COMPARATIVE PROGRAM ON HEALTH AND SOCIETY 2002/3 WORKING PAPER SERIES

Before the Welfare State: poverty, public medicine and the English Poor Law in

eighteenth-century London and pre-Confederation Toronto.1

Kevin P. Siena Trent University

© 2003

The workhouse. The very name makes us shudder as we recall Dickensian

visions of dank, horrible institutions. That reaction is not misplaced. However, it is less

common to think of the workhouse as a place that healed. Both the popular -- and indeed

the scholarly -- constructions of workhouses have tended to overlook the medical services

provided by workhouses. Yet in some cases these were considerable. Beginning in the

early eighteenth century London workhouses became crucial medical institutions for the

urban poor. The English Poor Law, the system that administered workhouses, played a

crucial medical role in the lives of plebeian Londoners, which has not received the

attention that it deserves. This article hopes to explore the genesis of workhouse

medicine in order to gauge what the workhouse meant to members of London’s

underclass forced by need to use them when they fell ill. However, it hopes to achieve a

fuller understanding of workhouse medicine by also charting how the English approach

to poor relief, and indeed the workhouse itself, traveled: in this case, to Toronto. A

comparison of the medical services provided by the Toronto House of Industry portrays a

1 This comparative study of public poor relief in London and Toronto is a work in progress, which was made possible by support of the Lupina Foundation through the Comparative Program in Health and Society, and a partial teaching release from Trent University; for both of which I am extremely grateful. The conclusions drawn here are tentative, and I will welcome suggestions from readers. ksiena@trentu.ca

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stark contrast. While Upper Canadians clearly drew on the English model and

appropriated the workhouse, the crown jewel of the English poor relief system, they

clearly had their own vision, their own approach to welfare provision. The different poor

relief systems that emerged in the two cities created different institutional landscapes for

the poor to traverse. A pauper in London faced a different set of options when he or she

fell ill. In the end, it becomes clear that the English Poor Law – that Dickesnsian horror

show, so much maligned – actually empowered the poor in important ways, granting

them greater traction than their Toronto counterparts for confronting poor relief agencies.

The extent to which workhouses medicalized in London and Toronto was contingent on

the leverage that the users of those institutions could bring in their attempts to steer poor

relief resources towards their medical needs.

What was The English Poor law? The English government enacted a new

approach to poor relief in the mid-sixteenth century, largely as a response to the

Protestant Reformation. Because the English had cast out the Catholic Church, they had

also unwittingly undermined their social welfare system, almost all of which had been

some form of catholic Charity throughout the middle ages. In its place it set the Poor

Law, which functioned thus. It made each parish responsible for caring for its own poor.

To do that, parishes were empowered to assess all property holders, collect taxes (called

Poor Rates) and use these funds to relieve the poor.2 Despite that it sounds as if this is

2 The English Poor relief has been expertly explored by Paul Slack. For an overview of the system and its administration readers are directed to Poverty and Policy in Tudor and Stuart England (London: Longman, 1988); The English Poor Law, 1531-1782, (Basingstoke, 1990) and From Reformation to Improvement: Public Welfare in Early Modern England (Oxford University Press, 1999). See also Lynn Hollen Lees, The Solidarities of Strangers: The English Poor Laws and the people, 1700-1948 (Cambridge University press, 1998).

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still a religious operation, the parish actually doubled as a municipal unit. The system

was essentially secular. England had, therefore, in the mid-sixteenth century a system

that bears several identifiable modern characteristics: a secular authority assessed

community assets, raised tax monies, and redistributed those resources to the poor. Thus,

fully three centuries before the lauded welfare state allegedly brings us public, tax-based

welfare, one finds it in England, and, as research is showing, elsewhere in Europe.3

This was established nation wide, but it is not administered at the national level. It

remained entirely local; the parishes were to function as self-sufficient units, each taking

care of their own poor. The nation at this time did not have nearly the bureaucracy to

administer a national welfare program – the state is miniscule at this point in history. So

this was not a welfare state. But it was public welfare – if we mean by the term welfare

supported by tax revenue, and administered by secular government officials, (albeit local

officials.)

In the sixteenth and seventeenth centuries, relief was almost entirely what was

called “outdoor” relief, not institutional care, but usually some form of a dole. They very

simply redistributed the funds to those in need. As far as medicine was concerned, these

included payments to the sick, and frequently parishes contracted with a local surgeon to

treat the poor. 4 But England transformed rapidly as the eighteenth century dawned, and

poor relief changed as a result. The population of England skyrocketed, and people

3 Ole Peter Grell and Andrew Cunningham (eds.) Health Care and Poor Relief in Protestant Europe, 1500-1700 (London: Routledge, 1997), Ole Peter Grell, Andrew Cunningham, and Jon Arrizabalga (eds.) Health care and Poor Relief in Counter Reformation Europe (London: Routledge, 1999) and Ole Peter Grell, Andrew Cunningham and Robert Jütte Health Care and Poor relief in Eighteenth and Nineteenth century Northern Europe (Aldershot: Ashgate, 2002). 4 Margaret Pelling, Healing the Sick Poor: Social Policy and Disability in Norwich, Medical History 29 (1985): 115-37 and “Illness among the Poor in an Early Modern Town: the Norwich Census, 1550-1640” Continuity and Change 3 (1988): 153-75. For London see Andrew Wear, “Caring for the Sick Poor in the Parish of St. Bartholomew’s Exchange, 1580-1679” in W. F. Bynum and Roy Porter (eds.) Living and Dying in London (Medical History Supplement 11, London 1991), 41-60.

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began migrating en masse to urban centers. London exploded 500%, in two centuries

becoming the first European city to reach to a million people by 1800.5 This brought

massive urban poverty to London. Urban parishes responded to the dramatically

increased demands for relief by institutionalizing relief in workhouses, which became the

central form of urban poor law provision from about the 1720’s onward.

The earliest advocates of workhouses saw them as panaceas, which would solve a

range of problems in one stroke. By institutionalizing relief in the workhouse – in other

words by forcing those who sought relief to enter the workhouse, rather than hand out a

dole – it was believed that parishes would be able to tap into an a labour pool, set it on

work, and turn a profit.6 Advocates believed that workhouses would fund themselves,

easing the burden on the tax payers; so this must be seen as a clear tax-cutting measure.

