“Bold Bad Girls in a First-Class Institution”: A Microhistorical Account of the 1893 Inquiry into Abuse at the Waterloo County Poorhouse

« Des filles audacieuses et rebelles dans une institution de première classe » : Récit microhistorique de l’enquête de 1893 sur les abus au refuge des pauvres du comté de Waterloo

Sandra Hoy, MSW, PhD
Associate Professor, School of Social Work
Laurentian University

shoy2 [at] laurentian [dot] ca

Kathleen Sloftstra, MSW, MSc
Research Assistant, School of Social Work
Laurentian University

k [dot] slofstra [at]laurentian [dot] ca

Ginette Lafrenière, MSS, PhD
Professor, Faculty of Social Work
Wilfrid Laurier University

glafreniere [at] wlu [dot] ca

Abstract

The study of Poorhouse is a study of power. This article presents a microhistorical account of the 1893 investigation into allegations of abuse at the Waterloo County House of Industry and Refuge (1869-1951), the first municipally operated poorhouse in Canada. The poorhouse offered shelter, food, clean clothes, and medical care to people who had few alternatives during a time before broader social welfare protections. Drawing from administrative archives, newspaper coverage, and public records, we reconstruct the inquiry and contextualize it within broader patterns of institutional governance, carceral care, and epistemic injustice. Through a critical disability and social work lens, we explore how the institutional logics of discipline, containment, and moral judgment shaped the lives and deaths of residents, most of whom were destitute due to lack of protections for people with disability, illness, aging, mental health and substance use challenges, parental loss, or lone motherhood. The public reports of the inquiry offer a rare glimpse into the perspectives of residents and servants from the poorhouse, whose voices are mostly absent from the decades of poorhouse archives. The result of the investigation led to modest administrative reforms and left the institutional model intact. By centring resident experiences, highlighting local community advocacy, foregrounding moments of resistance and testimony, and critically engaging with the silences and biases of the archive, this article offers a counter-narrative to institutional histories that privilege administrative perspectives, illuminating how a carceral approach has been embedded in Canada’s social welfare systems from inception.

Résumé

L’étude des refuges pour les personnes pauvres est indissociable de celle du pouvoir. Cet article propose un récit microhistorique de l’enquête menée en 1893 sur les allégations d’abus à la Maison d’industrie et de refuge du comté de Waterloo (1869-1951), premier refuge municipal au Canada. Cette institution offrait hébergement, nourriture, vêtements propres et soins médicaux à des personnes disposant de peu de ressources, dans un contexte précédant l’instauration de mesures de soutien social plus étendues. À partir d’archives administratives, de couvertures médiatiques et de documents publics, nous reconstituons le déroulement de l’enquête et l’inscrivons dans les dynamiques plus larges de gouvernance institutionnelle, de soins carcéraux et d’injustice épistémique. En mobilisant une perspective critique issue des études du handicap et du travail social, nous examinons les logiques de discipline, de confinement et de jugement moral qui ont façonné les vies et les décès des résidentes et résidents, souvent précarisés par le handicap, la maladie, le vieillissement, des troubles de santé mentale ou liés à la consommation de substances, la perte d'un parent ou la monoparentalité, précarisation aggravée par l'absence de protections adéquates. Les rapports publics de l’enquête offrent un rare aperçu des perspectives des résidentes et résidents et du personnel du refuge, des voix largement absentes des archives institutionnelles. L’enquête a mené à des réformes administratives modestes, sans transformer le modèle institutionnel. En centrant les expériences des résidentes et résidents, en mettant en lumière l’engagement communautaire, les résistances et les témoignages, et en interrogeant les silences et biais du travail d’archive, cet article propose un contrerécit aux histoires institutionnelles centrées sur l’administration. Il révèle l’enracinement d’une approche carcérale dans les systèmes sociaux canadiens dès leur mise en place.

Keywords: Microhistory, Nineteenth Century Ontario, Institutional Abuse, Poorhouse System, Carceral Social Welfare


Mots-clés : Microhistoire, Ontario du XIXe siècle, abus institutionnels, système des refuges de pauvres, bien-être social carcéral.



