|Stuart Wildman, University of Birmingham
||The UKAHN Bulletin|
|Volume 10 (1) 2022|
This article examines a relatively neglected area of history, namely the issue of caring for the sick and vulnerable at night within workhouses in England. Workhouses were important institutions for providing health care as they dealt with almost five times as many sick people than their voluntary hospital counterparts. Examples from workhouses in a number of locations are utilised to explore the nature of the dangers that were said to threaten the inmates and the debate about improving care at night within the workhouse. The suitability of workhouse buildings and facilities as well as medical and nursing staffing, the management of the workhouse and the attitude of poor law guardians and the central authorities to the care of the sick is addressed. Most arguments, in the late nineteenth century, focussed upon the need to end the system of utilising pauper inmates as nurses. The involvement of women as guardians of the poor and visitors to workhouses and the entry of working-class people into the political arena had some effect on reforming the staffing of the workhouse at night. However, by 1914 it is still far from certain that workhouse infirmaries and sick wards, particularly those in rural areas, were safe places for patient care as compared to their voluntary sector counterparts.
The Poor Law Amendment Act and the Care of the Sick
The care of the destitute and impotent poor had been a concern in medieval times but official provision was enshrined in the Elizabethan Poor Law act of 1601. This established that the poor who were unable to provide for themselves were to be the responsibility of the Parish, the lowest level of government, and financed by a property tax, known as the rates. This system lasted for over two hundred years but became a cause of concern within the upper echelons of society because of spiralling costs and harsher views about the poor receiving relief. In response, the 1834 Poor Law Amendment Act established a New Poor Law with a central government department to oversee the system and approximately 600 Poor Law unions made up of groups of parishes in England and Wales. The central authority supervised unions through its inspectors and auditors. Each union had an elected board of guardians who managed the system and employed officers to conduct the day-to-day business. One aim of the Act was to force the poor to become more independent, by reducing access to relief in the home (known as outdoor relief) and forcing all who claimed support to enter the workhouse and receive indoor relief. The threat of the workhouse was supposed to have the effect of ‘encouraging’ the poor to work harder to support themselves. This was known as the workhouse test. Workhouse conditions were based on segregation, strict discipline and some form of hard labour for the able-bodied. The level of support for each pauper was to be set at a level lower than the income of the lowest paid labourer in the locality, known as the principle of less-eligibility. This was intended to act as a deterrent for all but those in genuine need, as only the destitute would contemplate entering the workhouse.
There was little reference to medical care in the Act, and it was expected that support of the sick would go on much the same as before. Workhouse and workhouse infirmaries, in the main, admitted paupers who were ill and destitute which, as well as the acutely ill, included the elderly and infirm, the chronically ill, venereal patients, those with infectious and skin diseases, women in childbirth and the insane, all of whom would not be admitted to most voluntary hospitals. Accommodating and treating paupers with such a range of problems would prove difficult for many poor law unions.
The use of paid nurses was not stipulated in the 1834 Act. However, some poor law authorities, in cities like Birmingham, Bristol and London, had a long tradition of employing nurses. In addition, there was widespread use of nurses in and outside of the workhouse before 1834, even in rural parts of the country. A General Order issued in 1842 to all poor law unions permitted able-bodied female inmates and girls above the age of seven to be used as nurses. Paupers were not to be paid for this service but were meant to be given extra rations. They were to be supervised by the workhouse matron who was usually the wife of the master, who may or may not have had any experience or knowledge of caring for the sick. The 1847 Consolidated Order first stipulated the duties of paid nurses, that is, to attend the inmates in the sick and lying-in wards, to administer all medicines and applications under the directions of the medical officer, to report any defects in the wards and finally, to keep a light burning at night. It was expected that nurses would be able to read and write. Thus, guardians could obtain nurses by directly employing men or women, use the inmates in the workhouse or do both.
Concern about the New Poor Law started from its introduction in 1834. Scandals regarding the treatment of paupers in the workhouses in Bridgewater and Andover in the 1830s and 1840s, and in London in the 1860s mobilised opposition. These prompted people, especially women, to campaign for reform of the system. Prominent amongst these was Louisa Twining, a founder of the Workhouse Visiting Society and a leading advocate of the involvement of ladies as visitors, guardians and inspectors and in the reform of workhouse nursing. Florence Nightingale took a similar stance and initiated an experimental nursing scheme in Liverpool in the 1860s and London. Later in the century, other prominent campaigners, such as Dr John Milson Rhodes, a leading authority on Poor Law medicine and chairman of the Northern Workhouse Nursing Association, called on others to support the improvement in care of the sick poor in workhouses. Their campaigns centred on the reform of workhouse nursing.
