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© The Society for the Social History of Medicine 2005, all rights reserved
Practitioners' Income and Provision for the Poor: Parish Doctors in the Late Eighteenth and Early Nineteenth Centuries
Trinity Hall, University of Cambridge, Cambridge CB2 1TJ, UK. E-mail: skw30{at}cam.ac.uk
By the beginning of the nineteenth century, contracts between surgeon-apothecaries and parishes to provide medical care for the poor were replacing bills by item of service. Such agreements were not only an important source of income for practitioners, but also provided a means by which parishes could predict and limit medical spending. This article is a regional study of provision for the poor in east Bedfordshire in the later eighteenth and early nineteenth centuries. By the beginning of the second decade of the nineteenth century, almost three-quarters of parishes in east Bedfordshire were engaged in contractual arrangements with local surgeon-apothecaries to provide a range of services. Remuneration of practitioners, the geographical concentration of poor law practices, and the changing nature of contracts, are all assessed. Interpretation is also undertaken in relation to the status of practitioners, length of service, levels of competition, and how much the contract was worth in real terms to practitioner and parish. It is concluded that the medical market in east Bedfordshire was competitive and that many practitioners used poor law contracts as a means to keep out rivals.
Keywords: poor law; payments for medical care; surgeon apothecaries; practitioners' practices; competition
1 S. K. Williams, ‘Poor Relief, Welfare and Medical Provision in Bedfordshire: The Social, Economic and Demographic Context, c.1770–1834’ (unpublished Ph.D. thesis, University of Cambridge, 1999), ch. 6; S. King, Poverty and Welfare in England (Manchester, 2000), chs 6 and 7.
2 M. Fissell, ‘The "Sick and Drooping Poor" in Eighteenth-Century Bristol and its Region’, Social History of Medicine, 2 (1989), 35–58; idem, Patients, Power and the Poor in Eighteenth-Century Bristol (Cambridge, 1991).
3 B. Reay, Microhistories: Demography, Society and Culture in Rural England, 1800–1930 (Cambridge, 1996), ch. 3.
4 G. W. Oxley, Poor Relief in England and Wales 1601–1834 (Newton Abbot, 1974), pp. 65–73; M. Pelling, ‘Healing the Sick Poor: Social Policy and Disability in Norwich 1550–1640’, Medical History, 29 (1985), 115–37; M. Fissell, ‘Charity Universal? Institutions and Moral Reform in Eighteenth-Century Bristol’, in L. Davidson, T. Hitchcock, T. Keirn, and R. B. Shoemaker (eds), Stilling the Grumbling Hive: The Response to Social and Economic Problems in England, 1689–1750 (Stroud, 1992), 121–44, pp. 123–4; A. Berry, ‘Patronage, Funding and the Hospital Patient c.1750–1815: Three English Regional Case Studies’ (unpublished D.Phil. thesis, University of Oxford, 1995), pp. vi, 208, 221–7.
5 I. Loudon, Medical Care and the General Practitioner 1750–1850 (Oxford, 1986); A. Digby, Making a Medical Living: Doctors and Patients in the English Market for Medicine, 1720–1911 (Cambridge, 1994); D. Porter and R. Porter, Patient's Progress: Doctors and Doctoring in Eighteenth-Century England (Cambridge, 1989); A. L. Wyman, ‘The Surgeoness: The Female Practitioner of Surgery 1400–1800’, Medical History, 28 (1984), 22–41.
6 King draws a very different picture for the north and west compared to the south and east. In the north, fewer people were in receipt of poor relief and lower sums were generally given out. King, Poverty and Welfare, chs 6 and 7.
7 Bedfordshire, Huntingdonshire, Norfolk, Suffolk, Essex, Sussex, Buckinghamshire, Oxfordshire, Wiltshire, Berkshire, and Northants all spent at least 15s per capita on poor relief in 1831–2. G. R. Boyer, An Economic History of the English Poor Law, 1750–1850 (Cambridge, 1990), p. 111.
8 Pelling, ‘Healing the Sick Poor’; idem, ‘Illness among the Poor in an Early Modern Town: The Norwich Census of 1570’, Continuity and Change, 3 (1988), 273–90.
9 Pelling, ‘Healing the Sick Poor’, pp. 121–2.
10 P. Rushton, ‘The Poor Law, the Parish and the Community in North-East England, 1600–1800’, Northern History, 25 (1989), 135–52, p. 146.
