–1900 (Woodbridge: Boydell and Brewer, 2007): 29. See: Hurren, Protesting about Pauperism: 253; E. Hurren, ‘Labourers are revolting: penalising the poor and a political reaction in the Brixworth Union, Northamptonshire, 1875–1885’, Rural History 11, 1 (2000): 37–56; E. Hurren, ‘Agricultural trade unionism and the crusade against outdoor relief: poor law politics in the Brixworth Union, Northamptonshire, 1870–1875’, The Agricultural History Review 48, 2 (2000): 200–22; E. Hurren, ‘Welfare to work schemes and a crusade against outdoor relief in the Brixworth Union, Northamptonshire, in the 1880s’, Family and Community History 4 (2001): 19–30; E. Hurren, ‘Poor law versus public health: diphtheria, sanitary reform, and the “crusade” against outdoor relief 1870–1900’, Social History of Medicine 18, 3 (2005): 399–418. Williams, From Pauperism to Poverty: 91–144. For a succinct context of such issues in British welfare debates, see: S. King and A. Tomkins, ‘Conclusion’, in: S. King and A. Tomkins (eds), The Poor in England 1700–1850: An Economy of Makeshifts (Manchester: Manchester University Press, 2003): 258–79.

Chapter 2 1 2 3 4

5

6

Mulcahy, Disputing Doctors: 9. Crowther, The Workhouse System: 157. Crowther, The Workhouse System: 42; Loudon, Medical Care: 258. For example, see: N. Durbach, ‘ “They might as well brand us”: working-class resistance to compulsory vaccination in Victorian England’, Social History of Medicine 13 (2000): 45–63. Digby, Making a Medical Living; I. Waddington, The Medical Profession in the Industrial Revolution (Dublin: Gill & Macmillan Press, 1984); P. Bartrip, Themselves Writ Large: The British Medical Association 1832–1966 (London: British Medical Journal, 1996). S. Hempel, The Medical Detective: John Snow and the Mystery of Cholera (London: Granta Books, 2006): 227–49.

192 7

8 9 10 11 12 13

14 15 16 17 18 19 20

21 22 23 24 25 26 27

Notes F.F. Cartwright and M. Biddiss, Disease & History. Second Edition (Stroud: Sutton Publishing, 2000): 121; Lane, A Social History of Medicine: 48, 78; J.M. Eyler, ‘William Farr on the cholera: the sanitarian’s disease theory and the statistician’s method’, Journal of the History of Medicine and Allied Sciences 28 (1973): 84. Oliver Wendell Holmes, quoted in: Hawkins, Mishap: 3. [anon.], The Medical Profession and Its Morality. Reprinted with Corrections and Additions from the Modern Review (London: Pewtress & Co. 1881): 11. R. Porter, The Greatest Benefit to Mankind: A Medical History of Humanity from Antiquity to the Present (London: Fontana Press, 1999): 369. [anon.], The Medical Profession and Its Morality: 7–8. T. McKeown, The Modern Rise of Population (London: Edward Arnold, 1976). L.B. McCullough, John Gregory’s Writings on Medical Ethics and Philosophy of Medicine (London: Kluwer Academic Publishers, 1998): 170; A.R. Jonsen, A Short History of Medical Ethics (Oxford: Oxford University Press, 2000): 57–62; L. Haakonssen, Medicine and Morals in the Enlightenment: John Gregory, Thomas Percival and Benjamin Rush (Amsterdam: Rodopi, 1997): 235–8; S. Miles, The Hippocratic Oath and the Ethics of Medicine (Oxford: Oxford University Press, 2004): 51–9. For example, see Haakonssen, Medicine and Morals: 235–38. See: Digby, Making a Medical Living: 35. For example, see ‘Are medical practitioners “traders?” ’, BMJ, 14 January 1888: 105. BMJ, 22 February 1862: 205. C. Hamlin, ‘Edwin Chadwick “mutton medicine” and the fever question’, Bulletin of the History of Medicine 70, 2 (1996): 233–65. W.G. Lumley, Manuals of the Duties of Poor Law Officers. The Medical Officer. Third Edition (London: Knight and Co., 1871): xxviii–xxix. For example, see: ‘The Sheffield Board of Guardians and their medical officers’, BMJ, 5 June 1875: 762; in Southwell, a medical officer was forced to resign for repeatedly missing attendance dates and times at the workhouse, but it also stemmed from tensions with the guardians. Nottinghamshire Archives: PLS 1/1/7 Southwell Union Guardians’ Minutes 1867–1875: 80–121. TNA MH 12/15308 Letter from the workhouse medical officer to Penistone Guardians, 6 January 1870; see also TNA MH 9/13: 105. TNA MH 12/15308. Mulcahy, Disputing Doctors: 3. B. Hurwitz and A. Sheikh, ‘Healthcare mistakes, violations and patient safety’, in: B. Hurwitz and A. Sheikh, Healthcare Errors: 1–5. Reader and Gillespie, ‘Patient neglect in healthcare institutions’: 8. BMJ, 26 December 1863: 694. The period from the Reform Act of 1832 to the 1870s is considered by some historians to be a time of ‘equipoise’ for many professions, particularly those that sought social standing and prestige. See W.L. Burn, The Age of Equipoise: A Study of the Mid-Victorian Generation (London: George Allen & Unwin, 1968): passim; R. MacLeod (ed.), Government and Expertise: Specialists, Administrators and Professionals, 1860–1919 (Cambridge: Cambridge University Press, 1988): 9; J.W. Childers, ‘Observation and representation: Mr Chadwick writes the poor’, Victorian Studies 37 (1994): 405–32; Hamlin, ‘Edwin Chadwick’: 233–65; C. Hamlin, Public Health and Social Justice in the Age of Chadwick: Britain 1800–1854 (Cambridge: Cambridge University Press, 1998): passim; C. Kent, ‘Higher journalism and the

Notes

28 29 30 31 32 33 34

35

36 37 38 39 40 41 42 43 44 45 46

47 48 49 50 51 52

193

mid-Victorian clerisy’, Victorian Studies 13, 2 (1969): 181–98; J. Don Vann and R.T. VanArsdel (eds), Victorian Periodicals and Victorian Society (Aldershot: University of Toronto Press, 1994): 5. Kent, ‘Higher journalism’: 181–98; Vann and VanArsdel, Victorian Periodicals: 5. See: Childers, ‘Observation and representation’: 405–32; Hamlin, ‘Edwin Chadwick’: 233–65; Hamlin, Public Health: passim. Cartwright and Biddiss, Disease & History: 108–25. McKeown, The Modern Rise of Population. Digby, Making a Medical Living: 12–35. Loudon, Medical Care: 194; J. Hostettler, Thomas Wakley: An Improbable Radical (Chichester: Barry Rose Law Publishers, 1993), 50–1. I. Loudon, ‘The vile race of quacks with which this country is infested’, in: W.F. Bynum and R. Porter (eds), Medical Fringe and Medical Orthodoxy, 1750–1850 (London: Croom Helm, 1987): 122; M.J. Peterson, The Medical Profession in MidVictorian London (Berkeley : University of California Press, 1978): 224. W.F. Bynum and J.C. Wilson, ‘Periodical knowledge: medical journals and the their editors in nineteenth-century Britain’, in: W.F. Bynum, S. Locke and R. Porter (eds), Medical Journals and Medical Knowledge: Historical Essays (London: Routledge, 1992): 42; P. Bartrip, Mirror of Medicine: A History of the British Medical Journal (Oxford: Clarendon Press, 1990): 69 and 169; P. Vaughan, Doctor’s Commons: A Short History of the British Medical Association (London: Heinemann, 1959): 131. M. Wolff, J.S. North and D. Deering (eds), The Waterloo Directory of Victorian Periodicals 1824–1900 (Waterloo: Wilfred Laurier University Press, 1977): ix. Charles Hastings cited in: P.R. Jones, Doctors and the BMA: A Case Study in Collective Action (Farnborough: Gower, 1981): 13; also see Bartrip, Writ Large: 4–8. Jones, Doctors and the BMA: 18–19. Lancet, 15 October 1859: 395. Lancet, 15 October 1859: 395. Loudon, ‘The vile race of quacks’: 106–128. For a more in-depth discussion of medical journals and their role in nineteenthcentury professionalization, see Bynum, Locke and Porter, Medical Journals: passim. Vaughan, Doctor’s Commons: 14–19. Hostettler, Thomas Wakley: 50–1, 57–124. This was in the BMA’s early form as the Provincial Medical Surgical Association, discussed above: Hodgkinson, The Origins of the National Health Service: 430. R. Cooter, ‘Bones of contention? Orthodox medicine and the mystery of the bone-setters craft’, in: W.F. Bynum and R. Porter (eds), Medical Fringe and Medical Orthodoxy, 1750–1850 (London: Croom Helm, 1987): 161–2; R. Porter, Quacks: Fakers and Charlatans in English Medicine (Stroud: Tempus, 2001): 206. Vaughan, Doctor’s Commons: 35. Vaughan, Doctor’s Commons: 35. BMJ, 7 January 1853: 24. Mulcahy, Disputing Doctors: 13–14; Ferguson, Should a Doctor Tell?: 33. R. Smith, ‘The development of ethical guidance for medical practitioners by the General Medical Council’, Medical History 37 (1993): 62. For a contrasting view of the 1842 Order’s limited impact, see S. Shave, ‘ “Immediate death or a life of torture are the consequences of the system”: the Bridgwater Union scandal and policy change’, in: J. Reinarz and L. Schwarz (eds), Medicine and the Workhouse (Rochester, NY: University of Rochester Press, 2013): 164–91.

194 53

54

55 56 57 58 59

60 61

62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81

82

Notes R. Griffin, The Grievances of the Poor Law Medical Officers Elucidated in a Letter to the Members of the Legislative and a Commentary on the Proposed Act of Parliament for Redress, by Richard Griffin, Chairman of the Poor Law Medical Reform Association, 1858 (London: Poor Law Medical Reform Association, 1858): 36–7. As was recommended by a Parliamentary Select Committee in 1854. W.G. Lumley, Manuals of the Duties of Poor Law Officers. The Medical Officer. Second Edition (London: Knight and Co., 1857): xi–xii; Lumley, Manuals (1871): xx–xxiii. Lumley, Manuals (1871): 38. Lumley, Manuals (1871): 37–8. ‘The Skipton Guardians’, BMJ, 13 November 1875: 626; ‘The Skipton Guardians’, BMJ, 4 December 1875: 721. ‘The Leeds Workhouse’, BMJ, 7 April 1877: 440. R. Griffin, The Grievances of the Poor Law Medical Officers Further Elucidated in the Report of the Proceedings of the Deputation to the Poor Law Board, February 24 (Weymouth: Poor Law Medical Reform Association, 1859): 5. BMJ, 19 April 1862: 416. Hodgkinson, The Origins of the National Health Service: 430. For a detailed account of the BMA and its journal, see Bartrip, Mirror of Medicine: 17–18, 27–8, 32–6, 69; Bartrip, Writ Large: 4–8; Jones, Doctors and the BMA: 13, 18–9; Vaughan, Doctor’s Commons: 30, 32, 35, 14–19, 40–6. Hodgkinson, The Origins of the National Health Service: 430. For example, see Hodgkinson, The Origins of the National Health Service: 415–27. Vaughan, Doctor’s Commons: 30. BMJ, 22 July 1853: 633. Vaughan, Doctor’s Commons: 30. Hodgkinson, The Origins of the National Health Service: 430. BMJ, 16 June 1854: 543. BMJ, 15 December 1854: 1133. E. Edwards, in: T.H. Barker (ed.), Photographs of Eminent Medical Men of All Countries, with Brief Analytical Notices of Their Works. (London: 1867): 53–7. ‘The Late Richard Griffin, J.P., M.R.C.S.’, Lancet, 20 November 1869: 722. ‘The Late Richard Griffin, J.P., M.R.C.S.’, Lancet, 20 November 1869: 723. BMJ, 9 July 1864: 37. ‘Mr. Griffin’, BMJ, 20 November 1869: 567; ‘The Late Richard Griffin, J.P., M.R.C.S.’, Lancet, 20 November 1869: 723. BMJ, 7 December 1855: 1096–7; BMJ, 21 December 1855: 1138. BMJ, 7 June 1856: 489. BMJ, 7 December 1855: 1096. BMJ, 19 January 1856: 50. BMJ, 9 July 1864: 38. Lumley, Manuals (1871): xxiv. British Library 8285.b.16 ‘Letter addressed to the House of Commons on poor law medical relief with remarks in the report of the select committee on poor law relief so far as regards medical relief ’, from Richard Griffin, chairman of the Poor Law Medical Relief Association, 12 June 1865: 10. British Library 8285.b.16 ‘Letter addressed to the House of Commons on poor law medical relief with remarks in the report of the select committee on poor law relief so far as regards medical relief ’, from Richard Griffin, chairman of the Poor Law Medical Relief Association, 12 June 1865: 10.

Notes 83 84 85

86

87 88 89 90 91 92 93

94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116

195

Crowther, The Workhouse System: 168. Crowther, ‘Paupers or patients?’: 37. British Library 8285.b.16 ‘Letter addressed to the House of Commons on poor law medical relief with remarks in the report of the select committee on poor law relief so far as regards medical relief ’, from Richard Griffin, chairman of the Poor Law Medical Relief Association, 12 June 1865: 13. O’Neill himself allures to the persuasiveness of Griffin’s reform agenda. It was Griffin who emphasized the need for an outdoor dispensary system, which was included in the final bill for the Metropolitan Poor Act of 1867 and which became the central reform agenda for Joseph Rogers: J.E. O’Neill, ‘Finding a policy for the sick poor’, Victorian Studies 7, 3 (1964): 265–84. J. Rogers, Reminiscences of a Workhouse Medical Officer (London: T. Fisher Unwin, 1889): 101. Rogers, Reminiscences: 33. Lumley, Manuals (1871): xxxi. Webb and Webb, The State and the Doctor: v–ix. S. King, A Fylde Country Practice: Medicine and Society in Lancashire c1760–1840 (Lancaster: Centre for North-West Regional Studies, 2001): 66. King, A Fylde Country Practice: 78–9. J. Oppenheim, Shattered Nerves: Doctors, Patients, and Depression in Victorian England (Oxford: Oxford University Press, 1991): 3–15, 141–80; A. Tomkins, ‘Mad doctors? The significance of medical practitioners admitted as patients to the first English county asylums up to 1890’, History of Psychiatry 23 (2012): 437–53. Tomkins, ‘Mad doctors?’: 450. Vaughan, Doctor’s Commons: 32. H. Perkin, The Rise of Professional Society: England since 1880 (London: Routledge, 2002): 38. Perkin, Professional Society: 36–40. Perkin, Professional Society: 36–40. Peterson, The Medical Profession: 222. Griffin, ‘Grievances’ (1859): 27. BMJ, 2 November 1861: 476. Harling, ‘The powers of the Victorian State’: 25–50; Parry, The Rise and Fall of Liberal Government: 167–78. Griffin, ‘Grievances’ (1859): 31. BMJ, 18 May 1861: 530. BMJ, 22 Feb 1862: 205. BMJ, 6 December 1856: 1045. Griffin, ‘Grievances’ (1858): 12. BMJ, 17 January 1857: 52. ‘Poor-law medical relief ’, BMJ 184 (1864): 38. ‘Philo Bumble. Medical Officers Asking for More’, Punch (24 June 1876): 261. Vaughan, Doctor’s Commons: 38. Loudon, Medical Care: 248. Tomkins, ‘Mad doctors?’: 444. BMJ, 9 June 1854: 511. BMJ, 5 June 1858: 462. A. Digby, The Evolution of British General Practice 1850–1948 (Oxford: Oxford University Press, 1999): 247–50. See also Digby, Making a Medical Living: 300.