Of course, the workhouse would also instill a work ethic and discipline a group that

reformers perceived to be an unruly, immoral and lazy underclass. Through forced

labour the poor would no longer get a free ride, but would be severely disciplined, all

while turning a tidy profit. We can, of course, hardly underestimate the early social

engineering attempts being made here.

5 A succinct chart of London’s population growth can be found in Francis Sheppard, London : A History, (London: Oxford University Press, 1998), 362. The population model described above relies on pioneering demographic works such as E. A. Wrigley and R. S. Schofield, The Population History of England, 1541-1871 (Cambridge: Cambridge University Press, 1981); E. A. Wrigley, “A Simple Model of London’s Importance in Changing English Society and Economy, 1650-1750,” Past and Present 37 (1967): 44-70; and Roger Finlay and Beatrice Shearer, “Population Growth and Suburban Expansion,” London 1500-1700: the making of a metropolis eds. A. L. Beier and R. Finlay, (London: Longman, 1986), 39-57. For a review of the demographic literature see Vanessa Harding, “The Population of London, 1550-1700: a Review of the Published Evidence,” London Journal, 15 (1990): 111-128. 6 Tim Hitchcock, “Paupers and Preachers: The SPCK and the Parochial Workhouse Movement,” in eds. Lee Davison et al., Stilling the Grumbling Hive, 145-166. For a fuller study see Hitchcock’s D. Phil. Thesis The English Workhouse: A Study in Institutional Poor Relief in Selected Counties, 1696-1750,” (Oxford Univ. D. Phil. thesis, 1985). For a look at the some seventeenth century antecedents see Valerie Pearl, “Puritans and Poor Relief: The London Workhouse 1649-60” in D. Pennington and K. Thomas (eds.) Puritans and revolutionaries: Essays in Seventeenth-Century History presented to Christopher Hill (Oxford, 1978) pp. 206-32.

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The plan proved to be dreadfully naïve; none of the workhouses ever turned a

profit. However, they did succeed in one respect. Workhouses dramatically reduced the

amount of welfare that parishes paid out. In parish after parish, the number of applicants

for relief fell by 50% in a single year after they opened a workhouse.7 In other words, as

soon as parishes made relief contingent on entering the workhouse, half of those who

would have applied now choose to rough it on their own. This, argue historians who

have studied the workhouse movement, was the real purpose of the workhouse – to make

relief so nasty, so unpalatable, that only the truly destitute would apply. And the actions

of paupers clearly show that they indeed hated the workhouse. They resented having to

give up their freedom of movement, having to don a parish uniform that labeled them

with public stigma, and submitting to forced labour. Many refused to enter, and many

others who did, ran away. In short, eighteenth-century Londoners hated workhouses, and

there is reason to believe that they were designed to elicit just that response.

However, many people needed them. One reason why the utopian visions of the

workhouse failed, and workhouses did not become profit-turning factories, was because a

significant portion of the folks who had it so bad that they were willing to enter a

workhouse were physically unwell. The link between illness and poverty is crucial here.

For example, in the parish of St. Luke’s Chelsea, fully 55% of all the inmates who

entered the workhouse were not the able-bodied workers that reformers had hoped for,

but rather those listed as “sick,” “infirm/lame,” “injured,” or “foul.” (this last designation

meant syphilitic).8 In other words more than half of all the people who entered the

7 Hitchcock, “Preachers and Paupers”, 146. 8 London Metropolitan Archives, St. Luke’s Chelsea Workhouse Admissions and Discharges (1743-1769, 1782-1799), Microfilm, x/15/37. A database that comprises the complete surviving workhouse admissions registers for St. Luke’s Chelsea is now available on the CD-Rom Economic Growth and Social Change in

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workhouse did so because they physically unwell. It is important to note is that they

were not just there for convalescent nursing: if we deduct the inmates who were listed as

‘lame’ or ‘infirm’ – in other words those who were unwell but not candidates for specific

treatment -- we are still left with 40% of all inmates who entered the workhouse for

therapeutic care. Convalescent nursing was a major service provided by the parish, but

the medical services became much more sophisticated than that.

We get a sense of the range of care from a 1733 list of ‘cures’ performed by the

workhouse surgeon for the parish of St. Margaret’s Westminster. He recorded 152

specific cures that year, which cover a wide range of eighteenth-century diagnoses. The

infirmary treated everything from broken limbs, to rheumatism, to syphilis, to eye

problems. The list goes on.9 The workhouse infirmary was a diverse medical operation,

every bit as diverse as any small hospital of the time. Workhouses ran obstetrical

operations for the ever-present pregnant (usually single) women who came in to give

birth. 10 And they became a veritable of dumping ground for the mentally ill and

mentally challenged. One indication of how workhouses became recognized as medical

centers is their use as an emergency room. Coroner’s records show that accident victims

the Eighteenth-Century English Town (History Courseware Consortium,1998) designed by Tim Hitchcock and Robert Shoemaker. 9 Westminster City Library, St. Margaret’s Westminster Workhouse Committee Minutes, E2634, pp. 242-3. 10 For recent work on unwed mothers and their encounters with relief agencies see Tim Hitchcock, “‘Unlawfully begotten on her body’ : illegitimacy and the parish poor in St. Luke’s Chelsea” in Hitchcock, Peter King, and Pamela Sharpe, eds., Chronicling Poverty: The Voices and Strategies of the English Poor 1640-1840. (London: Macmillan, 1997); R. B. Outhwaite, “‘Objects of Charity’: Petitions to the London Foundling Hospital, 1768-72” Eighteenth-Century Studies 32 (4) (1999): 497-510. On the broader European context see several contributions to John Henderson and Richard Wall (eds.) Poor Women and Children of the European Past, (London: Routledge, 1994) On deserted mothers see David A. Kent, "Gone for a Soldier": Family Breakdown and the Demography of Desertion in a London Parish, 1750-91”, Local Population Studies 1990 (45): 27-42.

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were routinely rushed to the workhouse because it became known that they had a fulltime

medical staff on hand.11 In short, workhouses became significant medical institutions.