11 A. Tomkins, ‘Paupers and the Infirmary in Mid-Eighteenth-Century Shrewsbury’, Medical History, 43 (1999), 208–27, pp. 214–16.
12 A. Wear, ‘Caring for the Sick Poor in St Bartholomew's Exchange: 1580–1676’, in W. F. Bynum and R. Porter (eds), Living and Dying in London (1991), Medical History Supplement 11, 41–60, pp. 45–53; J. Boulton, ‘Miniature Welfare States? Medical Care of the Poor in the Parishes of Seventeenth-Century Westminster’, unpublished seminar paper given at the Cambridge Group for the History of Population and Social Structure, pp. 8–13.
13 Wear, ‘Caring for the Sick Poor’, pp. 45–53.
14 A. Fessler, ‘The Official Attitude Towards the Sick Poor in Seventeenth-Century Lancashire’, Transactions of the Historic Society of Lancashire and Cheshire, 102 (1951), 85–113.
15 Loudon, Medical Care, p. 231.
16 Digby, Making a Medical Living, p. 225.
17 Loudon, Medical Care, pp. 78–9, 231; idem, ‘The Nature of Provincial Medical Practice in Eighteenth-Century England’, Medical History, 29 (1985), 1–32, pp. 10, 12.
18 H. Marland, Medicine and Society in Wakefield and Huddersfield 1780–1870 (Cambridge, 1987), ch. 3.1.
19 Tomkins, ‘Paupers and the Infirmary’, pp. 214–16; S. and B. Webb, English Local Government: English Poor Law History: Part I. The Old Poor Law (London, 1927), pp. 304–8.
20 F. G. Emmison, The Relief of the Poor at Eaton Socon (Bedfordshire Historical Record Society, XV, Bedford, 1933), pp. 71–6.
22 J. R. Smith, The Speckled Monster (Chelmsford, 1987), p. 54; A. F. J. Brown, Essex at Work (Essex Record Office Publications, 49, Chelmsford, 1969), pp. 139–42.
23 M. Barker-Read, ‘The Treatment of the Aged Poor in Five Selected West Kent Parishes from Settlement to Speenhamland (1662–1797) (unpublished Ph.D. thesis, Open University, 1989), ch. 3.
24 It is probable that medical care for the poor was given in many other places. F. M. Eden, The State of the Poor: Or an History of the Labouring Classes in England, 3 vols (London, 1797), vols 2 and 3; R. P. Hastings, Poverty and the Poor Law in the North Riding of Yorkshire c. 1780–1837 (Borthwicke Papers, York, 61, 1982), pp. 13–14. In some cases, where the poor were farmed out, it was up to the contractor to make arrangements with the doctor and for any other medical assistance. See Webb and Webb, English Poor Law History, ch. IV.
25 Bedford and Luton Archives and Records Service [hereafter BLARS,] P64/18/6.
26 Digby, Making a Medical Living, p. 225.
27 E. G. Thomas, ‘The Old Poor Law and Medicine’, Medical History, 24 (1980), 1–19, pp. 7–8.
28 Smith, The Speckled Monster, p. 54; J. Lane, ‘The Provincial Practitioner and his Services to the Poor, 1750–1800’, Bulletin for the Society for the Social History of Medicine, 28 (1981), 10–13, p. 11.
29 Cited by M. W. Flinn, ‘Medical Services under the New Poor Law’, in D. Fraser (ed.), The New Poor Law in the Nineteenth Century (Basingstoke, 1976), 45–66, p. 47.
31 Rushton, ‘The Poor Law in North-East England’, p. 146; Marland, Medicine and Society, section 3.1; Hastings, Poor Law in the North Riding of Yorkshire, pp. 13–14.
32 S. Hindle, The Birthpangs of Welfare: Poor Relief and Parish Governance in Seventeenth-Century Warwickshire (Dugdale Society Occasional Papers, Stratford-on-Avon, 40, 2000); P. Slack, English Poor Law 1531–1782 (London, 1990); T. Wales, ‘Poverty, Poor Relief and the Life-Cycle: Some Evidence from Seventeenth-Century Norfolk’, in R. M. Smith (ed.), Land, Kinship and Life-Cycle (Cambridge, 1984), 351–404; King, Poverty and Welfare.
