Chapter XIII: Act 1898: ; or (iv.) a parent of the child has been sentenced to (1)

imprisonment in respect of any offence against any of his or her children; or (v.) a parent of the child is permanently bedridden or disabled, and is the inmate of a workhouse, and consents to the resolution hereinafter mentioned; or (vi.) both the parents (or in the case of an illegitimate child, the mother of the child) are (or is) dead; the guardians may, at any time, resolve that until the child reaches the age of eighteen years, all the rights and powers of such parent as aforesaid, or, if both parents are dead, of the parents, in respect of the child shall, subject as in this Act mentioned, vest in the guardians." Penalties were also enacted against any person who shall knowingly assist or induce any child adopted by the guardians to leave their control. If any child maintained by the guardians is, with their consent, adopted by some other person, their responsibility for the child does not at once cease, for they are required, during three years after the date of the adoption, to cause the child to be visited at least twice a year, by some person appointed by them for the purpose; and they have the power, if they see fit, to revoke their consent to the adoption, and reassume custody of the child.[658]

[658] Poor Law Act, 1899, 62 & 63 Vic. c. 37, secs. 1-3.

Some boards of guardians--often on the suggestion of the inspectorate--promptly made use of their new powers. On 1st June 1902, the number of children already adopted up to that date was no fewer than 7724, of whom 1503 were then over fifteen.[659] It is to be noted that, though the powers are applicable to all pauper children, the Central Authority has not suggested their use except in respect of the children in Poor Law institutions (including, however, the "ins and outs"),[660] together with those technically "boarded out," or in certified schools; and we do not find that they have ever been made use of for any of the children maintained by the guardians on outdoor relief, however disastrous is their upbringing.

[659] Thirty-second Annual Report, 1902-3, pp. lxii-lxiii.

[660] _Decisions of the Local Government Board_, 1903-4, by W. A.
Casson, 1905 p. 45.

_E._--THE SICK

We broke off the description of the policy of the Central Authority with regard to the sick with the suggestive quotation from the Annual Report of the Poor Law Board in 1870, over Mr. Goschen's signature. "The economical and social advantages," said the last President of the Poor Law Board, "of free medicine to the poorer classes generally as distinguished from actual paupers, and perfect accessibility to medical advice at all times under thorough organisation, may be considered as so important in themselves as to render it necessary to weigh with the greatest care all the reasons which may be adduced in their favour."[661]

[661] Twenty-second Annual Report of the Poor Law Board, 1869-70,
p. lii.

(i.) _Domiciliary Treatment_

So far as published documents go, we cannot find that any inquiry was made by the Local Government Board (at any rate on its Poor Law side) as to the advantage and feasibility of this suggestion of providing free medical assistance, under thorough organisation, to the poorer classes generally. There was no breach of continuity in the policy, begun in 1865, of transforming the provision for the sick paupers in the workhouse, into elaborately equipped, adequately staffed, and separately administered general hospitals, which were called Poor Law infirmaries. But in the general crusade against outdoor relief, initiated by the able and zealous inspectorate in 1871, there was no exception made for outdoor medical relief.[662] There was accordingly (just as we have shown to be the case in regard to widows and the aged) no limitation, corresponding to the express exceptions of the General Orders in favour of the sick, in the phrases condemnatory of outdoor relief generally, which are to be found in the Annual Reports and Circulars of these years. The inspectors, it is clear, made no distinction, in their persistent pressure against "outdoor relief," between medical and other relief, between hygienic advice and money doles. Mr. Longley, indeed, went so far as to condemn, expressly because it provided medical relief otherwise than in the workhouse, the whole system of Poor Law dispensaries which the Central Authority had itself just initiated and practically forced on the Metropolitan Boards of Guardians.[663] This report of Mr. Longley's was honoured by notice in the annual volume, and commended by the Local Government Board for "careful consideration."[664] There is, therefore, some warrant for the inference that the Local Government Board, under Mr. Stansfeld and Mr. Sclater-Booth, had not only put aside the suggestion of providing free medical attendance for the poorer classes generally, but also that it had now become the policy of the Central Authority--so far as we can discover, for the first time since 1834--to restrict, as far as possible, even such domiciliary medical attendance as was being given under the Poor Law to the sick poor.

[662] Mr. Longley, indeed, in his Report on the Administration of
Outdoor Relief in the Metropolis, seems to allude to the official
dictum of the Poor Law Board under Mr. Goschen, in favour of "free
medicine to the poorer classes generally." He sternly condemns
"any gradual drifting into a system of medical State charity," and
deprecates the fact that this tendency "has received higher
sanction than that of the prevalent belief of the poor, or even of
the practice of Boards of Guardians" (Third Annual Report of the
Local Government Board, 1873-4, p. 161).

[663] "The dispensary system should be regarded, in common with
every improved form of out-relief, not as a final object of Poor
Law administration, but merely as a means of administering with
greater efficiency that legal relief which, as I have attempted to
show elsewhere, is most safely and effectually given in the form
of indoor relief. It would, of course, be idle, and worse than
idle, to stifle all attempts to reform the administration of
out-relief, on the ground that it is desirable, and may, at some
remote period, be possible to abolish, or at least greatly to
curtail it; and no reform of the practice of relief was probably
more urgently needed, or has proved more effectual, than that now
under consideration. It must not, however, be forgotten that side
by side with Poor Law dispensaries, has grown up, also under the
sanction of the Metropolitan Poor Act, a system ... which by
encouraging and affording special facilities for the grant of
indoor relief to sick paupers, must, if the policy of the Act be
unflinchingly carried out, eventually tend ... to the gradual
abolition of out-relief to the sick, other than those incapable of
removal from their homes. If this be so, Poor Law dispensaries ...
must ultimately be found to have had for the most part a merely
temporary place in the system of relief in London.... The
character of permanence should not be hastily affixed to the
system which they represent" (Mr. Longley's Report on Indoor
Relief in the Metropolis, in Fourth Annual Report, 1874-5, pp.
41-42). In spite of this criticism, the Central Authority
continued to sanction Poor Law dispensaries. Elaborate
institutions on the London plan were established in other unions
under the general powers of the Act of 1834; _see_, for instance,
the Special Order of 9th June 1873, to Portsea Island Union; those
of 4th March and 28th August 1880, to Birmingham; those of 30th
November 1885, and 9th January 1895, to Plymouth.