196 117 118 119 120 121 122

123 124 125 126 127 128

129 130

131 132

133 134 135

Notes Crowther, The Workhouse System: 157. Bartlett, The Poor Law of Lunacy: 126. Lumley, Manuals (1871): xxx. Lumley, Manuals (1871): xxx. Lumley, Manuals (1871): xxx. For example, the Circular of 14 December 1880, in: C.H. Leach and C.H. Leach, The Poor-Law Officers’ Superannuation Acts (London: Law & Local Government Publications, 1930): 163. Letter addressed to the House of Commons (1865): 9. Griffin, ‘Grievances’ (1859): 8. Griffin, ‘Grievances’ (1859): 31. ‘Poor law medical officers’ association’, BMJ, 18 April 1874: 529. Particularly the combined effect of the 1846 Poor Removal Act and the 1865 Union Chargeability Act, see Green, Pauper Capital: 228–9. T.M. Romano, ‘The cattle plague of 1865 and the reception of “the germ theory” in mid-Victorian Britain’, Journal of the History of Medicine and Allied Sciences 52, 1 (1997): 52. General Meeting of the PLMOA 29 November 1870: 8. See also ‘Poor law medical officers’ Association’, BMJ, 18 April 1874: 529. D. Fox and R. Klein, ‘Ethics and health policy in the UK and US: legislation and regulation’, in: R.B. Baker and L.B. McCullough (eds), The Cambridge World History of Medical Ethics (New York, NY: Cambridge University Press, 2009), 668. J. Stewart and S. King, ‘Death in Llantrisant: Henry Williams and the new poor law in Wales’, Rural History 15(2004): 82. This figure was sourced from the MH9 series of volumes, which showed that a total of 2,022 workhouse medical officers (discounting paid assistants) began employment between 1834 and 1900; of those, nearly 800 had a disciplinary action noted in their record. Extract from Report Book: Bedfordshire and Luton Archives: PULBH 4/1 Leighton Buzzard Union Board of Guardians’ Minutes 1868–1902: 220. Letter addressed to the House of Commons (1865): 10. Lancet, 20 February 1864: 232.

Chapter 3 1 2 3 4 5 6 7 8 9 10

Eastwood, ‘Rethinking the debates’: 102–3. Eastwood, ‘Rethinking the debates’: 102–3. Provincial Medical & Surgical Journal, 18 March 1846: 124. Bartrip, Mirror of Medicine: 61. Crowther, ‘Paupers or patients?’: 53. Lancet, 1 July 1865: 15. Hart, ‘An account of the condition of the infirmaries of London workhouses’: 15. Hart, ‘An account of the condition of the infirmaries of London workhouses’: 4. Hart, ‘An account of the condition of the infirmaries of London workhouses’: 4. Hart, ‘An account of the condition of the infirmaries of London workhouses’: 5.

Notes 11

12 13 14 15 16

17

18 19 20 21 22 23 24

25 26 27 28 29 30 31 32 33 34 35 36

197

Bodleian Library: 1518e.5 (26) (Box B000000204372) An address delivered by Dr Joseph Rogers (president of the association) at a general meeting of the Poor Law Medical Officers’ Association held at the Freemasons Tavern, Great Queen Street, London, 27 April 1870 [Hereafter: PLMOA General meeting 27 April 1870]: 2. W. Booth, In Darkest England and the Way Out (London: Funk & Wagnalls, 1890): passim. John Liddle, Medical Officer of Health for Whitechapel, quoted in: A. Wohl, Endangered Lives: Public Health in Victorian Britain (London: Methuen, 1983): 64. J. London, The People of the Abyss. Centenary edition. First Edition. 1903 (London: Pluto, 2001): 39. London, The People of the Abyss: 96, 153. M. Harris, ‘Social diseases? Crime and medicine in the Victorian press’, in: W.F. Bynum, J. Locke and R. Porter (eds), Medical Journals and Medical Knowledge: Historical Essays (London: Routledge, 1992): 110. R. Richardson, ‘ “Notorious abominations”: Architecture and public health in The Builder 1843–1883’, in: W.F. Bynum, J. Locke and R. Porter (eds), Medical Journals and Medical Knowledge: Historical Essays (London: Routledge, 1992): 90. Richardson, “Notorious abominations”; Harris, ‘Social diseases?’: 122. Lancet, 1 July 1865: 14. TNA MH12/13904 Case of John Hall. Lunatic Pauper Removed from Droitwich Asylum. Report of Edmund Head, Assistant Commissioner, 13 March 1840. TNA MH12/13904. TNA MH12/13904 ‘Removal of Lunatic Paupers’. Letter from Edwin Chadwick, Secretary, 3 March 1840. J. Rogers, ‘A Paper on the Relation between Boards of Guardians and Their Medical Officers’ (London, 1884): 1. N. Wilson, ‘The making of Victorian Ipswich: Middle-class leadership in a nineteenth-century town’, The Suffolk Review 3 (1884): 16–20; G. Crossick, ‘Classes and the masses in Victorian England’, History Today 37 (1987): 29–35. N.R. Saunders, ‘Relief of Poverty in Ipswich 1800–1845’ (PhD thesis, Cambridge University, 1976): 46. The Clerk of the Ipswich Union Guardians writing to the Commissioners, in: Saunders, ‘Relief of Poverty in Ipswich’: 49–50. Saunders, ‘Relief of Poverty in Ipswich’: 97. I. Anstruther, The Scandal of the Andover Workhouse (London: Geoffrey Bles, 1973): 57–71. Anstruther, The Scandal: 62–70. Anstruther, The Scandal: 70. Anstruther, The Scandal: 92. Anstruther, The Scandal: 90–1. Anstruther, The Scandal: 119. ‘The Andover Union. Horrible Disclosures (from our own correspondent)’, The Times, 13 August 1845: 6. ‘The Andover Union (from our own correspondent)’, The Times 16 August (1845): 3. R. Fulton, ‘Walter, John (1776–1847)’, Oxford Dictionary of National Biography (Oxford: Oxford University Press, 2004). Online edition (May 2007). http://www. oxforddnb.com/view/article/28637 [accessed 19 November 2013].

198 37

38 39 40 41 42

43

44 45 46 47

48 49

50 51 52 53 54 55 56 57 58 59 60

61 62 63 64

Notes D. Porter, ‘Walter, John (1818–1894)’, Oxford Dictionary of National Biography (Oxford: Oxford University Press, 2004). Online edition (May 2007). http://www. oxforddnb.com/view/article/28638 [accessed 19 November 2013]. Anstruther, The Scandal: 22–3. Anstruther, The Scandal: 132. Anstruther, The Scandal: 132. Anstruther, The Scandal: 129–30. R. Baker and B. Hurwitz, ‘Intentionally harmful violations and patient safety: the example of Harold Shipman’, in: B. Hurwitz and A. Sheikh, Health Care Errors (Oxford: Wiley-Blackwell, 2009): 35. Sir James Graham, in: ‘The Andover Union’, Hansard, House of Commons Debate, v. 84, 5 March 1846: c. 649. Hereafter: Graham, ‘Andover’. http://hansard. millbanksystems.com/commons/1846/mar/05/the-andover-union [accessed 4 December 2013]. Provincial Medical & Surgical Journal, 18 March 1846: 124. Graham, ‘Andover’: c. 638. Provincial Medical & Surgical Journal, 2 September 1846: 417. T. Wakley, in: ‘Medical Relief ’, Hansard, House of Commons debate, v. 97, 16 March, 1848: c. 632–91; http://hansard.millbanksystems.com/commons/1848/mar/16/ medical-relief#S3V0097P0_18480316_HOC_40 [accessed 4 December 2013]. James L. Shuter, ‘Horrible Case of Union Treatment’, letter to The Times, 24 December 1864: 7. ‘The Case of Timothy Daly’, The Times, 24 February 1865: 5. Nightingale’s letter to Sir John McNeil, cited from Mrs Woodham-Smith in: G.M. Ayers, England’s First State Hospitals and the Metropolitan Asylums Board 1867–1930 (Berkeley : University of California Press, 1971): 6. BMJ, 21 January 1865: 70. Lancet, 21 January 1865: 71. ‘The sad story of poor Richard Gibson’, The Times, 18 May 1865: 11. S. Squire Sprigge, The Life and Times of Thomas Wakley (London: Longmans, Green and Co., 1897): 485. See also Hostettler, Thomas Wakley: 128. Lancet, 15 April 1865: 410. Professor Thorald Rogers, in: Rogers, Reminisces: xvii. Lane, A Social History of Medicine: 64. Lynn Hollen Lees also described the changing perceptions of poverty, see Hollen Lees, Solidarities of Strangers: 242–58. P. Ashbridge, ‘Paying for the poor: A middle-class metropolitan movement for rate equalisation 1857–67’, London Journal 22, 2 (1997): 119. Richardson, ‘ “Notorious abominations”: 90. Harris, ‘Social diseases?’: 110 and 122. Lancet, 15 July 1865: 72. For discussions of Dickens, Dickensian narrative and social reportage see N. Philip and V. Neuberg (eds), Charles Dickens: A December Vision; His Social Journalism (London: Collins, 1986): 106–13 and 118–23; C. Fox, ‘The development of social reportage in English periodical illustration during the 1840s and early 1850s’, Past and Present 74 (1977): 90–113. Rogers, Reminiscences: 50. Rogers, Reminiscences: 48. Rogers, Reminiscences: 41–2. ‘The Lancet Sanitary Commission for Investigating the State of the Infirmaries of Workhouses. Reports of the Commissioners: No. IV Metropolitan Infirmaries: The Strand Infirmary’, Lancet, 12 August 1865: 186.

Notes 65

66

67 68

69 70 71 72

73 74 75 76 77 78 79 80 81 82

83 84 85 86 87

88 89 90 91 92 93 94 95 96

199

‘The Lancet Sanitary Commission for Investigating the State of the Infirmaries of Workhouses. Reports of the Commissioners: No. IV Metropolitan Infirmaries: The Strand Infirmary’, Lancet, 12 August 1865: 184. ‘The Lancet Sanitary Commission for Investigating the State of the Infirmaries of Workhouses. Reports of the Commissioners: No. IV Metropolitan Infirmaries: The Strand Infirmary’, Lancet, 12 August 1865: 184. Hart, ‘An account’: 7–8. ‘The Lancet Sanitary Commission for Investigating the State of the Infirmaries of Workhouses. Reports of the Commissioners: No. IV Metropolitan Infirmaries: The Strand Infirmary’, Lancet, 12 August 1865: 186. Hart, ‘An account’: 20. See Rogers, ‘Boards of guardians and their medical officers’. Letter to the Strand Board of Guardians from Charles Pelham Villiers, poor law president, 2 July 1866: TNA MH12/7844 The Strand 1 January 1866 to 31 December 1866. ‘Return to an order of the Honourable the House of Commons dated 29 May 1868; – for copy ‘of Correspondence between the Guardians of the Strand Union, the Poor Law Board, and Dr. Rogers, relating to the Resignation of Dr. Rogers’ (House of Commons, 1868), No. 6: 11. Lancet, 23 December 1865: 711–13. Chorlton Pauper Hospital in: Lancet, 3 November 1866: 493–4; Camberwell Imbecile Ward in: Lancet, 23 September 1865: 355–7. Lancet, 10 November 1866: 554. For example, Lancet, 10 November 1866: 554; Lancet, 17 February 1866: 178. Lancet, 26 May 1866: 580. Lancet, 26 May 1866: 580. Lancet, 14 July 1866: 47. Lancet, 14 July 1866: 50. Lancet, 14 July 1866: 51. Charles Dickens’ letter to the Association for the Improvement of the Infirmaries of London Workhouses, read aloud at the Association’s first meeting in 1865, cited in: R. Richardson and B. Hurwitz, ‘Joseph Rogers and the reform of workhouse medicine’, History Workshop Journal 43 (1997): 221. Rogers, Reminiscences: 232. Lancet, 3 March 1866: 233. Quoted in: Lancet, 3 March 1866: 233. Ayers, State Hospitals: 11. TNA MH 10/30 ‘Metropolitan Workhouses (Infirmary wards) return to an Order of the Honourable The House of Commons, dated 2 July 1866; – for, Copy “of Report of H.B. Farnall, Esquire, Poor Law Inspector, on the Infirmary Wards of the several Metropolitan Workhouses, and their existing Arrangements” ’: 6. TNA MH 10/30: 6. TNA MH 10/30: 7. Rogers, Reminiscences: 57. Ayers, State Hospitals: 10. Lancet, 2 June 1866: 612. Lancet, 1 July 1865: 16. Rogers, Reminiscences: 61. Professor Thorald Rogers in: Rogers, Reminiscences: xix. Green, Pauper Capital: 245–6.