The call for improvements in the care of the sick was boosted by an inquiry in 1865 initiated by the Lancet into medical care in some London workhouses, which identified neglect and abuse of the sick. This prompted the Poor Law Board to review medical care in the metropolitan and some provincial workhouses. The Metropolitan Poor Act of 1867 allowed for a separate system of hospitals and dispensaries for paupers in London and a similar act in 1868, encouraged provincial boards of guardians to build separate workhouse infirmaries. The crusade against out-relief, an attempt to stop all payments to applicants outside of the workhouse in the 1870s and 1880s, initiated by the inspectorate, pushed more people into workhouses. During this time, the problems associated with the workhouse at night came to prominence and the employment of adequately trained nurses was seen as a major way in which the sick and vulnerable could be cared for, protected and supported. Further revelations by the British Medical Journal in the mid-1890s highlighted the continuing problems of using paupers as nurses and the inadequate care provision within rural unions. In 1892 Dr Arthur Downes, the Local Government Board’s medical inspector wrote to unions calling for the end to paupers giving care and advocated the employment of trained nurses for the sick in workhouses. This advice was reiterated by the Board in 1895. In 1897, unions were instructed to stop using paupers as nurses for the sick.
The Workhouse at Night
By the end of the nineteenth century textbooks of nursing emphasised the crucial role of night nurses in the treatment and care of hospital patients and the need for trained and experienced nurses in the wards. In earlier times, the night was seen as both a time of fear and one of opportunity, particularly for those who had less than honest intentions. Thus this excerpt from a devotional prayer from Germany: ‘The night, the ways of hell, the time of Satan’s reign’ probably sums up what many felt about the workhouse at night under the New Poor Law as there is sufficient evidence to show that, the sick and other vulnerable groups were subject to indifference, neglect, cruelty and incompetent care from its inception in 1834 to the beginning of the First World War in 1914. These problems were not confined to the physical and mental welfare of the inmates but also the moral dangers that were said to be associated with the workhouse. In particular, the corrupt influence of the adults in the workhouse was used as a reason to remove children to other facilities or to enforce strict segregation within workhouses. The existence of amoral practices was thought to occur as a result of housing decent (but poor) people with the depraved and the degraded. An account by James Greenwood, a journalist, describing a night in the casual or vagrant wards of the Lambeth workhouse was published in the Pall Mall Gazette, in early 1866, indicating that homosexuality was rife. This caused a sensation and reinforced the idea of the workhouse as a dangerous place for the vulnerable. Inspectors’ reports in the following year indicate that it was not uncommon for children to mix with adults, even at night. In one instance, Inspector R B Cane reported that two men and two boys slept together in one bed in the ‘itch’ (scabies) ward at the Preston workhouse in Lancashire. He described the workhouse as wholly unfit for purpose and his visit as ‘one of the most distressing and repulsive’ he had ever made to a workhouse.
Evidence of the issues associated with workhouses is available in the records of local guardians, the central authority (Poor Law Commission (PLC), 1834-1847; Poor Law Board (PLB), 1848-1871; and Local Government Board (LGB), 1871-1919) and reports in professional journals and from national and local newspapers. In the latter, scrutiny that came from coroners and their juries was widely publicised to demonstrate what was seen as a dangerous environment and the poor care offered within workhouses. What then threatened the welfare of the inmates who were sick, infirm, mentally ill or intellectually impaired?
The problem for the Poor Law authorities was that no-one envisaged that workhouses would end up being, essentially, facilities for the elderly, infirm, sick and the insane by the end of the nineteenth century. Edwin Chadwick, one of the principal authors of the Poor Law Commission’s Report, had proposed that separate buildings for the different classes of paupers, including the sick, should be built. However, the reality of the situation in which guardians baulked at the cost, coupled with the central authority’s inability to compel boards of guardians to build new facilities, meant that unions utilised existing buildings or decided to construct new, all-purpose workhouses. Many of the former were deemed not fit for purpose in subsequent visits by government inspectors. In some places the creation of unions allowed for larger workhouses to be built where internal segregation of the different classes of paupers could take place. Nationally, the construction of workhouses or specialist facilities such as wards for the sick can be seen to proceed in stages.
Following a phase of building all-purpose workhouses from 1835 onward, the period after 1866 saw the building of specialist accommodation for the different categories of paupers, including sick, fever and lying-in wards. Large-scale building of purposely designed infirmaries, separate from the workhouse, proceeded in many unions of which those in London, Manchester, Birmingham and other sizeable towns were the largest and most resembled the voluntary hospitals in terms of facilities, management and staffing. However, not all accommodation for the sick was seen as being of such envious quality. As late as 1895 the Truro workhouse infirmary, in Cornwall, was said to be in a poor state made up of a large number of small rooms, where the bedsteads were unsatisfactory and there was no supply of hot water to the infectious ward. This was a common occurrence, as many workhouses had poor accommodation for the sick with insufficient space between beds, poor toilet facilities and equipment, unsuitable bedding, sparse linen supplies and a lack of hot water.