[664] Fourth Annual Report, 1874-5, p. xxi.

It is, however, fair to say that this policy of restricting outdoor medical relief was not expressed in any alteration of the General Orders, nor, explicitly, in any published minute or circular of the Central Authority itself. In the 1871 Circular, discouraging outdoor relief generally, it is, for instance, merely suggested that all paupers receiving relief on account of temporary sickness--among whom there were at that date apparently some 119,000 sick persons[665]--should be visited at least fortnightly by the relieving officer.[666] The Central Authority clung to the general disqualification of paupers, even those in receipt of medical relief only, though the Parliamentary Secretary had to admit that: "No doubt the Legislature had made an exception in the cases of vaccination and of education, and it might be that the exception should be extended to infectious diseases."[667] But when it was pressed to impose a limit of one month to each grant of outdoor relief, the request was, on the cautious advice of the permanent advisers, definitely refused, lest hardship should be caused in cases of sickness; though it was said that the guardians themselves might put such a limit, "where such ... may properly be imposed."[668]

[665] _See_ the statistics in Twenty-second Annual Report of the
Poor Law Board, 1869-70, p. xxiv.

[666] Circular of 2nd December 1871; in First Annual Report of the
Local Government Board, 1871-2, p. 67.

[667] Mr. Salt, as Secretary of the Local Government Board, on
Disqualification by Medical Relief Bill, _Hansard_, 11th December
1878, vol. 243, p. 630. In 1876 the disqualification had been
explicitly re-enacted in the Divided Parishes and Poor Law
Amendment Act (39 & 40 Vic. c. 61, sec. 14), promoted by the
Central Authority itself, whose Parliamentary representatives
continued for years to resist all proposals for its abolition or
attenuation. In 1883 it was incidentally undermined by maintenance
and treatment in the infectious diseases hospitals of the
Metropolitan Asylums Board being declared not to be parochial
relief (Diseases Prevention Act 1883, 46 & 47 Vic. c. 35). Not
until 1885 did the Central Authority consent to its abolition, as
regards persons in receipt of medical relief only, in the Medical
Relief Disqualification Act 1885 (48 & 49 Vic. c. 46). Even then
the "stigma of pauperism" was preserved, by omitting to repeal
sec. 14 of the 1876 Act above cited, so that persons in receipt of
medical relief only are still nominally disqualified from voting
at an election of a Poor Law guardian, "or in the election to an
office under the provisions of any statute."

[668] Local Government Board to Chairman of Central Poor Law
Conference, 12th May 1877; in Seventh Annual Report, 1877-8, p.
55.

The Central Authority was willing to consider any proposal to amend the law, so as to allow of the compulsory removal to the workhouse of sick persons who had no proper lodging accommodation.[669] But even to a person who had refused to enter the workhouse, the guardians were not to deny outdoor medical relief if sick,[670] and in no case were the sick to be removed from their homes unless certified by the medical officer as physically able to endure the journey.[671] There was thus, even between 1871 and 1885, no explicit reversal, on grounds of Poor Law principle, of the old policy which, it will be remembered, had not been condemned by the 1834 Report of outdoor relief to the sick. If a "destitute young husband or wife were sick," Mr. Sclater-Booth, speaking as President of the Local Government Board, told the House of Commons in 1876, "they would not be taken into the workhouse, but would receive outdoor relief."[672] Two years later the Central Authority actually declared itself in favour of supplying to the sick poor who were under domiciliary treatment, not only medical attendance and maintenance, but also skilled professional nursing. There was, it said in reply to influential medical pressure, "nothing to prevent the guardians supplying such assistance," and the Central Authority was even "desirous of encouraging this arrangement as much as possible," though the insufficient supply of qualified nurses was likely to "render impracticable for some time to come any general application of the system of paid nurses in the treatment of the poor at their own homes."[673]

[669] _Ibid._ p. 54.

[670] Local Government Board decision, in _Local Government
Chronicle_, 11th June 1904, p. 635.

[671] Circular of 23rd May 1879, in Ninth Annual Report, 1879-80,
p. 92.

[672] _Hansard_, 13th June 1876, vol. 229, p. 1780 (in Committee
on Poor Law Amendment Bill).

[673] Local Government Board to Dr. Mortimer Glanville (_Lancet_
Memorial on Poor Law Medical Relief Reform), 12th November 1878;
in Eighth Annual Report, 1878-9, pp. 91-2. In spite of this
official answer, we may infer a certain internal conflict of
policy with regard to these salaried outdoor Poor Law nurses.
Though the Central Authority expressed itself as "desirous of
encouraging" the experiment, we cannot find that it issued the
Order, without which no board of guardians could create a new
salaried office, for nearly fourteen years. The District Nurses
Order, which was merely permissive, and which, therefore, could
not have been delayed merely because there were, in 1878, not
enough trained nurses to supply every union in the Kingdom, was
not issued until 27th January 1892 (Twenty-second Annual Report,
1892-3, pp. 12-13). We cannot find that any "paid nurses in the
treatment of the poor at their own homes" were sanctioned before
that date. Moreover, even then, it is difficult to feel sure that
the Central Authority was still, to use its words of 1878,
"desirous of encouraging this arrangement as much as possible." In
sending the Order to boards of guardians, it accompanied it by a
circular, which can scarcely be deemed encouraging. It was of
opinion that "it can only be under exceptional circumstances that
a sick pauper, whose illness is of such a character as to require
that the services of a nurse should be provided by the guardians,
can, with propriety, be relieved at home. At the same time it
appears ... that where circumstances render it desirable the
nurses employed in such attendance should be duly appointed
officers of the guardians, having recognised qualifications for
the position, and being subject in the performance of their duties
to the control of the guardians, and the Board have consequently
decided to empower boards of guardians to appoint such officers"
(Circular of 1st February 1892; in Twenty-second Annual Report,
1892-3, p. 9). Fifteen more years have elapsed; but we do not
gather that the experiment, which the Central Authority in 1878
was desirous of encouraging, has been very strenuously pressed by
the inspectors, or the power made publicly known. The result is
that we cannot find that it has yet taken shape even to the extent
of as many as a dozen salaried Poor Law nurses for the outdoor
sick from one end of the Kingdom to the other.