“In each society there are favored ways in which two individuals can approach and have dealings with each other, for example, as kindred to kindred, or high caste to low.” — Erving Goffman, Asylums (1961, p. 323)

In 1869, Waterloo County became the first municipality in Canada to admit a resident to a municipally funded poorhouse: the Waterloo County House of Industry and Refuge. James “Jimmy” White, an Irish immigrant and labourer, was the first to be officially committed by Ephraim Erb, the Warden of Waterloo County (Waterloo County House of Industry and Refuge [WCHIR], 1869a, entry 1). Described as a “grogger” (drinker), White had lived in the region for 30 years before entering the poorhouse. Gravely ill, Jimmy died 31 days later from “dropsy,” becoming the first of approximately 1,350 people who would have their deaths recorded in the poorhouse burial registry (WCHIR, 1869b, entry 1). That same year, 75 other men, women, and children were admitted for reasons ranging from destitution to illness, old age, disability, and orphanhood. By the time the poorhouse transitioned to a long-term care home in 1951, thousands had passed through its doors (WCHIR, 1869a).

Fifteen others joined Jimmy White in the poorhouse cemetery that year, including 92-year-old Jean Kay and 11-week-old Charlie, a foundling weighing three pounds (WCHIR, 1869b). The cemetery ceased operation in 1898 (WCHIR, 1869b). Its markers were removed, the land sold, and eventually paved over -covered by roads, houses, and businesses in the now-urban centre of Kitchener, Ontario, Canada. Though the remains of hundreds lie beneath this part of the city, their presence has been largely forgotten, and their burial grounds remain unmarked.

This article presents a microhistorical account of the 1893 official inquiry into allegations of abuse at the Waterloo County House of Industry and Refuge. Our original intention in studying the poorhouse was to understand the everyday lives of its residents. Archival records predominantly reflect the perspectives of the upper- and middle-class men who built and managed the institution. We found that the most sustained public attention to residents’ experiences emerged during local newspaper coverage of the 1893 abuse inquiry. Through close readings of archival committee logbooks, correspondence, genealogical records, and press reports, we reconstruct the events that led to the investigation and reveal glimpses of the lived realities of residents and workers at the time.

The study of the poorhouse Is a study of power - how it is structured, justified, and resisted within institutional settings. Poorhouses reveal how charitable intent intersected with municipal authority and medical judgment, embedding hierarchies of class, gender, and ability. Following Ginzberg (1993), we approach this inquiry through a microhistorical lens to uncover unexpected relationships and tensions. Inspired by Reaume (2000), we foreground the experiences of marginalized residents using a critical social work and disability studies framework.

The 1893 Waterloo investigation may be among the earliest documented municipal responses to institutional abuse in Ontario. While not the first of its kind – the 1848 Brown Royal Commission examined staff conduct at Kingston Penitentiary, and Cole (in Henton & McCann, 1995) claims that at least 15 other commissions addressing mistreatment in Ontario’s orphanages, training schools, and detention centres occurred during this time—the poorhouse inquiry is notable for its local and public character. The Department of Indian Affairs also began investigating abuse in residential schools as early as 1886 (LeBeuf, 2011). Yet, as Daly (2014) notes, these early investigations had minimal impact, with findings rarely resulting in systemic change, an observation made in her analysis of Newfoundland’s 1989 Hughes Inquiry into the Mount Cashel Orphanage—the first national inquiry of its kind.

By the 1990s, allegations of abuse in over 70 Canadian institutions came under scrutiny (LCC, 2004). More recently, in 2016, the Ontario government agreed to a class-action settlement compensating former residents of 12 government-run facilities for adults with developmental disabilities who suffered neglect and abuse (CBC News, 2016). Additional suits have addressed abuse in Ontario Training Schools (CBC Docs POV, 2021) and among Crown Wards in foster and group home settings (Fraser, 2024). Ongoing truth and reconciliation processes continue to expose the cultural genocide enacted through residential and Indian Day Schools (TRC, 2015; Wadsworth et al., 2021). Collectively, these cases suggest that institutional and carceral settings are not anomalies in enabling abuse, but systems where harm is routinely structured and sustained.