These were hardly appropriate facilities for the sick but how did the buildings affect care during the night? The physical layout, in some instances, adversely affected the care of the sick. Those patients who were some distance from the resident workhouse officers had difficulty in summoning help during the night. Often there were no night nurses and the inmates were either left to themselves or a pauper attendant slept within the same room. More than likely inmates were locked in their sleeping accommodation with no communication system such as a bell to summon help. Charles Dickens reported, in 1867, that the pauper night attendant, in a Staffordshire workhouse, slept in a room which was separated from the nurse’s bedroom ‘by a stone staircase, three thick doors, a substantial flooring, and a lock and key at night’. There was no bell and if he needed help, he was expected to climb the stairs, traverse a long corridor and kick at a door to wake the nurse. This may sound like sensational journalism but in 1884 at the Fir Vale workhouse, Sheffield, a man fell ill and the male nurse was summoned by the other patients, by means of a bell. He slept in a room at one end of the building whilst the ward was at the other. He had to get dressed and unlock a number of doors and he arrived in the ward some ten to fifteen minutes later by which time the patient was dead.
Lighting was also something that troubled inspectors and coroners’ juries alike. Although the 1847 Consolidated Order first stipulated the duties of paid nurses, including keeping a light burning at night this was often ignored or the lights were often inadequate. In 1859, inmates at an inquest into the death of a woman in the night at the Chelsea workhouse complained that the pauper attendant refused to provide a light or call for help. The jury lamented that she died in the dark without medical attendance. Similarly, in 1892, a coroner’s jury, which had passed a verdict of manslaughter on a ward attendant who had beaten a partly paralysed inmate to death in the Totnes workhouse, complained that in order to view the body they had to walk along passages that were completely dark and as strangers they could not find their way. This lack of light, common in many small workhouses, together with the poor quality of night attendance undoubtedly contributed in a failure to properly observe the sick at night. This is supported by reports documenting the discovery of inmates being found dead in bed in the morning, including a number of epileptic inmates who had obviously had seizures and had suffocated, unknown to anyone in authority.
The system of classifying paupers potentially threatened their safety. Newly admitted paupers were often placed in probationary or receiving wards until they had been seen by the medical officer and classified as able-bodied or not. In November 1876, a single woman was admitted to a ward of the Birmingham Workhouse, in labour. Although she was told that someone would check on her during the night, no-one came. The baby was born and the other inmates attempted to alert the night watchman by shouting and knocking at the door. The child was found dead in the morning. It was later revealed that the call bell had not worked for two years. This was described as a ‘painful picture of workhouse mismanagement’ and a subsequent coroner’s jury found that the officials and guardians on the visiting committee had been neglectful in their duty. A similar incident occurred in in January 1903 in the Malton Workhouse, Yorkshire, when a man was placed, on his admission, in a refractory cell under the impression he was drunk. He was found dead the next morning, attributed to ‘exposure to cold and want of nourishment’, in other words hypothermia. The Workhouse master was reprimanded for a grave error of judgement in not calling for a medical examination.
The split in responsibility for the sick poor between the workhouse master and the medical officer could work against the interests of paupers admitted to the workhouse in need of medical care. The master and the medical officer of the Stratford-upon-Avon union resigned in 1870 as neither had dealt adequately with an acutely sick pauper who remained in a receiving ward with her child for three days and nights without any attention. She was found dead early one morning and the master had then altered the death register to try and cover up his mistakes. The use of padded wards for containment of patients with challenging behaviour or for the protection of those with epilepsy also contributed to problems. In 1858 a nurse in Birmingham workhouse confined an epileptic inmate to a padded room and forgot to tell the night nurse. The patient was found dead in the morning. A similar outcome happened in Liverpool in 1876 where a man said to be suffering from delirium tremens should have been observed every hour but was left in a cell for eight hours overnight. These were not isolated occurrences.
If the possibility of getting attention at night within the workhouse was difficult, those on the outside trying to obtain admission because of medical emergencies also had problems as many workhouses in small towns and rural areas employed no one to man the entrance at night. In 1893, the Chesterfield Board of Guardians debated the necessity of having an external bell to summon the porter after one urgent case of illness and another of impending birth were unable to gain access because nobody within the institution could be woken.
Attendance on and care of the sick
Lack of medical and skilled nursing attendance was probably the most serious cause of harm to the sick in the workhouse at night. Poor Law medical officers, in the main, were part-time appointments and as such the workhouse medical officer was not available most of the time. Doctors operated in a competitive market and in order to survive financially, many medical officers took on low paid appointments for local poor law unions. Their goal was to establish a private practice and their poor law duties, whilst giving a regular income, often took second place in their order of priorities which accounted for many medical officers neglecting to visit their pauper patients in a timely manner. As virtually all workhouse medical officers were not resident, calling in a doctor at night was often problematic. In May 1887, a message sent to the medical officer of the Birkenhead workhouse, in the middle of the night, failed to persuade him to travel the four miles from home; the patient died before he attended at 10 o’clock the next morning. Even if there was a resident medical officer it is not certain that he could deal with the sheer number of patients in a large workhouse: a coroner’s jury criticised the ‘disgraceful’ state of the Lambeth workhouse in London in 1902, when an inmate was discovered one morning, having died some seven hours before. The resident medical officer in this case had to cover 1550 beds.