33 Oxley, Poor Relief, pp. 65–73.
34 Slack, English Poor Law, p. 30; J. P. Huzel, ‘The Labourer and the Poor Law, 1750–1850’, in J. Thirsk (ed.), The Agrarian History of England and Wales, vol. VI, 1750–1850 (Cambridge, 1989), 755–810, pp. 760, 762.
35 C. Feinstein, ‘Pessimism Perpetuated: Real Wages and the Standard of Living in Britain during and after the Industrial Revolution’, Journal of Economic History, 58 (1998), 625–58, app. Table 1, pp. 52–3.
36 Oxley, Poor Relief, pp. 65–73. There are examples of the issue of price versus quality for Dorset and Essex, but I have found none for Bedfordshire. G. Body, ‘The Administration of the Poor Law in Dorset 1760–1834, with Special Reference to Agrarian Distress’ (unpublished Ph.D. thesis, University of Southampton, 1968), pp. 193–7; Thomas, ‘Poor Law and Medicine’, pp. 7–8.
37 Digby highlights a strong tradition of medical altruism. Digby, Making a Medical Living.
38 A. Berry, ‘Community Sponsorship and the Hospital Patient in late Eighteenth-Century England’, in P. Horden and R. M. Smith, The Locus of Care: Families, Communities, Institutions, and the Provision of Welfare since Antiquity (1997), 126–50; Thomas, ‘Poor Law and Medicine’.
40 E. G. Thomas, ‘The Treatment of Poverty in Berkshire, Essex and Oxfordshire, 1723–1834’ (Ph.D. thesis, University of London, 1971); Tomkins, ‘Paupers and the Infirmary’, pp. 216–17; Thomas, ‘Poor Law and Medicine’, p. 4.
41 Whitbread Collection, BLARS, W1/773–805. Loudon used this source in his assessment of the medical incomes of surgeon-apothecaries, but only drew on part of the table W1/773 (see Table 1 in the text below) and refers to only a few of the letters. Loudon, Medical Care, pp. 231–5. Digby refers to this part of Loudon's analysis in her discussion of contract payments in rural areas, Making a Medical Living, p. 226.
42 Dictionary of National Biography.
43 BLARS, Bedfordshire Directory, 1847.
44 S. K. Williams, ‘Poor Relief, Labourers’ Households and Living Standards in Rural England c.1770–1834: A Bedfordshire Case-study’, Economic History Review, LVIII(2005), 485–519.
45 J. Godber, History of Bedfordshire 1066–1888 (Bedford, 1984); BLARS, W1/762–772, W1/736–740, W1/741, W1/814–825.
46 Williams, ‘Poor Relief, Welfare and Medical Provision’.
47 A. F. Cirket (ed.), Samuel Whitbread's Notebooks, 1810–11, 1813–14 (Bedfordshire Historical Record Society, Bedford, 50, 1971), p. 8. It is probable that Whitbread was more influential in his jurisdiction as a magistrate than other JPs. For excellent county-based research on local government, see D. Eastwood, Governing Rural England: Tradition and Transformation in Local Government 1780–1840 (Oxford, 1994).
48 Eden, The State of the Poor.
49 BLARS, W1/773. It is not known who compiled this table, but presumably one of Whitbread's clerks. The format provides an easy-to-read summary of the letters. Amendments and additions are footnoted in Table 1.
50 This includes the three parishes of Haynes, Gravenhurst, and Clophill, which were just outside, but bordering on Whitbread's jurisdiction. BLARS, P45/12/1–2, P17/12/1, P6/12/1.
51 BLARS, Directory for Bedfordshire 1785.
52 BLARS, P18/12/1–2, X514/1–3.
54 Lane finds that 34 of the 89 parishes (30 per cent) she researched had contracts by 1800. Those parishes (89) represented 41 per cent of total parishes in Warwickshire. Lane, ‘The Provincial Practitioner’, p. 11. Smith, Speckled Monster, p. 54.
55 Lane, ‘Provincial Practitioner’, pp. 10–11.
56 1811 Census; Godber, Bedfordshire, p. 84.
57 A Spearman's rank correlation coefficient was significant at the 0.1% level. Pay in relation to the population of a parish had a result of rs=0.736. rs=0.64, significant at the 0.001 level. Whitbread sample (W1/773–805); 1811 census. 31 parishes, towns, and cities in Eden, The State of the Poor, vols 2 and 3; 1801 census.
