Anyone who has kept hens knows that these unattractive creatures make a point of brutality to any among them sick or weak. Some other ‘social’ animals share this antisocial tendency. The human species has a wide pattern of response to distress, but under the influence of moral or religious pressures, or of medical fancies, it is as capable as hens of behaving badly to those least able to withstand unkindness. The story of organised care and welfare includes a large number of instances of what intrinsically appear as policies of systematic mental or physical cruelty.
Of course cruelty was not recommended as such: it was seen as necessary moral discipline, physical hygiene or the route to a cure. Nineteenth-century provision of social welfare in Britain was dominated by the belief that the basic problem was not poverty but pauperism. If relief could be so organised as to be intolerable, and people would starve rather than accept it, pauperism would be lessened. This was the basic ‘less eligibility’ policy of the English New Poor Law. The poor would be forced into vast workhouses where their circumstances must be ‘less eligible’ than those of the lowest segment of self-supporting labour. Since in material terms the workhouse had to offer a sound roof and what was thought to be an adequate diet – features which many families of self-supporting labourers could not aspire to – it was the discipline that had to discourage entry, by regimentation, degrading work, sexual segregation, demeaning uniform. And these features were extended from the physically fit to the old and decrepit.
Scotland had not shared in the English Poor Law reform because the Scottish Poor Law had been reinterpreted by young Whig lawyers early in the 19th century to disqualify the ‘merely destitute’. In Scotland, it was now proclaimed, only the ‘disabled’ could aspire to poor relief: unemployment was not a qualification. Yet the Scots, when they were eventually forced to make their system of relief more generous, borrowed the ideas of discipline and less eligibility for a relief system which by definition did not extend to those suitable for discipline. There were local enthusiasts who were prepared to state that the first aim of a poor law must be to discourage applications for relief, and the central board, set up to secure adequate provision, agreed, for instance, that if a pregnant woman already in possession of a family of young children would rather sleep rough with them in the fields than go into a poorhouse, the law had fulfilled its duty of support. Given the wretched conditions which obtained in the cities and larger industrial towns and the squalor of many rural settlements, the attitude was understandable. Any distinction between the independent poor and those qualified for relief was bound to involve harshness, but a line as hard as this was more difficult to sustain in the better living conditions which came to obtain in the period covered by Levitt’s book. In the 1890s poor relief in Scotland became welded onto ordinary local government: its management was no longer the preserve of groups carefully structured to keep out the sort of people who might fall into its ministrations. Democracy had got in, and some democratic voices were prepared to argue that relief was a right which should extend to all, even to the unemployed.
There were other voices, not all supporting wider welfare. A frequent theme in the poor law debate was that poverty was the result of alcoholism; so, often, was insanity. Of course there were links, but these might be two-way. Alcohol was certainly the shortest way out of squalor. The eugenics movement of the 1890s and onwards would have liked to prevent breeding by those with a propensity to drink, destitution, insanity or the production of bastard children, but this would have involved too much bureaucratic control over the habits of citizens of all classes.
In the long run, the most effective strand of opinion was the desire of some doctors and some laymen to protect the health of women and children, especially children, and it was this which broke down the restrictions on aid. The rule that the dependents of an able-bodied man should not be aided on their own was rebutted early in the 20th century. One parish protested at the new policy on the grounds that ‘married life will turn out a failure and a serious imposition on the rates will ensue’ – a remark which forestalls the view of our present government that there is some link between immorality and high rates. The standards of provision were gradually allowed to rise. Children in homes might be allowed clean clothes once a fortnight and use knives and forks at meals. Starving children would be removed from neglectful parents, even when the parents were not paupers. In the 1920s relief came to be offered, hesitantly, for the families of strikers, but by then unemployment and health insurance were making poor relief a minority aspect of welfare.
It might be expected that a relief system nominally only for the disabled would be generous in medical and nursing care. But for much of the 19th century nursing in poor-houses was done by untrained paupers. Operations were carried on in the open ward. Even in the main cities, which possessed prestigious voluntary infirmaries, the infirm poor were left in insanitary and often unheated conditions. It was one thing for Parliament to back a programme of hospital provision, another to secure the linkage of such schemes to the areas of severe illness. In any case, until living standards for the working class were raised, hospitals were bound to be overburdened with cases which needed only a moderate level of comfort.
The story which Levitt tells is on the whole one of increasing generosity of spirit, which was eventually translated into material provision. The new emphasis on care outflanked the fortifications of less eligibility. But in the story of tuberculosis, itself a major cause of unemployment and pauperism, brutality was slower to yield. The two books here, by F.B. Smith and Linda Bryder, explore both the decline of the disease as a cause of death and the treatments offered or forced upon its unfortunate victims. There is a sinister relevance in these stories today, for popular fears and fantasies about the spread of tuberculosis meant that its sufferers experienced much the same sort of exclusion from society as do sufferers from Aids.