However, the lack of nurses at night was probably a greater problem. In 1890 the body of a young woman was found dead in bed in the morning at the Burton-on-Trent workhouse: there was one night nurse, a 72-year-old inmate, who had three wards consisting of 40 beds each. In the Oldham workhouse there was one trained night nurse and six pauper nurses for over 230 patients in three different blocks, when in 1894, a patient with suicidal tendencies threw himself from a third-floor window. During the same night, the nurse, said to be distressed by the incident, gave a patient atropine instead of whisky and the inmate died shortly afterwards. It transpired that the nurse worked twelve hours every night other than ten hours on a Sunday. The coroner called for action by the guardians to increase the nursing staff at night.
If there was no workhouse medical officer or head nurse available then other officers stepped in and made decisions about what should happen to those inmates who became sick, suddenly deteriorated or were admitted in the night; this was often the workhouse master, being the most senior resident officer. In 1873, an inquiry by the LGB into the death of a patient from smallpox at the Warwick workhouse concluded that the master should not have allocated his care to another inmate, who was said to be ‘quite unfit to have the charge night and day of a case requiring skilful nursing’. Officers were also accused of cruel treatment. In 1882, paid officers at the Shardlow union workhouse in Derbyshire tied two patients, who had diarrhoea and were apt to wander, to their beds: their wanderings inconvenienced the officers in the night. The patients were left in this position for ten hours over night on several occasions and both died within a month. A committee of the guardians preferred to believe the statements of the inmates rather than the ‘general untruthfulness of the resident officers’. The master, matron, porter and his wife and the nurse were all forced to resign. Paid nurses were also implicated in cruel practices, particular in using physical violence against inmates. In Sheffield, in 1871, a head nurse was committed for trial for assaulting and killing a woman admitted in a ‘violent state of lunacy’. In 1889, a pauper who died at night from a head injury in a ward of the Foleshill workhouse near Coventry had been left under the charge of a brutal pauper, named Moore. There was said to be no firm evidence to implicate the man, but the jury, whilst passing a verdict of accidental death, stated that he was unfit to be left in charge of the ward. In 1894 another scandal was reported at the Newton Abbot Workhouse in Devon. Here the conditions and standards of care were truly horrific, as it was customary to strip the elderly and insane naked and tie them in sacks, known as jumpers, at night. Most nursing was undertaken by pauper nurses and as a result of this case the British Medical Journal initiated an enquiry into 50 workhouses finding that only six employed trained nurses at night. The rest utilised paupers as the sole means of caring for the inmates.
Pauper nurses were associated with the worst cases of abuse against their fellow inmates. Reports of violence and cruelty are numerous and at least one report per decade of an inmate being beaten to death by a pauper nurse can be found between 1840 and 1900.
Vulnerable individuals and groups were particularly in danger. Poor Law unions had a responsibility for the care of pauper lunatics, idiots and imbeciles, collectively labelled as the insane. Following legislation in 1845, county and borough lunatic asylums were built but, within a few years, many were unable to accommodate the growing numbers of inmates and, as a result, some lunatics, idiots, imbeciles and the demented elderly continued to be maintained within workhouses. Almost one quarter of those classed as insane on 1 January 1871, in England and Wales, were maintained in workhouses. Facilities and care provided by the workhouses were inspected by the Commissioners in Lunacy. In 1895, an Inspector called the supervision given on an imbecile ward at the Coventry workhouse by two paupers as ‘almost valueless’: one of them was a blind girl and the other, an old woman aged 77, who also sat up both day and night with the inmates. In many workhouses there were specific wards for lunatics and imbeciles but in the smaller ones they were scattered throughout the house. In some cases, they were left unsupervised at night leading to some committing suicide and others resorting to violence. For instance, in 1909 James Latham admitted to the Brownlow Hill workhouse in Liverpool attempted to cut his throat with a razor but succeeded in killing himself by jumping out of a window some 30 feet from the ground. It was reported that there had been six such cases in the previous fifteen years and that the guardians had considered putting bars across the windows but felt that it would give the place too much the appearance of a prison. In 1881 a coroner in Sunderland criticised the guardians for allowing both a suicidal man and violent lunatic to be left under the supervision of other insane inmates, while in another case the death of pauper lunatic Fred Rawle, caused by a beating inflicted by three unidentified inmates in a lunatic ward of the Kingsbridge Workhouse, Devon, occurred at night in late December 1896. Lack of supervision and security also resulted in some insane inmates escaping from secure accommodation. In two cases men escaped through the small windows of cells: one, a demented half naked man in Liverpool, was found to be dancing on the roof of the workhouse in the middle of the night in April 1896, whilst in 1913 another escaped from the Nantwich workhouse and was discovered naked and covered in lacerations amongst the railway lines at Crewe, some four miles away.