But this was not the intention of these institutions. When one looks at the

literature of the workhouse movement it says virtually nothing about illness. Proponents

specify work, discipline, and reform – not medicine. What reformers had in their minds

were factory/prisons, not hospitals. However, it is striking just how quickly parish

officers retooled their workhouses to contain infirmaries. In the parishes of St. George

Hanover Square, St. Sepulchre, and St. Margaret’s Westminster, the workhouses were not

open a year before officers in each parish had to order ward space set aside to build

infirmaries. At St. Margaret’s, for just one example, parish officials converted six rooms

into an infirmary in the first six months, adding additional rooms for contagious patients,

“the mad”, two pediatric wards, a VD ward, and a separate room for medical supplies, all

within the first year. More than half of the physical space of the workhouse was devoted

to medicine in less than a year.12

Why was this ? Why was it that the original planners who were so set about their

vision for the workhouse, who saw the workhouse performing a particular function, why

were they so willing to transform their infant institutions into infirmaries so quickly?

Here a view from below is helpful. I contend that that it was the poor who medicalized

workhouses. It was the expectations that the poor had for these institutions that marks the

key. The founders envisioned a kind of correctional factory, but the poor had other ideas.

Essentially, the poor forced workhouse administrators to devote an increasing amount of

11 Westminster Abbey Library and Muniments Room, Westminster Coroner’s Inquests, 1760-1800. 12 WCL, St. George’s Hanover Square, Workhouse Committee Minutes, 1726-1729, C869, p. 65; Guildhall Library, St. sepulchre (London Division) Workhouse Committee Minutes, 1727-1729, MS 3137/1, pp. 29-30, 93, 96 and 101; WCL, St. Margaret’s Westminster, Workhouse Minute Book, E2632, Aug. 23, 1726, Oct. 27, 1727, Nov. 16, 1727, Aug. 22, 1727 and Oct. 3, 1727.

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resources towards medical care, and effectively they changed the overall purpose of these

institutions.

This may seem strange. How could such a weak and politically marginalized

segment of the population, who we tend to think had little influence at all, have affected

this kind of change? They were able to do this because the English Poor Law endowed

them with an entitlement to relief. Members of a parish community had a duty to pay the

poor rates; this was not charity. The other side of that coin was entitlement. Parish

officials were obligated to relieve destitute members of the parish community.13 They

could not turn them away. They might refuse to simply hand out a dole. They might

now tell applicants who sought relief that it was the workhouse or nothing. And this

undoubtedly drove many away. But others stayed, and the parish had to relieve them. As

the records show a large portion of those who applied needed medical attention. By

building workhouses parishes had concentrated the vast majority of their relief resources

in these new institutions, but that did not change their wider civic obligations. Historians

have recently begun to show that the demands of the poor for relief were widely

considered legitimate, and that the obligations of parish officials to respond to those

demands were similarly widely acknowledged.14 It was the collective force of the poor

13 Several contributions to Chronicling Poverty: The Voices and Strategies of the English Poor 1640-1840, eds. Tim Hitchcock, Peter King, and Pamela Sharpe, (London: Macmillan, 1997) discuss early modern views on parish relief as a right: see Tim Hitchcock, Peter King, and Pamela Sharpe “Introduction,” 10-11, and Jeremy Boulton, “Going on the Parish: The Parish Pension and its Meaning in the London Suburbs, 1640-1724,” 19-21. On the tension over the issue between poor law administrators and welfare recipients see Steve Hindle, “Exhortation and entitlement: negotiating inequality in English rural communities, 1550-1650” in Negotiating Power in Early Modern Society: Order, Hierarchy and Subordination in Britain and Ireland, eds. Michael J. Braddick and John Walter, (Cambridge : Cambridge University Press, 2001), 102-122. For a discussion of contested senses of entitlements in a different forum, see Margaret R. Hunt, “Wives and marital ‘rights’ in the Court of Exchequer in the early eighteenth century in Londinopolis: Essays in the cultural and social history of early modern London, eds. Mark S. R. Jenner and Paul Griffiths, (Manchester University Press, 2000), 107-129. 14 Mary Fissell suggested a similar picture for Bristol, where she claims that the ways in which patients used medical institutions in the eighteenth century helped to shape the services that infirmaries provided.

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who simply continued to show up demanding relief on the basis of sickness that was

responsible for medicalizing London workhouses.

In some ways, this seems a rosy picture; we should commend the agency of

paupers who sought to access much needed medical resources and succeeded in forcing

authorities to turn their institutions to meet their needs by exercising their rights under the

law. The poor made workhouses into local clinics that offered significant medical

services. However, we should not lose sight that these folks were entering a dreaded,

stigmatized, disciplinary, institution – simply to access medical care. We can be sure that

the people who entered workhouses when they fell sick were those who could not access

care otherwise. Here it is worth situating workhouse medicine, public medicine, against

the backdrop of what we might call private care. What were these people missing out

on? What were they excluded from?

At the risk of anachronism, eighteenth-century London had a two-tiered medical

system. The free, tax based medical resources of the parish existed alongside fee-based

private care. And the latter dominated. Hiring a private physician was far and away the

optimum medical choice in the eighteenth century. Contemporaries agreed that the best

available care came in the form of a private physician hired to treat patients in the

comfort of their own homes. Even if patients needed surgery, they hired private

surgeons. In contemporaries’ eyes private care was far superior. And to the extent that

historians can make such comparisons, they were right. We lack statistics on health

“The ‘Sick and Drooping Poor’ in Eighteenth-Century Bristol and its region” Social History of Medicine 2 (1989) p. 56-7. She, too, suggested that the expectation of entitlement played a major role, and made convincing case that “[p]erhaps English society may have been characterized by a belief in entitlement to free health care for far longer than we have thought.” p. 58. This does not mean that churchwardens did not wield discretionary latitude concerning whom to relieve. On parochial flexibility in defining the ‘deserving’ poor see Claire S. Schen, “Constructing the Poor in early Seventeenth-Century London” Albion 32 (3) (2000): 450-463.

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indicators like life expectancy or mortality rates to make such a comparison definitavely,

but my own research has shown that workhouses and hospitals refused to administer

costly treatments that were widely available on the medical marketplace. We further

know that institutionalized patients got rather little attention from hospital and workhouse

doctors, who relied on their private practice for the majority of their income.15 So

contemporaries were on fairly solid footing when they privileged private care over public

care.

But what of hospitals ? Here, too, a public/private comparison may be useful,

though of a different sort. London had no dearth of hospitals providing healthcare for

the poor (i.e. for those who could not hire a doctor.) Although they were not private in

the sense that they operated for profit, they were in private hands. They were private in

the sense that they remained entirely independent from the state. They were charities. In

the eighteenth century a particular model became dominant and administered hospitals of

all shapes and sizes throughout London. These were called voluntary hospitals, and they

functioned thus. Groups of wealthy and middle class reformers, usually folks from the

urban mercantile class, pooled their resources to found a hospital. They were supported

entirely by private donations, of usually modest, but regular annual sums, a system called

‘subscription.’ For a small annual donation, donors became ’governors’ or ‘trustees’.