(ii.) _Institutional Treatment_

Meanwhile, however, the substitution of indoor for outdoor relief in the case of the sick[674] was being supported on grounds, not of Poor Law principle, but of medical efficiency. The transformation of the workhouses into what the Poor Law inspectors themselves began to call "State hospitals" made more striking than ever the contrast between the light, clean, and airy newly-built infirmary ward, with trained nurses, a resident doctor, complete equipment, and a scientifically determined dietary, on the one hand; and the insanitary and overcrowded hovel or slum tenement, on the other, in which the sick pauper had no other food than was provided by the pittance of outdoor relief, no further nursing than his family could supply, and no better medical attendance than the grudgingly accorded order on the district medical officer could command. Quite irrespective of "Poor Law principles," the case for institutional rather than domiciliary treatment of nearly every sick case became, to the medical experts who now advised the Central Authority, simply overwhelming. "The treatment which in sickness the poor receive in workhouses constitutes," said the Central Authority in 1878, "one of the most valuable forms of medical relief. _With a considerable portion of the population, indeed, it is the only mode in which, when overtaken by sickness, their medical needs can be adequately met._"[675] This policy led not only to an incessant pressure on boards of guardians to provide the "State hospitals" which had, from 1865 onwards, been expected from the guardians of all populous unions,[676] but also to a positive encouragement of sick persons, whether or not actually destitute in the technical sense of the term, to take advantage of them. We see this first with regard to infectious diseases. The hospitals of the Metropolitan Asylums Board, maintained out of the Poor Rate exclusively for paupers, and technically only workhouses like any others, soon came to be used, free of charge, by small-pox and fever patients who were not paupers.[677] It became the official policy, well understood by the Central Authority, to get removed to these Poor Law institutions every patient, whether destitute or not, who could not be adequately isolated at home.[678] Already in 1875 the Central Authority expressly authorised the medical superintendent to admit without an order any small-pox or fever patient presenting himself, if refusal to admit might involve danger,[679] and in 1887 it expressly permitted even non-urgent cases to be admitted on the certificate of any medical practitioner.[680] Nevertheless, in 1877 the Central Authority was still taking the line that "the hospitals ... of ... the Metropolitan Asylums Board are essentially intended to meet the requirements of the destitute class, and that the admission ... of persons not in need of poor relief is altogether exceptional."[681] Two years later, however, by a statute promoted by the Central Authority itself, the Metropolitan Asylums Board were expressly empowered to receive non-pauper patients, though only under contracts with the local public health authorities, by which they were to be paid for.[682] We cannot discover which vestries and district boards, if any, entered into such contracts. Not until 1883, when these fever and small-pox hospitals had been a dozen years in use by non-paupers, was the position temporarily legalised by the Diseases Prevention Act of 1883[683]--a measure also carried by the Central Authority itself--which, whilst leaving these hospitals as Poor Law institutions, administered by a Poor Law authority, and kept up out of the poor rate, declared that admission, treatment, and maintenance therein should--whether the patients were or were not otherwise paupers--not be deemed parochial relief, or carry with it any disqualification whatever.[684] Since that day we have the remarkable spectacle of the Poor Law Authorities, Central and Local, annually congratulating themselves on the fact that, year after year, they were managing to attract into these expensive Poor Law institutions, for gratuitous maintenance and treatment, a larger and larger percentage of the total number of cases notified.[685]

[674] "The sick" were held to include not only acute cases, but
also cases of "chronic disease requiring regular medical treatment
and trained nursing" (and also venereal and skin diseases,
including the itch). (Local Government Board to Poplar Union,
October 1871; MS. Minutes, Poplar Board of Guardians, 6th October
1871).

[675] Local Government Board to Dr. Mortimer Glanville (_Lancet_
Memorial on Poor Law Medical Relief Reform), 12th November 1878;
in Eighth Annual Report, 1878-9, p. 91.

[676] The more old-fashioned guardians failed to keep pace with
the Central Authority in its ignoring of the principle of "less
eligibility" with regard to the sick; _see_, for instance, _The
New Pauper Infirmaries and Casual Wards_, by a Lambeth Guardian,
1875, in which the elaborate hospital requirements are objected to
as being far too good for paupers. Where the guardians persisted
in refusing to provide the elaborate and expensive new infirmary
accommodation considered necessary, the Central Authority at last
issued a peremptory Order requiring them to submit plans within a
month, under penalty of having plans "prepared at the expense of
the union" and of being deprived of "the benefit of participation
in the Common Poor Fund" (Local Government Board to St. Olave's
Union, June 1873; see _Local Government Chronicle_, 5th July 1873,
p. 379).

[677] For unions out of London we have to note an extraordinary
provision of 1879, proposed by the Central Authority itself.
Boards of guardians in rural districts were empowered to transfer
any of their buildings (into which only destitute persons could
legally be received) from themselves as Poor Law authorities to
themselves as public health authorities (in which case the
buildings became available, without the stigma of pauperism, for
all classes of the population) (Poor Law Act 1879 (42 & 43 Vic. c.
54, sec. 14)). We cannot discover in which cases, if any, this
provision was acted upon, and the necessary confirmatory Order
issued by the Central Authority; or what difference it made to the
buildings.