All of these incidents could be seen as examples of what workhouse reformers, such as Louisa Twining, Florence Nightingale and Dr Milson Rhodes, claimed to be the problems associated with a lack of trained nurses in workhouses. In 1895, the Countess of Warwick, an elected guardian for the Warwick Union, put the case for the appointment of a night nurse at the workhouse infirmary to replace care by the inmates. She described the practice of using paupers as night nurses as ‘a pick among life’s failures’ which would hardly produce the most ‘promising recruits for the post of assistant nurse.’ These, she said, were people with no sense of responsibility and this quality could not be ‘developed in the infirmary, hence they can never be trustworthy attendants on the sick.’ The Countess had visited the Reading Infirmary and had consulted widely before proposing the changes, which after much discussion were approved.
It was not just the influential who intervened. By the end of the century working class people began to exert their influence upon the decisions of the guardians. In September 1895, political and social groups representing working people within Coventry (including the Social Democratic Federation and the Independent Labour Party) attended a public meeting to protest at the decision of the Coventry poor law guardians not to appoint a night nurse for the workhouse infirmary. The issue had been first raised by the LGB two years earlier, but after some deliberation a majority of the guardians rejected the request and in July 1894 an appointment again was thought not to be necessary at that time. Debate ensued the following year with some guardians commenting on untoward scenes occurring in the wards of the infirmary at night, yet a motion to employ night nurses was not carried, nor was a further motion in September 1895. This was essentially an issue of cost which the majority guardians felt was unnecessary, claiming that the workhouse medical officer, the day nurses and the patients themselves were not asking for a change in policy. It was at this point that the working-class groups intervened. A letter from the Independent Labour Party stated that ‘the alleviation of suffering and poverty is of a higher importance than mere shillings and pence’. This stance was supported by a sizeable number of guardians including the female members of the Board. Finally on 23 October the Coventry guardians gave in to demands and voted to provide a night nurse, after two years of bickering and debate. This example illustrates how important the issue of caring for the sick, the infirm, the insane and other vulnerable groups had become and how public opinion had begun to demand improvements in the care of patients within the workhouse.
National reformers wished to put poor law nursing on a par with that in the voluntary hospitals, in that they proposed to have the control of nursing taken out of the hands of the workhouse matron, a woman who more than likely had no nursing experience, and to be placed under the control of a trained head or superintendent of nursing. To them sick wards or infirmaries attached to workhouses were hospitals and as such should be under the control of doctors and nurses not, in their opinion, poorly educated and ignorant officials. They regarded the system based upon the principles of less-eligibility and the strict conditions in the workhouse as totally alien to the concept of caring for the sick. They pointed to the relatively new infirmaries that were separately administered from the workhouse in in the large towns and cities, as examples of what should be provided for the sick-poor.
In contrast many guardians, particularly in rural districts did not share this vision. Their conception of the medical service they should offer was that which was within limits that the law stipulated, and the resources that ratepayers were prepared to spend. When a debate about appointing a trained night nurse in the Aylesbury workhouse took place in 1900, one guardian asked ‘how many ratepayers can afford the luxury of a trained nurse when sickness invades their houses?’ and he hoped that a committee of investigation would ‘not recommend any further addition to the burdens already pressing on the ratepayers.’ This type of attitude meant many small and rural workhouses were in poor repair and did not have appropriately modern facilities to care for the sick and infirm. In 1904 the LGB objected to the proposals of the guardians of the Atherstone Union, Warwickshire, who wanted to build a new boardroom. The LGB thought that there was a pressing need for new accommodation for the sick, not improved comfort for the guardians. And as late as March 1914 the LGB’s architect reported that the workhouse in Honiton, Devon, was damp, the roof was leaking, there was no hot water system, and that the hospital had no appropriate sinks or modern toilet facilities making the nursing of patients very difficult. The guardians deferred a decision to repair or replace the workhouse.
The status quo was supported by the Poor Law Officer’s Journal which castigated the interference of the reformers and claimed that many poor law infirmaries were better equipped than their voluntary hospital counterparts. In addition, they excused the continuation of ‘old methods’ in rural areas as these were the standards that were tolerated by the local ratepayers. It was claimed that the presence of the workhouse matron prevented medical experimentation and injected common sense into the operation of the workhouse. Thus, representatives of the paid officials believed in a different version of care in the workhouse.