Their subscription bought them the right to sit on the administrative board, attend all

meetings, and help determine hospital policy.16 Since these were entirely private,

15 Kevin Siena, The Foul Wards: Venereal Disease and the Poor in London Hospitals, 1600-1800 (Rochester, NY: University of Rochester Press, forthcoming), Chapter Two. 16 See Roy Porter’s overview of the this approach to charity “The Gift Relation: philanthropy and provincial hospitals in eighteenth-century England,” in Porter and Granshaw (eds.) The Hospital in History pp. 149-178. Donna Andrew, Philanthropy and Police: London Charity in the Eighteenth Century (Princeton University Press, 1989) remains the standard work on the topic. Institutional histories that demonstrate this approach in action include A. E. Clark-Kennedy London Pride: the story of a voluntary

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governors constructed their hospitals however they saw fit. For example many voluntary

hospitals prohibited venereal patients.17 There was a strong feeling among the middle

class reformers who supported such endeavors that venereal patients led an immoral

lifestyle, and therefore were unworthy of their hospital’s charity. This notion of a so-

called ‘worthy object of charity’ is central to understanding voluntary hospitals in this

period. Only ‘worthy objects of charity’ were to be supported; governing boards were

adamant about this. On the one hand worthy meant needy, legitimately poor. But in

more telling ways “worthy” meant morally deserving. The hospitals enforced this in an

important way. One of the most important features of subscribing to one of these

voluntary hospitals was that governors reserved the right to nominate patients for

admission. In fact, this was the only way to get into the hospital. Looking at these

institutions from the outside, from the perspective of aspiring patients, the only way to

access these resources was to be hand-picked by a governor. The admission ticket that

they could bestow was literally the key to entry. Governors were instructed to inspect,

and interview candidates for admission, and only if they found them to be morally worthy

of care, properly deferential and grateful, were they to issue the all-important admissions

ticket.

Returning to workhouses then, the people who ended up in the workhouse

infirmary were those who had failed to access these forms of private care. They were

those who were first, unable to afford a private practitioner, and second those who had

charity (London: Hutchinson Benham, 1979) and Gould and Uttley, A Short History of St. George’s Hospital (London: Atlantic Highlands, 1997). 17 The Westminster Infirmary is just one example. The trustees ruled in 1738 “That no person having the venereal Disease shall be admitted into this Infirmary. That if any person having the venereal disease and not discovering the same shall obtain Admission under pretence of some other distemper such person upon discovery afterwards made thereof shall be immediately discharged without cure.” London Metropolitan Archives, “Resolutions and Orders of the Westminster Hospital”, H2/WH/A1/64, p. 119.

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failed to negotiate the peculiar admissions process to access a voluntary hospital. Who

were they? By and large three groups dominated in workhouses: the very young, the very

old, and women. Taking the first two groups: the workhouse records of St. Luke’s

Chelsea show that the combination of children under the age of 16, and adults over the

age of 55, accounts for 64% of all its workhouse inmates. That means only a little over a

third of the workhouse population were working age adults between 16-55. Of these,

78% were women.18 The gender breakdown of the population in the infirmary mirrors

that of the general population. Focusing initially exclusively on venereal patients, it

emerged that in four separate parishes female syphilitics in workhouse infirmaries

outnumbered male syphilitics by more than three to one.19 A wider analysis

showsvirtually the same picture for workhouse infirmaries in general: 76% of all the

patients recorded in the infirmary in St. Margaret’s Westminster, regardless of diagnosis,

were women.20

This differs markedly from the voluntary hospitals, in which the clientele

typically hovered between 60-65% male.21 In broad terms, then, London’s private

hospitals treated almost two men for every woman, while its public workhouse

infirmaries treated three women for every man. Workhouse infirmaries became the

primary healthcare centers for London’s very poor, and it is beyond doubt that London’s

very poor was disproportionately female. There was thus a gendered geography of

18 Hitchcock, “The English Workhouse,” 194-5. 19 Kevin Siena “Poverty and the Pox: Venereal Disease in London Hospitals, 1600-1800” (University of Toronto, Ph.D. thesis, 2001), p. 131. Women represented 73%, 78.6%, 74%, and 78% of all venereal patients in the workhouses of St. Luke’s Chelsea, St. Margaret’s Westminster, St. Sepulchre, and St. Andrew Holborn respectively. 20 WCL, St. Margaret’s Westminster, Workhouse Committee Minutes, E2634, pp. 242-3. 21 For example, such figures that emerge from the records of the London Lock Hospital, for which I reconstituted the patient population from the board minutes. For a description of the database and these figures see Siena, “Poverty and the Pox”, 252. The same can be said for the Royal Hospitals such as St. Thomas’s Hospital. LMA, St. Thomas’s Hospital Patient Index (1768-1772).

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London hospitals. Women’s economic disadvantages rendered them less able to access of

the services of the private medical marketplace. However, they were also less successful

when trying to access voluntary hospitals. There are a range of factors which come into

play here, including the networking resources needed to contact, and to be favorably

recommended to, the more prominent, (exclusively male) members of the community

who ran hospitals. But we must also consider the all important skill of appearing worthy

of charity in governors’ eyes, which gender prejudices likely influenced. We certainly

know that men and women were held to vastly different moral yardsticks in the

eighteenth century. The idea of a male ‘worthy object of charity’ may have differed from

a female ‘worthy object of charity’, in crucial ways, though more research is needed on

this. Finally, it is also quite possible that the men who controlled London’s voluntary

hospitals simply privileged the health of ‘breadwinning’ men and thus steered the

majority of their medical resources towards men’s health.

Rather than rehearsing the dire conditions in workhouses -- the corporeal

punishment that workhouses were empowered to mete out, the attempts by parish

administrators to try to refuse relief to certain applicants by challenging the parish

membership, the attempts to physically remove burdensome parishioners to other

jurisdictions -- or the pressures that massive migration brought for a community based

system not intended to handle wide scale demographic shift, it is worth while to try to put

a human face on these institutions. What did workhouse mean to members of London’s

underclass ?