The poorhouse story remains relevant today. Institutional care based on this model persists in long-term care homes, prisons, shelters, treatment centres, and group homes, where individuals with disabilities and others often face confinement and limited autonomy (Spagnuolo, 2016). At the height of COVID-19, a Canadian Armed Forces report on Ontario long-term care homes revealed disturbing parallels to the 1893 inquiry, including inadequate staffing and unsafe conditions that enabled systemic neglect (Canadian Armed Forces, 2020).

This microhistorical account helps illuminate what life may have been like inside of a 19th-century Ontario institution. It documents structures of power and discipline but also instances of resistance and community action. It reveals how media and political actors shaped public understanding of the poorhouse, offering a view into the values of an early municipal democracy. In recovering this history, we contribute to a broader understanding of how institutional violence is maintained, justified, and resisted; and how the past continues to shape systems of care today. These accounts also serve as important reminders to guard against future turns toward institutionalization and forced treatment directed at marginalized people.

Methodology

This project adopts a microhistorical approach, not through the lenses of trained historians, but rather from the point of view of social work educators, researchers, and practitioners committed to understanding how 19th-century systems of institutional care shaped the lives of marginalized people, and how these systems persist in contemporary forms. Microhistory, as a method, focuses on the intensive study of small units. The focus is on a single individual, event, or institution using contextualized analysis to illuminate broader social, cultural, and structural forces (Ginzberg, 1993; Magnusson & Szijártó, 2013). We are guided by the idea that seemingly ordinary or isolated events can serve as entry points into the larger mechanisms of power, governance, and exclusion. As Port (2015) argues, a microscopic lens can reveal underlying ideologies, behaviours, and institutional logics that would otherwise be invisible in a broader, birds-eye historical account. Importantly, microhistory emphasizes the agency of ordinary people, not as passive objects of institutional rule, but as individuals who resisted, adapted, and shaped their social worlds.

Our methodology involved close analyses of a range of archival sources from 1865 to 1900: administrative records from the House (logbooks, meeting minutes, and copies of correspondence), and coverage from local newspapers, which provided detailed accounts of the inquiry. These materials were supplemented by genealogical and census information that allowed us to trace the lives of individual residents, staff, and committee members. Our aim was not to reconstruct a single authoritative version of events, but to uncover multiple perspectives, from those of institutional elites to residents, staff, journalists, and the broader public.

Our approach departs from value-neutral historical inquiry. As social work scholars, we hold a dual commitment to scholarship and to ethical practice grounded in dignity, rights, and social justice. Our analysis is specifically anchored in critical social work and critical disability studies. Critical social work (Campbell & Baikie, 2012) mandates a structural critique of power, viewing individual suffering as inseparable from systemic inequalities. Critical Disability Studies (Burghardt et al., 2021) specifically rejects the medical model of disability, arguing that institutions like the poorhouse enact ableist violence and social control by policing "unproductive" bodies. This combined, anti-oppressive lens reveals the poorhouse as a site of carceral social welfare and situates the 1893 inquiry within the unbroken lineage of Canadian institutional violence - from Residential Schools (Truth and Reconciliation Commission of Canada, 2015) and former facilities for intellectual disabilities (Rossiter & Clarkson, 2013; Spagnuolo, 2016) to contemporary long-term care issues (Canadian Armed Forces, 2020). This ethical, structural analysis compels us to reject the Law Commission of Canada’s (2004) view that past institutional decisions should be judged only by the standards of their time. Appeals to “good intentions” obscure real harm and reinforce a white, settler, middle-class moral lens, while marginalizing those subjected to institutional violence.

