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Kevin Siena argues that medical historians have been slow to explore workhouses prior to the NPL and, as a result, they have not been integrated into the history of eighteenth-century institutional medicine.8 Jeremy Boulton and Leonard Schwarz affirm that medical services provided by the parish workhouse under the Old Poor Law have been neglected within the study of institutional provision, despite delivering increasing amounts of medical care in the later part of the eighteenth century.9 As a result, the traditional view that by the early nineteenth century there existed only a rudimentary medical service for the poor has prevailed. The relative neglect of poor law medicine by both medical and welfare historians continued into the nineteenth century and, according to Steven King, has meant that ‘an understanding of the exact medical role of the workhouse remains elusive’.10 Outdoor medical relief has received more attention than workhouse medicine since it played a larger part in the relief of the sick poor, partially due to the attempts by sick paupers to obtain alternative sources of support in order to avoid care in the workhouse. Furthermore, the majority of studies of the NPL institutional medical service have approached it as a vehicle for the development of state medicine and the rise of the National Health Service. Thus, further studies, utilising the available archival material, continue to be required. As John Stewart and King have pointed out: ‘cumulative surveys of the historiography of the NPL have raised many questions about the operation and impact of poor law policy and emphasized just how much remains to be done in an empirical K. Siena, ‘Contagion, Exclusion and the Unique Medical World of the Eighteenth-Century Workhouse’, in Reinarz and Schwarz (eds), Medicine and the Workhouse, p.19.

J. Boulton and L. Schwarz, ‘The Medicalisation of a Parish Workhouse in Georgian Westminster: St Martin in the Fields, 1725-1824’, Family & Community History, 17 (2014), pp.122, 130.

King, ‘Poverty, Medicine’, p.230.

sense on the voluminous local and national archives.’11 Moreover, research carried out in different geographical localities can lead to a greater understanding of the complexity of arrangements that grew up after the NPL.

This study will elucidate the character, scope and scale of medicine practised in the workhouse. By delineating the range and intensity of diseases suffered by sick inmates, it will bring to the fore a disadvantaged group, previously neglected by medical historians. It will add to the current understanding of NPL institutional medical care in a number of ways. Although the metropolis has dominated local and regional studies of workhouses and their infirmaries, provincial studies have managed to cover most geographical areas of England. The one major exception has been the urban west midlands, in which the workhouses of Birmingham and Wolverhampton are situated. The research into these two workhouses will aid in promoting the place of poor law infirmaries in the history of medical institutions, an under-researched area within medical history. It will highlight inmates with chronic disease and disability, a group that is difficult to identify within the workhouse classification system It will demonstrate how the division between acute and chronic hospitals took place as disabled inmates became to be regarded as not requiring medical care and were not moved from the workhouse into the separate infirmary in Birmingham. The role of workhouses in the control of epidemics and infectious disease has not previously been given prominence in the discourse of isolation institutions. This study will redress this deficiency, as well as highlighting the interrelationship between the poor law guardians and the sanitary and local authorities. By so doing, it will demonstrate the importance of the poor law institutions to the health of the communities they served.

J. Stewart and S. King, ‘Death in Llantrisant: Henry Williams and the New Poor Law in Wales’, Rural History, 15 (2004), p.69.

An understanding of the day-to-day doctoring and nursing within the workhouse infirmary remains unclear and this study will address this issue of the ‘reality of poor law doctoring’.12 In the same manner, it will show what it was like to work as a nurse in the infirmary and that it was not dissimilar to nursing in voluntary hospitals. It will illuminate another unexplored area of medical practice in workhouses, by delineating the wide range of medical treatments that patients received, such as diet, drugs, alcohol and physical therapies, as well as listing the surgical operations that took place in these institutions. The research has unearthed a few letters written by former sick inmates, providing insight into patients’ experiences and their perspective on the treatment they received in the workhouse, material that has not been previously available.13 As a result, a more complex picture of the medical care within the workhouse will emerge. In summary, this chapter will challenge the traditional narrative of workhouse medicine as relevant only to the later development of state medical services and demonstrate that it was an important element of medical care for sick paupers in the nineteenth and early twentieth centuries.