[678] This was, in effect, to hold that inability to secure
isolation, when isolation was required, amounted to destitution,
so far as this kind of medical relief was concerned, just as a man
requiring an expensive surgical operation was legally within the
definition of destitute for the purpose of the operation if he
could not pay the market price of it, even if he had ample food,
clothing, and shelter. We cannot discover, however, that this
explanation was actually given in an official document. Under it,
not merely "a considerable portion of the population," but
practically five-sixths of it would, in cases of infectious
disease, have to be deemed destitute.

[679] Order of 10th February 1875, art. 4.

[680] Circular of 8th July 1887, in Seventeenth Annual Report,
1887-8, p. 9.

[681] Circular of 2nd January 1877, in Sixth Annual Report,
1876-7, p. 33.

[682] Poor Law Act 1879 (42 & 43 Vic. c. 54, sec. 15).

[683] 46 & 47 Vic. c. 35.

[684] The Central Authority was apparently loth to accept the
situation. The statute was deliberately made only a temporary one,
expiring in a year. But it was annually renewed, and in 1891 the
provision was made permanent in the Public Health (London) Act of
that year. Meanwhile the Poor Law Act 1889 (52 & 53 Vic. c. 56,
sec. 3), had expressly authorised the admission of non-paupers,
entitling the guardians to recover the cost from the patients if
the guardians chose; but making their expenses, in default of such
recoupment, chargeable (as were the expenses of the pauper
patients) on the Common Poor Fund. We cannot discover that any
attempt was made to recover the cost from the patients; and in
1891 the very idea was abandoned.

[685] Annual Reports of the Metropolitan Asylums Board, 1889-1906.
In 1888, in anticipation of the necessary amendment of the law,
the Central Authority authorised the admission of diphtheria cases
(Local Government Board to Metropolitan Asylums Board, October
1888; _Local Government Chronicle_, 27th October 1888, p. 986;
Poor Law Act 1889 (52 & 53 Vic. c. 56, sec. 3); Order of 21st
October 1889, in Nineteenth Annual Report, 1889-90, p. 96). The
boards of guardians outside the Metropolis failed, we believe
everywhere, to respond to the invitations of the Central Authority
to provide similar accommodation for infectious diseases. In 1876
the inspector was doing his utmost, by special Order of the
Central Authority, to induce the Manchester, Salford, Chorlton,
and Prestwich Boards of Guardians to unite in establishing out of
the poor rates a hospital for infectious diseases, which should
admit non-paupers on payment (MS. Minutes, Manchester Board of
Guardians, 17th February 1876).

A similar enlargement of the sphere of the Poor Law institution has, of late years, been going on in other than infectious cases. "The poorer classes generally," to use Mr. Goschen's words, "as distinguished from actual paupers," came more and more to appreciate the practical distinction between the workhouse and the Poor Law infirmary; and, especially in the Metropolis and the large towns, the latter became more and more freely used as a general hospital.[686] This tendency was facilitated in London by the operation of the Metropolitan Common Poor Fund established by the Central Authority itself, which, from 1870 onward, bore the bulk of the cost of maintenance of the Poor Law infirmaries, as of the hospitals of the Metropolitan Asylums Board.[687] The Central Authority saw with approval the increasing attractiveness of these institutions, not only in London but throughout the country. In an official memorandum communicated to all boards of guardians in 1892, it observed that: "The sick poor can usually be better tended and nursed by skilled nurses in well-equipped sick wards than in their own homes; and the regularity, neatness, and order of the wards _tend to diminish the repugnance to entering the workhouse_, which is often evinced by the sick poor of the better class when reduced to want by failing health."[688] It did not refuse to permit them to be made use of by paying patients, where--as is usually the case in rural districts--no "non-pauper institution" was available. "If," writes the Central Authority in 1902, there is "a sick person who is in receipt of an allowance from a benefit club or similar society," and who "is unable to obtain in a non-pauper institution such treatment as the illness from which he suffers requires," the Central Authority will "offer no objection to his admission to the workhouse infirmary."[689]

[686] In 1889, for instance, the Central Authority provided that,
in cases of sudden or urgent necessity, the medical superintendent
or his assistant should admit patients on his own responsibility,
without order from the relieving officer (Special Order to Mile
End Old Town, 10th October 1889).

[687] Under the Metropolitan Poor Amendment Act 1870, the cost of
the maintenance of adult paupers in workhouses and sick asylums,
to the extent of 5d. per head per day, was thrown on the
Metropolitan Common Poor Fund. To two-thirds of the Metropolitan
unions, including all the poorer ones, this operated as a bribe in
favour of indoor (or infirmary) treatment as against domiciliary
or dispensary treatment. Mr. Longley wished to go much further. In
order practically to compel all the Metropolitan boards of
guardians to provide these elaborate and expensive hospitals, he
recommended that the whole cost of indoor maintenance of the sick,
when in infirmaries separated in position and administration from
the ordinary workhouses, should be made a charge on the
Metropolitan Common Poor Fund (Mr. Longley's Report on Indoor
Relief in the Metropolis, in Fourth Annual Report, 1874-5, p. 54).

[688] Memorandum on Nursing in Workhouse Sick Wards, April 1892;
in Twenty-fifth Annual Report, 1895-6, p. 114.

[689] Decision of Local Government Board in _Local Government
Chronicle_, 18th October 1902, p. 1051.