Consider the story of a woman named Elizabeth Wyatt. Elizabeth lived in the

parish of St. Luke’s Chelsea. She was in and out of the workhouse 14 times between

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1750 and 1761. She first entered the workhouse at the age of 16 to see the doctor in June

1750 and did so again the following year, for something more serious this time, spending

142 days in the infirmary.22 But she recovered and seems to have remained well for the

next 6 years. At the age of twenty-three, merely described as “sick” she entered the

workhouse infirmary in October 1757. Over the next twenty-four months Elizabeth

would enter the infirmary on five subsequent occasions, always listed as “sick.”23 She

expressed her opinion of life in the workhouse on February 24, 1759 when she ran away.

But less than a year later Elizabeth was forced to return to workhouse infirmary; she

found herself infected with syphilis.24 The surgeon tried to treat her over the course of

five months, but finally decided that she needed hospital care. The parish paid to send

her to Guy’s Hospital on April 9, 1760.25 Discharged from the hospital she convalesced

in the workhouse until mid-June, when she decided that seven months of institutional

care was quite enough for her. She ran away again on June 28, 1760. She did not make

it far, because she applied for re-admission to the infirmary just two days later, the

register stating she was “not well from being foul.”26 After just five days back in the

workhouse she re-affirmed her earlier decision and escaped into the night for the third

time.27 By December illness brought Elizabeth back to the workhouse. And the pattern

continued. The parish sent her to a hospital in December. She returned and convalesced

in the workhouse until April and set out again on her own. She returned ill to the

22 LMA, St. Luke’s Chelsea, Workhouse Admission Register, Elizabeth Wyatt, June 16, 1750, July 6, 1750, July 30, 1750, Nov. 10, 1750, Dec. 24, 1750, May 15, 1751. 23 Ibid., Elizabeth Wyatt, Oct. 26, 1757, Nov. 8, 1757, Dec. 13, 1757, May 2, 1758, May 9, 1758, Jan 24, 1759, Feb. 24, 1759, Oct. 26, 1759, Nov. 8, 1759. 24 Ibid., Elizabeth Wyatt, Dec. 4, 1759. 25 Ibid., Elizabeth Wyatt, April 9, 1760. 26 Ibid., Elizabeth Wyatt, June 12, 1760, June 28, 1760, June 30, 1760. 27 Ibid., Elizabeth Wyatt, July 5, 1760.

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workhouse in October. Over the next year she would be in and out of the workhouse

infirmary three more times before she finally disappears from the records.28

Elizabeth’s tale was typical. We could repeat virtually the same narrative for

Margaret Cock, who was in and out of St. Luke’s workhouse repeatedly between 1746

and 1753. By the tender age of 21 she had been in the infirmary (also for syphilis) 10

separate times, and she, too, ran away.29 Such patients clearly loathed the workhouse.

But they clearly needed the services that it provided. Margaret and Elizabeth were both

the kinds of folk who would have found it exceedingly difficult to access private forms of

care; they were too poor to hire a private physician, and they both would have had a hard

time proving they were “worthy objects of charity” to the supercilious governors of

voluntary hospitals, especially once they contracted the syphilis. But despite that others

might turn them away, they recognized that they were not without options, and they could

access medical care through the parish if all else failed. Their repeated attempts to escape

the workhouse demonstrate just what a difficult decision it was to choose between giving

up one’s freedom of movement or enduring illness. It was not pretty by any stretch, but

the workhouse clearly played a major role in the lives of plebeian Londoners. It was their

primary healthcare provider. It was not designed to perform this service. But the efforts

of women like Elizabeth Wyatt and Margaret Cock to exercise their legal entitlement and

demand relief in the form of medical provision transformed these institutions.

28 Ibid., Elizabeth Wyatt, Dec. 3, 1760, Jan. 14, 1761, Feb. 4, 1761, April 8, 1761, October 10, 1761, Nov. 10, 1761. 29 LMA, Microfilm, X/15/37, Margaret Cock, Sept. 5, 1746, Ann Cock, Nov. 6, 1746, Grace Cock, Nov. 6, 1746, Hannah Cock, Sept. 21, 1746, Margaret Cock, Nov. 18, 1746, April 17, 1748, May 2, 1748, Dec. 8, 1749, Dec. 13, 1749, Oct. 3, 1750, Dec. 24, 1750, Jan. 9, 1751, Jan. 17, 1751, Feb. 21, 1751, July, 19, 1751, Oct. 7, 1751, April 22, 1752, Oct. 31, 1752, Nov. 2, 1752.

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The early Upper Canadian context, specifically the case of early Toronto,

provides a fruitful comparison. Some parts of Canada adopted the English Poor Laws:

Nova Scotia and New Brunswick both adopted the Poor Law in the 1780’s.30 However,

they were the last British North American colonies to do so. Both Upper Canada and

Lower Canada rejected the English Poor Law. In 1792 at its very first meeting the

legislature of Upper Canada decided to accept the entirety of English civil law in all

matters relating to property and civil rights, with the notable exceptions of England’s

Poor Laws and bankruptcy laws.31 In other words, Upper Canada happily adopted the

broad swathe of English laws on virtually everything, except for two particular laws that

the legislature made a specific point to exclude. They had something against the English

Poor Law in early Upper Canada.

A lot of people in England had begun to criticize the Poor Law, too. At the close

of the eighteenth century a debate about the so-called ‘pauperizing’ effects of public

relief began in England, which lasted well into the nineteenth century. Conservatives and

laissez faire theorists of such fame as Edmund Burke spoke out against what they

perceived as the social determent caused by public relief.32 To those in the anti-Poor Law

30 On poor relief in the Maritimes see Judith Fingard “English Humanitarianism and the Colonial Mind: Walter Bromley in Nova Scotia, 1813-1825,” Canadian Historical Review (1973): 123-151; “The Winter’s Tale: The Seasonal Contours of Pre-Industrial Poverty in British North America, 1815-1860,” Historical Papers (1974):65-94; and “The Relief of the Unemployed Poor in Saint John, Halifax, and St. John’s, 1815-1860,” Acadiensis (1975): 32-53; Bereton Greenhaus, “Paupers and Poorhouses: The Development of Poor Relief in Early New Brunswick, Histroire Sociale/Social History 1 (1968); James Whalen, “The nineteenth-Century Almshouse System in Saint John County” Histoire Social/Social History 4 (1971), pp. 5 – 27 and “Social Welfare in New Brunswick, 1784-1900,” Acadiensis 2 (1972) pp. 54-64; and Melvin Baker, “The Politics of Poverty: Providing Public Poor Relief in Nineteenth- Century St. John’s, Newfoundland,” Newfoundland Quarterly 58 (1982), pp. 20-23. 31 Russell C. Smandych, “William Osgoode, John Graves Simcoe and the Exclusion of the English Poor Law from Upper Canada” in Louis Knafla and Susan W. S. Binnie (eds.) Law, Society and the State: Essays in Modern Legal History (Toronto, 1995), p. 99. 32 On this debate, see especially Gertrude Himmelfarb, The Idea of Poverty: England in the early Industrial Age (New York : Vintage Books, 1983) and J. R. Poynter, Society and Pauperism: English Ideas on Poor Relief, 1795-1834, (London, 1969).