There are limitations of using archival records created for administrative ends. As Trouillot’s work (1995) reminds us, archives embody silences, recording some voices while erasing others. Stoler (2009) emphasizes that administrative records should be read “along the grain,” as products of institutional logics rather than reflections of lived experience. Similarly, Port (2015) shows that such records document power relations between rulers and ruled but remain partial and shaped by asymmetry. The poorhouse archives offer detail, but they must be approached critically, with attention to what they omit as well as what they preserve. We argue that transparency about our doubts, hypotheses, and positionalities strengthens rather than weakens interpretation. We approach the archives shaped by the powerful with suspicion, and centre empathy for those silenced, pathologized, or labeled as morally or genetically deficient. Following Jensen (2024), we aim to foreground the lives too-often absent from official accounts: those of the wandering and working poor, the children bound out[1] as labourers, the older adults, the people with disabilities left destitute, and the working-class mothers forced to surrender their children. Through exploring this microhistory, we see evidence of how the ways of knowing and organizing care established in the earliest institutions have influenced the formation of present-day systems and practices.

Context for Houses of Industry and Refuge

Poorhouses evolved from both medieval European almshouses, which were charitable institutions providing shelter and care, and from the more punitive workhouses of 16th-century Europe. English workhouses, created under the Poor Laws, were notorious for their harsh treatment of the destitute (Wagner, 2005). While 19th-century North American poorhouses were somewhat less brutal, they remained strict, paternalistic institutions that sought to control and reform the poor (Baehre, 1981; Katz, 1986; Wagner, 2005). Despite their widespread presence in Canada and the U.S., poorhouses remain under-researched (Baehre, 1981; Park & Wood, 1992; Wagner, 2005).

In mid-19th-century Ontario, poorhouses emerged in response to rapid industrialization, precarious wage labour, and lack of social and medical care. The Gilded Age brought significant economic disparity, poor living conditions, and an influx of impoverished newcomers (Di Matteo, 2001). Those without anywhere else to go: “the wandering poor,” “vagrants,” the adults who were older, the children who were orphaned, and people of any age with illness or disabilities - were often confined to overcrowded, inadequate county gaols before poorhouses were an option in Canada (Government of Ontario, 1870). Studies of poorhouses underscore tensions between charitable intent and coercive control. Wagner (2005) describes the “repressive benevolence” of poorhouses as a dual effort to assist and control at the same time.

Development of the First Municipal Poorhouse in Canada

Ontario’s 1837 House of Industry Act allowed municipalities to fund poorhouses, and by 1866, provincial grants encouraged their construction. Although a mandate to build poorhouses was proposed in 1868, it was not enacted until 1890. Waterloo County acted early, purchasing 142 acres for $9,000 and borrowing $20,000, a significant portion of the county budget at the time (Municipal Council of the County of Waterloo, 1869), to build its own. Leaders, mostly German settlers, developed policies and studied U.S. models (County of Waterloo, 1865–1872). With an estimated cost of $3,000 per year, they aimed to offset some expenses through farm income and a few paying inmates.[2] The poorhouse became one part of a growing network of institutions managing poverty and deviance in Ontario, often transferring residents deemed unfit to asylums, gaols, or other facilities.

The House

Constructed in 1868 on farmland, the central brick structure was designed to house up to 120 inmates, alongside accommodation for the Keeper and staff. The main building contained kitchens, dining areas, living quarters, dormitories, and a hospital ward. Over time, the site expanded to include additional barns, a washhouse, a carpenter’s shop, a “piggery”, a hen house, and a pest house for isolating contagious people. The House was accountable to the Waterloo County council and a standing committee of local councillors, typically influential male business owners and lawyers, who met quarterly to review budget and operational matters and produce public reports. Bylaws required that admission to the House be made under the signed order of a Reeve or Deputy Reeve of a municipality within the County. Inmates were washed, clothed, fed, housed, and given medical care. Their stay could last from days to years.