By the 1890s the LGB was pressing guardians to improve the care of the sick and although it would seem that there was an intense level of scrutiny of unions from the central authorities, local boards of guardians had a lot of leeway to decide whether to act upon guidance. Historian, Kim Price, claims that apart from the first few years of the PLC and the first two decades of the LGB, the central authority did relatively little to challenge the decision of boards of guardians in the local administration of the poor law. A reading of the minutes of boards of guardians does provide instances, such as an example from the Nuneaton Union, in 1879, where the LGB decided it would approve the appointment of a nurse, although Mary Harris ‘could not read the written instructions of the Medical Officer’. As a result, they missed an opportunity to impose standards on the care offered in the workhouse. Advice given to boards of guardians to stop using paupers was ignored by most. It wasn’t until orders issued in 1897 and 1913 put nursing on a different footing, preventing the use of pauper nursing and insisting on the employment of trained nurses and superintendents in order to offer a greater quality of care for the sick and vulnerable.
This article has identified the care of the sick and vulnerable at night in the workhouse as problematic, as a result of the unsuitability of buildings and facilities, the use of pauper nurses and the resistance to employing trained nurses at night. Although, the poor law authorities had powers they could not compel local unions to spend money on extra staff or new facilities. Instead the inspectors had to persuade local boards to adopt new ways of working. They had difficulty in effecting any change in many unions. This was particularly a problem in London but also in the north of England where hostility to the Poor Law Amendment Act was greatest. Many local boards were made up of guardians who were elected on the promise of not increasing the tax burden. Thus any increase in staffing or improvement in accommodation were resisted, or went ahead only if it was required by law. The general public was ignorant of the workings of the poor law and many saw the poor as feeding off the resources of industrious people. There are instances of guardians right up to 1914 resisting the employment of trained nursing staff in workhouses because the majority of the voting public would not have been able to afford a nurse in times of need. Workhouses were closed institutions and many people were not aware of the conditions within them and especially the situation at night. As one judge, sentencing an assistant nurse for manslaughter at the Chester workhouse, remarked ‘they seldom got to know what happened in places of this kind’.
The philosophy behind the establishment of the new regime in 1834 made conditions within workhouses deliberately hostile for the able bodied. The principle of less-eligibility made conditions just as bad as for those who were ill or in need of care, as for able-bodied inmates. The workhouse environment was under the control of staff (master and matron) who more than likely were not aware of the needs of the sick; they allocated able-bodied paupers to undertake tasks within the workhouse including nursing and they controlled resources needed by paid nurses such as linen, towels, food, stimulants and so on. Many were seen as an obstacle to the care of the sick and there are a number of instances of clashes between masters and matrons and their nurses as the century progressed. The poor law medical officer was also potentially problematic for nursing. The workhouse doctors, with little incentive to invest time in the care of these patients, often did not consider the quality of care provided within the workhouse or advocate change in the nursing arrangements. Resident doctors aside, they would rarely visit the sick wards at night, so they too were probably ignorant of the treatment to which the sick were subjected.
With hindsight it is easy to identify the solution to the problem of care in the workhouse at night – employ more and better nurses. This is exactly what the Lancet Inquiry in the 1860s advocated. However, even if this policy had been adopted there were just not enough trained or experienced nurses available. Although the practice of employing paid nurses was established by 1870 and more were employed with development of new wards and infirmaries, the problem of staffing remained an issue right up to the First World War and beyond. This was not just an issue of resources but an attitude of mind in which the deterrence of the workhouse applied to the sick as well as the able-bodied.
 Brian Abel-Smith, The Hospitals, 1800-1948 (London: Heinemann, 1964), 46. For most of the nineteenth century the sick poor were able to access in-patient health care through one of two institutions, depending on their status. Voluntary hospitals were charities dependent upon donations and subscriptions to fund treatment for poor working people. They concentrated upon curable, acute conditions and patients had to be referred by a subscriber. The first voluntary hospital was established in the early eighteenth century and their number grew rapidly over the next 150 years . Sick paupers (people who could not support themselves and therefore were forced to rely on poor relief) would not as a rule be admitted to voluntary hospitals, but would receive their health care through workhouses and their associated infirmaries.
 Anthony Brundage, The English Poor Laws, 1700-1930 (Basingstoke: Palgrave, 2002), 75-81.
 Poor Law Commission Ninth Annual Report of the Poor Law Commissioners (London: Charles Knight & Co, 1843), 154-156; Chris Upton, The Birmingham Parish Workhouse, 1730-1840 (Hatfield: West Midlands Publications, 2019), 134-53; Kevin Siena, ‘Contagion, Exclusion, and the Unique Medical World of the Eighteenth-Century Workhouse: London infirmaries in their widest relief’, in Medicine and the Workhouse, ed. by Jonathan Reinarz and Leonard Schwarz (Rochester: University of Rochester Press, 2013), 20 & 24.