Like Aids, tuberculosis struck at relatively young adults. Since it takes time to transmit, it was not readily recognised as infectious. Slow infection and even slower recognition meant that many victims had donated it to their families by the time their disease was diagnosed. As a result, it was thought to be inherited. The disease’s enervating effects made victims an unsatisfactory labour force, and so forced them into poverty. So it came under the generalisation associated with the miasmatic theory of diseases: that it is by their way of life that individuals lay themselves open to the impact of disease. Irregularity in diet, alcohol, over-indulgence in sexual activity, vitiated air and general poverty predispose to disease. With Aids, the moral emphasis has been on irregular sexual activity. The strictures on tuberculosis covered a wider range of alleged vices, and of course poverty, which, though not as strongly disapproved of in Victorian values as homosexuality, was seen as a sin, and, conveniently, one which could be openly talked about. The moral dimension justified harshness of treatment. Fear of tuberculosis and distaste for those suffering from it continued at popular level long after the nature of the infection was understood, and led to ‘nimbying’ (the verbal felicity of Nicholas Ridley, and his personal commitment to the attitude, have given us this acronym for the ‘not in my backyard’ syndrome). Linda Bryder shows how a Welsh holiday village was able in the 20th century to resist having a sanatorium set up near its water supply. Patients dismissed from hospitals nominally cured might be ostracised by their relatives, and could only by concealing their medical history have a chance of a job.
As with Aids, tuberculosis had to raise the issue of controlling the victims. The main item here was compulsory notification. Most infectious diseases were short-lived attacks, often in epidemics. Notification could help indicate where public health resources were inadequate, and give authority for isolating those afflicted and fumigating homes. With tuberculosis, notification accentuated the problems of the patients and gave little help to improved management of the disease. Kindly doctors postponed it while their patients could still hope for an active life, in a sizeable number of cases till after death. We might expect a similar tendency on Aids. The legislation of 1913 which made notification compulsory was, in epidemiological terms, a failure, but it gave dispensaries, hospitals and local authorities an opportunity for authoritarian behaviour.
There are other similarities with Aids. Myths about transmission persisted among doctors as well as among the public: economic failure, dirt, urban life, migration, God, civilisation and masturbation were all alleged as causes. Bringing God into the debate meant that fierce and traumatic treatment could be seen as a sort of terrestrial purgatory, and this view gave additional strength to the normal hospital enthusiasm for disciplining the patients. All programmes of treatment involve some degree of discipline, and since visitors are likely to undermine this, by subversive talk, by bringing chocolate to the overweight or whisky to those undergoing detoxification, hospitals regard contact with the outside world as a risk to the patient. Because of this, because of the cost, and because of the nimby syndrome, as well as the overriding belief in the curative values of exposure to cold and fresh air, sanatoria were set up in remote places. There the patients could be trained in hygienic practices which might protect their families when they were allowed to emerge into normal life.
It all sounded fine. Patients should be prepared to suffer loneliness and regimentation for their own good. But, as both these books point out, no real research was done into the curative achievements of the various regimes. Some sanatoria believed in controlled and graduated labour, at least for working-class patients, so these were set to gardening, quarrying and tree-felling. This visibly improved the hospital grounds, but there is less clear evidence of what it did to the patients. Alternatively, and in total contradiction, there was rest therapy, with the patients kept in bed, a revival of a popular and dangerous 19th-century treatment. Rest therapy got a boost with the development of surgical processes which collapsed the lung. So, as Bryder shows, did the medical staff, for the development of surgical skills enabled the sanatoria doctors to move up the pecking order of the medical world. Soon they passed the job of maintaining the collapse of the lung to dispensaries, which had to be specially equipped with a back-door so that patients who collapsed in the process could be smuggled out unobserved. Collapse was only an extreme form of the unpleasant effects of some treatments. There were shots of sancrosyn, which were as likely to lead to the back-door exit, or patients might be injected for no good reason with varieties of creosote. For all these treatments no comparative information exists to tell whether they did any good. Estimates of survival to five years after sanatorium treatment range from a half to a quarter. But treatment convinced doctors, nurses and patients that something was being done.
The two books on tuberculosis tell much the same story, without repetition, for they draw on different types of source, a fact which shows the wealth of material available for the social history of medicine. There is, though, a deeper examination of the implications of the mass radiography programme of the 1940s in Bryder’s book. The programme showed up a vast iceberg of actively infectious cases of people who had so far felt no ill-effects. Since there were not enough hospital places for the cases already known, the prospect of more cases, running into six figures, created a crisis for administration. It also created a difficult issue of social policy, for there was no likelihood that people who did not feel ill would consent to the lower standard of living and the social and economic ostracism experienced by those acknowledged as tuberculous. Only the advance of chemotherapy got the medical administration off an impossible hook.
Both in welfare and specifically in tuberculosis treatment the real transformation from the hardships of the Victorian world was made possible by the rising general standard of living. Economic growth took some time before it was transformed into more plentiful and less contaminated food, more spacious and more sanitary housing, a shorter working week. In the 20th century came a change in motivation. The poor were to be admitted on more generous terms to the accepted way of life of the majority. In a period when this later decision apears to have been reversed it is worthwhile absorbing the lesson of these books. There are risks to all sections of society from the acquiescence in the exclusion of the poor from the benefits of an advanced economy.