200 97 98 99

100

101

102

103

104 105 106 107

108 109 110

Notes Bartrip, Mirror of Medicine: 55. Also, see Lancet, 21 April 1866: 440–3. Green, Pauper Capital: 246. For background on public health history, see Wohl, Endangered Lives: passim; Waddington, Charity and the London Hospitals: 5–20, 100–90 and 214–15; Hodgkinson, The Origins of the National Health Service: 163, 631–3, 637–40, 669–71, 694; A. Hardy, ‘Public health and the expert: The London medical officers of health, 1856–1900’, in: MacLeod, Government and Expertise: 128–297; D. Porter, Health, Civilisation and the State: A History of Public health from Ancient to Modern Times (London, 1999): passim; D. Porter, ‘Public health and centralisation: the Victorian British state’ in: W.W. Holland, J. McEwan and G.S. Omenn (eds), Oxford Textbook of Public Health: Volume 1: The Scope of Public Health. Third Edition (Oxford: Oxford University Press, 1997): 18–34, 19; Lane, A Social history of Medicine: 134–60; D. Fraser, The Evolution of the British Welfare State: A History of Social Policy since the Industrial Revolution. Second Edition (Basingstoke: Macmillan, 1984): 56–77; R. Porter, Disease, Medicine and Society in England 1550–1860 (London: Macmillan Education, 1987): 48–66. For articles that mention or discuss Rogers as a member of the BMJ editorial staff, see ‘Poor Law Medical Officers’ Association’, August 24, 1878: 300; ‘Poor Law Medical Officers’ Association’, BMJ, 18 May 1878: 727; Poor Law Medical Officers’ association’, BMJ, 28 June 1879: 989; ‘Poor Law Medical Officers’ Association’, BMJ, 27 August 1881: 373. For articles and commentary written by Rogers himself, see ‘Poor-Law Medical Relief ’, BMJ, 5 November 1870: 513–14; ‘The Cost of Poor Relief ’, BMJ, 24 December 1870: 694; ‘The Public Health Act’, BMJ, 14 January 1873: 24; ‘The General Election’, BMJ, 31 January 1874: 155. After his death, several articles paid homage to Rogers, including a lengthy obituary: ‘Dr Joseph Rogers’, BMJ, 13 April 1889: 847; ‘Obituary: Joseph Rogers, M.D., Chairman of the PoorLaw Medical Officers’ Association’, BMJ, 13 April 1889: 864–7; ‘The Late Dr Joseph Rogers’, BMJ, 20 April 1889: 914–15. H. Preston-Thomas, C.B., The Work and Play of a Government Inspector. With a Preface by the Right Hon. John Burns, M.P. President of the Local Government Board (London: William Blackwood and Sons, 1909): 51. This is a summarized version of some of the nine PLMOA objectives outlined in 1870; see ‘An address delivered by Dr Joseph Rogers [President of the Association] at a general meeting of the Poor Law Medical Officers’ Association held at the Freemasons Tavern, Great Queen Street, London, 29 November 1870’: 6–7. ‘Poor-Law Medical Officers and the Sanitary Service’, BMJ, 14 October 1871: 454; ‘The recommendations of the Royal Sanitary Commission’, BMJ, 21 October 1871: 460–1; ‘Poor-Law Medical Officers’ Association: the Public Health Act’, BMJ, 19 April 1873: 450–1; ‘The Public Health Act’, BMJ, 14 January 1872: 24; ‘Mr Corrance MP and the Public Health Bill’, BMJ, 12 April 1873: 419. Lumley, Manuals (1871): xxviii. Rogers, Reminiscences: 101. MacLeod, ‘The Frustration of State Medicine, 1880–1899’: 32–40. E. Hart, Local Government: As It Is and as It Ought to Be; Being the Address to the Sanitary Congress at Leicester Delivered 24 September 1885 (London: Smith, Elder & Co., 1885): 47. MacLeod, ‘The Frustration of State Medicine, 1880–1899’: 15–40. Hart, Local Government: 47. Hart, Local Government: 47.

Notes 111 112 113 114 115 116 117

118

119 120

121

122 123 124

125 126 127

201

Rogers, Reminiscences: 102–3. Rogers, Reminiscences: 101. For a more detailed description of ‘new’ liberalism, see Kidd, State, Society and the Poor: 160–1. Rogers, Reminiscences: 101. Preston-Thomas, Government Inspector: 50. ‘Poor Law Medical Officers Association quarterly meeting, April 28th’, BMJ, 4 June 1870: 574. For a succinct description of the bill, see PLMOA, quarterly meeting, 26 January 1870, in: BMJ, 5 February 1870: 145; BMJ, 20 August 1870: 197. For the detailed rules of superannuation, and their development over time, see Lumley’s Manuals (three editions referenced above) and W.H. Dumsday, The Workhouse Officers’ Handbook: Being a Complete and Practical Guide to the Laws Relating to the Powers, Duties, and Liabilities of the Master, The Chaplain, The Medical Officer, and Other Workhouse Officers (London: Hadden, Best & Co, 1907): 17, 25–32. For Rogers’ opinions on Superannuation, see ‘Superannuation of Poor Law Medical Officers’, BMJ, 26 February 1870: 224; ‘The Poor-Law Medical Officers’ Superannuation Bill’, BMJ, 2 April 1870: 351–2; ‘Dr Brady’s Medical Officers’ Superannuation Bill’, BMJ, 11 June 1870: 612; ‘Aide-Toi, Et Dieu T’Aidera’, BMJ, 18 July 1874, 68. For more contemporary opinions on ageing MOs, see ‘Superannuation of Poor-Law Medical officers’, BMJ, 5 March 1870: 252; ‘House of Commons – Wednesday, June 22nd – Poor-Law Medical Officers Superannuation Bill’, 25 June 1870: 662; ‘Medical Officers’ Superannuation Bill’, BMJ, 25 June 1870: 656. PLMOA quarterly meeting reported in: BMJ, 4 June 1870: 573. Sup. (U. Officers) Act 1864 (27 & 28 vict., chap 42) – ‘[Guardians] at their discretion, with the consent of the Poor Law Board, [may] grant to any officer, whose whole time has been devoted to the service of the union or parish …’, in: Leach and Leach, The Poor-Law Officers’ Superannuation Acts: 97. For a succinct discussion of the working of the poor law superannuation regulations, see ‘Poor Law Medical Officers’ Association quarterly meeting, April 28th’, BMJ, 4 June 1870: 573. ‘An address delivered by Dr Joseph Rogers [President of the Association] at a general meeting of the Poor Law Medical Officers’ Association held at the Freemasons Tavern, Great Queen Street, London, 27 April 1870’: 15. ‘Conference of Poor Law Medical Officers’, BMJ, 23 August 1873: 234. ‘Poor Law Officers’ (England) Superannuation Act’, BMJ, 5 June 1880: 871; ‘Superannuation of Poor-Law Medical Officers’, BMJ, 21 May 1881: 828–9. West Bromwich Union, for example, provided a test case for the medical officers to demonstrate their objectives to the wider profession: ‘The West Bromwich Guardians’, 23 June 1877: 797; ‘The West Bromwich Board of Guardians and Mr Downes’, BMJ, 4 August 1877: 161; ‘The West Bromwich Board of Guardians’, BMJ, 11 August 1877: 205; ‘What Poor-Law Surgeons May Expect’, 20 September 1873: 356; ‘Superannuation of Public Medical Officers’, BMJ, 27 October 1877: 600–1; ‘Mr Downes: Superannuation and the West Bromwich Board of Guardians’, BMJ, 10 November 1877: 682. Drawn from poor law employee records contained in the TNA MH9 Series. Digby, Making a Medical Living: 122–4. Dumsday, Workhouse Officers’ Handbook: 17, 25–32; Leach and Leach, Superannuation Acts: 103–12.

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13 14 15 16 17 18 19 20

21 22 23 24 25 26 27 28

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Crowther, The Workhouse System: 81. Crowther, The Workhouse System: 81. Bellamy, Administering Central-Local Relations: 273. Bellamy, Administering Central-Local Relations: 273. Bellamy, Administering Central-Local Relations: 274. Crowther, The Workhouse System: 115. C. Webster, ‘Conflict and consensus: explaining the British National Health Service’, Twentieth Century British History 1, 2 (1990): 115. Hurren, Protesting about Pauperism: 144. Brand, ‘The parish doctor’: 103–5. Brand, ‘The parish doctor’: 103–5. ‘Medical Inspectors under the Poor Law’, Lancet, 9 January 1869: 55–6. ‘Report of the Committee of the British Medical Association on Parliamentary Bills, 1867–1868: Presented at the Annual Meeting, Held in Oxford, August 1868’, BMJ, 8 August 1868: 144. The Pall Mall Gazette article was reproduced in: ‘The Poor-Law Relief Bill: Medical Inspectors’, BMJ, 8 August 1868: 146. Pall Mall Gazette. Pall Mall Gazette. Letter from Nunquam Dormio [pseud.], ‘Poor law medical inspectors’, Lancet, 2 January 1869: 27. ‘Workhouse Inspectors’, BMJ, 16 March 1895: 623. E. Hart, The Sick Poor in Workhouses. Reports on the Nursing and Administration of Provincial Workhouses and Infirmaries (London: Smith, Elder & Co., 1895): 39. Macleod, ‘The frustration of state medicine’: 32–4. For parallel context that describes the subtle differences in regional legal practices (and trends) for criminal law, see P. King, Crime and Law in England, 1750–1840: Remaking Justice from the Margins (Cambridge: Cambridge University Press, 2006): 1–69. Fraser, The Evolution of the British Welfare State: 53. Fraser, The Evolution of the British Welfare State: 54–5. For a more full discussion of this idea, see Fraser, The Evolution of the British Welfare State: 52–5. Hurren, Protesting about Pauperism: 257. Digby, Pauper Palaces: 230. Crowther, The Workhouse System: 82. Preston-Thomas, Government Inspector: 284. For an engaging introduction to the problem of doctors (who had similar logistical barriers), distance and the difficulties of nineteenth-century travel, see I. Loudon, ‘Doctors and their transport, 1750–1914’, Medical History 45 (2001): 192. Similarly, for nurses, see R. White, Social Change and the Nursing Profession: A Study of the Poor Law Nursing Service, 1848–1948 (London: Henry Kimpton, 1979): 43. Preston-Thomas, Government Inspector: 266. Preston-Thomas, Government Inspector: 266. Preston-Thomas, Government Inspector: 266: 278. Preston-Thomas, Government Inspector: 266: 360.

Notes 33 34 35 36

37 38 39 40 41 42 43 44

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48 49 50 51 52

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Kidd, State, Society and the Poor: 47–8. King, Women, Welfare and Local Politics: 36. King, Women, Welfare and Local Politics: 55. For an example of the LGB’s difficulties with guardians in the north-west, and the interplay of medical scandals, see the official inquiry into the conduct of Rose Morris and Dr Marsh (respectively, nurse and workhouse medical officer): Bolton Library and Archive: GBO/1/24 Bolton Union Guardians’ Minutes 1888–1890: 462–513. King, Women, Welfare and Local Politics: 55. Crowther, The Workhouse System: 83. As argued by Crowther (among other historians); see Crowther, The Workhouse System: 168. Mulcahy, Disputing Doctors: 30. Lumley, Manuals (1871): xxxv. Lumley, Manuals (1871): xxxv. Lumley, Manuals (1871): xxxii. For trade in the dead, see E. Hurren, ‘A pauper dead-house: the expansion of the Cambridge anatomical teaching school under the late-Victorian poor law, 1870– 1914’, Medical History 48, 1 (2004): 69–86; R. Richardson. Death, Dissection and the Destitute (London: Routledge and Kegan Paul, 1987). For ‘orthodox’ versus ‘quack’ medicine, see Loudon, ‘The vile race of quacks’: 106–28; Porter, Quacks. Hamlin, ‘Chadwick’: 233–65. Hamlin, ‘Chadwick’: xxxi. The scale of the General Consolidated Order’s dominance is clear in employee manuals: Lumley, Manuals (1871): 86–78; Dumsday, The Workhouse Officers’ Handbook. Griffin ‘Grievances’ (1858): VIII and 38. Lumley, Manuals (1871): 37. Lumley, Manuals (1871): 37. Mulcahy, Disciplining Doctors: 53. K.A. De Ville, Medical Malpractice in Nineteenth-Century America: Origins and Legacy (New York: New York University Press, 1990): 184. See also J.C. Mohr, Doctors and the Law: Medical Jurisprudence in Nineteenth–Century America (Baltimore: Johns Hopkins University Press, 1996): 109–21. Giesen, International Medical Malpractice: 51. Giesen, International Medical Malpractice: 51. Giesen, International Medical Malpractice: 11. For aspects of this, see: H. Weightman, The Medical Practitioners’ Legal Guide; or, the Laws Relating to the Medical Profession (London: Henry Renshaw, 1870): 37. Charlesworth, Forgotten Past: 92–8. For an introduction to the counter-claims to this important book, see King’s review in: Rural History, 22, 2 (2011): 271–3. P. King, ‘Legal change, customary right, and social conflict in late eighteenth-century England: the origins of the great gleaning case of 1788’, Law and History Review 10, 1 (1992): 2. Giesen, International Medical Malpractice: 17. See: B. Rodgers, ‘The medical relief disqualification removal act of 1885: A storm in a political teacup’, Parliamentary Affairs, 9, 2 (1956):188–94. Weightman, Legal Guide: 147.

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66 67 68 69 70 71 72 73 74 75

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77 78 79 80 81 82 83 84 85 86

Notes For an introduction to this development, see A. Jonsen, The Birth of Bioethics (New York: Oxford University Press, 1998): 368–71; Mulcahy, Disputing Doctors: 82–103. R. Charon, ‘The ethicality of narrative medicine’, in: B. Hurwitz et al. (eds), Narrative Research in Health and Illness (Oxford: Blackwell, 2004): 23–36; R. Richardson, ‘Narratives of compound loss: parents’ stories from the organ retention scandal’, Narrative: 239–56; C. Vincent and L. Page, ‘Aftermath of error for patients and health care staff ’, in: B. Hurwitz and A. Sheikh (eds), Health Care Errors and Patient Safety, (Oxford: Wiley-Blackwell, 2009): 179–92. M. Fissell, ‘The medical market place, the patient, and the absence of medical ethics in early modern Europe and North America’, in: R.B. Baker and L.B. McCullough (eds), The Cambridge World History of Medical Ethics (New York: Cambridge University Press, 2009): 533. For discussions of ‘Trust’ and ‘sympathy’ as tools of the medical trade, see McCullough, John Gregory’s Writings on Medical Ethics and Philosophy of Medicine: 170. Waddington, The Medical Profession: 157. Waddington, Medical Profession: 153–75. Weightman, Guide: 147. Weightman, Guide: 149. The life of Thomas Wakley serves as a paragon for intra-professional struggle: Hostettler, Thomas Wakley: 50–1. Also, see Loudon, Medical Care: 194. Weightman, Guide: 151. Waddington, Medical Profession: 153–75. Vaughan, Doctor’s Commons: 35. W.G. Lumley, Manuals of the Duties of Poor Law Officers. The Medical Officer (London: Knight and Co., 1849): 31. See also Lumley, Manuals (1857): 40. Weightman, Guide: 131. Extracts from the general orders of the Poor Law Commissioners, the Poor Law Board, and the Local Government Board relating to the duties of workhouse medical officers (London: Eyre and Spottiswoode,1896): 4. Alfred Sheen was a Cardiff workhouse medical officer. He also wrote letters of advice and some articles that were published in the BMJ. A. Sheen, The Workhouse and Its Medical Officer. Second Edition (Bristol: John Wright and Co., 1890): 38–9. Norfolk Record Office: C/GP 17/12 Thetford Union Board of Guardians’ Minute Book 1874–1881: 285. Norfolk Record Office: C/GP 17/12 Thetford Union Board of Guardians’ Minute Book 1874–1881: 388 Norfolk Record Office: C/GP 17/12 Thetford Union Board of Guardians’ Minute Book 1874–1881: 388. Lumley, Manuals (1857): 41. Lancashire Archives: Copy of letter from Dr Roe to the Board of Guardians, 15 May 1889: PUE/2/20 Barton-Upon-Irwell Union Guardians’ Minutes 1888–1889: 398. Copy of letter from Dr Roe, 26 April 1889. Lancashire Archives: 397. Lancashire Archives: PUE/2/20 Barton-Upon-Irwell Union Guardians’ Minutes 1888–1889: 402. Lancashire Archives: PUE/2/20 Barton-Upon-Irwell Union Guardians’ Minutes 1888–1889: 402. Lancashire Archives: PUE/2/21 Copy of letter from the LGB, 24 July 1889: BartonUpon-Irwell Union Guardians’ Minutes 1889–1891: 17–20. Charlesworth, Forgotten Past: 52.