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lobby the guarantee of relief made people lazy and immoral. It produced paupers – not

just poor people – but, in a sense, a new class of people who internalized a particular

moral structure that led to lifelong “pauperism”. In a debate with stunning modern

parallels conservatives argued that providing a guaranteed safety net essentially worsened

poverty. It made poverty everlasting by producing dependency. In England this debate

produced the Poor Law reform of 1834, a tougher, somewhat meaner version of the Poor

Law, which expressly forbid the “able-bodied” from receiving relief.33 What is

interesting about the 1834 Poor Law for medicine is that it galvanized sickness as one of

the only legitimate causes of poverty and laid the groundwork for nineteenth-century

poor relief to focus even more extensively on medical provision.34

Those who have looked at the Upper Canadian rejection of the poor law tend to

see it as an ideological rejection, growing directly out of this English debate. Historians

cast the Upper Canadian rejection of the Poor Law as evidence of a particular social

vision popular among the politically dominant class, steeped in a notion of self reliance.

The vast resources of Upper Canada seemed to offer plenty of opportunities for the

population. Surely citizens could support themselves given the ample Canadian bounty.

The English system that offered public relief as an entitlement served to numb the drive

for self-support, and create a dependent slothful class. Upper Canadian legislators sought

33 An excellent study covering the transition from Old Poor Law to New Poor Law is Lynn Hollen Lees, The Solidarities of Strangers: the English poor laws and the people, 1700-1948 (Cambridge, 1998). See also M. A. Crowther, The Workhouse System, 1834-1929: the history of an English social institution (Athens, 1982) and Derek Fraser (ed.) The New Poor Law in the Nineteenth Century (London, 1976). 34 See M. W. Flinn “Medical Services under the New Poor Law” in Fraser op. cit., pp. 45- 66. The significant attention that the New Poor Law of 1834 has received, and the centrality of ‘able-bodied-ness’ to the debate has created an historiography that recognizes nineteenth-century workhouse medicine, but which assumes it to be a new development. This has cast a major shadow over the significant medicalization of eighteenth-century workhouses which goes largely still unnoticed.

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a hard working, self-reliant society, and saw publicly funded poor relief as antithetical to

this emerging liberal vision. So they rejected it out of hand.35

This should mean that we do not find workhouses in Upper Canada. Yet we do.

The Toronto House of Industry opened in 1837.36 Ultimately, Upper Canadians rejected

the legislation and social welfare system that produced the workhouse, but they kept the

workhouse itself. They rejected the system, but they embraced its product. They hated

the idea of the Poor Law, but they were quite attracted the idea of the workhouse. This is

not as inconsistent as it may seem. The same drive to force self-reliance, to prevent the

growth of dependency, and to end indiscriminant almsgiving, was exactly what the drove

original workhouse movement a century earlier. After all, workhouses made the poor

earn their keep; they ended indiscriminant almsgiving, and they promised to instill a work

ethic on the lazy poor. However, without the Poor Law to supply a tax base, how did

they fund it and administer it? The rejection of the Poor Law meant that virtually all

social welfare initiatives that we witness in early Upper Canada functioned as private

charities. Thus Upper Canada did draw heavily on an English model, but it was not the

public poor law model, rather it was the private voluntary charity model. They

constructed the Toronto workhouse to function as a charity, just like the voluntary

35 Smandych especially stresses the theoretical issues at stake and the influence on the English poor law debate on members of the Upper Canadian legislature. He suggests that the refusal of the Bankruptcy Law likely sprang from the same political economy, noting that the English bankruptcy were considered far too lenient, and thus similarly at odds with notions of individual responsibility and self reliance. See “William Osgoode, John Graves Simcoe and the Exclusion of the English Poor Law”, pp. 99-129. It is worth noting, that other scholars have stressed the practical difficulties inherent in transplanting the English system to a relatively poor, frontier, colonial context. See Richard Splane, Social Welfare in Ontario, 1791-1893: A study of public welfare administration (Toronto, 1965), pp. 65-68. 36 The best concentrated study on the Toronto House of Industry is James Pitsula’s dissertation “The Relief of Poverty in Toronto, 1880-1930” (York University Ph.D thesis, 1979). However, as the title indicates it does not cover the first four-plus decades of its history.

19

hospitals we witnessed in London. Annual donors became trustees with the right to sit on

the board, design policy, nominate and approve--or deny-- all those who got in.

Thus social welfare in what became Ontario was left almost entirely to the

initiative of private charity.37 But this does not mean that a complete split between the

public and the private had been affected. In fact, a particular public/private partnership

ensued, as Upper Canadian charities became quickly dependent for their survival on

public monies, because their private fundraising efforts regularly fell short. Mariana

Valverde has rightly described the system that developed as a kind of ‘mixed social

economy’ in which seemingly private charities actually received an increasing amount of

public support as the nineteenth century wore on. Tax monies went towards poor relief,

but they did so only as supplemental grants to private charities, somewhat below the

radar screen, leaving the administration of those funds completely in private hands.38

Valverde has argued persuasively that we need to see this approach to welfare as an

important piece of Ontario’s political inheritance, which never fully disappeared with the

coming of the welfare state, and which has, importantly, made something of a comeback.