A Keeper and Matron were hired by the Standing Committee to live in and manage the House and farm. The Keeper oversaw the day-to-day running of the institution, including the enforcement of rules, direction of inmate labour, and supervision of the farm’s operation. Bylaws gave him the authority to punish inmates at his discretion, including the use of solitary confinement no longer than 24 hours (Municipal Council of the County of Waterloo, 1870, p. 47). Infractions such as drunkenness, profanity, theft, or disobedience were punishable by confinement. Inmates were not allowed to leave the premises or communicate with those in solitary without permission. The cells in the basement, described as “idiot cells,” were designated for “idiots, lunatics, vagrants and other offenders against the rules,” (Municipal Council of the County of Waterloo, 1869, p. 32) and could be used to discipline inmates with bread-and-water diets and restricted communication. The role of the Matron (Municipal Council of the County of Waterloo, 1870, p. 48) was similarly outlined in bylaws to oversee all indoor operations as well as the care of female inmates, ensuring cleanliness, decorum, and appropriate labour assignments. She was responsible for laundering, managing personal belongings, and supervising conduct among the domestic servants. The House Inspector, a salaried administrative officer, served as the main liaison between the institution and County Council (Municipal Council of the County of Waterloo, 1870, p. 47). He was tasked with enforcing policies, visiting at least once a week, hearing inmate complaints, inspecting operations, and maintaining official registers, including lists of admissions, deaths, and children bound out to service. He was authorized to adopt out children, typically those under five, or to bind out older children as indentured labourers to local farmers and families. The physician assigned to the house visited regularly and had sanitary oversight of the House and was required to examine and care for ill inmates and document all deaths and births (Municipal Council of the County of Waterloo, 1870, p. 48) . Also on salary were a team of farm workers and domestic servants.

According to William Jaffray’s lecture shared at a June 1871 County Council Meeting (Jaffray, 1872), the daily routine at the Waterloo County Poorhouse began at 5:00 a.m. with communal washing and chamber pot emptying, followed by a quiet, gender-segregated breakfast. Inmates who were able contributed to farm, domestic, or mending work, though most were physically unable to do so. Tobacco, which was consumed or smoked, was provided by the House and was described as a behavioral incentive for many inmates. Meals served at that time were porridge in the morning, soup and meat at midday, bread and tea in the evening, and the day ended with a final call for tobacco before lights out. Jaffray’s public lecture describes the House as more a place of “refuge” than “industry,” and recounts eating with inmates with “deranged intellects and imbecility” (Jaffray, 1872, p.37). His language, mocking and dehumanizing, echoes the pseudoscientific racism and ableism of the emerging eugenics movement (McLaren, 1990).

Context for the 1893 Investigation

“I was forced to saw wood before my shoulder had healed,” testified former poorhouse inmate John Bergman. “And I saw Mr. Itter strike Lucinda Potter with a horsewhip ("The County Poorhouse," 1893a, p. 8). Through Mr. Bergman and others’ sometimes dramatic testimonies, a picture emerged in 1893 of an institution where some residents were subjected to harsh control, and internal oversight failed to prevent or address abuse. The inquiry briefly opened a space for public scrutiny and offered a rare window into the poorhouse from the perspective of those who lived and worked there. But how did this window open into the institution? Although the public testimony was exceptional, it reflected deeper tensions that had been growing for the previous decade. Before examining the investigation itself, we turn to the events that likely set the stage for the sworn accusations brought forward by former inmates, former servants, and community members.

Limited Archival Evidence for Neglect or Abuse Prior to 1893

During the first two decades of the House’s existence (1869–1880), there is no available documentation of widespread neglect or abuse at the poorhouse, though this absence of evidence cannot be taken as testimony that such conditions did not exist. Older, compliant, or “deserving” residents may have experienced a relatively stable existence, especially compared to the alternatives for the destitute at the time. Many people lived there for years, and records suggest efforts were made to maintain cleanliness and prevent disease. Some local people turned to the institution for medical care, even raising concerns that it was being used as a substitute for the lack of hospital services in the County (Municipal Council of County of Waterloo, 1878, p. 37).

The institution was visible and locally governed, with quarterly Standing Committee meetings held at the House and annual reports widely circulated in both English and German. The Inspector/Clerk maintained a direct line between the House and County Council. Unlike distant institutions such as the London Asylum or Huronia Institute, the Waterloo poorhouse remained relatively accessible to local scrutiny. This proximity may have offered limited, but real, opportunities for advocacy.