Notes 87 88 89 90 91

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Crowther, The Workhouse System: 168. Hodgkinson, The Origins of the National Health Service: 682. M.A. Crowther, ‘Paupers or patients?’: 40. ‘Poor Law Medical Officers’ Association’, BMJ 1130 (1882): 380. For example, see TNA MH 12/13388 1877–1879 Coventry Union Correspondence: 1879, official inquiry into the charges against Mr Thomas Millerchip, district medical officer [who received the association’s full support]. See: 4 & 5 Will. 4, c. 76 (Poor Law Amendment Act, 1834); 5 & 6 Vict. C. 57 (Poor Law Amendment Act, 1842); 10 & 11 Vict. C. 109 (Poor Law Board Act, 1847), in: W.H. Dumsday, The Workhouse Officers’ Handbook. Dumsday, Workhouse Officers’ Handbook: 16. Lumley, Manuals (1871): 37–8. Lumley, Manuals (1871): 37–8. Rogers, Reminiscences: 251–2. Mulcahy, Disciplining Doctors: 150. Klein, Complaints against Doctors: 60–120. Lumley, Manuals (1871): 39. Lumley, Manuals (1857): 32. Kidd, State, Society and the Poor: 29. Kidd, State, Society and the Poor: 29; K. Price, ‘A regional, quantitative and qualitative study of the employment, disciplining and discharging of workhouse medical officers of the New Poor Law throughout nineteenth-century England and Wales’ (PhD thesis, Oxford Brookes University, 2008); K. Waddington, ‘Paying for the sick poor: financing medicine under the Victorian poor law – the case of the Whitechapel Union, 1850–1900’, in: M. Gorsky and S. Sheard (eds), Financing Medicine: the British Experience Since 1750 (London: Routledge, 2006): 102–5; Hurren, Protesting about Pauperism: 253; Hurren, ‘Poor law versus public health’: 399–418; Williams, From Pauperism to Poverty: 91–144; M. MacKinnon, ‘English poor law policy and the crusade against out-relief ’, The Journal of Economic History 47 (1987): 603–25; C. Smith, ‘Family, community and the Victorian asylum: A case study of the Northampton General Lunatic Asylum and its pauper lunatics’, Family and Community History 9 (2006): 116. Hurren, Protesting about Pauperism: 56.

Chapter 5 1

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3 4 5

See Webb and Webb, The State and the Doctor: 9–10; MacKinnon, ‘English poor law policy’: 603–25; Waddington, ‘Paying for the sick poor’: 102–5; Hurren, Protesting about Pauperism: passim; Williams, From Pauperism to Poverty: 91–144; Smith, ‘Family, community and the Victorian asylum’: 116. S. Webb and B. Webb (eds), The Minority Report of the Poor Law Commission, Reprint of the 1909 ed. Published in two parts by Longmans, Green, London (New Jersey, NJ: A.M. Kelley, 1974): 213. Webb and Webb, The State and the Doctor: 9–10. Williams, Pauperism: 103. Williams effectively introduced the crusade to historians, but confines its ambit to very few unions. See Williams, Pauperism: 96–107.

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12 13 14 15 16 17 18 19 20 21 22 23 24 25 26

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Notes For examples of otherwise comprehensive works, see L. Hollen Lees, The Solidarities of Strangers; B. Harris, The Origins of the Welfare State: Society, State and Social Welfare in England and Wales, 1800–1945 (Basingstoke: Palgrave Macmillan, 2004). Hurren, Protesting about Pauperism: 250. R. Humphreys, Sin, Organized Charity and the Poor Law in Victorian England (New York, NY: St Martin’s Press, 1995): 29. P. Wood, Poverty and the Workhouse in Victorian Britain (Stroud: Alan Sutton, 1991): 119. Wood, Poverty and the Workhouse: 119. See also ‘The Cotton famine’, The Lady’s Newspaper, 9 August 1862: 93; ‘Lancashire Distress’, The Lady’s Newspaper, 2 August 1862: 70. ‘The Distress in the North’, John Bull, 28 December 1862; ‘The Relief of Lancashire’, The Friend of India, 28 August 1862: 968; A. Borsay, Disability and Social Policy in Britain since 1750: A History of Exclusion (London: Palgrave Macmillan, 2005): 31. Although Perkin views the ‘Great Depression’ of the late nineteenth century as a myth, he recognized that there was recession (and want) in certain areas of England and Wales: Perkin, Professional Society: 38; White, Social Change and the Nursing Profession: 46–8. ‘The Local Government Board’, Capital and Labour: Promoted by the National Federation of Employers of Labour, 13 December 1876: 729. ‘Conferences of Poor Law Guardians’, The Morning Post, 16 November 1875: 4; see also ‘The Various Poor-Law Conferences’, The Morning Post, 13 September 1877: 4. Humphreys, Organized Charity: 28. Hurren, Protesting about Pauperism: 71. Hurren, Protesting about Pauperism: 255. ‘Out-Door Relief and the Workhouse’, The Pall Mall Gazette, 27 January 1873: 341. ‘Out-Door Relief ’, The Times, 3 February 1872: 4. ‘Poor Law Conference’, The Times, 14 December 1877: 3. Williams, Pauperism: 104–5. For example, see ‘Poor-Law Reform’, Capital and Labour. Promoted by the National Federation of Employers of Labour, 12 July 1876: 450. ‘Mr E.W. Bear on Out-Door Relief ’, The Essex Standard, West Suffolk Gazette, and Eastern Counties’ Advertiser, 23 March 1877: 5. John Bull, 9 December 1876: 807. For example, J. Riley, Sick, Not Dead: The Health of British Workingmen during the Mortality Decline (London, 1997): 18–19, 221–30. Riley, Sick, Not Dead: 18. Hurren, ‘Labourers’: 37–56; Hurren, ‘Agricultural’: 200–22; Hurren, ‘Welfare’: 19–30; Hurren, ‘dead-house’: 77–84; Hurren, ‘public health’: 399–418; Hurren, Protesting about Pauperism: passim. For example, see ‘Poor-Law Reform’, Capital and Labour. Promoted by the National Federation of Employers of Labour, 12 July 1876: 450; ‘The Out-Door Relief Question’, Berrow’s Worcester Journal, 20 January 1877: 6; ‘The Speaker on Out-door Relief ’, The Times, 11 September 1876: 6. For the right to relief, see L. Charlesworth, Welfare’s Forgotten Past: A Socio-Legal History of the Poor Law (Abingdon: Routledge, 2011): 1–6, 50–2. Hence the Charity Organisation Society distinguished itself from the poor law, because it was not underpinned by any ‘legal right’ to outdoor relief. See letter from C.E. Trevelyan,

Notes

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30 31 32 33 34 35

36

37 38 39 40

41 42 43 44 45 46 47 48 49 50 51 52 53

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one of England’s most influential civil servants and founding member of the Society: ‘Out-Relief and Charity Organisation’, The Leeds Mercury (30 November 1880). Those attitudes did alter, but it was not until the 1890s that socially informed reforms re-emerged as a movement (discussed in the final chapter), before finding their realization in the Liberal welfare reforms of the early twentieth century. See G.C. Gosling, ‘Charity and Change in the Mixed Economy of Healthcare in Bristol, 1918–1948’ (PhD thesis, Oxford Brookes University, 2011): 57. Waddington, ‘Paying for the sick poor’: 95–7. Hurren, ‘Welfare to Work Schemes’: 19–30; Hurren, Protesting about Pauperism: 242; MacKinnon, Poor Law Policy: 603–8. M. MacKinnon, ‘English poor law policy and the crusade against outrelief ’, The Journal of Economic History, 1987, 47: 614. Hollen Lees, Solidarities: 240. Hurren, Protesting about Pauperism: 144. For further details on Goschen, see Humphreys, Organized Charity: 21; for contemporary accounts, see H. Bosanquet, Social Work in London 1869–1912. Introduction by C.S. Yeo (First published in 1912 by John Murray. Brighton: The Harvester Press, 1973): 266–9; S.H. Jeyes, The Life and Times of the Right Honourable the Marquis of Salisbury K.G. A History of the Conservative Party during the Last Fifty Years, Volume 1 (London: Virtue and Company, c1900): 79–92. ‘Relief to the Poor in the Metropolis – Minute of the Poor Law Board’, in M.E. Rose, The English Poor Law 1780–1930 (Newton Abbot: David & Charles, 1971): 226–8. For a discussion of mid-Victorian Charity, see K. Waddington, Charity and the London Hospitals 1850–1898 (Woodbridge: RHS Boydell Press, 2000): 22–132. C.S. Loch, Charity Organisation (London: Swan Sonnenschein, 1890): 1. Loch, Charity Organisation: 10. ‘Out-Relief and Charity Organisation’, The Leeds Mercury, November 30: 1880. Henry Longley was appointed ‘legal inspector of the Board to hold official inquiries’ – from when he was ‘relieved a portion of his inspectorial work’. Part of a memorandum, in: TNA MH32/9 Inspector’s Correspondence, R.B. Cane: 13 December 1870. Humphreys, Organized Charity: 27. Williams, Pauperism: 96. ‘Out-door Relief – Circular from the Local Government Board to the Poor Law Inspectors’, in: Rose, English Poor Law: 228. Humphreys, Organized Charity: 27. Humphreys, Organized Charity: 27. Humphreys, Organized Charity: 27. Hurren, Protesting about Pauperism: 249. Rose, English Poor Law: 228. Rogers, Reminiscences: 91. Webb and Webb, Minority Report: 213. Rogers, Reminiscences: 100–1 and 90–1. Rogers, Reminiscences: 100–1. ‘Motion for a Select Committee’, Hansard, House of Commons Debate, v. 196, 10 May 1869: cc. 471–538. http://hansard.millbanksystems.com/commons/1869/ may/10/motion-for-a-select-committee#S3V0196P0_18690510_HOC_36 [accessed 4 December 2013]

208 54 55 56

57 58 59 60

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65 66 67 68 69

Notes Webb and Webb, Minority Report: 213. Williams, Pauperism: 96. For examples, see ‘Provident dispensaries’, BMJ 20 January 1872: 83; ‘Pauper medical relief at Guildford’, BMJ 27 September 1873: 382; ‘Out-door medical relief ’, BMJ, 30 November 1878: 820–21; ‘Poor-law medical relief in the Docking and Freebridge Lynn unions’, BMJ, 26 July 1879: 156; ‘Fees’, BMJ, 22 February 1879: 295; ‘The Plomesgate poor-law guardians and the medical officer of Aldeburgh’, BMJ, 9 July 1881: 64; ‘Medical relief in the Hartismere Union’, BMJ, 24 December 1881: 1039–40; ‘Medical relief in the Hartley Wintney Union’, BMJ, 6 September: 392; ‘A constitutional question’, BMJ, 2 March 1878: 322; ‘The Poor-Law Medical Officers’ Association, the Local Government Board, the Saffron Walden Board of Guardians, and Mr Buck’, BMJ, 16 March 1878: 394; ‘The case of Mr Buck and the Saffron Walden Board of Guardians’, BMJ, 23 November 1878: 785; ‘The Horsham Board of Guardians and the supply of expensive medicines’, BMJ, 23 September 1876: 418; ‘Poor-law medical officers and medicine’, BMJ, 7 October 1876: 482; ‘The Horsham Board of Guardians and the supply of expensive medicines’, BMJ, 2 December 1876: 732. TNA MH32 Letter to the President of the Local Government Board from the secretary, J. Lambert, 2 February 1872. TNA MH32. ‘Out-Door Relief ’, The Times, 20 November 1872: 10. Medway Archives: G/ST/AM 14 North Aylesford Union Board of Guardians’ Minutes 1871–74: ‘Interesting Poor Law Conference’, 3 October 1872; also see ‘OutDoor Relief ’, The Times, 29 January 1872: 6. Centre for Buckinghamshire Studies: G 5/5 Potterspury Union Board of Guardians’ Minute Book 1867–76: 153–501; G/4/9 Newport Pagnell Board of Guardians’ Minutes 1872–5: 64–280; G/4/9 Newport Pagnell Board of Guardians’ Minutes 1869–72: 228–448. See also: ‘Mr Hailey and the Newport Pagnell Union’, BMJ, 18 September 1875: 381 and NA MH12/494 Newport Pagnell Union 1875–6. Oxfordshire Record Office: PLU 7/G/1A1/20 Woodstock Union Board of Guardians’ Minutes 1885–8: 5–434; PLU 7/G/1A1/19 Woodstock Union Board of Guardians’ Minutes 1883–5: 118–500; Bedfordshire and Luton Archives: PULBH 4/1 Leighton Buzzard Union Board of Guardians’ Minutes 1868–1902: 139–257; PULBC 1/5 Manuscript Letter Book 1875–6. Summarized from: Medway Archives: G/ST/AM 14 North Aylesford Union Board of Guardians’ Minutes 1871–74: ‘Interesting Poor Law Conference’, 3 October 1872. Medway Archives: G/ST/AM 14. Lax was the most common adjective used to describe generous outdoor relief. For example, ‘The Out-Relief Question’, The Times, 2 June 1880: 12; ‘The Ipswich conference – Out-Relief ’, The Essex Standard, West Suffolk Gazette, and Eastern Counties’ Advertiser (30 June 1876): 4; ‘Outdoor Relief – letter to the Editor’, Ipswich Journal (7 August 1875). Williams, Pauperism: 100. Brand, ‘Parish doctor’: 106. King, A Fylde Country Practice: 35–6. ‘Poor Law Medical Officers and “Extras” ’ BMJ, 25 January 1879: 134. Digby, The Evolution of British General Practice: 251.