To those boards of guardians who clung to the policy of "deterring" the sick poor from obtaining medical relief--which, as we have shown, Mr. Gathorne Hardy had, on behalf of the Central Authority, in 1867 expressly repudiated[690]--all this official encouragement to enter Poor Law institutions seemed revolutionary. The fact that the sick poor came more and more to draw a distinction between the workhouse on the one hand, and the Poor Law infirmary or isolation hospital on the other, appeared seriously objectionable. When it was noticed that the Central Authority officially styled the separate institution for the sick "an asylum for the sick poor,"[691] or "the hospital," or simply the "infirmary,"[692] the Manchester guardians revolted, and definitely instructed their medical and relieving officers "to avoid using the word 'hospital' or 'infirmary,' and simply to use the word 'workhouse.'"[693] Other boards, we believe, insisted--although "the infirmary" was an entirely distinct institution--that it should be entered only through the workhouse itself. Against this lingering objection on grounds of Poor Law policy to get the sick cured in the most efficient way, we see the inspectorate in the later years more and more explicitly protesting. "I wish it were possible," said Mr. Preston-Thomas in 1899, "to get rid of the name of workhouse (which, by the way, has become singularly inappropriate), for I believe that it is to the associations of the name rather than to the institution itself that prejudice attaches. The disinclination of the independent poor to enter the hospitals of the Metropolitan Asylums Board, which was considerable at first, has now practically vanished, and I do not see why there should not be the same change of feeling with regard to Poor Law infirmaries in the country."[694]

[690] _Hansard_, 8th February 1867, vol. 185, p. 163; _see_ ante,
pp. 120-21.

[691] Metropolitan Poor Act 1867 (30 & 31 Vic. c. 6); Special
Order to Central London Sick Asylum District, 13th May 1873.

[692] Special Order to Lambeth, 25th August 1873.

[693] MS. Minutes, Manchester Board of Guardians, 14th August
1879. Some of the inspectors seem to have shared this objection.
As late as 1901 we find one reporting that "the admission into our
workhouse infirmaries of persons above the pauper class, and not
destitute, is, I fear, increasing" (Mr. J. W. Preston's Report, in
Thirtieth Annual Report, 1900-1, p. 97).

[694] Mr. Preston-Thomas's Report, in Twenty-eighth Annual Report,
1898-9, p. 135.

In the same spirit we see the Central Authority in these three decades persistently pressing Boards of Guardians to build new workhouse infirmaries.[695] The report becomes current in the Poor Law world that Local Government Board officers, in interviews, went so far as to say that a certain board of guardians was morally guilty of manslaughter in refusing to embark on extensive new building operations. The official architect's criticisms on the Poor Law infirmary plans submitted to him are all on the lines of making these into up-to-date general hospitals. The proposals sanctioned by the Central Authority go up to a capital outlay of £350 per bed. The Central Authority even sanctions special hospitals established by the guardians at the expense of the poor rate, for particular classes of patients, such as the "West Derby, Liverpool and Toxteth Park Hospital, ... for the reception of persons suffering from tuberculosis," many of whom are so little destitute that they pay the cost of their treatment and maintenance;[696] or, as at Croydon, Kingston, and Richmond, "for the reception of epileptic and feeble-minded persons," who cannot be certified as of unsound mind.[697] Persons in receipt of medical relief only are no longer disqualified as paupers from being registered as Parliamentary and Municipal electors, and it has even been held that admission to a Poor Law hospital, sick asylum, or infirmary because of ill-health, and for the purpose of being medically treated, amounts to medical relief only, even though it incidentally involves also maintenance at the expense of the poor rate.[698] By 1903 we have the Central Authority laying it down in general terms, "that it is the guardians' duty to provide for their sick poor, and no sanction ... is necessary to sending such cases to institutions for curative treatment ... and ... paying reasonable expenses involved in so doing."[699] The Central Authority seems, indeed, to exhaust official ingenuity in securing the best possible treatment and also the comfort of the patients in the sick wards.[700] Any reasonable fee may be paid for calling in consultants whenever the medical officer thinks it "necessary or desirable," without any special sanction being requisite.[701] We need not recite the constant struggle to get more nurses and better. As early as 1879 a president could (perhaps with some ministerial optimism) declare that: "in the new infirmaries I have succeeded in abolishing pauper help almost entirely."[702]

[695] "the curtailment of the stage of convalescence," urged the
medical inspector in 1875, on a hesitating board of guardians,
"alone rapidly covers any additional outlay that may have been
incurred in structural arrangements, whilst the increased chances
of recovery to the sick and afflicted are not to be measured by
any mere money standard" (Dr. Mouat, medical inspector of Local
Government Board, in Report on Infirmary of Newcastle Union; MS.
archives, Newcastle Board of Guardians, 26th November 1875).
Already by 1891 the Central Authority is able to inform Parliament
that the number of "sick beds" provided in Poor Law Institutions
throughout the country--irrespective of the mere infirm aged--is
no less than 68,420 (House of Commons, No. 365 of 1891;
Twenty-first Annual Report, 1891-2, p. lxxxvi). In 1896 there were
58,551 persons occupying the workhouse wards for the sick, of whom
19,287 were merely aged and infirm, whilst there were in
attendance 1961 trained nurses, 1384 paid but untrained nurses
(probationers), and 3443 pauper helpers, of whom 1374 were
convalescents (Twenty-sixth Annual Report, 1896-7, p. lxvi; House
of Commons, No. 371 of 1896).

[696] Special Orders to West Derby, Liverpool and Toxteth Park,
5th April 1900 and 25th January 1901. In 1888 two other Boards of
Guardians were even urged and authorised to combine in the taking
over and maintenance of a specialised hospital for a particular
class of diseases, and to conduct it as a Poor Law institution
with the aid of a small annual subsidy from national funds, on the
understanding that all local cases were taken. There was to be no
sort of "deterrent" influence. Patients, suffering from these
diseases, were to be admitted on the authority of the medical
superintendent of the hospital, without there being necessarily
any order from the relieving officer; and without any express
restriction to the destitute. The well-understood object of this
Poor Law institution was, in fact, positively to encourage all
persons suffering from the diseases in question to come in and be
cured. There was to be no obvious sign that it was a Poor Law
institution. It was especially ordered that it should be styled
"The Aldershot Lock Hospital" (Special Orders to Farnham and
Hartley Wintney Unions, 19th September 1888 and 16th November
1894). This went on for seventeen years, and was given up in 1905
(_ibid._ 30th December 1905).

