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

In this well-researched and highly informative book, Alistair Ritch, formerly a geriatric medicine consultant at the City Hospital in Birmingham and Senior Clinical Lecturer at the University of Birmingham, provides a detailed study of sickness in the parish of Birmingham and Wolverhampton Union after the passing of the New Poor Law. Ritch chose these two nearby jurisdictions, similar in some ways but quite different in scale and with different initial relationships to the central authority, to explore the actual practice of medicine and nursing in the workhouse. This type of study is usually complicated by an absence of sufficient records and difficulties with those that survive, in particular the absence of clear-cut categories of sick patients that might permit quantitative analyses. Ritch's overall conclusion highlights the "positive side" (28) of workhouse care, noting that inmates for the most part received humane care not significantly different from the care provided in voluntary hospitals.

Ritch's study generally fits well with the current narrative of medicine under the New Poor Law, which sees an initial decline in quality after 1834 relative to care under the Old Poor Law followed by a later-century upturn. He complicates this narrative, though, highlighting the disparity between different places over time and even within the same region, let alone around the country. Ritch considers sickness in the workhouse from several angles, including the incidence of acute and chronic illness, the management of fevers, "disorderly" patients and their care, the medical and nursing staff and the care they provided, and finally, the standard of workhouse medicine.

In each chapter, Ritch provides an informative survey of the major historical developments of the topic under consideration and a useful synopsis of the historiography, the claims of which often anchor the chapter's argument. The first chapter thus challenges the conventional claim that workhouses were filled up with the elderly and chronically ill, and here Ritch thoughtfully grapples with the methodological challenges posed by Victorian poor law record keeping. In the second chapter, Ritch demonstrates the importance of considering the workhouse in the context of the local institutional environment and demonstrates the co-operation with, for example, other local authorities in the management of smallpox outbreaks, and to a lesser extent diphtheria. In the third chapter, Ritch explores the care of people with epilepsy and mental challenges and patients with venereal disease, particularly with reference to the way in which guardian parsimony and the structural disciplinary orientation of the New Poor Law may have impacted patient treatment.

The next three chapters focus on doctors, nurses, and everyday care. Ritch's careful archival work here allows him to bring welcome specificity to some of the key providers over the course of the period. In terms of medical staffing levels, Birmingham's did not align with those of voluntary hospitals until 1889, although in some cases central government intransigence contributed to staffing shortfalls, and Ritch admits that "it is difficult to imagine that Wolverhampton's [medical] officers could be providing adequate care" (151). In terms of poor law nursing, Ritch notes that Wolverhampton's staffing levels were again low and Birmingham's again comparable to those of voluntary hospitals, although he claims that is difficult to judge if the increase in trained staff over the course of the period demonstrably improved the overall quality of care.

In some sense, the voluntary hospital standard of care that Ritch uses as a metric is itself difficult to determine for such a highly differentiated sector, but even granting that the standard existed, due to record-keeping limitations it is occasionally difficult to know if it was met on an ongoing basis. Perhaps more amenable to evaluation is the uptake of medical innovations, and here the evidence is ambiguous. Anaesthesia during surgical procedures, to take an example, was not approved for use in workhouses until the 1890s (58), and surgical operations...