Notes 70

71 72

73 74 75 76 77 78 79

80 81 82

83

84 85 86 87 88 89 90 91 92

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For example, see ‘Administration of Out-Door Relief ’, The Times, 8 February 1870: 10; ‘The Starvation Case at Sunderland’, BMJ, 17 March 1877: 340; ‘Out-door Relief ’, Reynold’s Newspaper, 5 August 1877; The “Starvation Case,” Isle of Wight’, Lancet 16 June 1877. ‘The Case of Charlotte Hammond’, The Times, 26 June 1876: 10. ‘Out-door Relief ’, The Times, Monday, 3 February 1872; 4. In 1880, St George remained at the forefront of crusading. See ‘The Out-Relief Question’, The Times, 2 June 1880: 12. Also, see Kidd, State, Society and the Poor: 51. ‘Mr E.W. Bear on Out-Door Relief ’, The Essex Standard, West Suffolk Gazette, and Eastern Counties’ Advertiser, 23 March 1877: 5. ‘The Case of Charlotte Hammond’, The Times, 26 June 1876: 10. ‘The Case of Charlotte Hammond’, The Times, 26 June 1876: 10. ‘The Case of Charlotte Hammond – Yesterday’, The Times, 24 June 1876: 14. ‘The Case of Charlotte Hammond – Yesterday’, The Times, 27 July 1876: 7. ‘The Case of Charlotte Hammond – Yesterday’, The Times, 27 July 1876: 7. ‘The Case of Charlotte Hammond’, BMJ, 22 July 1876: 118–19. See also: ‘The Guardians of St George’s, Hanover Square, And Mr Fenton’, BMJ, 20 January 1877: 90. Hurren, ‘dead house’: 86. ‘Poor-law Medical Officers’ Association’, BMJ, 4 September 1880: 405. ‘Poor-law Medical Officers’ Association’, BMJ, 4 September 1880: 406. See also ‘Poorlaw medical relief at Cambridge’, BMJ, 2 October 1880: 569; ‘Poor-law medical relief at Cambridge’, BMJ, 25 September 1880: 532. For Robert Ransom, see Cambridgeshire Record Office: G/C/AM23 Cambridge Union Board of Guardians’ Minute Books 1868–9: 4–575; G/C/AM22 Cambridge Union Board of Guardians’ Minute Books 1867–8: 201–595; G/C/AM21 Cambridge Union Board of Guardians’ Minute Books 1865–6: 356–440; G/C/ AC 4 Cambridge Union Board of Guardians’ Letter Book 1866–70: 52–387; ‘The guardians and the doctor’, The Cambridge Chronicle, 21 December 1867: 8; ‘Suspension of Dr Ransom and vote of confidence in the workhouse master’, and, ‘Dr Ransom and the guardians’, The Cambridge Chronicle, 28 December 1867: 7; ‘The workhouse master surcharged’, The Cambridge Chronicle, 14 December 1867; ‘The Cambridge guardians’, The Cambridge Chronicle, 28 January 1868; ‘Poor-law medical relief at Cambridge’, BMJ, 25 September 1880: 532; ‘Poor-law medical relief at Cambridge’, BMJ, 2 October 1880: 569. Cambridgeshire Record Office: G/C/AM22 Cambridge Union Board of Guardians’ Minute Books 1867–8: 11. ‘Out-door medical relief ’, BMJ, 25 April 1874: 563. A. Digby, The Evolution of British General Practice: 247–50. See also Digby, Making a Medical Living: 300. Gloucestershire Record Office: G/Sto/8a/15 Stow-on-the-Wold Board of Guardians’ Minutes: 7 December 1876. Hurren, ‘Labourers’: 37–56; Hurren, ‘Agricultural’: 200–22; Hurren, ‘Welfare’: 19–30; Hurren, ‘public health’: 399–418; Hurren, Protesting about Pauperism: passim. ‘Out-door medical relief ’, BMJ, 25 April 1874: 563. ‘Out-door medical relief ’, BMJ, 25 April 1874: 563. Rogers, Reminiscences: 131. Hurren, Protesting about Pauperism: 62.

210 93

94 95 96 97 98 99 100 101 102 103

104 105

Notes NA: MH12/13353 Birmingham Union: LGB letter to A.B. Simpson, requiring his resignation: 2 August 1886; ‘Charge against the medical staff of the Birmingham workhouse’, BMJ, 17 December 1881: 993; A lively meeting’, Birmingham Gazette, 16 June 1886; ‘Persecution in Bumbledom’, Birmingham Daily Mail, 16 June 1886. For further discussion of the context of Simpson’s employment at Birmingham Workhouse, see J. Reinarz and A. Ritch, ‘Exploring medical care in the nineteenthcentury provincial workhouse: A view from Birmingham’, in: J. Reinarz and L. Schwarz (eds), Medicine and the Workhouse (Rochester, NY: University of Rochester Press, 2013): 146–57. ‘The alleged punishment of sick paupers’, BMJ, 7 January 1882: 33. Death in a padded room’, BMJ, 13 January 1877: 59. NA: MH12/9461 Nottingham Union 1872: Letter from the Nottingham Union Board of Guardians, 20 August 1872. Medway Archives: G/ST/AM 14 North Aylesford Union Board of Guardians’ Minutes 1871–74: 31 and 218–9. Waddington, ‘Paying for the sick poor’, 107; also see Smith, ‘Family, community and the Victorian asylum’: 109–24. ‘The Local Government Board’, Capital and Labour: Promoted by the National Federation of Employers of Labour (13 December 1876): 729. ‘The Local Government Board’, Capital and Labour: Promoted by the National Federation of Employers of Labour (13 December 1876): 729. For an overview of the scale, see entries for medical staff in this period: TNA MH9 Series of volumes. Baker and Hurwitz, ‘Intentionally harmful violations’: 36. J. Reason, Managing the Risks of Organizational Accidents (Aldershot: Ashgate, 1997): 9–15. For the model’s application to medical harm, see Baker and Hurwitz, ‘Intentionally harmful violations’: 37. D.J. Rothman, Strangers at the Bedside: A History of How Law and Bioethics Transformed Medical Decision Making (New York, NY: BasicBooks, 1991): 1–14. Although Wright does not say the crusade played a part in this ‘exodus’, Borsay has attributed rising numbers to widespread crusading: D. Wright, ‘Learning disability and the New Poor Law in England, 1834–1867’, Disability and Society, 2000, 15: 731–45, 740; Borsay, Disability: 31–3.

Chapter 6 1 2

3 4

5 6

‘Motion for a select committee’: cc. 471–538. Humphreys, Organised Charity: 171; also see L. Hollen Lees, ‘The survival of the unfit: welfare politics and family maintenance in London’, in: P. Mandler (ed.), The Uses of Charity: The Poor on Relief in the Nineteenth-Century Metropolis (Philadelphia: University of Pennsylvania Press, 1990): 80–1. Humphreys, Organised Charity: 31. Williams, From Pauperism to Poverty: 128; F. Driver, ‘The historical geography of the workhouse system in England and Wales, 1834–1883’, Journal of Historical Geography 15 (1989): 276–84. ‘The Terrors of Pauperism’, BMJ, 31 March 1894: 702. ‘The Terrors of Pauperism’: 702.

Notes 7 8

9

10

11 12 13 14 15 16 17

18 19 20 21 22 23

24 25 26 27

28

211

‘The Terrors of Pauperism’: 702. Standards of care in workhouses are at the hub of controversies in the literature of the new poor law. For penetrative discussions of this, see A. Negrine, ‘Practitioners and paupers: medicine at the Leicester Union workhouse, 1867–1905’, and S. King, ‘Poverty, medicine, and the workhouse in the eighteenth and nineteenth centuries: an afterword’, in: Reinarz and Schwarz, Medicine and the Workhouse: respectively, 192–211 and 228–51. Bodleian Library: 24764c.1 (2) Extracts from the general orders of the Poor Law Commissioners, the Poor Law Board, and the Local Government Board relating to the duties of workhouse medical officers, 1896: 4. ‘Reports on the nursing and administration of provincial workhouses and infirmaries: special commission of the British Medical Journal; XX Falmouth’, BMJ, 13 October 1894: 816. ‘The nursing of provincial workhouses a further scandal’, BMJ, 18 August 1894: 366–7. Hart, The Sick Poor in Workhouses: 3. Williams, From Pauperism to Poverty: 128. See also Driver, ‘Historical geography’: 276–84. Webb and Webb, Minority Report: 214. Flinn, ‘Medical services under the New Poor Law’: 66. Leicestershire Record Office: G/8/8a/9-10 Lutterworth Union Board of Guardians’ Minutes 1870-4: 14 April 1870. Leicestershire Record Office: G/8/8a/9-10 Lutterworth Union Board of Guardians’ Minutes 1870-4: 377; Bartlett, The Poor Law of Lunacy: 37; L.D. Smith, ‘ “Cure, Comfort and Safe Custody”: Public Lunatic Asylums in Early-Nineteenth Century England’ (London: Leicester University Press, 1999): 284; R. Ellis, ‘The asylum, the poor law, and a reassessment of the four-shilling grant: Admissions to the county asylums of Yorkshire in the nineteenth century’, Social History of Medicine 19(2006): 55; E. Murphy, ‘Workhouse care of the insane, 1845–90’, in: P. Dale and J. Melling (eds), Mental Illness and Learning Disability Since 1850: Finding a Place for Mental Disorder in the United Kingdom (London: Routledge, 2006): 24–45. Wright, ‘Learning disability’: 740; Borsay, Disability and Social Policy: 31–6. Bartlett, Poor Law of Lunacy: 44; Hurren, Protesting about Pauperism: 45; Smith, Public Lunatic Asylums: 286. Murphy, ‘Workhouse care’: 495–524. ‘The insane in workhouses’, BMJ, 31 December 1881: 1065. ‘The nursing of provincial workhouses: A further scandal’: 366–7. For further contemporary accounts of nursing, see ‘Pauper nurses’, BMJ, 28 June 1890: 1518; ‘Workhouse infirmary nursing association’, BMJ, 4 June 1892: 1213–4; ‘Trained nurses in workhouse infirmaries’, BMJ, 17 July 1880: 99–100; ‘Trained nurses in workhouses’, BMJ, 12 March 1898: 714. Hart, The Sick Poor in Workhouses: viii. TNA MH10/56 Circular Letters from the Local Government Board. Volume 21. P. Ardern, When Matron Ruled (London: Robert Hale, 2002): 28. ‘Pauper Nurses’: 1518; ‘Nursing in country workhouses’, BMJ, 11 November 1893: 1063. For further context, see Ardern, When Matron Ruled: 28; White, Social Change and the Nursing Profession: 56–9. Sheen, The Workhouse and Its Medical Officer: 14.

212 29

30 31 32

33

34 35 36 37 38 39 40 41 42 43

44 45

46 47 48

Notes G.J. Thurgood, ‘A history of nursing in Halifax and Huddersfield 1870–1960’ (PhD thesis, University of Huddersfield, 2008): 189. http://eprints.hud.ac.uk/8353/1/PhD_ Thesis.pdf [accessed: 8 December 2013]. Thurgood, ‘A history of nursing in Halifax and Huddersfield 1870–1960’: 188. White, Social Change and the Nursing Profession: 95. ‘On nursing in workhouse infirmaries’, BMJ, 26 September 1896: 857; ‘Reports on the nursing and administration of provincial workhouses and infirmaries: special commission of the British Medical Journal; VI Bath’, BMJ, 7 July 1894: 26. A number of London’s workhouses employed paid nurses immediately after the Lancet reports had been published. ‘Results of our commission on workhouse infirmaries’, Lancet, 1 September 1866: 244–5. ‘The training of nurses in workhouse infirmaries’, BMJ, 27 January 1894: 209. ‘The training of nurses in workhouse infirmaries’: 103. A. Negrine, ‘Medicine and poverty: a study of the poor law medical services of the Leicester union, 1867–1914’ (PhD thesis, University of Leicester, 2008): 98–123. Dr Rhodes to The Times, in: ‘Workhouse Nursing’, BMJ, 22 January 1898: 235. ‘Workhouse Infirmary Nursing Association’: 1213–4; Rhodes, ‘Workhouse Nursing’: 235. ‘The Workhouse Infirmary Nursing Association’, The Times, 13 July 1894: 14. ‘Workhouse Infirmary Nursing Association’, The Times, 3 December 1897: 10. ‘The Workhouse Infirmary Nursing Association and the Bedford guardians’, The Nursing Record and Hospital World, 15 September 1894: 175. The famous Nightingale training school for nurses, at St Thomas’ Hospital, had also begun in the 1860s. White, Social Change and the Nursing Profession: 54–5, 97. For more contextual background to the clash of doctors and nurses, see White, Social Change and the Nursing Profession: 53–7; B. Abel-Smith, A History of the Nursing Profession (London: Heinemann, 1970): 61–98; A.M. Rafferty, The Politics of Nursing Knowledge (London: Routledge, 1996): 10–11; T. Olsen, ‘Ordered to care?: professionalization, gender and the language of training, 1915–37’, in: A.M. Rafferty, J. Robinson and R. Elkan (eds), Nursing History and the Politics of Welfare (London: Routledge, 1997): 150–64; R. Dingwall, A.M. Rafferty and C. Webster (eds), An Introduction to the Social History of Nursing (London: Routledge, 1988): 1–77; C. Maggs, The Origins of General Nursing (London: Croom Helm, 1983): 5–31; C. Maggs, ‘Nursing history: contemporary practice and contemporary concerns’, in: C. Maggs (ed.), Nursing History: The State of the Art (London: Croom Helm, 1987): 1–8; C. Davies, ‘Introduction: The contemporary challenge in nursing history’, in: C. Davies (ed.), Rewriting Nursing History (London: Croom Helm, 1980): 11–18. White, Social Change and the Nursing Profession: 55. North Yorkshire County Record Office: BG/KN1 MIC 1650/11 Knaresborough Union Guardians’ Minute Books 1891–93: 247–430; BG/KN1 MIC 1668/12 Knaresborough Union Guardians’ Minute Books 1893–6: 12–26. North Yorkshire County Record Office: BG/KN1 MIC 1668/12 Knaresborough Union Guardians’ Minute Books 1893–6: 16–25. Rhodes, ‘Workhouse Nursing’: 235. ‘Wrong again’, Oldham Chronicle, 16 August 1873: 4. Also see ‘A case deserving of inquiry by the guardians’, Oldham Chronicle, 16 August 1873: 8; Oldham Local Studies and Archives: PUO 1/15-17 Oldham Union Board of Guardians’ Minutes 1872–3, 1873–184 and 1874–5.

Notes 49 50 51 52 53 54 55

56

57 58 59 60 61 62 63 64 65 66

67

68

69 70 71 72 73 74 75 76 77

213

White, Social Change and the Nursing Profession: 57–8. White, Social Change and the Nursing Profession: 60–1 and 95. See also: ‘Paupers’ diet at Newton Abbott’, BMJ, 13 January 1894: 111. ‘The terrors of pauperism’: 703. ‘General Inspectors of the Local Government Board’, BMJ, 28 April 1894: 939. ‘Obituary: Ernest Hart, M.R.C.S., D.C.L.; Editor of the British Medical Journal’, BMJ, 15 January 1898: 178. ‘Reports on the nursing and administration of provincial workhouses and infirmaries: Specially reported to the “British Medical Journal”. I’, BMJ, 2 June 1894: 1197. The research for this book viewed the 50 specific reports of the Commission and the relevant subsidiary articles, printed in the BMJ between 1894 and 1897; also see Hart, The Sick Poor in Workhouses. TNA MH10/56. Hart, The Sick Poor in Workhouses: 10. Hart, The Sick Poor in Workhouses: 16. Hart, The Sick Poor in Workhouses: 16. Hart, The Sick Poor in Workhouses: ix. It was known as the Nursing in Workhouses Order. General Order, 6 August 1897, article 1 (1): Dumsday, Workhouse Officers’ Handbook: 110. ‘At last! The death blow to Pauper nursing’, BMJ, 21 August 1897: 493. ‘Obituary: Ernest Hart, M.R.C.S., D.C.L.; Editor of the British Medical Journal’: 175–86. ‘Nursing in country workhouses’: 1063. B. Forsythe, J. Melling and R. Adair, ‘The new poor law and the county pauper lunatic asylum – the Devon experience 1834–1884’, Social History of Medicine 9 (1996): 353. For examples, see Oldham Local Studies and Archives: PUO 1/15 Oldham Union Board of Guardians’ Minutes 1872–3: 62; Shropshire Archives: Atcham Union Guardians’ Minute Book PL1/2/2/11: 9. The micro study of Edward’s care in this chapter draws from the inquiries of the Coroner and Local Government Board, following his death: TNA Ministry of Health Records Local Government Board and predecessors, correspondence with Isle of Wight Poor Law Union, 1877–8 MH12/11106-7 (henceforth: TNA IWU). TNA IWU: Affidavit of Francis Henry Munns at the official inquiry: 8–11. TNA IWU: Affidavit of Henry Cooper at the official inquiry: 51–3. TNA IWU: Affidavit of Henry Cooper at the official inquiry: 54. Preston-Thomas, Government Inspector: 54. Rogers, Reminiscences: 181–3. F. Condrau, ‘The patient’s view meets the clinical gaze’, Social History of Medicine 20 (2007): 536. Fraser, The Evolution of the British Welfare State: 144. Borsay, Disability and Social Policy: 31–6. Hollen Lees, ‘The survival of the unfit’: 72; J. Melling, B. Forsythe and R. Adair, ‘Families, communities and the legal regulation of lunacy in Victorian England: assessments of crime, violence and welfare in admissions to the Devon Asylum, 1845–1914’, in: P. Bartlett and D. Wright (eds), Outside the Walls of the Asylum: the History of Care in the Community 1750–2000 (London: The Athlone Press, 1999): 153.