[697] Special Order to Croydon, Kingston, and Richmond, of 27th
December 1904. We gather that this institution has not been
established. A similar one exists at Manchester.

[698] By some Revising Barristers under the Medical Relief
Disqualification Removal Act 1885 (48 & 49 Vic. c. 46).

[699] _Decisions of the Local Government Board_, 1902-3, by W. A.
Casson, 1904, p. 7. The Poor Law Act 1879 had, in fact, expressly
authorised boards of guardians to subscribe to charitable
institutions to which paupers might have access. It was held, for
instance, that boards of guardians may, if they choose, send their
sane adult epileptics to an epileptic colony, and pay the cost of
their maintenance there (_Local Government Chronicle_, 29th
October 1904, p. 1123). In 1901, the Central Authority sanctioned
the payment of £70 by the Bramley Board of Guardians for a cot in
the sanatorium of the Leeds Association for the Cure of
Tuberculosis (Local Government Board to Bramley Union, February
1901, in _Local Government Chronicle_, 23rd February 1901, p.
184).

[700] In 1903 it sanctioned the expenditure involved in the
setting up of Röntgen Ray apparatus in a Poor Law infirmary
(_Decisions of the Local Government Board_, 1902-3, by W. A.
Casson, 1904, p. 10).

[701] _Decisions of the Local Government Board_, 1903-4, by W. A.
Casson, 1905, p. 39.

[702] _Hansard_, 24th July 1879, vol. 248, p. 1173.

The guardians are reminded that the epileptics are especially to be incessantly accompanied by trained nurses, lest they should be suffocated in their fits.[703] The sick men in the workhouse may be allowed tobacco and snuff, the sick women tea, in addition to that prescribed in the dietary table.[704] The doctor is expressly reminded that it is his duty to "order such food as he may consider requisite."[705] When a complaint was made that beer was supplied in a Norfolk workhouse, the Central Authority refused to interfere with a "beer allowance" to sick paupers, given and renewed from week to week by direction of the medical officer.[706] The guardians are even reminded of the importance of providing illustrated books and newspapers for the sick.[707]

[703] Local Government Board decision, in _Local Government
Chronicle_, 1st November 1902, p. 1102.

[704] General Order of 8th March 1894, in Twenty-fourth Annual
Report, 1894-5, pp. xcix, 4-5.

[705] Circular of 29th January 1895, in Twenty-fifth Annual
Report, 1895-6, p. iii.

[706] Mr. Long in House of Commons (23rd June 1904; _Hansard_,
vol. 136, p. 971).

[707] Circular of 23rd January 1891; Twentieth Annual Report,
1890-1, p. xc; Report of Royal Commission on Aged Poor, 1895, vol.
iii. p. 967, (Cd. 7684 II).

Meanwhile the standard of equipment, of resident medical attendance, and especially of trained nursing[708] required by the Central Authority in the Poor Law institutions is constantly rising, in correspondence with the progress of hospital science. We see all this reflected in the advice and criticisms pressed by the inspectorate on the boards of guardians. "The workhouses of a past and bygone age," says Mr. Hervey in 1903, "are no longer refuges for able-bodied, but are becoming every day more of the nature of State hospitals for the aged, sick, and infirm. _As such, they should be furnished with the very best nursing procurable._"[709]

[708] _See_ the references to nursing in Circulars of 29th January
1895 and 7th August 1897; and the General Order (Nursing of the
Sick in Workhouses) 6th August 1897; Twenty-fifth Annual Report,
1895-6, pp. 109-110; Twenty-seventh Annual Report, 1897-8, pp.
27-31.

[709] Mr. Hervey's Report, in Thirty-second Annual Report, 1902-3,
p. 69. The total cost of Poor Law medical relief in 1904-5 was
£518,994 indoor (to which might be added £640,833 for what are now
called the "public health purposes" of the greatest of all Poor
Law authorities, the Metropolitan Asylums Board); and £268,537
outdoor (Thirty-fifth Annual Report, 1905-6, pp. 251, 589, 590).
This aggregate total of £787,531 (excluding the fever hospitals of
the Metropolitan Asylums Board) omits the maintenance of the sick
themselves, but includes, however, some items not previously
included. For comparative purposes we must take the figure for
1903-4 (£423,554), which includes only doctors' salaries and
drugs. This may be compared with the corresponding figure for 1881
of £310,456; for 1871, of £290,249; and for 1840 of £151,781
(Twenty-second Annual Report of the Poor Law Board, 1869-70, p.
227; Eleventh Annual Report of the Local Government Board, 1881-2,
p. 237).

