Notes from The Workhouse System, 1834-1929

For many of the sick poor, the alternative to treatment in a voluntary hospital such as Dorset County Hospital was the workhouse infirmary.  The following extracts from The Workhouse System, 1834-1929: the History of an English Social Institution, by M. A. Crowther (Methuen, 1983) highlight some of the differences and similiarities between workhouse infirmaries and voluntary hospitals, for both staff and patients.

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Chapter 7: The Medical Staff and the Infirmaries

1834-1867

Page 157

Nearly all [workhouse doctors] combined workhouse duties with private practice. In the voluntary hospitals, consultants were unpaid, but undertook the work for its prestige, its contact with wealthy patrons, and the fees from teaching. The workhouse doctor had to accept an underpaid Poor Law post because his private practice did not support him adequately, or because he wished to keep other doctors out of his territory.  A workhouse doctor did not expect his work to increase his prestige, rather the reverse.

Page 158

Although after 1842 [Poor Law] medical appointments were no longer offered for tender, guardians could exploit the weaknesses of local doctors. The medical profession was highly competitive, and guardians knew that weak or possessive local practitioners would often accept Poor Law work at uneconomic salaries.  At a time when patronage was still important in building up a practice, the doctor may also have hoped that his contacts with the guardians would bring him private practice – though it was also argued that the gentry would not wish to employ the ‘parish doctor’.

Page 160

The workhouse doctor was not paid extra for operations, for the [Poor Law] Commissioners argued that he ought to send surgical cases to a voluntary hospital if possible.

Pages 162-63

[Workhouse] infirmaries could not be used for medical education or research. To the doctors, this was the ultimate proof of inferior status, since much of the prestige of the voluntary hospitals came from their work in these fields.  Medical students were admitted into the infirmaries in 1867, but banished again in 1869.  Here the [Poor Law] Board simply bowed to public fears. The peculiar dependency of sick paupers would make them vulnerable to medical experiments if they were not protected. The pauper was thus free from becoming a subject for clinical investigation, while the patient in the voluntary hospital had to submit as part of his free treatment. A regulation which the doctors saw as an insult seemed to laymen a necessary safeguard.

The policy of the same voluntary hospitals added to the Poor Law doctor’s burdens, for most voluntary hospitals excluded chronic cases, and also infectious and venereal cases. Hence the doctor in even the best workhouse infirmary would feel aggrieved, for not only was he subject to the dictates of laymen, but he received the least amenable patients, who could not be denied admission to the workhouse.

Page 165

The profession of nursing hardly existed, and commanded little social respect before the days of Florence Nightingale. The voluntary hospitals had similar problems, but some of them did at least employ literate and reasonably orderly women.

Page 166

The Poor Law Commissioners had not foreseen the great expansion of hospitals, and had recommended that the sick poor be given outdoor relief as far as possible. All they required of workhouse nurses was sobriety, and, on afterthought, enough literacy to read the doctor’s instructions. The rapid developments in the voluntary hospitals brought workhouse nursing into disrepute, particularly in the 1860s, when professional nursing began to expand. … It was useless to argue, as the Manchester guardians did, that the standards of care were better than the poor could afford in their own homes, for the standards had to follow the voluntary hospitals.

1867-1914

Page 167

The gap between the physical conditions in infirmaries and the homes of the poor widened rapidly, especially in towns, but the gap between the infirmaries and the voluntary hospitals widened yet more. This must be set against a background of rapid expansion in hospital provision. In 1861, voluntary hospitals had provided only 18.51 per cent of the hospital beds in England and Wales: but by 1911 they provided 21.89 per cent, while local authorities independent of the Poor Law provided another 16.7 per cent. Although the responsibility of the Poor Law authorities was therefore declining proportionately, in numerical terms it continued to expand. In 1861 workhouses provided about 50,000 beds for the sick; in 1911, 121,161.34

At the same time there was both an administrative and a medical revolution in the voluntary hospitals. The advent of trained nurses encouraged order and hygiene. The gradual diffusion of antiseptic techniques made safer the operations which anaesthetics had previously made painless. Finally, from the 1880s onwards, bacteriology conquered the medical profession, and precipitated a rush to discover the micro-organisms of specific diseases. All this added to the prestige of a profession which was already claiming respect on account of its superior education and ethical standards. The Poor Law doctors shared in the new esteem for their profession, but remained at the bottom of its hierarchy.

Page 174

Sneers about the youthfulness of resident medical officers were common [but] in fact the medical superintendent of the large [workhouse] infirmaries was usually an experienced man: of the 24 London superintendents listed in the Medical Directory for 1905, only two had been qualified less than 10 years, and only three for more than 30. The 30 assistant medical officers whose qualifications were listed were indeed young men: 20 of them had been qualified less than five years. This was of course similar to the practice in the voluntary hospitals, where the residents were usually young men waiting for promotion. The young residents in Poor Law hospitals, however, did not benefit from the regular visits of consultants, and their responsibilities were correspondingly heavy.

Pages 174-75

[R]ecords of individual unions show that a dangerous amount of inefficiency could produce an official caution rather than dismissal. In Bromley, for example, a child died in 1911 because the overworked infirmary doctor had forgotten that it needed an operation. The guardians … expected him to run a large infirmary single-handed, with a grossly inadequate team of nurses, and their own regulations required him to keep detailed records of the ‘extras’ he ordered, not case-papers of his patients. The doctor was in charge of an infirmary with 300 infirm and chronic patients in residence every week. In a six-month period before the war, he assisted at 22 operations, delivered 21 babies, officiated at 49 deaths, and had to supervise 37 lunatics and 31 imbeciles. He had little time for paperwork, nor was it surprising that he took little interest in therapeutic occupations for the aged and infirm.

Page 175

The workhouse doctors lacked supervision, unlike the residents in the voluntary hospitals. Neither the guardians nor the lay Inspectors could judge their medical competence, and the central authority could not intervene unless guardians complained.

In the nursing service, relations between laymen and professionals were even more strained. Guardians accepted the need for trained doctors, but were less convinced of the need for trained nurses. Nursing was a new profession: it had been proved on the battlefields and in the voluntary hospitals, but guardians often argued that the type of patient usually found in workhouses did not need specialized attention.

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