Still, evidence of punitive treatment and paternalistic judgment surface within the archives. Punishments for “unruly” inmates were vaguely mentioned, with basement “idiot cells” designed to confine inmates considered disruptive or unmanageable (Municipal Council of County of Waterloo, 1869, p. 32). Inmates deemed “lunatics,” who may have been difficult to manage were often sent to other institutions (County of Waterloo, 1881-1888, July 24, 1888 entry; WCHIR, 1869a) such as the Huronia Institute where we know systematic abuse was likely their reality (Rossiter & Clarkson, 2013). Staffing levels remained low, with increased reliance on temporary servants and able-bodied residents to support the care of the sick and dying. This, combined with the lack of running water and trained staff, created clear conditions of neglect.

In 1877, a physician reported high death rates and insufficient nursing support (Municipal Council of County of Waterloo, 1878, p. 37). Around that time, a fire at the Norfolk poorhouse killed 17 residents, prompting some safety updates at Waterloo, though others were delayed (Municipal Council of County of Waterloo, 1878, p. 30). Prior to 1893, three inquests were held into deaths of inmates including an inmate found dead by the river (1876), a suicide (1877), and a fall from a window (1891). Available records suggest that the local coroner led these smaller scale inquiries (“Poorhouse Investigation”, 1893; WCHIR, 1869b, entries 67, 81).

In 1880, an inmate’s complaint prompted the Standing Committee to investigate the physician for neglect (County of Waterloo. Standing Committee of County Council of the House of Refuge Board [WCSCRB], 1869–1906, Meeting of December 1, 1880). Though the physician defended himself, ongoing concerns led the Committee to request his resignation in March 1881 (WCSCRB, 1869–1906, Meeting of March 15, 1881). Correspondence marked as “private” in the Clerk’s letterbook reveals that Inspector Bauman intentionally omitted the incident from the official minutes to protect reputations, framing the resignation as voluntary (County of Waterloo, 1881-1888, March 16, 1881 entry). Around the same time, the committee ordered a review of all children bound out across the County, reflecting concerns about their welfare (WCSCRB, 1869–1906, Meeting of December 17, 1880). These actions suggest a pattern of archival curation aimed more at shielding officials than fully documenting institutional realities. Thus, we can only speculate at what the conditions for inmates and bound out children may have been like.

The Itters Reign as Keeper and Matron

By 1893, over 1200 inmates had resided at the Waterloo County Poorhouse (WCHIR, 1869a). With the retirement of the McMachons in 1880 (original Keeper and Matron appointed 1869–1880), the institution had come under the control of Peter Itter and his wife Susannah, who died at the poorhouse in 1886. A year later Itter’s new wife Alvina Klem, a former poorhouse servant becomes Matron. Under Itter’s leadership, a more authoritarian style seems to have emerged. The archives reveal he opposed releasing inmates who were useful for labour (County of Waterloo, 1888-1894, April 15, 1890 and May 7, 1891 entries; WCSCRB, 1869–1906, Meetings June 18, 1890 and November 28, 1891). Itter also restricted religious access, once banning a visiting reverend, prompting a written reprimand from the Inspector (County of Waterloo, 1881-1888, January 4, 1882 entry). His growing control and resistance to oversight, coupled with moral disdain for certain inmates, laid the groundwork for the 1893 inquiry, ultimately catalyzed by the advocacy of inmate Jemima Frame’s friends.

Jemima Frame and Friends: THe Role of the "Charitable Ladies"

Jemima Frame, a Scottish immigrant, entered the poorhouse destitute in 1886 after years of living alone following her husband's death (“Death in the Poorhouse”, 1888; WCHIR, 1869a, entry 1114) . When her friends Margaret Young and Celina Dietrich visited her in 1888, they were disturbed by her condition and requested a special nurse; an offer the Committee denied, claiming it would “demoralize the institution” (WCSCRB, 1869–1906, Meeting September 5, 1888). Jemima died three days later, but Young and Dietrich continued to advocate for reforms after her death. By 1893, the group expanded to include other women and then identified themselves as members of the Order of King's Daughters. The Order of the King’s Daughters was founded in New York City in 1886 and spread to Canada, where it attracted women interested in combining Christian service, charitable outreach, and moral reform (Christie & Gauvreau, 1996). In Canada, the King’s Daughters established and supported hospitals, homes for women and children, and visiting nurse services, filling gaps left by underdeveloped public systems (Dodd & Gorham, 1994).