(iii.) _The Municipal Medical Service_

It may be that it is on the Public Health side, which was in 1871 added to the Poor Law work of the Central Authority, that we may trace the influence of the suggestion that was under discussion at the Poor Law Board under Mr. Goschen's presidency, just prior to its merging in the Local Government Board. The idea of "free medicine to the poorer classes generally, as distinguished from actual paupers, and perfect accessibility to medical advice at all times under thorough organisation"--which the new permanent secretary, Sir John Lambert, may have brought back from his official visit to Ireland--finds a certain expression in the Public Health Act of 1872, re-enacted with additions in 1875, which created "one local authority for all public health purposes in every place, so that no area should be without such an authority, or have more than one." In the rural districts the board of guardians became this authority. As such they came under a series of responsibilities based upon ideas diametrically opposed to those of the Poor Law. Instead of confining their action to actual applicants for help, they had to search out cases of nuisance or dangerous disease. Instead of restricting their administration to those who were willing and anxious for it, they were charged with compelling to be done all that was required. Instead of being limited in purview to a small class specially stigmatised as paupers, the guardians had to consider the whole population as needing their attention without distinction of class or subjection to stigma. They were expressly authorised, not merely to repress nuisances, but to provide hospitals "for the use of the inhabitants," without any limitation to infectious or any other diseases.[710] They were even empowered, with the consent of the Central Authority, to "provide or contract with any person to provide a temporary supply of medicine and medical assistance for the poorer inhabitants of their district."[711] The Central Authority eagerly pressed on the local authorities the policy of the new Act.[712] We see the Poor Law inspectors--who were "in possession of the views of the (Local Government) Board on the subject"--explaining to boards of guardians in unions having rural districts their new duties; the future work of their new Public Health staff of medical officer of health and sanitary inspectors; and their responsibility for maintaining and improving the health, not of paupers only, but of the whole community.[713] We are not here concerned with the progress of public health administration, in which the boards of guardians cannot be said to have been apt or willing disciples. It is not to the boards of guardians, in 1907 still the sanitary authorities in non-urban districts, that we owe the elaborate medical organisation of an up-to-date Public Health Department, with its peripatetic health visitors and diagnosing doctors, its milk depots and campaign against infantile mortality, its gratuitous supply of anti-toxins and diarrhoea medicine, its gratuitous hospitals and sanatoria no longer confined to small-pox and fever. We need only notice here the gradual appreciation, by the Central Authority and the Poor Law inspectors, of the intimate connection between shortcomings in the public health service and an excess of pauperism. Even from the narrowest standpoint of Poor Law principles, the causal connection between disease and pauperism could no longer be ignored. "The effect of bad house accommodation on the health of the poor," writes Mr. Bagenal in 1902, "has often been demonstrated by experts in public health. Not only are serious illnesses more frequent, but damp and draughty dwellings lower vitality to such an extent that the bodily vigour and activity, as well as the spirits, are affected, and the system becomes unable to withstand actual disease. Families are often pauperised on account of sickness produced by living in unhealthy conditions. Labourers also often become permanently disabled, and fall upon the rates, owing to premature old age brought on by insanitary houses. To prevent sickness and to prolong the working term of a labourer's life must be a gain to the ratepayers, as well as to all classes of the community."[714] To take only one specific instance, in the Redruth Union the reason for a high average of pauperism in 1906 was found in the large amount of destitution produced by "miner's phthisis," and the great number of widows and orphans which it caused, "the total number of persons pauperised owing to this special cause being ... 333," besides other cases of infirmity of the miners themselves. "A substantial proportion of the excessive pauperism in the Redruth Union is thus accounted for."[715]

[710] Sec. 131 of Public Health Act 1875 (38 & 39 Vic. c. 55).

[711] Sec. 133 of _ibid._ This had been already included in the
Sanitary Act of 1868 (31 & 32 Vic. c. 115, sec. 10).

[712] Circular of 17th August and 12th November 1872, in Second
Annual Report, 1872-3, pp. 19-20, 41-52.

[713] _See_, _e.g._ the letters of Mr. Hedley, in September 1872,
in MS. archives of Newcastle Board of Guardians.

[714] Mr. Bagenal's Report, in Thirty-first Annual Report, 1901-2,
p. 139.

[715] Mr. Preston-Thomas's Report, in Thirty-fifth Annual Report,
1905-6, pp. 471-2.

_F._--PERSONS OF UNSOUND MIND

It does not seem necessary to trace the slight changes in the law relating to pauper lunatics, or in the orders and circulars of the Central Authority. There appears to have been no alteration in the relation of the Central Authority to the Lunacy Commissioners, practically no steps being taken to initiate policy except upon the suggestion of the latter, whose standard of accommodation and treatment continues steadily to rise for pauper as for non-pauper lunatics.

The only point of interest is the continuance, virtually unchanged, of the three methods of treatment, viz. maintenance in the workhouse, treatment in a lunatic asylum, or grant of outdoor relief.

The number of persons of unsound mind in the workhouse continued practically undiminished, without any steps being taken to prevent their retention among the aged, the sick, and the children, who came more and more to make up the workhouse population.[716] There were, in fact, three classes of cases in which a lunatic might be detained in a workhouse. Firstly, there is the old provision, under which "the visitors of any asylum may, with the consent of the Local Government Board and the Commissioners, and subject to such regulations as they respectively prescribe, make arrangements with the guardians of any union for the reception into the workhouse of any chronic lunatics, not being dangerous, who are in the asylum, and have been selected and certified by the manager of the asylum as proper to be removed to the workhouse."[717] Secondly, "where a pauper lunatic is discharged from an institution for lunatics, and the medical officer of the institution is of opinion that the lunatic has not recovered, and is a proper person to be kept in a workhouse as a lunatic, the medical officer shall certify such opinion, and the lunatic may thereupon be received and detained against his will in a workhouse without further order, if the medical officer of the workhouse certifies in writing that the accommodation in the workhouse is sufficient."[718] Thirdly, if it is necessary for the welfare of a lunatic, or for the public safety, that he should immediately be placed under care and control, pending regular proceedings for his removal, he may be taken to a workhouse (if there is proper accommodation therein) by a constable, relieving officer, or overseer, and may be detained there for three days, during which time the proceedings are to be taken; and in any case in which a summary reception order has been or might be made, he may be further detained on a justice's order till he can be removed, provided that the period does not exceed fourteen days.[719] Moreover, any other lunatic might be "allowed to remain in a workhouse as a lunatic" if "the medical officer of the workhouse certifies in writing: (_a_) that such a person is a lunatic, with the grounds for the opinion; and (_b_) that he is a proper person to be allowed to remain in a workhouse as a lunatic; and (_c_) that the accommodation in the workhouse is sufficient for his proper care and treatment, separate from the inmates of the workhouse not lunatics, unless the medical officer certifies that the lunatic's condition is such that it is not necessary for the convenience of the lunatic or of the other inmates that he should be kept separate." Such a certificate signed by the medical officer is sufficient authority for detaining the lunatic in a workhouse for fourteen days, but no longer, unless within that time a justice signs an order for his detention. Failing such a certificate, or, after fourteen days, such an order, or if at any time the lunatic ceases to be "a proper person to be allowed to remain in a workhouse," he becomes "a proper person to be sent to an asylum," and proceedings are to be taken accordingly.[720]

[716] It seems to have been entirely as an exception that the
Rochdale Guardians fitted up what was practically a lunatic asylum
in their workhouse, adequately equipped, staffed, and isolated;
and took in a number of Lancashire chronic lunatics (Special Order
of 13th April 1893; Twenty-third Annual Report, 1893-4, p. xcii).