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’ (unpublished PhD thesis, Oxford Brookes University, 2008), pp.2, 326.

A. Tomkins, ‘Workhouse Medical Care from Working-Class Autobiographies, 1750-1834’ in J.

Reinarz and L. Schwarz (eds), Medicine and the Workhouse, pp.99; E. C. Bosworth, ‘Public Healthcare in Nottingham 1750-1911’ (unpublished PhD thesis, University of Nottingham, 1998), p.209; D. R.

Green, Pauper Capital, Farnham, 2010, p.238.

Methodology The historiography of the social history of medicine has been influenced mainly by the introduction of sociological concepts and, more recently, by the cultural turn.14 In promoting the social dimension within the history of medicine, Henry Sigerist wished to see history of medicine move away from the ‘institutions and characters of medicine’ to ‘include the history of the patient in society and of the relations between physician and patient’, as well as the impact of illness and medical institutions on people’s lives. 15 American medical historians were at the forefront in the 1970s of this call to move away from the study of eminent physicians to those who remained unknown and to put patients at the centre of medical history studies. One important landmark in the move to this new social history was the publication in 1979 by Susan Reverby and David Rosner of Health Care in America: Essays in Social History.

They wished to redefine the specialty as the history of health care that would focus on the social relations of medicine. They saw as the instrument of change, the influx of non-medical doctoral students who would engage in social histories of such issues as race, gender, class, politics and demography. The approach they sought was ‘more as a social enterprise than as purely Scientific or celebratory one’.16 This would contrast with, in their view, the dominance of physician-historians and their professional allegiances. As a result, the history of medical institutions, such as hospitals, has moved from being mostly written by the doctors who practised in them, detailing their progress, concentrating mostly on medical staff and rarely putting the account into a This development is covered in F. Huisman and J. H. Warner (eds), Locating Medical History, Baltimore, 2004; J. C. Burnham, What is Medical History?, Cambridge, 2005; M. Jackson (ed.), The Oxford Handbook of the History of Medicine, Oxford, 2011.

Sigerist quoted in C. Webster, ‘Historiography of Medicine’ in P. Corsi and P. Weindling (eds), Information Sources in the History of Science and Medicine, London, 1983, p.39.

S. M. Reverby and D. Rosner, ‘“Beyond the Great Doctors” Revisited’, in Huisman and Warner (eds), Locating Medical History, pp.167-68, 173.

general historical framework. Now, systematic investigations by historians are ensuring that the social structure of the hospital and the position of managers, nurses, therapists and other ancillary staff, as well as patients are all being studied in order to understand the full nature of the institution, as experienced by all those who came into its ambit. Furthermore, institutional histories are made more relevant by setting them in the context of the life of the local community. Reverby and Rosner’s book has been deemed a ‘manifesto of the new social history movement in the history of American medicine’ by later historians.17 Around the same time, Anne Digby and Anne Crowther incorporated this approach into their histories of English workhouses.18 A further impact of the new social history has been the emphasis on the patients’ perspective of the medical care they received and the interaction between patients and

medical practitioners. Historian Mary Fissell describes this development succinctly:

‘By starting with the patient, we arrive at an alternate version of the development of medical institutions and professional authority’.19 The experience of medical care by the ordinary person, which had been ignored previously, was now the focus of research, but, as Digby has stressed, needed ‘considerable interpretation and intervention by the historian to produce a synthesis’ since a patient’s experience could vary over time.20 The work of Roy and Dorothy Porter has pioneered the writing of the history of medicine from the patient’s point of view, emphasising the voice of the F. Huisman and J. H. Warner, ‘Medical Histories’ in Huisman and Warner (eds), Locating Medical History, p.21.