58 This was significant at the 0.1% level. Pay in proportion to the number of its poor rs=0.696 or 0.746. W1/773–805, 1811 census, numbers of paupers for 1813 from P.P. 1818 XIX, Abstract of the Poor [1813–1815]. There are no similar sources to estimate the number of poor in Eden's towns and cities in the late eighteenth century.
59 The national population totals rose from 8,285,852 in 1801 to 14,860,783 in 1841, an increase of 79 per cent. Shefford's percentage increase is 87 per cent, whereas Campton's is only 58 per cent. For national totals, see E. A. Wrigley and R. S. Schofield, The Population History of England 1541–1871 (Cambridge, 1989), Appendix 6, table A6.7, total (1).
60 J. Howlett, ‘On the Population and Situation of the Poor in England’, Annals of Agriculture, vol. XVIII, 105 (1792), 573–81.
61 Williams, ‘Poor Relief and Living Standards’.
62 A. Digby, Pauper Palaces (London, 1978), ch. 3 and 11; Eastwood, Governing Rural England.
63 Feinstein, ‘Pessimism Perpetuated’, app. Table 1, pp. 652–3.
64 For example, the contracted practitioner in Henlow agreed to ‘undertake the care of the paupers of Henlow within my ride’ (BLARS, W1/783), while the contracted man in Gravenhurst was to be ‘paid for all Journeys to Paupers residing out of the said Parish & exceeding the Distance of Gravenhurst from Shefford’ (BLARS, P17/12/1).
65 Marland, Medicine and Society, ch. 3.1.
66 Digby, Making a Medical Living, pp. 117–18; J. Lane, ‘Eighteenth-Century Medical Practice: A Case-Study of Bradford Wilmer, Surgeon of Coventry, 1737–1813’, Social History of Medicine, 3 (1990), 369–86, p. 378.
67 BLARS, P45/12/2, P17/12/1. Mr Gay had been contracted practitioner in 1803. BLARS, P44/12/7.
68 BLARS, P18/12/1–2, X514/1–3, P6/12/1.
70 Hertfordshire Record Office [hereafter HRO], D/P7/12/3–4, D/P80 11/3.
71 Loudon argues that they were easily earned. Loudon, Medical Care, p. 234.
72 In 1983 the average list size was 2,116. C. Webster, The Health Services Since the War, vol. 1. Problems of Health Care. The National Health Service before 1957 (London, 1988), p. 356.
73 Webb and Webb, English Poor Law History, p. 306.
74 See medical contracts in the poor law account books for BLARS, P44/12/7, P32/12/1, P17/12/1, P45/12/2, P6/12/1, P22/12/2, P29/12/2.
75 BLARS, P45/12/1–2. See also Potton, BLARS, P64/18/4.
76 Proportions of paupers were ascertained from the numbers of paupers given in P.P. 1803–04 XIII.I, Abstract of the Poor in England.
77 Williams, ‘Poor Relief and Living Standards’.
78 Pelling, ‘Healing the Sick Poor’; idem, ‘Illness among the poor’; M. Pelling and C. Webster, ‘Medical Practitioners’, in C. Webster (ed.), Health, Medicine and Mortality in the Sixteenth Century (Cambridge, 1979), 165–235.
79 Eden, The State of the Poor, vols 2 and 3; Marland, Medicine and Society, ch. 3.1.
80 £84 in 1800 and £100 in 1802. P. J. Wallis and R. V. Wallis, Eighteenth-Century Medics (Newcastle upon Tyne, 1988).
81 Loudon, Medical Care, pp. 113, 229, 261. MacGrath served eight parishes by contract or bill. In 1810/11, the six contracts earned him £66 19s, the bills £31 8s 8d, with an additional £45 for the contract with Biggleswade every other year. This gives a total of £143 7s 8d.