She states: “The non-governmental social service sector, though by no means new, has

been rehabilitated by neoconservative politicians trying to justify welfare cutbacks

37 Case studies that demonstrate this model in action include Lynne Marks, “Indigent Committees and Ladies Benevolent Societies: Intersections of Public and Private Poor Relief in Late Nineteenth-Century Small Town Ontario” Studies in Political Economy 47 (1995):61-87; Margaret Little “The Blurring of Boundaries: Private and Public Welfare for Single Mothers in Ontario” Studies in Political Economy 47 (1995): 89-109; Splane, Social Welfare in Ontario, op. cit.; Stephen A. Speismen, “Munificent Parsons and Municipal Parsimony: Voluntary vs. Public Poor relief in Nineteenth-Century Toronto” Ontario History 65 (1973): 33-49; For Montreal see Janice Harvey “Dealing with ‘the destitute and the wretched’: The protestant House of Industry and Refuge in Nineteenth-Century Montreal” Journal of the Canadian Historical Association 12 (2001). 38 Mariana Valverde, “The Mixed Social Economy as a Canadian Tradition” Studies in Political Economy 47 (1995): 33-60.

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through the rhetoric of family and community self-help.”39 Here she cites both Thatcher

and Brian Mulroney who in 1983 promised “ a complete revision of social programs in

order to save as much money as possible. One way of meeting that objective is to

encourage the voluntary sector to participate more in the implementation of social

programs.”40 One need not reflect even two decades to find such assertions; the proposal

remains alive and well in the US in George Bush’s continuing call for welfare reform

according to so-called “faith-based initiatives” which would see federal funding steered

increasingly to private charities. The nineteenth-century case, therefore, may provide a

useful case study to consider the effects of such an approach to medical welfare.

Valverde uses it to call for a more sophisticated understanding of the relationship

between government and civil society.

The pre-confederation Toronto House of Industry fits Valverde’s description

perfectly. Very quickly the House of Industry found that its subscriptions only covered a

portion of its expenses. Despite their best fundraising efforts,41 they soon found

themselves lobbying the government for additional support. The workhouse petitioned

for, and received, grants from the municipal, provincial and the federal levels of

government at various points during their first decade of operation.42 The grants from the

provincial legislature came to be its mainstay, becoming annual and quite regular. Yet,

this funding did not bring any real ‘public’ control of the charity. It was only much later

in the century when the workhouse was already four decades old that the Ontario

39 Valverde, “The Mixed Social Economy”, p. 35 40 As cited in Ibid. 41 In addition to subscriptions The House of Industry regularly called on local clergy to raise quarterly collections in churches of all denominations. City of Toronto Archives, Toronto House of Industry Board Minute Book, SC 35 A Box 1, volume 2, Aug, 13, 1838. 42 Ibid., Dec. 3, 1838, April 17, 1839.

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government moved to organize and even monitor the charities that received public

funding, still leaving the administration in essentially private hands.43

The private administration of social welfare in the pre-confederation period had

important ramifications for medicine. The Toronto workhouse simply did not become

medicalized to the extent that its London counterparts did. Early on, the workhouse

clearly refused applicants who required medical attention.44 They were adamant that

“those seeking treatment should apply to the hospital,” noting “ that this Charity does not

possess the means of separating the sick from the healthy.”45 Architectural discussions of

the workhouse from 1846 support that statement, demonstrating that the workhouse did

not reserve any rooms for sick wards, like the ones that made up such a large portion of

the ward space in London workhouses.46 When we finally find a statement of house rules

in 1848 the governors were explicit: groups deemed ineligible for admission included:

I. “ Women who are depraved in their morals and whose general characters are bad.”

II. “Persons who are able to support themselves or….who have friends able & willing to support them.”

III. “All persons afflicted with contagious disorders or who require constant medical treatment.”47

London workhouses became infirmaries offering sophisticated therapeutics almost

immediately. The evidence from the first decades of the Toronto workhouse displays a 43 See Pitsula, “The Relief of Poverty in Ontario” esp. Chapter 5, “The Attempt to Organize Charity, 1880-1912” pp. 188-221; Valverde, pp. 44-47. See also Pitsula, “The Treatment of Tramps in Late Nineteenth-Century Toronto” Historical Papers (1980). 44 For example, on Dec. 9, 1842 they ordered that two children recommended for admission were “not in a proper state of Health to be Admitted into the House.” Toronto City Archives, Toronto House of Industry, Board Minute Book, SC 35 A Box 1, volume 2, December 9, 1842. 45 Ibid., Nov. 3, 1840. On the Toronto General Hospital in this period, which also functioned according to voluntary charity model, see J. T. H. Connor, Doing Good: the Life of the Toronto General Hospital (Toronto, 2000), pp. 15-80; W. G. Cosbie, The Toronto General Hospital, 1819-1965: A Chronicle (Toronto, 1975), pp. 1-80. 46 TCA, Toronto House of Industry, Board Minute Book, SC 35 A Box 1, volume 2, February 5, 1846. 47 TCA, Toronto House of Industry, Board Minute Book, SC 35 A Box 1, volume 3. Note: this volume begins in 1848. This list of rules begins the volume, but is not precisely dated.

22

very different picture. The Toronto trustees held firmer to the original plan for the

workhouse. They had a much freer hand in who they would admit. Just as English

voluntary hospitals had refused those not considered “worthy objects of charity”, so too

did the Toronto House of Industry refuse undesirables. The clearest example was their

response to single pregnant women. Whereas London workhouses admitted unmarried

pregnant women almost daily, the Toronto House of Industry put such women on the

street. As they did to Mary Rogers in May 1841: “Resolved that Mary Rogers be

dismissed this House. She having become pregnant of an illegitimate child whilst an

inmate…”48 Just like the governors of English voluntary hospitals, the Toronto trustees

were able could pick and choose precisely who they would help and who they would

refuse, which services they would provide, which they would not. And they remained

steadfast in their refusal to treat the sick.

Yet there remained enormous tension. The connection between sickness and

poverty was no less present in Toronto than it had been in London. Toronto workhouse

trustees faced the same pressures of sick, injured, and incapacitated people in need of aid.

Moreover, because the early Torontonians shared the same liberal political economy that

forbid offering welfare to the able-bodied, they, too, stressed physical incapacity (non

able-bodied-ness) as one of the lone acceptable causes of poverty and excuses for relief.

In addition to orphans, they specified two groups that they considered eligible for charity:

“The Blind, The Aged and Infirm whose age or Infirmities preclude their self support and

who have no friends able to support them” and “Patients discharged incurable from the

General Hospital, or in so weak a state of health as to unfit them for a time from earning

48 Ibid., May 11, 1841.

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their own living.”49 Their own rhetoric and laissez faire political economy had tied the

trustees to relieving the unwell. Thus the workhouse found itself caught between the

Scylla of not wanting to transform itself into a hospital, and the Charybdis of targeting

the physically incapacitated. To heal or not to heal? That was the question. And the

Toronto House of Industry chose to steer a kind of uneasy middle course.