Five years after Jemima’s death, the King’s Daughters of Berlin and Waterloo met privately with members of the poorhouse Standing Committee. Notably, the Keeper and Inspector were not invited. Perhaps the women intentionally sought to circumvent the authority of those managing daily operations at the House. At that meeting, the women pressed for the appointment of a trained nurse for the hospital wards and a night watchman to ensure care overnight. The Committee denied their suggested reforms but suggested they be given visitation rights to observe the workings of the House for themselves (WCSCRB, 1869–1906, Meeting March 14, 1893).

By June 1893, we can assume the women’s frustrations with the lack of response from the Committee had become more pointed. The women or someone with knowledge of their advocacy efforts reaches out to local media, with what appears to be a targeted media campaign.

The Push in Local Media

In early June of 1893 two editorials appeared in local newspapers advocating an investigation into the poorhouse. The Waterloo Chronicle article refers to calls from community members, particularly a group of “charitably disposed ladies,” for improved care of the institution’s residents (“An Investigation Demanded”, 1893, p. 4). Allegations were made against the institution’s Keeper, Mr. Itter, including detaining residents capable of independent living against their will and defying orders from County Council. Additional concerns were raised about the lack of accountability in the management of the House’s farm and the inappropriate practice of County officials dining at the institution’s expense during inspection visits. Despite a Grand Jury’s previous recommendations to enhance safety and oversight, no substantive actions have been taken.

A Berlin Daily Record article, “INVESTIGATE! INVESTIGATE! A Call for Investigation into Alleged Poor House Mismanagement,” is a letter written by an anonymous “Samaritan” (“Investigate! Investigate!”, 1893). The author calls for an investigation into allegations of neglect and abuse, highlights persistent rumors of mistreatment, including reports that inmates were locked in their rooms overnight without access to assistance, and alleges an older man died alone while his wife was forced to keep vigil by his corpse because the Keeper had locked the couple inside their room overnight. The letter also describes a “strong, healthy girl” was reportedly kept in the poorhouse against her will because she was useful for labour. The author describes “charitably disposed ladies” being given permission to visit the poorhouse by the County Council and then being refused admittance when they called. The author argues that, if true, these accounts reveal cruelty, while if false, an investigation is needed to clear the officials of blame. The plea is framed as a matter of justice and human dignity, urging authorities to ensure the poorhouse functions as a genuine refuge for “unfortunate humanity.” Together, both articles reflect a level of unusual critical scrutiny for the poorhouse leadership. They reflect the broader Victorian ethos that charitable institutions must serve both public trust and humane care, and that failure to do so is not only a managerial lapse but a moral one, in opposition to Christian faith; a view made explicit in the editorial signed “A Samaritan,” who after recounting the various rumours of ill treatment concluded, “If true, such occurrence seems sadly out of place in a professedly Christian community” (“Investigate! Investigate!”, 1893).

Itter Demands and Investigation

Itter responds to the accusations in a letter of his own to the Berlin Daily Record on June 9, 1893 (as cited in “Mr. Itter the Keeper replies to the Article in the Chronicle”, 1893, p. 4). His letter is then reprinted in the Waterloo Chronicle on June 15. Itter’s response is marked by a tone of defensiveness, personal grievance, and open disdain for his critics. He denies all allegations concerning mismanagement or mistreatment of inmates and frames the complaints as unfounded and personally motivated. Itter positions himself as a loyal and long-serving administrator unjustly attacked by “charitably disposed ladies,” whom he accuses of spreading rumours, seeking domestic servants, and undermining his authority. Itter implies the women advocating for changes at the poorhouse are motivated by their interest in having female inmates released so they can be available as domestic help for themselves. Further he contends that he too would like more resources to care for inmates of the Poorhouse. He explained that he held the female inmate at the Poorhouse against the will of Council so that an investigation would be triggered to clear his name. He writes, “If those good ladies who take so much interest in the inmates of the Poor House would give their attention to outside affairs, they would be better employed and have a much larger field of operation ” (“Mr. Itter the Keeper replies to the Article in the Chronicle”, 1893, p. 4).