82 Holden's Directory, 1811; Wallis and Wallis, Eighteenth-Century Medics.
83 Wallis and Wallis, Eighteenth-Century Medics; BLARS, Directory for Bedfordshire 1785.
84 BLARS, Directory for Bedfordshire 1792.
85 BLARS, AB/W; Wallis and Wallis, Eighteenth-Century Medics; BLARS, Directory for Bedfordshire 1785.
86 BLARS, P18/12/1–2, X514/1–3.
87 The Medical Register 1780; BLARS, AB/W, ABP/W.
88 Wallis and Wallis, Eighteenth-Century Medics.
89 BLARS, HO: B/A1; Wallis and Wallis, Eighteenth-Century Medics.
90 Digby, Making a Medical Living, ch. 4.
91 BLARS, P18/12/1–2, X514/1–3, P70/12/1–2; BLARS, Directory for Bedfordshire 1785.
92 Marland, Medicine and Society, ch. 3.1.
93 Loudon, Medical Care, pp. 208, 231–5.
94 The parish where stipends fell as well as rose was Campton, which increased its stipend sum temporarily in 1793, 1796, and 1801.
95 Feinstein, ‘Pessimism Perpetuated’, app. Table 1, pp. 652–3.
96 Numbers of letters mentioning exemptions are as follows—midwifery 11; smallpox, vaccinations or inoculations 8; accidents 7; broken bones 4; physicians prescriptions 2; venereal disease 1.
97 Work undertaken by Leigh Shaw-Taylor at the Cambridge Group on poor relief for the sick in Colyton, Devon, in the 1840s and 1850s reveals that broken bones and ‘ruptures’ were a common cause for parish assistance. See also Reay, Microhistories, ch. 3. The costs of setting broken bones are for Campton (BLARS, P18/12/1–2, X514/1–3) and Renhold, a parish that borders Willington (BLARS, P32/12/1).
98 BLARS, P18/12/1–2, X514/1–3.
99 Cirket, Samuel Whitbread's Notebooks, case 646.
100 Digby, Making a Medical Living, pp. 226–7.
101 Eden, The State of the Poor, vols 2 and 3.
102 Body, ‘Poor Law in Dorset’, pp. 193–7.
103 Marland, Medicine and Society, ch. 3.1.
104 E. Melling, Kentish Sources: IV The Poor (Maidstone, 1964), Part II, D.
105 Williams, ‘Poor Relief, Welfare and Medical Provision’; P. Grey, ‘The Pauper Problem in Bedfordshire from 1795–1834’ (M.Phil. dissertation, University of Leicester, 1975).
106 BLARS, P18/12/1–2, X514/1–3, P45/12/2, P70/12/1–2; HRO D/P7/12/3–4.
107 A phrase used by Loudon, Medical Care, p. 88. See also idem, Death in Childbirth: An International Study of Maternal Care and Maternal Mortality, 1800–1950 (Oxford, 1992), and A. Wilson, The Making of Man-Midwifery: Childbirth in England, 1660–1770 (London, 1995); Digby, Making a Medical Living, ch. 9.
108 Cambridge Record Office, P152/12/1; PP 1837–8 XVIII, Select Committee on the Poor Law Amendment Act, Report 26, pp. 12–13.
109 Cirket, Samuel Whitbread's Notebooks, cases 332, 334, 341, 654.
110 Cirket, Samuel Whitbread's Notebooks, cases 334, 341; BLARS, P29/18/2.
111 Eden, The State of the Poor, vol. 2.
112 Including medical contracts and payment by bill.
113 HRO D/P7/12/3–4; BLARS, P18/12/1–2, X514/1–3.
117 BLARS, W1/781/1, W1/795/1, P64/18/4–5, P70/12/1–2.
118 All except Joseph Pulley, who was employed by rotation in Clophill with Gay and Layman. This agreement is the only one in observation for Pulley but it is highly likely that he was employed in other parishes to the southwest of Clophill.
119 Digby, Making a Medical Living, ch. 4.
120 Digby highlights these urban/rural considerations in her comparison of William Goodwin and William Elmhurst, Making a Medical Living, ch. 4.
121 Holden's Directory for 1811.
122 Lane, ‘The Provincial Practitioner’, p. 10; Godber, Bedfordshire, p. 84.
123 BLARS, P22/12/2, P45/12/1–2; BLARS, Directory for Bedfordshire 1792.
125 Wallis and Wallis, Eighteenth-Century Medics. Doctors are also listed for Dunstable and Leighton Buzzard, but these towns are too far from Whitbread's district. One practitioner is also given for Riseley, a parish too far to the north of the county to be within reach of east Bedfordshire.
127 Webbs, English Poor Law History, pp. 306–7.