It became something of a convalescent home. While the board minutes rarely

discuss the sick, and routinely refused those who require specific treatment, an 1840

report on the workhouse demonstrates just how prominent the infirm and frail became

from a very early point. In this just its third year of operation, the house had 56 inmates:

21 adults and 35 children. Of the adults just 6 were able-bodied -- all of them deserted or

widowed women with children. This left 15 of the 21 adults listed as “crippled”,

“paraletic”, “infirm” “sickly” “discharged from the hospital as incurable”, “confined to

bed”, or ‘idiots’. Moreover, of the 6 able-bodied adult women, 2 had children listed as

‘sickly’. In other words, 17 of 21 or 80% of the adult population in the house were there

as a direct result of physical infirmity.50 While there is evidence of some rudimentary

medical treatment for these kinds of folk within the workhouse, records suggest that it

never evolved further into a full infirmary. As late as 1886 one still finds the board

considering the novel suggestion that an “Infirmary in connection with the House of

Industry” might make a useful addition.51 However, it seems never to have materialized.

Why?

49 See note 47. 50 Appendix to the Journal of the House of Assembly of Upper Canada for the third day of December, 1839 to the tenth day of February, 1840, (Toronto, 1840), “Statement of the Inmates of the House of Industry” January 20, 1840. 51 TCA, Toronto House of Industry, Correspondence of Superintendent (1854-1918), SC 35, Series K Box 1, folio 61, April 15, 1886.

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I suggest that House of Industry’s sense of civic obligation remained

questionable, unclear, and muddy as a direct result of its particular public/private hybrid

structure, and that this prevented it from medicalizing further. There was undeniably

contemporary, unresolved, tension around the question of just what kind of public

responsibility arose from the acceptance of public monies by this allegedly private

institution. Just one example displays this tension. In October of 1851, a boatload of

Norwegian immigrants docked in Toronto. Normally the workhouse excluded

foreigners.52 But many were ill and the mayor ordered them into the workhouse.

However, the workhouse refused them. The city council debated the issue and it split the

councilors. Some aldermen complained that the workhouse could not accept “such filthy

diseased persons such as [these],” noting that it regularly refused both sick and foreign-

born applicants. Another challenged that the city had no right to dictate to a private

charity: “[The City] which did not vote anything towards its support had scarcely a right

to heap expenses upon the House of Industry.” But other Aldermen fired back that the

City had granted the workhouse £400 as recently as two years ago, and that this should

give the mayor the right to nominate people for admission. Another concurred,

expressly stating that since the House of Industry had “received £400 from the

citizens…they had a right to expect that the interest of their money should be expended

for the support of helpless persons.”53 In the end, they struck a compromise to deal with

the Norwegians in the short-term, but the larger debate about the nature and purpose,

52 Throughout the 1840’s the house regularly steered immigrants to the government “Emigrant Agent”. See for example, Ibid., June 29, 1840. 53 Quotations come from newspaper clippings dated October 13 and 15, 1851 enclosed in the House of Industry Board Minutes (Volume 3). For the Board’s own commentary on the incident see TCA, Toronto House of Industry, Board Minute Book, SC 35 A Box 1, volume 3, October 21, 1851.

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indeed the civic responsibility of such a public/private schemes remained unsettled and

continued to resurface.54

In both London and Toronto we see social welfare networks knit together by

various elements of public and private participation. In neither case did one exist without

the other. But the arrangements of these elements differed with important consequences

for medicine. Overall what can be said about the effects of these two distinct approaches

to social welfare for those living in eighteenth-century London and pre-confederation

Toronto? First, there are similarities. There can be no doubt that the medical systems

that provided care in both contexts established drastically different sets of options for

those who could afford care within the dominant medical marketplace, and those who

could not. A two-tiered medical system of fee-based private care alongside public

provision for the poor pervaded in both cities, and is thus not merely a hypothetical future

development, but an indelible part of both British and Canadian medical history, the

realities of which would be well worth exploring by those considering moving in that

direction. And in both cases, we are hardly surprised to find that a range of factors

including gender, age, religion, and nationality helped determined just who came to rely

on forms of medical welfare. However, the forms that such welfare took differed in

important but subtle ways in the two contexts. In both cases the workhouse, a rather

dreaded, but nonetheless important local welfare institution, came to play an important

medical role in the community, one which has been too often overlooked by medical

54 Another incident that exposes similar tension involved an attempt by Catholic Trustees to seat prominent Catholic citizens at a Board meeting to vote on an issue involving alleged discrimination. They tabled a motion “endeavouring to show that parties whether Subscribers or not had a right to take part in proceedings as Rate Payers.” It did not pass. Ibid, January 19, 1853.

26

historians on both sides of the Atlantic. However, in the London case workhouses

became medicalized to a much greater extent than the Toronto House of Industry, which

never seemed to move beyond offering basic convalescent care. By contrast London

workhouses became full range infirmaries of quite considerable scope. The political

visions of those who established and administered workhouses in both cities cannot be

held as the key factor explaining this difference. In both cases we see the same general

views on poverty and welfare pervading over a very long time: overly indiscriminate

charity would lead to institutionalized sloth and immorality. This was a maxim held by

workhouse administrators on both sides of the Atlantic for well over a century. (Indeed,

it is a view that still remains, marking another important political inheritance we owe to

this period of history.) The difference, therefore, stems not from the core values of those

running the institutions. Instead, the forces for change emanated from below. And

differences here tell the story. In both cities sickness played a major causative role in

urban poverty, and in both cities the poor tried to turn available local resources to their

particular needs. Plebeian Londoners were vastly more successful in doing so, because

they came to the workhouse armed with an entitlement under the law, a vital tool that

their Upper Canadian counterparts lacked. Hence the reason we see syphilitics, single

mothers, and others who faced an uphill battle to secure medical resources successful in

their attempts to use London workhouses as medical clinics, but failing to do so in

Toronto. Put simply, in London if the sick poor failed to succeed at being hand-picked

by a governor for hospital care, they fell into the workhouse. That situation seems bleak

until compared with Toronto, where pauper’s who failed to be hand-picked for charity

simply went without.