 Samantha Williams, ‘Caring for the Sick Poor: Poor Law Nurses in Bedfordshire c1770-1834’ in Women, Work and Wages in England 1600-1850, ed. by Penelope Lane, Neil Raven and K. Snell (Woodbridge: Boydell, 2004), 141-69; Jeremy Boulton, ‘Welfare Systems and the Parish Nurse in Early Modern London’, Family and Community History 10/2 (2007), 127-51; Steve King, ‘Nursing Under the Old Poor Law in Midland and Eastern England, 1780-1834’, Journal of the History of Medicine and Allied Sciences 70/4 (2015), 588-622.
 Poor Law Commission, Consolidated General Order, 1847. Reprinted in Peter Higginbotham, The Workhouse Encyclopedia (Stroud: History Press, 2012), 422-56.
 Samantha Shave, ‘“Immediate Death or a Life of Torture Are the Consequence of the system”: The Bridgewater Union Scandal and Policy Change’, in Medicine and the Workhouse ed. by Jonathan Reinarz and Leonard Schwarz (Rochester: University of Rochester Press, 2013), 164-91; Ian Anstruther, The Scandal of the Andover Workhouse (London: Bles, 1973).
 Janet E Grenier, ‘Twining, Louisa (1820–1912)’, Oxford Dictionary of National Biography, Oxford University Press, 2004 [http://www.oxforddnb.com/view/article/38083].
 Monica E Baly, Florence Nightingale and the Nursing Legacy, (London: Whurr, 1997), 84-102.
 J. M. Rhodes, ‘Nursing in Workhouse Infirmaries’, British Medical Journal, 18 August 1894, 387-88.
 ‘The Lancet Commission on Workhouse Infirmaries’, The Lancet, 1 July 1865, 4.
 British Parliamentary Papers (BPP), Metropolitan Workhouse Infirmaries. Report of Dr Edward Smith, Medical Officer to the Poor Law Board, on the Metropolitan Workhouse Infirmaries and Sick Wards, 1866. BPP, Provincial Workhouses. Report of Dr Edward Smith, Medical Officer to the Poor Law Board, on the sufficiency of the existing arrangements for the care and treatment of the sick poor in forty-eight provincial workhouses in England and Wales, 1868.
 Alan Kidd, The State and the Poor (Basingstoke: MacMillan, 1999), 52-3.
 E. Hart (ed.), The Sick Poor in Workhouses (reprints from the British Medical Journal), 2 volumes, (London: Smith, Elder & Co., 1894 & 1895).
 Rosemary White, Social Change and the Development of the Nursing Profession: a study of the Poor Law Nursing Service, 1848-1948 (London: Henry Kimpton, 1978), 78-82.
 See for instance: Catherine Jane Wood, A Handbook of Nursing for the Home and Hospital (London: Cassell, Petter & Galpin, 2nd Edition, no date), 121-7; Eva C E Luckes Lectures on General Nursing (London: Keegan, Paul, Trench, Trubner & Co., 4th edition,1892), 43-4.
 A. Roger Ekirch, At Day’s Close: A History of Night-time (London: Weidenfield and Nicholson, 2005), 140.
 Frank Crompton, Workhouse Children (Stroud: Sutton Publishing, 1997), 33-44.
 Seth Koven, Slumming: Sexual and Social Politics in Victorian London (Princeton: Princeton University Press, 2006), 26-40.
 British Parliamentary Papers, Reports by Poor Law Inspectors on Workhouses in their Districts, in pursuance of Instructions, October 1866. (House of Commons, Vol 61, December 1867), 389-92.
 Brundage, The English Poor Laws, 76.
 Felix Driver, ‘The Historical Geography of the Workhouse System in England and Wales, 1834-1883’, Journal of Historical Geography, 15/3 (1989), 269-86.
 See for instance: British Parliamentary Papers, Report of the Committee Appointed to Consider the Requisite Amount of Space and Other Matters, in Relation to Workhouses, and Workhouse Infirmaries (London: Eyre & Spottiswoode, February 1867); The Lancet Sanitary Commission, Reports of the Commissioners on Metropolitan Infirmaries (reprints from the Lancet), (London: The Lancet, 1866); Hart, The Sick Poor in Workhouses.
 Charles Dickens, ‘Another Workhouse Probe’, Household Words, 7 December 1867, 560.
 ‘A Peculiar Case’ Sheffield Daily Telegraph, 4 December 1884, 6.
 ‘Chelsea Workhouse’, Holborn Journal, 17 September 1859, 3.
 ‘The Alleged Ill Treatment at Totnes Workhouse’, Exeter and Plymouth Gazette, 26 January 1892, 5.
 ‘Workhouse Mismanagement’, British Medical Journal, 18 November 1876, 659.
 ‘Malton Workhouse Scandal’, Hull Daily Mail, 5 January 1903, 2.
 Shakespeare Birthplace Trust (SBT) DR252/7 Stratford on Avon, Guardians’ Minute Book, 30 April 1870.
 ‘Extraordinary death at the workhouse of a female epileptic pauper’, Birmingham Daily Post, 18 January 1858, 2.