214 78

79 80

81

82

83

84

85

86

87

88 89 90 91 92 93 94 95 96

97 98

Notes S. King, ‘ “Stop this overwhelming torment of destiny”: Negotiating financial aid at times of sickness under the English old poor law, 1800–1840’, Bulletin of the History of Medicine 79 (2005): 234. Merry and McCall Smith, Errors, Medicine and the Law: 33–5. The search for cause and culpability in medical errors can be traced back to ancient Greece: S. Miles, The Hippocratic Oath and the Ethics of Medicine (Oxford: Oxford University Press, 2005): 113–17. Historians, such as Wright, have lamented the lack of such resources. D. Wright, Mental Disability in Victorian England: The Earlswood Asylum, 1847–1901 (Oxford: Clarendon Press, 2001): 47. P. Rushton, ‘Idiocy, the family and the community in early modern north-east England’, in: D. Wright and A. Digby (eds), From Idiocy to Mental Deficiency: Historical Perspectives on People with Learning Disabilities (London: Routledge, 1996): 47–9. Rushton, ‘Idiocy, the family and the community in early modern north-east England’: 58; M. Thomson, The Problem of Mental Deficiency: Eugenics, Democracy, and Social Policy in Britain c. 1870–1959 (Oxford: Clarendon Press, 1998): 7; Wright, Mental Disability: 10, 15. Wright, Mental Disability: 16; A. Digby, ‘Contexts and perspectives’, in: D. Wright and A. Digby (eds), From Idiocy to Mental Deficiency: Historical Perspectives on People with Learning Disabilities (London: Routledge, 1996): 1. For medicine and disability, see D. Turner, ‘Introduction: approaching anomalous bodies’, in: D. Turner and K. Stagg (eds), Social Histories of Disability and Deformity, (London: Routledge, 2006): 1–16. Although David Wright has said that such care has been ‘exaggerated by historians’, Anne Borsay has said that the decline of familial care is a ‘myth’. Borsay, Disability and Social Policy: 175–87; Wright, Mental Disability: 66. D. Wright, ‘ “Childlike in his innocence”: lay attitudes to “idiots” and “imbeciles” in Victorian England’, in: D. Wright and A. Digby (eds), From Idiocy to Mental Deficiency: Historical Perspectives on People with Learning Disabilities (London: Routledge, 1996): 118–33, 19–27. Williams, From Pauperism to Poverty: 96–129. Hurren, Protesting about Pauperism: 56. ‘Cost of out-relief: Hampshire’, The Hampshire Advertiser, 26 February 1876: 3. Hurren, ‘Public health’: 403; paraphrasing Williams, From Pauperism to Poverty: 99. ‘The “starvation case,” Isle of Wight’. Edward’s parish of residence was Brading in the Ryde district. As Chapter 4 demonstrated, there were between five and ten times the regular annual incidence of charges of neglect against workhouse medical officers in the 1870s. TNA IWU: Affidavit of Mary Cooper at the official inquiry (henceforth: affidavit of Mary): 1–26. TNA IWU: ‘Report of the inspectors’, May 1877: 1–2. Hurren, Protesting about Pauperism: 256; M. Hanly, ‘The economy of makeshifts and the poor law: A game of chance?’ in: S. King and A. Tomkins (eds), The Poor in England 1700–1850: an Economy of Makeshifts (Manchester: Manchester University Press, 2003): 76–99; S. King and A. Tomkins, The Poor in England 1700–1850: an Economy of Makeshifts (Manchester: Manchester University Press, 2003): 272–9. Borsay, Disability and Social Policy: 152. Borsay, Disability and Social Policy: 152.

Notes 99 100

101

102 103 104

105 106 107

108 109 110 111 112 113 114 115 116 117 118 119 120

121 122 123 124 125 126 127 128

215

Wright, ‘Lay attitudes’: 131. Atherley arranged for Edward’s place in the workhouse, bypassing the relieving officer. He reassured Mary that Edward would be well cared for by the master, who had met with Atherley. This irregular committal was censored by the LGB inspectors. Waddington, ‘Paying’: 98; E. Ross, ‘Hungry children: housewives and London charity, 1870–1918’, in: P. Mandler (ed.), The Uses of Charity: The Poor on Relief in the Nineteenth-Century Metropolis (Philadelphia: University of Pennsylvania Press, 1990): 163. A study of lay attitudes to idiocy ‘cuts against the grain’, from: Wright, ‘Lay attitudes’: 118. Borsay, Disability and Social Policy: 175–82; Bartlett, Poor Law of Lunacy: 176–89. Borsay, Disability and Social Policy: 169–96; D. Englander, ‘From the abyss: pauper petitions and correspondence in Victorian London’, London Journal 25 (2000): 71–81; King and Tomkins, Economy of Makeshifts: 274–5; T. Sokoll, Essex Pauper Letters, 1731–1837 (Oxford: Oxford University Press, 2001): 15; T. Sokoll, ‘Writing for relief: Rhetoric in English pauper letters, 1800–1834’ in: A. Gestrich S. King and L. Raphael (eds), Being Poor in Modern Europe (Oxford: Peter Lang, 2006): 91–112. Wright, Mental Disability: 47. Mandler, The Uses of Charity: 1. For further context in domestic care, see Wright, ‘Learning disability’: 738; Forsythe, Melling and Adair, ‘The New Poor Law and the county pauper lunatic asylum’: 350. TNA IWU: Daniel Beckingsale under cross-examination by Dr Mouat, LGB Inspector. TNA IWU: Isle of Wight Chronicle 7 June 1877 (cutting: original unavailable). TNA IWU: Mary Cooper’s statement at the Coroner’s inquest: 1. TNA IWU: Emma MacMahon’s statement at the Coroner’s inquest: 18. TNA IWU: James Walker’s statement at the Coroner’s inquest. TNA IWU: Emma MacMahon’s statement at the Coroner’s inquest. Wright, ‘Lay Attitudes’: 127. Affidavit of Mary: 12–15. Wright has said that families ‘continued to occupy a separate sphere of interpretation’, Wright, ‘Lay attitudes’: 130. Borsay, Disability and Social Policy: 181; Wright, Mental Disability: 52. Affidavit of Mary: 9–12. Affidavit of Mary: 9. For a discussion of single-parenthood, see K.D.M. Snell and J. Millar, ‘Lone-parent families and the Welfare State: Past and present’, Continuity and Change 3 (1987): 389–404; Ross, ‘Hungry children’: 161. Melling, Forsythe and Adair, ‘Families’: 178. TNA IWU: LGB inspector’s observations on the case: 11–12. TNA IWU: Dr John Beckingsale’s statement at the coroner’s inquest: 30. TNA IWU: Affidavit of Dr John Beckingsale at the official inquiry: 3 TNA IWU: Dr Charles Meeres’ statement at the coroner’s inquest. TNA IWU: Affidavit of Dr John Beckingsale at the official inquiry: 3. TNA IWU: Affidavit of Dr John Beckingsale at the official inquiry: 10. TNA IWU: ‘Points shown by the evidence of the medical officer’.

216 129 130 131 132 133

134 135

Notes TNA IWU: ‘Grounds stated in Boards letter for their decision as to the medical officer of the workhouse and his deputy’. TNA IWU: ‘Grounds stated in Boards letter for their decision as to the medical officer of the workhouse and his deputy’. ‘The “starvation case,” Isle of Wight’: 921. The Royal College of Surgeons of England: Plarr’s Lives of the Fellows Online: http://livesonline.rcseng.ac.uk/biogs/E002251b.htm [accessed: 1 March 2014] C. H. [Charles Holmes], Sick Paupers and Their Medical Attendants: An Expose of the Fraud Inflicted on the Sick Poor and the Ratepayer, in the Employment by PoorLaw Medical Officers of Unqualified Assistants (London: Horne and Co, 1878): 3. Hampshire Independent, 9 June 1877: 6. Baker and Hurwitz, ‘Intentionally harmful violations’: 36–7.

Chapter 7 1 2 3

4 5 6 7 8 9 10

11 12 13 14 15 16 17 18 19 20

21

Digby, Making a Medical Living: 244. Reason, Managing the Risks: 9–15. Notably, Baker and Hurwitz used Reason’s research as a frame of reference to describe the actions of Harold Shipman, the notorious English doctor who murdered at least 250 patients. Baker and Hurwitz, ‘Intentionally harmful violations’: 36–7. J. Reason, Human Error (Cambridge: Cambridge University Press, 1990): 211. Reason, Human Error: 211. Reason, Human Error: 211. Green, Pauper Capital: 212 and 213–46. Reason, Human Error: 212. P. Ekman, Telling Lies: Clues to Deceit in the Marketplace, Politics, and Marriage (New York, NY: W.W. Norton & Company, 2001): 327. See statements of Mr Hope, Mr J.T. Woodcock, Mr Whittington, Mrs Hamilton, Mrs Reynolds, Mr Pearse: West Sussex Archives: WG8/1/12 Chichester Board of Guardians’ Minute Book 1886–1890: 233–45. From the statement of Mr J.T. Woodcock: West Sussex Archives: WG8/1/12 Chichester Board of Guardians’ Minute Book 1886–1890: 237–9. From the statement of Mr J.T. Woodcock: West Sussex Archives: WG8/1/12 Chichester Board of Guardians’ Minute Book 1886–1890: 237–9. From the statement of Mr Hope: West Sussex Archives: WG8/1/12 Chichester Board of Guardians’ Minute Book 1886–1890: 242. From the statement of Mr Hope: West Sussex Archives: WG8/1/12 Chichester Board of Guardians’ Minute Book 1886–1890: 242. Reason, Human Error: 195. Reason, Human Error: 195. Reason, Human Error: 173. C. Dickens Our Mutual Friend (London: Macdonald, 1957; First edition 1865). Wakley, ‘Medical Relief ’, cc. 632–91. Gloucestershire Record Office: G/CH/8a Cheltenham Union Minutes of the Board of Guardians 1866–7: 289; see also TNA MH12/3924 and 5 Cheltenham Union 1866–7. Sheen, The Workhouse: 7.

Notes 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

217

N.C. Walsh, The Medical Officer’s Vade-Mecum or, Poor Law Surgeon’s Guide (London: Henry Renshaw, 1866): 36–7. J.R. Pretyman, Dispauperization: A Popular Treatise on Poor-Law Evils and Their Remedies (London: Longmans, Green, and Co., 1878): 221–2. For medical extras, see Digby, Making a Medical Living: 244–9. Lumley, Manuals (1857): 16–27. Lumley, Manuals (1857): 16–27. Lumley, Manuals (1857): 16–27. Lumley, Manuals (1871): 32–3. Lumley, Manuals (1871): 27. Lumley, Manuals (1871): 24. Lumley, Manuals (1857): 16–27; Lumley, Manual (1871): 19–33. Lumley, Manuals (1871): 26. Rogers, Reminiscences: 19. Rogers, Reminiscences: 19: 21. Lumley, Manuals (1871): 29. Lumley, Manuals (1871): 28–30. Lumley, Manuals (1871): 29. Lumley, Manuals (1871): 29. Richardson, and Hurwitz, ‘Joseph Rogers’: 218–25. Lumley, Manuals (1871): 30. Lumley, Manuals (1871): 30. ‘Medical relief in the Bridgnorth union’, BMJ, 25 April 1885: 872. Lumley, Manuals (1871): 30. Lumley, Manuals (1871): 30–1. Lumley, Manuals (1871): 30–1. Lumley, Manuals (1871): 30–1. Lumley, Manuals (1871): 28–30. Walsh, Vade-Mecum: v. TNA MH 12/13514 Stratford-on-Avon Union 1870. TNA MH 12/13514 Stratford-on-Avon Union 1870. H.J. Davis and H.A. Owston, Overseers’ Manual: Showing Their Duties, Liabilities, and Responsibilities (London: Shaw and Sons, 1864): 97. Davis and Owston, Overseers’ Manual: 97–8. Davis and Owston, Overseers’ Manual: 98. Lumley, Manuals (1871): 30. Lumley, Manuals (1871): 30. Lumley, Manuals (1871): 19. Walsh, Vade-Mecum: 7. Dr Moss Campbell of Staunton, Gloucester, ‘Fees in cases of urgency’, letter in BMJ 658 (1873): 176. ‘A constitutional question’, BMJ, 2 March 1878: 322. Lumley, Manuals (1871): 25. ‘Medical relief in the Bridgnorth union’, BMJ, 6 June 1885: 1179. Digby, Making a Medical Living: 249. Digby, Making a Medical Living: 252. TNA MH12/3573: ‘statement re David Bruell’ ref 104521/97. TNA MH12/3573: Letter from David Overall to the secretary to the LGB, 14 August 1897.

