Sickness in the Workhouse: Poor Law Medical Care in Provincial England, 1834–1914 by Alistair Ritch (review)

The divide between professional history and professional medicine is not totally impermeable, but the barrier is seldom crossed. Historians retrain as clinicians very rarely: practitioners more often become historians of their institution or field. It is a brave person who seeks expertise in more than one context, so Alistair Ritch is notable for moving from consultant physician in Birmingham to historian of workhouse infirmaries in the wider West Midlands.

This book begins with the contention that workhouse infirmaries inevitably developed in tandem with voluntary hospitals, under different but complementary regimes. The voluntary hospital admitted the curable and exerted a lot of discrimination over the cases they accepted and retained, while workhouses had a statutory responsibility to cater for the poor settled in their areas. This meant that, initially, historians have observed a broad division between the "acute" capacity of a hospital and the "chronic" accommodation offered by a workhouse. Under Ritch's gaze, this difference remains but is substantially complicated.

His remit is the Birmingham and Wolverhampton workhouses, wherever possible incorporating institutions before 1834 as well as after. Chapters consider the "fevers" that preyed on the Victorian poor, and that necessarily afflicted workhouse patients, as drivers of institutional refinements including isolation wards and separate buildings. The disorderly lunatic poor were contained in both of the chosen workhouses despite the rapid expansion of institutional provision for the "mad" in England over the nineteenth century, and both were found wanting by Lunacy Commissioners in the 1850s and later. Ritch goes on to analyze the working lives of workhouse medical officers, to account for patients including their occupancy of different wards, and to consider the integration of trained nurses to these poor law institutions. Collectively the chapters assemble a mass of useful data. Nonetheless, a broad question remains: what was the wider significance of the Birmingham or Wolverhampton workhouse experience for the resident poor in English institutions?

In illustration of this point: venereal disease is covered in chapter 3 about disorderly behavior, and before reading this short section I anticipated that it might touch on the way that tertiary syphilis deprived its victims of both physical and mental control. Instead the subheading covered some of the circumstances whereby workhouse inmates contracted venereal disease (ensuring that here "disorderly" relates to sexual misdemeanor rather than disease victimhood). The section subsequently provided brief historical summaries of the emergence of syphilis and gonorrhea plus their treatments (both per se and in the English Midlands specifically), without pushing the analysis further. The section therefore misses the chance to consider why Birmingham and Wolverhampton offer us interesting illustrations for the application of venereal therapies. Why was Birmingham one of only eight provincial workhouses to make use of the first diagnostic blood test for syphilis? Did this relate to economies of scale in large institutions, or was it the result of a specific policy decision at Birmingham? Was the use of salvarsan for selected Wolverhampton paupers instituted very early in context (in 1912, after the drug's development in 1910), or on the contrary was it applied very meanly (being given only to selected patients)? In short, what can we now appreciate about workhouse medicine by considering it in these two places? What was distinctive and what was run-of-the-mill?

The discussion throughout is somewhat light on context, and this is reflected in the historiographical remit. Sheldon and Woods's Atlas of Victorian Mortality is missing, for example, despite Ritch's periodic focus on diagnoses and incidence of illness, while too little is made of the advances by research predecessors including Angie Negrine, Kim Price, and others.¹ Consequently, some of the general claims are not backed up or made with sufficient finesse: has the case of the sick poor really been neglected up to now (p. 2)? There is undoubtedly a point to be made here about...