[717] Lunacy Act, 1890, 53 Vic. c. 5, sec. 26.

[718] _Ibid._ sec. 25; cf. Lunacy Act 1889, 52 & 53 Vic. c. 41,
sec. 22.

[719] Lunacy Act 1890, secs. 20, 21; cf. Lunacy Act 1885, 48 & 49
Vic. c. 52, secs. 2 and 3.

[720] _Ibid._ sec. 24.

Meanwhile the Central Authority continued to permit the grant of outdoor relief in cases of lunacy; and about 5000 were always so maintained.

Regulations for the boarding-out of pauper lunatics first appear in the Act of 1889. "Where application is made to the committee of visitors of an asylum by any relative or friend of a pauper lunatic confined therein that he may be delivered over to the custody of such relative or friend, the committee may, upon being satisfied that the application has been approved by the guardians of the union to which the lunatic is chargeable, and, in case the proposed residence is outside the limits of the said union, then also by a justice having jurisdiction in the place where the relative or friend resides, and that the lunatic will be properly taken care of, order the lunatic to be delivered over accordingly." The authority liable for such a lunatic's maintenance is to pay an allowance for his support to the person who undertakes his care; the medical officer of the district is to visit him and report to the visiting committee every quarter, and two visitors may at any time order the lunatic to be removed to the asylum.[721] Any two Commissioners have also the right to visit any pauper lunatic or alleged lunatic not in an institution for lunatics or in a workhouse, and call in a medical practitioner; if the latter signs a certificate, and they think fit, the Lord Chancellor may direct that the lunatic be received into an institution.[722]

[721] Lunacy Act 1889, sec. 40.

[722] _Ibid._ sec. 42.

For the paupers of unsound mind in the Metropolis there was even a fourth alternative, namely, the "district asylums" of the Metropolitan Asylum Board. On the opening of the Darenth Asylum, the Central Authority quoted, without disapproval, the following remarks of the Lunacy Commissioners: "The withdrawal, for proper care, of helpless children of this kind [idiots] from the households of many of the industrious and deserving poor is a frequent means of _warding off pauperism in the parents_."[723] We do not find, however, any more explicit statement on this point. What the Central Authority continued to press on the Boards of Guardians was, not so much the importance of relieving the struggling poor from the burden of their insane or idiotic dependants, nor yet the freeing of the workhouses from the presence of persons of unsound mind; but rather of appropriate discrimination. "It is of great importance not merely to exclude from the [district] asylums those who, by reason of violence or irritability, are proper subjects for the county asylum, but also those who, from old age or disease, are unfit for the journey to the asylum, or who, from the slight degree to which their mind is affected, might more properly remain in the workhouse."[724] "The removal of helpless, bedridden persons, whose mental weakness is, in many cases, the result of old age, to asylums situated a considerable distance from the Metropolis, is calculated, on the one hand, to be injurious to the persons thus removed, and, on the other, to occupy the district asylums with a different class of persons from that for which they were constructed."[725] Imbecile children are to be kept in the workhouse till they are five years old, and may then be sent to the asylum at Darenth.[726] Outside the Metropolis there is no specialised Poor Law provision for idiots, who, if not received into the county asylum, must either be placed in non-Poor-Law institutions at considerable expense, or detained in the workhouse. In 1885 the Central Authority even suggested that harmless and aged lunatics had, on grounds of economy, better be retained in the workhouse, rather than removed to an asylum.[727] We hear incidentally of a Special Order in 1900 under which certain chronic lunatics were actually transferred from the Suffolk County Asylum to the workhouse of the Mildenhall Union.[728] As late as 1905 we find the Central Authority expressing regret that so many cases of senile imbecility were removed from the workhouses to asylums.[729]

[723] Eighth Annual Report, 1878-9, p. xli.

[724] First Annual Report, 1871-2, p. xxix.

[725] Circular Letter, "Metropolitan Asylums for Imbeciles," 12th
February 1875, in Fifth Annual Report, 1875-6, p. 3.

[726] Circular Letter, "Age of Children sent to Imbecile Asylums,"
24th July 1882, in Twelfth Annual Report, 1882-3, p. 17.

[727] Local Government Board to West Ham, January 1885; _Local
Government Chronicle_, 24th January 1885, p. 77.

[728] Special Order of 21st March 1900 (apparently not published);
referred to in Thirtieth Annual Report 1900-1, p. ci.

[729] Thirty-fifth Annual Report, 1905-6, p. clxxi.

Under this policy the number of paupers of unsound mind receiving outdoor relief diminished very slightly, being 4736 on 1st January 1906; those in the asylums of the Metropolitan Asylums Board and in county and borough lunatic asylums rose to no fewer than 92,409; whilst those in workhouses nevertheless did not fall off from the total of thirty-five years previously, being, in fact, on 1st January 1906, 11,484, or an average of nineteen in each workhouse.[730]

[730] _Ibid._ p. clxx.

Towards the latter part of the time we begin to find the inspectors, somewhat in disaccord with the suggestions of the Central Authority itself, protesting against the presence in the workhouses even of the chronic lunatic, the harmless idiot, or the senile imbecile, on the new ground that their presence caused annoyance to the sane inmates--annoyance which had, for seventy years, been apparently either unnoticed or not considered. "I am sorry to say," reported Mr. Preston-Thomas in 1901, "that in all but six of the workhouses in my district imbeciles mix freely with the other workhouse inmates. Many of them are mischievous, noisy, or physically offensive.