218 66 67 68 69 70 71 72 73 74

75 76 77 78 79 80 81 82

83 84

85 86 87 88 89 90 91 92 93 94 95 96 97 98

Notes TNA MH12/3573: Inspector Philipot Bagenal, 13 August 1897. TNA MH12/3573: Maldon Union Clerk, Alfred Freeman, letter to the secretary to the LGB, 7 August 1897. TNA MH12/3573: ‘statement re David Bruell’ ref 104521/97. TNA MH12/3573: Maldon Union Clerk, Alfred Freeman, letter to the secretary to the LGB, 7 August 1897. BMJ, 6 December 1856: 1045. BMJ, 6 December 1856: 1045. BMJ, 6 December 1856: 1045. ‘Medical relief in the Penistone union’, BMJ, 12 November 1881: 799. C.H. [Charles Holmes], Sick Paupers and Their Medical Attendants: An Exposé of the Fraud Inflicted on the Sick Poor and the Ratepayer, in the Employment by Poor-Law Medical Officers of Unqualified Assistants (London: Horne and Co, 1878): 17. C.H. [Charles Holmes], Sick Paupers and Their Medical Attendants: 4. Lumley, Manuals (1871): 41–5. C.H. [Charles Holmes], Sick Paupers and Their Medical Attendants: 18. C.H. [Charles Holmes], Sick Paupers and Their Medical Attendants: 18. C.H. [Charles Holmes], Sick Paupers and Their Medical Attendants: 19. Lane, A Social History of Medicine: 63. S. King and J. Stewart, ‘The history of the poor law in Wales: under-researched, full of potential’, Archives, xxvi, 105 (2001): 141. Few historians have emphasized this considerable and significant challenge for poor-law medicine in Wales. King and Stewart, ‘The history of the poor law in Wales’: 138. Also see: Crowther, ‘Paupers or patients?’: 42. Several Welsh unions had districts of over 30,000 acres – twice the English legal limit for a district. For examples, see TNA: MH9/1 Abergavenny Union: 21; MH9/1 Aberystwith Union: 41; MH9/3 Brecknock Union: 313; MH9/7 Gower Union: 707; MH9/10 Llandovery Union: 547; MH9/10 Llanrust Union: 607; MH9/12 Nerberth Union: 27; MH9/14 Ruthin Union: 493. King and Stewart, ‘The history of the poor law in Wales’: 144. J. Lane, ‘A provincial surgeon and his obstetric practice: Thomas W. Jones of HenleyIn-Arden, 1764–1846’, Medical History, 31 (1987): 334. ‘Narberth union’, BMJ, 15 April 1871: 408. Llangefni Archives: WG3 46a Bangor and Beaumaris Union Board of Guardians, Minute Book 1895–7: 258. TNA MH12/ 15724 Brecknock Union 1876. I. Loudon, ‘Doctors and their transport, 1750–1914’, Medical History, 45 (2001): 186–7. Loudon, ‘Doctors and their transport, 1750–1914’: 192. The words of W.J. Gordon, an 1890s’ ‘expert on horses’, from: Loudon, ‘Doctors and their transport, 1750–1914’: 192. Loudon, ‘Doctors and their transport, 1750–1914’: 196. Loudon, ‘Doctors and their transport, 1750–1914’: 198–206. Lumley, Manuals (1871): 44. Walsh, Vade-Mecum: 35. Walsh, Vade-Mecum: 35. Walsh, Vade-Mecum: 35–6.

Notes

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Chapter 8 1

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

18

19 20

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Other Victorians, such as Hart, saw public opinion as the only way to enforce reforms to poor law medicine. ‘The workhouse infirmary at Bath’, in: Hart, The Sick Poor in Workhouses: 39. For the Victorian free market, see Harling, ‘The powers of the Victorian State’: 25–50; Parry, The Rise and Fall of Liberal Government: 167–78. For a discussion of overstocked profession, see Loudon, Medical Care: 77. Crowther, The Workhouse System: 165 and 169. Crowther, The Workhouse System: 157. C.H. [Charles Holmes], Sick Paupers and Their Medical Attendants: 3. Smith, ‘The development of ethical guidance’: 56–67. Webb and Webb, The State and the Doctor: 9–10. Preston-Thomas, Government Inspector: 49–50. Webb and Webb, The State and the Doctor: 9–10. Rogers, ‘A paper on the relation between boards of guardians and their medical officers’. Hurren, ‘Poor law versus public health’: 403. ‘The case of Charlotte Hammond’: 10. Walsh, Vade-Mecum: 36. Hart, The Sick Poor in Workhouses: viii. ‘The terrors of pauperism’: 703; ‘General inspectors of the local government board’: 939. ‘Rights’ – specifically, how this interplays with pauper patients – remains a controversy at the hub of the history (and law) of the poor law medical services. See Charlesworth, Welfare’s Forgotten Past: passim; for an introductory counterpoint to Charlesworth’s claims on Black Letter pauper rights, see the review of Welfare’s Forgotten Past, in: King, Rural History: 271–8. Pauper narratives remain central to this endeavour. See King and Tomkins, The Poor in England: passim; King, ‘Stop this overwhelming torment of destiny’: 228–60; Steven King, ‘Regional patterns in the experiences and treatment of the sick poor, 1800–40: rights, obligations and duties in the rhetoric of paupers’, Family and Community History 10 (2007): 61–75; Sokoll, Essex Pauper Letters, 1731–1837; Sokoll, ‘Writing for relief ’: 91–112. King, ‘Regional patterns’: 63. For example, see TNA MH 12/13388 1877–79 Coventry Union Correspondence: 1879, official inquiry into the charges against Mr Thomas Millerchip, district medical officer. I. Burney, Bodies of Evidence: Medicine and the Politics of the English Inquest 1830–1926 (Baltimore, MD: Johns Hopkins University, 2000): 6; P. Fisher, An Object of Ambition? The Office and Role of the Coroner in Two Midland Counties, 1751–1888 (Leicester : Friends of the Centre for English Local History, 2003): 26–37. For an indication of the deep social division surrounding cuts to the disabled and vulnerable in the UK, see P. Gamble, ‘Disabled people are worst affected by bedroom tax and welfare reforms’, Guardian 11 December 2013: http://www.theguardian. com/housing-network/2013/dec/11/disabled-people-bedroom-tax-welfare-reformsaffected [accessed 29 April 2014]; Disabled People Against Cuts: http://dpac.uk.net/

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Index able-bodied 8, 9–12, 51, 54, 61, 66, 92, 108, 113–14, 123, 128, 137, 142 active failures 16, 116, 120–1, 148, 153 active neglect 21, 25, 35, 127, 139, 151–7, 160, 175–6, 181–5 adverse event 5, 25 Anatomy Act (1832) 27 Andover Union 14, 47, 49–50, 53, 55–8, 62, 98, 141 apothecary 26, 28, 30, 171 assistant commissioners 49, 53, 55, 57, 73 assistant inspectors 75, 81, 110 Association for the Improvement of London Workhouse Infirmaries 64–7 asylums 13, 35, 109, 127 attendance 11–14 cause of negligence 16, 24, 29, 36–7, 88–92, 107, 135, 147–73, 177–80 orders 88–9, 105–7, 135, 156–7, 160–7 rules 90–1, 152, 156–8 bacteriology 22, 71 barber surgeons 23 Bastille symbolism of workhouse 8, 53 Bazelgette, Joseph 25 Beaton, Matilda 65, 134 bedside manner 23 Bentham, Jeremy 8 Berkshire 81, 113 Better Care Fund 184 Bircham, Thomas 76, 81, 113 Bishop Stortford 130, 137 Blackstone, William 1 Bolam 2, 4 versus Friern Hospital 2 precedent 2, 183 test 3–4 bone crushing 55 bookkeeping 91–2, 97, 148 Booth, William 52

Brady’s (Medical Officers’ Superannuation) Bill (1870) 70 breach of duty 1, 3, 24, 28, 86, 91, 155 British Medical Association (BMA) 26–32, 58, 67–9, 75 British Medical Journal (BMJ) 26–33, 58, 60, 67, 71, 110, 118, 128, 130–3, 136 British Medical Journal Reports on the Nursing and Administration of Provincial Workhouse Infirmaries (1894–7) 135–8 Buckinghamshire 81, 113 Burial Acts 27 cadavers 22, 109 Cane, Richard 76, 78, 80–1, 111, 113 care in the community 13, 117, 140, 143 cattle plague 44 Chadwick, Edwin 8, 23, 53–4 charity 13–15, 66, 103–11, 118–24, 140 Charity Organisation Society (COS) 13–15, 108–24 Cheshire 34, 80 childbirth 157–62, 179 see also confinement; obstetrics civil law 1, 86 claiming poor relief 16, 70, 98, 103, 108–9, 116, 142, 152–6, 162, 179 clinical negligence 25, 46, 96 common law 1, 87 competition in medicine 29, 35–43, 93, 176 complaints against the medical profession 6, 16, 21–4, 46, 87, 95–8, 140, 155, 166, 173–6, 182–5 confidentiality 28 confinement 162, 166 Conservatives 65–6 Consolidated Orders (1855, 1857 and 1859) 28 Convention of Poor Law Medical Officers 31–3, 58

Index Cornwall 82 coroners 53, 95, 138–9, 144, 146, 164, 168, 183 courts, English 3, 4, 23, 28, 87, 95, 164, 183 crusade against outdoor relief 101–73 care in the community 143–5 negligence 13–15, 105–59 policy 12–14, 103–14 popularity 104–6 strategy 13, 108–22, 124–7 timing 103–4 workhouse standards of care 122, 124–39 Cumberland 81 Daly, Timothy 58, 64 Dansey, Richard 76, 81, 113 Davy, James 76, 81, 113 defence associations (medical) 5, 95 Derby-Disraeli government 65 Derbyshire 81 deserving paupers 9, 25, 52, 64, 103–9, 116–17, 123, 140 Devon 82 Dickens, Charles 64, 156 diet and nutrition 25, 56, 90–1, 115, 123, 143, 157 disability 11, 22, 45, 61, 126, 140–4, 146–9 disease 11, 22, 26, 44, 52, 60–1, 66–8, 77, 115–18, 140, 146, 156, 162 dispauperization 12, 159, 179 dissection 22 district medicine attendance 12–13, 118, 163 medical officers 11, 16, 90, 96, 154–6, 165 population and demography 44, 59–60, 66, 165–7 sizes 34–6, 68, 72, 78–83, 112, 117, 167–72 doctors, see general practitioners; medical profession Dorset 81, 113 Downes, Arthur 15, 78, 93, 128, 137 Doyle, Andrew 76, 105, 113 East End Unions 59, 66, 116 economy of makeshifts 13, 117, 142

229

engineering 25, 41, 139 epileptics 13, 137–8 error 6, 25, 120, 152–3, 185–6 Etwall, Ralph 56 eugenics 52, 182 exodus of vulnerable cases into workhouses during the crusade 14, 122, 124–7 familial care of vulnerable 13, 60, 123, 140, 143–50, 180, 182 Fleming, Baldwyn 76, 80–1, 98, 111, 113, 139, 147 Francis QC, Robert 184–5 Francis Report (2013) 184–6 free market 37, 41, 66, 176 free trade 14, 41, 45, 148 Friern Hospital 2 see also Bolam fringe medicine 27–8, 97, 171 funding cuts 13, 15, 38, 83, 104–6, 141, 159, 178–9, 184 medical officers’ salaries 33–47, 66–72, 85, 91–3, 106–8 poor law medical services 10–14, 21, 45, 67, 75–81, 83, 103, 110–114, 125, 153, 159 poor law medicaments 23–4, 33–7, 42–3, 65–6, 91–3, 107, 114–22, 157, 159, 167, 175 poor law relief 12, 55, 66, 103–22 General Consolidated Order (1847) 28–30, 43, 86, 90, 98, 125, 159, 161, 165 General Medical Council 28, 159, 168, 177 general practitioners 23–7, 30, 36–7, 42, 71, 89, 164, 170, 172 see also medical officers; medical practitioners Georgian governance 8 germ theory 44 Gibson, Richard 58–9 Gilbert’s Act (1782) 8 Goschen, George 12, 108–10, 123, 178 Goschen Minute 12, 108 government 8–9, 45, 65–6, 106, 178–9, 184 mediating local governance 9, 11, 45, 85

230

Index

Graham, James 57 Griffin, Richard 29, 32–4, 37, 39, 41–6, 51, 59, 61, 63 guardians as employers of medical officers 8–12, 24, 32–3, 41–7, 53, 61–2, 84–94, 101–2, 113–22, 128, 141–2, 155–9, 176–9 tendering for medical officers 28–30 Hammond, Charlotte 102, 115–17, 179 Hampshire 81, 113, 138, 141, 148 Hardy, Gathorne 65–6 Hardy’s Bill 61, 65 Hart, Ernest 26–7, 51–67, 69, 75, 77, 125 on nursing 128, 136–8, 181 Hastings, Charles 26, 27, 29 hazard theory 16, 72, 152–3, 176 Herefordshire 170 heroic medicine 22 Hibbert, J.T. 111 Hinton, Alice 135–6, 181 Hippocratic Oath 23 Hodgkin, Thomas 31 Holmes, Charles 148, 168–9, 177 Holmes, Oliver Wendall 22 homeopathic medicine 160 hospitals 10, 33, 51, 54, 59, 66, 87, 113, 124–6, 133, 180, 184 see also infirmaries; State hospitals House of Commons 51, 57, 77, 123, 156 House of Lords 75 idleness 7–9, 15, 106, 118, 123 incorporations 8 indoor relief 7, 55, 119, 141 infirmaries 10–15, 50–1, 60–6, 92, 119–38, 169, 170, 178–81 infirmary medical interns 66 inspectors assistant commissioners 49, 53, 57, 73 Local Government Board (LGB) 11–13, 74–84, 94–9, 108–22, 139–43, 152–9 Poor Law Board 9–12, 15, 24, 43, 62–4, 68–76 insubordination 96, 113, 119 insurance health and medical 87, 106, 183 liability 5

Ireland 30, 68–9 Isle of Wight 81, 123, 138–49, 153, 168, 176, 180 ‘jumper’ 136, 138 Justice of the Peace 10, 32, 163 Kent 80, 81, 113 Klein, Rudolf 5, 45, 97 Koch, Robert 22 labourers’ revolts 55 laissez faire 9, 73 Lancashire 36–7, 80–3 Lancaster 34 Lancet 12, 14, 26–7, 31, 46, 50–2, 55, 58, 60 Lancet Commission to Inquire into the State of Workhouse Hospitals (1865–6) 12, 55, 58–66, 136, 156, 176 latent failures 5, 12, 15, 21, 35, 98, 103–22, 127, 138, 148, 151–73, 175, 181 law administrative 5–8, 25, 53, 84–99, 114–22, 182–6 compensation 3–5, 24, 88, 140, 163–5, 185 contract 1–5, 11, 14–16, 23, 28, 33, 43, 86–97, 120, 129, 177, 183 England 1–3, 87 France 86–7 Germany 1 liability 1, 5, 42, 87, 107 libel 4–5, 71 North America 4, 23, 86, 88 patients 1–16, 28, 86–93, 147–9, 176–8, 182–6 tort 1–5, 23, 86, 87, 177, 183 lay power 2, 4, 11, 23, 25, 31, 98, 115, 119, 140, 144, 161, 183 legal culpability of medical officers 21, 24, 124, 148, 175 legal medicine 2, 3, 6, 16, 86, 88, 182 less eligibility 8, 143, 157 Liberals 45, 65, 69, 81, 106, 107, 115 Lincolnshire 81 litigation UK 3–6, 183–6 USA 4, 23, 86

