Early and mid-Victorian social reformers were optimistic regarding the middle classes’ ability to steer Britain towards a more prosperous future.1
Social action, sanitary reforms and medical science could be deployed to improve the condition of the working classes and cure their ills.2
However, the incurable, those whose disorders medical practitioners deemed refractory to treatment, presented a challenging barrier to this idealism and optimism.
In Victorian Britain, members of the working classes were more vulnerable than those of the middle and upper classes to physical impairment through industrial accidents, and to diseases such as tuberculosis, cholera, influenza and typhus due to crowded living conditions and privation.3
At the same time, their treatment in voluntary hospitals depended upon their adherence to middle-class standards of behaviour, including industriousness. As many individuals with long-term illness or impairment were either unable to maintain manual jobs or were excluded from doing so, they risked social classification among the so-called ‘idle poor’ and could therefore be deemed unfit for treatment. As a result, health status and social status interacted recursively, forging a conceptual link between individuals with chronic illness or impairment and the increasingly marginalised working classes. The medical establishment's ineffective amelioration of the health risks facing the working classes intersected with middle-class preoccupations with working-class reform to render the ‘cure’ of impairment socially as well as medically significant, engendering social disability and the stigma of impairment.
This process will be investigated through case studies drawn from two major Scottish voluntary hospitals, Glasgow Royal Infirmary (GRI) and the Royal Infirmary of Edinburgh (RIE). Scotland was influential in developing and disseminating the medical developments of the Victorian era. For example, Scotland led the British Isles in adopting the new stethoscope,4
which allowed practitioners to base diagnosis on the inference of internal pathology5
rather than on the external examination favoured during the eighteenth century.6
Scotland was also at the forefront of advancing infection control in hospitals under the influence of surgeons such as Joseph Lister (1827–1912) who advocated use of antiseptic measures in GRI and the RIE.7
Scotland further offered medical students accessible academic and practical training. Scottish medical education included pharmacology and surgery as well as clinical medicine.8
GRI touted affordable tuition rates, boasting in 1835 that ‘medical instruction … got for seven guineas in Glasgow, would in London cost above fifty, and in Edinburgh nearly twenty pounds’.9
Knowledge of Latin, a requirement for medical degrees throughout Europe, was somewhat de-emphasised in Glasgow and Edinburgh, such that individuals with only a ‘shaky’ grasp of the language preferred to receive medical training there.10
As a result, medical education acquired at GRI, the RIE and elsewhere in Scotland, while well respected, was also accessible to those with a moderate income. This approach proved popular in Scotland and beyond, with three-quarters of Edinburgh graduates at the turn of the nineteenth century originating outside of Scotland, and half from beyond the British Isles.11
Because of its more moderate cost and less lofty admission requirements, as well as the blurring, from the mid-seventeenth century, of the distinctions among apothecaries, surgeons and physicians, medical training in Scotland created a more cohesive and egalitarian practitioner workforce than elsewhere in Britain.12
The diversity of the economic status of Scottish practitioners is evident from the prevalence in Scotland of medical shop-keeping – an important activity for doctors who found themselves unable to live off their practice consulting fees alone, and so set themselves up as pharmacists to supplement their income.13
Nonetheless, qualification as a physician required a university degree in Scotland as elsewhere in the United Kingdom, limiting the profession on which this chapter focuses to individuals of at least middle-class education and economic status.
Both GRI and the RIE were founded in the eighteenth century with the aim of providing comprehensive medical training to student practitioners and charitable medical care to the ‘worthy poor’, i.e. the working poor as opposed to the ‘idle poor’. The managers of these hospitals held the treatment of the idle poor to be the responsibility of those individuals’ home parishes and, following the 1845 Poor Law Amendment (Scotland) Act, increasingly relied
upon rate-funded poorhouses to make hospital provision for paupers. The voluntary hospitals were supported through donations and subscriptions. Subscribers, which included employers, trade guilds, friendly societies, charitable organisations and patrons, paid an annual amount for the privilege of recommending patients to the infirmary. Except for the victims of accidents, prospective patients generally would not be granted admission to the infirmary without a ticket of recommendation from a subscriber. Voluntary hospitals such as GRI and the RIE were not generally patients’ first choice for treatment. Those who could afford to pay preferred treatment at home, in physicians’ or surgeons’ consultation rooms, at apothecary shops or from lay practitioners. Hospitals, it was popularly believed, experimented on patients; following the 1832 Anatomy Act, poor patients and their families also feared post-mortem dissection.14
For much of the nineteenth century, hospital treatment was sought only in extremis
. Even so, GRI and the RIE each treated more than 4,000 patients annually in the period 1837 to 1901.15
The particular focus of this chapter is on patients impaired by chronic disease, most commonly tuberculosis (TB) and related diagnoses such as consumption and phthisis. Even today, TB is most prevalent among marginalised people; during the nineteenth century, it gained significance as a benchmark for the health of the social body in Great Britain and the Western world more broadly.16
TB among working-class individuals was of particular concern during the latter half of the century, during which the middle classes increasingly exerted themselves in efforts to ‘improve’ the working classes, and at the turn of the century, when physical degeneration was increasingly invoked to explain their poorer health. While TB can affect the bones and joints, digestive system, genitourinary system and skin, the lungs were the most common site of tubercular disease recorded by medical staff in Victorian-era ward journals at GRI and the RIE. Because of this, and because practitioners in medical wards recorded more detailed case...