Negotiating medical welfare

This chapter foregrounds the concept of pauper agency. Using the largest corpus of letters by or about the poor ever assembled, it argues that sickness was the core business of the Old Poor Law by the early nineteenth century. Rather than paupers being simply subject to the whim and treatment of the parish, the chapter argues that they had considerable agency. Despite problems of moral hazard and the idea that sickness could be faked, paupers and officials agreed that ill health and its treatment was an area of acceptable contestation.

Defining and measuring

The central purpose of this chapter is to understand the scale of sickness confronted by the Old Poor Law during its so- called crisis stages and to for a definition of medical welfare. In terms of the former, the chapter brings together the largest corpus of evidence ever assembled for this period. It argues that sickness increased in frequency, intensity and duration, such that the crisis of the Old Poor law was co-terminus with a crisis of health. Looking at how parochial officials recorded responses to such sickness, the chapter argues that we must follow them in adopting the widest possible definition of medical welfare.

The medical economy of makeshifts

This chapter tries to situate parochial medical welfare within the wider medical economy of makeshifts. It argues that paupers engaged in a three strand set of responses to illness in addition to their negotiation of parochial relief. Sometimes they explored medical avenues (for instance charitable treatment by doctors) which shadowed the response of parishes; sometimes they explored avenues which complemented parochial activity; and sometimes (for instance through self-dosing and self-help clubs) they explored avenues which substituted for parochial spending. The chapter concludes that the medical welfare traceable in Old Poor Law records was a small subset of that garnered by the poor.

Institutions and the sick poor

This chapter shows that the workhouse was the single biggest category of institutional engagement by parish officers. In turn, most workhouse inmates were sick. Yet the workhouse played a variable part in medical welfare spending in most places. Only in Norfolk was its presence concerted and long-lasting. Over time, the range of engagements between parishes and other types of institution, notably hospitals, expanded massively. By the 1820s an institutional sojourn became an anticipated and expected parish response to sickness.

Dying, being buried and leaving people behind

This chapter focuses on the attitudes of parishes to those whose treatment failed and who thus spiralled into a last illness and death. It suggests that officials responded positively and even generously to last illnesses and that they erred on the side of caution when alerted to serious sickness. Where their efforts failed, the chapter explodes the myth that pauper funerals were miserable and punishing affairs. Rather they happened across a rich spectrum and were probably little different to those afforded to the independent labouring classes.

Medical people

This chapter focuses on one aspect of spending, that on ‘medical people’. In particular it looks at doctors, nurses and so-called irregular healers on a spectrum from bonesetters, lay healers and to quacks. Three core findings stand out: that doctors came to occupy an increasingly distinctive and expensive place in medical welfare in most places by the 1820s; that there were distinct regional cultures of nursing, with Norfolk employing few of them and paying them badly while in Berkshire nursing was integral to parish responses when faced by sick claimants; and that irregular providers did not die out as doctors extended their reach.

The ecology of poor relief

At the core of this chapter is the development of Old Poor Law historiography post-1750. The chapter argues that the thrust of such historiography has moved inexorably to a greater understanding of the lives and words of the poor. In this context, medical welfare has been sadly neglected. Historians have felt that sickness was so ubiquitous that the sick poor themselves cannot and should not be the subject of discrete study. The chapter disagrees.

Making sense of diversity

This chapter brings together the arguments which are core to the book. It argues that the sick poor became the totemic group of paupers in the last decades of the Old Poor Law and that medical welfare became the most insistent part of poor law spending. By 1834, the Old Poor Law was well on the way to becoming a proto medical service. This and the fact that the poor and officials expected the sick to negotiate their relief, has fundamental consequences for the stability and purpose of the post-1834 New Poor Law.

Wider medical welfare

This chapter is concerned with a rich vein of poor law spending: on cash allowances, drugs, payments in kind and head such as apprenticeship. In most county communities, cash allowances grew in importance over time, both because it was more convenient for officials to give such allowances and then let the poor buy their own medical care and because the poor increasingly requested such allowances. Nonetheless, there is a clear sense that many officers continued to be active in purchasing drugs, devices, false limbs and food for the sick.

Treating the sick poor: a quantitative overview

This chapter provides a quantitative overview of the scale and complexion of medical welfare for the period 1750-1834. It focuses on the records of 117 parishes across seven English counties, specially chosen to reflect the socio-economic distribution of English communities at the time. Investigating change over time, variation between different areas and between different community types, the essential finding of the chapter is that there was a concerted upward shift in the scale of medical welfare spending by the mid-1810s.