Index local government 9, 13, 69, 73, 85, 98, 178 Local Government Board (LGB) 9–15, 69–78, 83–8, 95–8, 104–26, 137–9, 141, 152–65, 177–8, 182 London 11, 14–15, 25–6, 34–5, 38–9, 47–50, 58–67, 78, 111, 128, 153 London, Jack 51–2 Longe, F.D. 76, 80, 111, 113 Longley, Henry 12–13, 109–11, 114, 118, 157 see also Longley Strategy Longley Strategy 12–13, 106–22 Lord, C.F.J. 31–2 Lumley, William Golden 23, 35, 84 Lunacy Commissioners 127, 143, 149 lunacy laws 16, 140, 144 malingering tests 42, 118–19, 128 manslaughter 5, 87, 183 McDougal, Colin 56–7, 63 McKeown, Thomas 25 Medical Act (1858) 11, 26, 27, 29, 42, 86 medical authority 34, 67–8, 73–7, 84–5, 127–8, 151 medical clubs 30, 35, 106 medical colleges 30, 117, 159–60, 168 medical conditions 11, 16, 44–5, 103, 118 cholera 22, 52, 59, 61 chronic illness 30, 45, 51, 60, 92, 126–8, 140, 172, 181, 184 confinement 162, 166 (see also obstetrics) epilepsy 13, 137–8 fever 22, 58–60, 162 idiocy 51, 126–7, 138–49 imbecility 63, 126–7, 130, 135, 138, 144, 146 learning disorders 13, 16, 124–8, 138 lunacy 16, 127, 140, 143–4 puerperal fever 22 sepsis 22 typhus fever 58–9 Medical Defence Union (MDU) 5 medical expertise 3, 11, 15, 77–8, 141, 179 medical extras 42, 110, 114–15, 118, 152, 157–9, 179–80 medical harm 1, 3, 22–3, 71, 185–6

231

medical officers assistants 29, 36, 148, 167–73, 175–7, 181 conduct 4, 22–5, 63, 91, 96, 116, 154, 165 conflict of interest 12, 43, 154, 177 disciplinary regulations 6, 14, 28, 45–6, 71–2, 84–99 divided time 11–13, 33–5, 41–7, 152–73 drug supply 33–41 (see also medical treatments) duties 12, 21, 24–30, 35, 42, 54, 64–70, 78, 84–93, 96, 120, 148, 151–73, 177, 181 resignations 24, 46, 63, 69, 71, 94–9, 116, 119–21, 155, 161 rules of employment 39, 84–94, 120, 149, 151–73, 177 scapegoats 5, 11, 15, 23, 25, 58, 117, 153, 176, 181, 183, 185 substitutes 96, 147, 168, 169, 172 Medical Officers of Health 67–9 Medical Officers’ Superannuation Act (1870) 70–1, 121 Medical Order (1842) 11, 28, 86, 159 medical press 33, 53, 60, 64 see also British Medical Journal; Lancet medical profession 2, 14, 15, 21–30, 31, 35–42, 44, 59, 140, 144, 178 duties 92, 116, 120, 134, 140, 147–9, 151, 155, 171, 177, 185 ethics 84–90 status 21–3, 26, 31, 36, 54, 66, 75–8, 84–6, 89, 169 see also British Medical Association; professionalization medical profession and the law 2–4, 15, 86–9, 184, 186 Medical Register 27–8, 59 Medical Relief (Disqualification and Removal) Act (1885) 87, 182 medical students 27, 66, 146, 169 medical trade 23–4, 28, 38, 41, 85 medical treatments 3, 11, 16, 22, 27, 34, 42, 60, 72, 85, 89–90, 93, 107–10, 119, 123, 132, 158–73, 178 amputation 22, 158, 160 bleeding 22

232

Index

bone-setting 27, 171 cod-liver oil 33, 117, 168 leeches 22, 23 poultices 33, 119 purging 22 quinine 33, 117, 156, 168 sarsaparilla 33 mental health 2, 13, 16, 30, 37, 54, 61, 124, 127, 138, 140–4, 149 incurables 30, 53–4, 106, 109, 126–7 Metropolitan Poor Act (1867) 12, 47, 60–7, 75, 80, 107, 153, 175 miasma 22, 71 Middlesex 81, 113 Midlands 80, 83 Mid-Staffordshire Foundation Trust 184 midwifery 61, 107, 114, 130, 154, 158, 162, 168 see also obstetrics model unions 13, 106, 110 Monmouthshire 80 Mouat, Frederick 78, 139 Mundy, Hugh 56 Murray Browne, L.T. 76, 81 National Federation of Employers of Labour 119 National Health Service (NHS) dissatisfaction 5–6, 12, 23, 84–5, 178, 184–6 see also negligence National Insurance Act (1911) 87, 183 neglect of duty 24, 36, 46, 72, 89, 91 negligence in the courts 2–6, 23, 25, 28, 32, 36, 87, 95–6, 127, 183 framed within the poor law 1–20, 73–102 local resolution 6, 152–9, 177, 181 mishap 24–5, 70, 83, 92, 120 rules 84–99, 151–74 nepotism in medical practice 29, 71, 92 New Liberalism 45, 69 new poor law background 6–16, 22–3, 30, 42, 45–7, 51–4, 73–8, 106–9, 186 Nightingale, Florence 58, 64–5, 134–5 North America 4, 23, 86, 88 Northamptonshire 113 north-east England 82

northern England 80, 82, 129 north-west England 33, 34, 82–3, 129 Nottinghamshire 34, 81, 119, 133 nursing nocturnal hours 127, 136–7 probationers 124, 128–9, 131–2, 134–5, 137, 169 professional 11, 62, 124–9, 134–5, 137, 146, 181 untrained 124, 132, 136, 138, 147, 169 Nursing Circular (1892) 128 Nursing in Workhouses Order (1897) 137, 181 obstetrics 22, 159–62 great difficulty 158, 161–2, 180 official inquiries 11–16, 74–84, 94–7, 109–10, 118, 143, 153, 169, 175–83 procedure 6, 15, 23, 36, 43, 78, 81, 84, 88, 95–8, 141–7 witnesses 96, 134, 136, 143, 146, 176, 181 old poor law 8–11, 86 orders for medical officers’ attendance 12, 13, 16, 24, 33, 89, 103, 107, 114, 135, 149, 157–6, 178, 180 orthodox medicine 26–8 outdoor relief 7, 9, 12–13, 54, 81, 101–22, 151–74, 178–80, 184 see also crusade against outdoor relief Outdoor Relief Prohibitory Order (1844) 108 overseers of the poor 4, 7, 162–7 Oxfordshire 81, 113 Parker, Henry 57 Parliamentary Select Committee on poor law medical relief (1844) 33 Parliamentary Select Committee on poor law medical relief (1854) 32–3 Parliamentary Select Committee on poor law medical relief (1861–4) 32–5, 41, 44 patients complaints 6, 16, 21, 24, 46, 59, 87, 95–8, 139–40, 155, 164, 166, 175–6, 182–3, 185 dissatisfaction 5–6, 121, 185 poor law 12, 16, 37, 87, 127, 152, 168, 170 rights 2, 88, 177–8, 182–3

Index safety 3, 6, 11, 119–20, 124–38, 143–9, 152–5, 185 workhouses 124–7, 135–49 pauperism, managing of 6, 9–12, 42–5, 74, 77, 82–7, 107–22, 123–7, 155–60, 177–81 pauper nurses 62, 65, 83, 124–38, 148, 177, 181 see also nursing pauper rights 6, 16, 87–8, 140, 177–83 pavilion workhouses 125–6 permanent officials of poor law 9, 15, 43, 73–84, 98, 103, 110, 137, 153, 162, 178 permanent relief lists 10, 16, 164, 167 pharmaceuticals 23, 167 physicians 1, 4, 22–3, 26, 30, 66, 89, 160 poor law bureaucracy 73, 75, 81, 84, 152, 161, 185 centralization 9, 12, 14, 43, 69, 73 conferences 13, 75, 105, 111, 113, 115, 141, 175 contracts 5, 6, 11, 14, 23, 28–47, 50, 86–99, 120, 129, 134–5, 136, 151–73, 177 dispensaries 7, 29, 66–9, 72, 94, 104, 124, 167 emergencies 16, 36, 44, 90, 107, 126, 135, 151–73, 179, 185 fees for medical services 13, 41–7, 88–90, 92, 107, 151–73, 177, 180 medical inspectors 67, 73, 75–8, 84 officers 10–12 paper tiger 11–12 policy 9–14, 35–47, 73–99, 103–21, 124–38, 151, 156, 179–86 presidents 12, 33, 41, 44, 58, 62–3, 65, 69, 73, 77, 108, 110, 123 Poor Law Amendment Act (1834) 7, 8, 10, 23, 51, 53, 55, 86, 95, 108 Poor Law Board 9–15, 23, 28–33, 43, 57–8, 63–73, 77, 89, 95, 108, 152, 159 Poor Law Board Act (1847) 95 Poor Law Commissioners 8–10, 14, 23, 47, 49–58, 156, 170, 176 Poor Law Medical Officers’ Association 34, 63, 110, 117–18, 160 Poor Law Medical Reform Association 32–5, 61, 63

233

poor law officers 86, 115, 160 masters 39, 46, 54, 56, 63, 90–2, 115, 131, 134–5, 139, 155, 157, 160, 162 matrons 39, 90–2, 131, 134–5, 137, 160, 162 nurses see nursing; pauper nurses porters 39, 156 relieving officers 9, 15, 46, 54, 102, 109, 111, 115–17, 120, 143, 151, 155–67, 179–80 see also medical officers poor law unions formation 7–14 individual Alton 141 Alverstoke 141 Andover 14, 47, 49–50, 55–8, 62, 98, 141 Atcham 111, 170 Bangor and Beaumaris 171 Barton Upon Irwell 92 Bath 129, 130, 137, 185 Bedford 133, 134 Birmingham 119, 124, 169 Bolton 83 Brecknock 170–1 Bridgnorth 161–2 Brixworth 105, 113, 118–19 Bromsgrove 53 Camberwell 63 Cambridge 113, 117, 119 Cheltenham 156–7 Chipping Norton 148 Chorlton 63 Clerkenwell 51 Falmouth 125, 131 Halifax 124 Havant 141 Holborn 58 Ipswich 54–5 Isle of Wight 81, 123, 138–49, 153, 168, 176, 180 Knaresborough 134 Lambeth 27, 116 Leeds 29 Leicester 129 Leighton Buzzard 46, 113 Liverpool 124, 133–4 Llanelly 111

234

Index

Lutterworth 113, 126, 137 Maldon 165, 166 Manchester 124 Mile End 129 Narberth 170, 171 New Forest 141 Newport 164 Newport Pagnell 113 Newton Abbott 82, 135–8, 176, 181 North Aylesford 113, 119 Oldham 125, 127, 132, 135 Penistone 24, 168 Petworth 154–5, 167 Poplar 116 Potterspury 113 Ringwood 141 Rotherhithe 65 Sheffield 24 Shoreditch 51, 116 Skipton 29 Southampton 141 Stepney 116 Stow-on-the-Wold 118, 170 St. George 59 St. George’s, Hanover Square 101–2, 115–17 St. Marylebone 116 St. Pancras 63 Strand 60–5, 97, 117, 160 Stratford-on-Avon 162 Thetford 91, 131 West Derby 119 Weymouth 32, 34 Whitechapel 116 Withington 129, 131 Woodstock 113 inspections 11, 68, 74–5, 127, 178 pathological organizations 153–4, 186 regionalism 10, 13, 51, 72, 74, 78–84, 111 poor rate 7, 163 Preston-Thomas, Herbert 67, 76, 82, 139, 178 private medical practice 1, 3, 11–12, 21, 22–5, 27, 29, 35–47, 61, 65, 71, 121, 154–5, 165–72, 176–80

professionalization medical profession 2, 14, 25–31 poor law medical officers 22, 31–5, 49–54, 67–72 professions 25, 38, 41–2 Provincial Medical and Surgical Association 26, 31 see also British Medical Association Public Health Act (1872) 25, 67 Public Health Act (1875) 25, 67 public health, subordination to the poor law 11, 67–70, 73–4, 178 quack medicine 26, 27, 85 qualifications, medical 27–30, 68, 87, 89, 129 Radnorshire 80 railway accidents 4 means of travel 82 Reason, James 104–5, 120, 152–5, 186 recession 12, 61, 104, 140, 176, 184 Reform Act (1867) 107 Representation of the People Act (the Reform Act) (1832) 25 residency loophole 28–9, 66, 171 right to relief 54, 60, 87, 106, 182 Rogers, Joseph defending medical officers 95–6, 117–19, 139 emoluments 43–4, 70, 103, 117 guardians 61–2, 70 leader of medical officers 33–5, 44, 46, 49, 61, 63–72, 175–8 managing childbirth 160–1 orders 160–1 standards of care 35, 37, 49, 52, 54, 60, 125 Royal Commission into the Operation of the Poor Laws (1832) 7, 54, 160 salaries inspectors 110–11 medical officers 31–47, 159–60, 176–7 nurses 127–35 Sanitary Act (1866) 107

Index sanitary measures 25, 52, 63, 67–9, 77, 123, 180 scandal 14, 16, 43, 46–7, 49–63, 83, 93, 98, 120, 127, 135–49 science 22, 27, 32, 71, 85 settlement laws 44 Simon, John 69, 73, 77–8 Smith, Edward 62, 64, 75 Snow, John 22 Somerset 82, 113 Staffordshire 170 standards of care 6–7, 13–14, 35, 37, 42, 50–1, 67, 75, 83, 93, 95, 104, 107, 122–5, 143, 152, 175–9, 181, 185 State doctors 10, 15, 33, 46, 124, 142 State hospitals 10, 15, 46, 124, 142 stigma of pauperism 52, 60, 141, 178, 183 sudden and urgent cases 151, 156, 162–5, 180 see also poor law, emergencies superannuation 37, 43, 70–2, 121 Superannuation (Union Officers’) Act (1864) 70 Surgeons 26, 89, 160, 168 Surrey 81, 113 Sussex 81, 113 Swiss Cheese Model 120 systemic faults 11, 15, 140, 148, 151, 176, 182, 184–6 The Times 49–50, 55–8, 64, 111 transport for medical officers 171–2 Treasury 15, 153, 176 Trevelyan, Charles 109, 118 Trollope, John 41 Twining, Louise 64, 135 undeserving paupers 9, 52, 108–9, 116–17, 123, 141 Union Chargeability Act (1865) 107, 121

235

Villiers, Charles 33, 62, 64–5 violation 25, 56, 95, 153 vulnerable patient groups 13–14, 16, 104, 122–4, 138, 148, 184–5 see also disability Wakley, James 58–9 Wakley, Thomas 26–8, 53, 56–8, 156–7 Wales 1, 5, 30, 37, 80–2, 111, 113, 170–3, 179 Walter, John 56–8 Warwickshire 113 Webb, Beatrice and Sidney 103, 110, 126, 178 Welfare State 6, 184 Westmorland 81 Weymouth 32, 34 widows 103, 123, 142 Wiltshire 81, 113 Worcester 26 Workhouse Infirmary Nursing Association 129, 134 workhouses medical officers 11–12, 15, 29, 37–40, 45–6, 58–67, 71, 90–5, 97, 112, 117, 121, 126, 134, 140–3, 157, 160, 162, 171 neglect of patients 123–49 nurses 127–38 overcrowding 61–3, 120, 126, 127 purpose 7–14, 53–6, 65, 75, 105, 108, 109, 115, 119–20, 180 staff 39, 137, 146, 148 standards of care 10 see also masters and matrons; nursing; pauper nurses workhouse test 9, 53, 55, 105, 109, 113, 116, 119, 180 Yorkshire West Riding 80, 81