Digby, Pauper Palaces; Crowther, Workhouse System.

Fissell, p.14; her study, Patients, Power and the Poor in Eighteenth-Century Bristol, tracks the social development of health practice from medical marketplace to hospital-based medicine and its effect on the poor of taking away control of their own bodies.

A. Digby, ‘The Patient’s View’, in I. Loudon (ed.), Western Medicine: an illustrated history, Oxford, 1997, p.297.

individual patient.21 However, their studies did not extend to institutional care.

Guenter Risse and John Harley Warner have argued that institutional clinical patient records can reveal more than the course of an illness and its therapy. As surviving artefacts of the interaction between physicians and their patients, they throw light on patients’ perceptions of illness and on their expectations of medical treatment.22 Patients’ views were given an even more prominent place in medical historiography with the introduction of the new cultural history in the late 1980s and 1990s. The influence of the ‘cultural turn’ was to bring into medical history a new approach, which was ‘self-reflective and conversational’ and to allow for different perspectives and insights from other disciplines, particularly anthropology.23 These are based around, as Fissell puts it, ‘the making of meaning - to how people in the past made sense of their lives, the natural world, of social relations, of their bodies’.24 Cultural

history addresses ways in which individuals and groups express themselves and asks:

‘How was it for him or her or them?’.25 It has a predilection for the marginal and attempts to bring in members of social groups whose thoughts had not previously been considered of historical interest. A further benefit of such an approach has been greater consideration of the structure of medical historiography with a return to the narrative text. In the mid-1990s, there was a drift toward the re-introduction into the historical discourse of a social element without returning to the previous conventional social analysis. According to Roger Cooter, this synthesis of ‘the social’ and ‘the A. Wear, ‘Introduction’, in A. Wear (ed.), Medicine in Society, p.4.

G. Risse and J. H. Warner, ‘Reconstructing Clinical Activities: Patient Records in Medical History’, Social History of Medicine, 5 (1992), pp.189-90.

M. Rubin ‘What is Cultural History Now?’ in D. Cannadine (ed.), What is History Now?, Basingstoke, 2002, pp.80-81.

M. Fissell, ‘Making Meaning from the Margins: The New Cultural History of Medicine’ in Huisman and Warner (eds), pp.34-35.

Rubin, p.81.

cultural’ gives the opportunity to ‘revisit old sites’, which had been lost from the social history of medicine, and ‘leaves the territory and the practice of the history of medicine wide open’.26 The cultural turn has also led to an upsurge of focussed local studies and John Pickstone has stressed the additional benefit of comparative local studies in understanding medical dynamics as social history.27 Furthermore, Barry Reay has demonstrated that microhistories can give rise to consideration of more general issues.28 A further influence on medical historiography that took place in the twenty-first century was the exploration of the science in medicine and the subsequent adoption of the ‘practice turn’.29 This deals with the performative aspects of clinical practice as a basis for promoting a greater understanding of how medical knowledge influenced routine patient care.30 This study will be a qualitative and quantitative local micro-study examining and comparing the medical provision and care in the large workhouses in Birmingham and Wolverhampton in the West Midlands, both with rapidly expanding populations R. Cooter, ‘“Framing” the End of the Social History of Medicine’, in Huisman and Warner (eds), p.328.

J. V. Pickstone, ‘Medicine in Industrial Britain: the Uses of Local Studies’, Social History of Medicine, 2 (1989), pp.197-98. One of the earliest local studies was Marland, Medicine and Society in Wakefield and Huddersfield 1780-1870; more recent studies include: Stewart and King, ‘Death in Llantrisant: Henry Williams and the New Poor Law in Wales’; A. N. Bergen, ‘The Blind, the Deaf and the Halt’ (unpublished PhD thesis, University of Leeds, 2004); S. Williams, ‘Caring for the sick poor.

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