Medical care was available in poor law institutions prior to the introduction of the New Poor Law in 1834. However, as Alistair Ritch argues in this recent and ground-breaking study, medical care became more prominent within the workhouse after this date. Whilst the workhouse was a relatively small aspect of pauper medicine within the New Poor Law, it was ‘the most important form of institutional provision for the sick poor’ (p. 220) prior to the First World War. In order to demonstrate this, Ritch uses themes such as acute illness and disability, fever patients and their segregation, the disorderly patients, the physicians and nurses who attended the sick, and medical therapies. Throughout, Ritch focuses on the workhouses of Birmingham and Wolverhampton, with occasional references to other workhouses, in order to place these two institutions within the national context.

Beginning with a discussion of acute illnesses and chronic disability, Sickness in the Workhouse shows how those with conditions often thought exempt from workhouse care were, in fact, treated within the institutions. Similarly, fever and smallpox wards were set up within the workhouse, providing an element of isolation along with spaces for those with infectious childhood diseases such as whooping cough, scarlet fever and measles, and for those suffering from conditions such as puerperal fever, diarrhoea and ‘dirt diseases’, such as typhus and typhoid fever (p. 78). With regards to admitting infectious patients, the guardians of the workhouse often had to work with town councils and sanitary authorities, which indicated the importance of the workhouses to attempt to halt the spread of infectious diseases. Workhouses were able to, and did, make their medical facilities available to nonpaupers: they often acted as a type of isolation hospital prior to such institutions being established by local governments.

Ritch shows that, in addition to being a place of importance for those with infectious diseases, the workhouse also treated individuals who demonstrated challenging behaviours, due to either physical or mental disabilities. Patients suffering with venereal diseases, particularly syphilis, were also treated within the workhouse in the same way as those suffering from fevers, smallpox and other medical conditions. The workhouse did not appear to discriminate against these patients, although, as Ritch points out, these patients were often restrained as a result of their violent behaviour: ‘mechanical restraint and seclusion were employed not only to control behavioural disorder in mentally ill patients, but generally to punish any form of bad behaviour or dissent by any of the inmates’ (p. 123). Therefore, there was a fine line between treatment and punishment within the workhouse as the Medical Officer had the dual role of disciplinarian and caregiver.

Alongside the provision of general medical care, the specific care provided within the workhouse union, and the ideas of the union’s guardians, are now considered to be the forerunners to a number of ground-breaking medical therapies. Epileptic patients were considered to be dangerous and challenging, but changes in treatments used for epilepsy at the beginning of the twentieth century modified such views. Epileptic patients were increasingly able to move around the ward with a little more freedom and could be engaged in work, as they were in Birmingham. In 1904, Birmingham led the way with the first epileptic colony at Monyhull to the south of the city. Suitable patients were moved from the workhouse to the colony which became ‘a pioneer in the care of people with what is now called learning difficulties and was copied by authorities all over the country’ (p. 115).

Both physicians and nurses were hired to attend to the sick within the workhouse, and this occurred in all poor law institutions around the country. In Birmingham and Wolverhampton, there was concern that the physicians in attendance at the workhouses were not there for the benefit of their patients. Ritch, however, argues that whilst this was the case for some, particularly in the earlier part of the period under consideration, many of the physicians were in fact highly committed to their work. In contrast, the nurses hired to care for poor law paupers were more difficult to keep in their jobs. The work was hard and turnover was high, but some nurses did remain in post for most of their working lives.

Overall, this is an excellent book, which places the workhouse in the broader context of medical care in the period 1834–1914. It provides a detailed examination of a variety of factors involved in workhouse medicine in the nineteenth and early twentieth centuries. This work places the medical care for society’s poorest at the forefront and reminds us of the importance of institutional care in the development of the history of medicine. This will be a valuable text for students and academics engaged in the history of medicine in the Victorian and Edwardian periods as well as those interested in institutional history more generally.