 ‘Neglect of a Workhouse Officer’, Edinburgh Evening News, 29 December 1876, 4.
 ‘Chesterfield Board of Guardians’, Derbyshire Times and Chesterfield Herald, 21 March 1893, 3.
 Kim Price, ‘The Shape of the Iceberg: Doctors and Neglect Under the New Poor Law’, in Complaints, Controversies, and Grievances in Medicine: Historical and Social Science Perspectives, ed. by Jonathan Reinarz and Rebecca Wynter (London: Routledge, 2015), 133.
 ‘Complaint Against a Workhouse Medical Officer’, Liverpool Mercury, 21 May 1887, 8.
 ‘Death in Workhouse: Singular Story’, Nottingham Evening Post, 28 August 1902, 3.
 ‘A Board of Guardians Censured’, Gloucester Citizen, 3 September 1890, 3.
 ‘Workhouse Revelations’, Derby Daily Telegraph, 11 August 1894; ‘Singular Poisoning Case at Oldham’, Manchester Courier and Lancashire General Advertiser, 13 August 1894, 8; ‘The Nurse Scandal at Oldham’, Daily Gazette for Middlesborough, 17 August 1894, 3.
 Warwickshire Records Office (WAR) CR0051/1595 Warwick Poor Law Union Guardians’ Minute Book, 8 November 1873
 ‘Alleged Cruelty of Workhouse Officials’, Nottingham Evening Post, 16 May 1882, 2.
 ‘The Tying-Down of Sick Paupers at Shardlow Workhouse’, Nottingham Evening Post, 31 May 1882, 3.
 ‘Charge Against a Workhouse Nurse’, Western Times, 1 December 1871, 2.
 ‘Foleshill: Mysterious Death at the Workhouse’, Leamington Spa Courier, 7 September 1889, 8.
 ‘A Serious Workhouse Scandal’, Weekly Dispatch, 1 April 1894, 11.
 Hart, The Sick Poor in Workhouses.
 The term lunatic was used for those who had some form of mental disturbance or illness, whilst those with intellectual impairment were labelled idiots or imbeciles. The distinction between the latter two terms was not precise but idiot was usually applied to those with a fundamental disability, usually thought to be congenital. See Higginbotham, Workhouse Encyclopedia, 171-3.
 Leonard Smith, ‘A Sad Spectacle of Hopeless Mental Degradation”: the management of the insane in West Midlands workhouses, 1815-60’, in Medicine and the Workhouse, ed. by Reinarz and Schwarz, 113.
 BPP, Poor Rates and Pauperism. Return (E) Insane Paupers on 1st January 1871, 1871, 3.
 Stuart Wildman, ‘He’s only a pauper whom nobody owns’: caring for the sick in the Warwickshire Poor Law Unions, 1834 – 1914, Dugdale Society Occasional Papers, Number 53 (Stratford-upon-Avon: The Dugdale Society, 2016), 35.
 ‘Leap to Death at Workhouse’, Lancashire Evening Post, 22 October 1909, 5.
‘Echoes of the Week’, Sunderland Daily Echo and Shipping Gazette, 21 March 1881, 3; ‘Lunatic Beaten to Death in a Workhouse’, Derby Daily Telegraph, 1 January 1897, 4.
 ‘Workhouse Nursing’, Coventry Herald, 1 March 1895, 6.
 ‘Important Question of Night Nursing’, Leamington Spa Courier, 2 March 1895, 3.
 ‘The Guardians Indignant: The Nursing Question’, Coventry Herald, 20 September 1895, 8; ‘The Nursing Question’, Coventry Herald, 4 October 1895, 8; ‘The Night Nursing Question’, Coventry Herald, 18 October 1895, 6.
 ‘A Night Nurse’, Coventry Herald, 7 July 1893, 5; Coventry History Centre (CHC) SLA/6/1/17 Coventry Poor law Union: Guardians’ Minute Book, 26 June 1894.
 ‘Coventry Union: Night Nursing’, Coventry Herald, 28 June 1895, 8.
 CHC SLA/6/1/18 Coventry Poor law Union: Guardians’ Minute Book, 14 September 1895.
 Coventry Herald, 20 September 1895, 8.
 ‘Aylesbury Board of Guardians’, Bucks Herald, 27 January 1900, 6
 WAR CR0051/121, Atherstone Poor Law Union, Guardians Minute Book, 23 August 1904.
 ‘General Complaint’, Western Times, 30 March 1914, 2.
 ‘Nursing Associations and Their Work’, Poor Law Officer’s Journal, 10 September 1897, 524.
 Kim Price, Medical Negligence in Victorian Britain: the crisis of care under the English Poor Law, c1834-1900 (London: Bloomsbury, 2015), 9.
 WAR CR0051/303 Nuneaton Poor Law Union Guardians’ Minute Book, 9 June 1875.
 ‘Cruelty at Workhouse’, Portsmouth Evening News, 3 November 1894, 3.