Alongside Itter’s letter in the Chronicle, the editors published a sharp critique to introduce Itter’s response, condemning his defiance of a unanimous Committee resolution and a direct release order for an inmate from the Warden. The editors called his justification “flimsy,” likened his insubordination to a fireable offense, and emphasized that the poorhouse’s reputation and public trust demanded a thorough investigation (“Mr. Itter’s Reply”, 1893a, p. 4). Itter then presents his demand for a poorhouse investigation to the County Council meeting on June 20 (Municipal Council of the County of Waterloo, 1894, p. 10). On June 20 the matter is referred to the Standing Committee on the House of Industry, but the matter is brought up again the next day at the continuation of the Council meeting.

Tipping Point: Hattie Strassburger's Letter

The June County Council resumed on June 21. According to the Berlin Daily Record, the reading of a letter from former inmate Hattie Strassberger “caused a sensation” at the meeting (“Second day’s doings: The Poorhouse matter discussed”, 1893); a rare instance in the archives where a resident’s voice appears directly. Likely encouraged by someone in the community (perhaps a “charitable lady”) and formally declared before a Justice of the Peace, Hattie’s sworn statement was read aloud at council and transcribed by the local press. The Berlin Daily Record, the Waterloo County Chronicle and the Galt Reformer all reprinted her testimony (“House of Industry sworn declaration”, 1893a; “House of Industry sworn declaration”, 1893b; “Second day’s doings: The Poorhouse matter discussed”, 1893). Because her testimony is so rare, we include it here in full:

I, Hattie Strassberger, of the town of Waterloo, do solemnly declare that I was a hired servant at the said House of Industry and Refuge for upwards of two years, under the present management, and I saw Mrs. Itter take hold of Lucinda Potter, one of the inmates of such house, by the hair and pull her about and otherwise ill-treat her, Mrs. Itter saying that she did so because the said Potter had forgotten to obey her orders. I frequently heard the said Mrs. Itter use indecent and abusive language towards the inmates and she in my presence violently pushed one Peter Worst, an inmate, against a post, causing his head to be cut in such a way that the services of a doctor were required to dress such cut. I know that the Keeper and Matron objected to and prevented the inmates from speaking to any of the parties visiting such House and also from speaking to the Committee of the Council when in such house and I learned from several of the inmates that it was from fear of being punished by such Keeper and Matron that they did not complain of the ill treatment they received at the hands of the Keeper and Matron. Henrietta Strassberger.
Declared before
Mr. F. Colquhoun, J.P., Waterloo.
(“Second day’s doings: The Poorhouse matter discussed”, 1893)

Born in New Hamburg to German immigrants, Hattie Strassberger entered the poorhouse at age nine with three siblings after her father’s illness. Her mother died in the poorhouse from consumption. Her siblings were sent to an orphanage, and Hattie was placed “on trial” in a private home (WCHIR, 1869 a, entries 837-842). She later returned to the poorhouse as a servant from 1887 for two years (WCHIR, 1887-1891). Shortly after her 1893 testimony, she married (Ontario, 1893) and moved to Buffalo, where she lived and worked until her death in 1941 (Waterloo County House of Refuge Project, 2016). Her letter ignited immediate debate in Council. While some downplayed the accusations or defended Keeper Itter, others called for a serious investigation. Councillor Wilkins highlighted grave concerns: neglect, poor food, and confinement, and pushed for immediate action (“Second day’s doings: The Poorhouse matter discussed”, 1893).

Keeper Itter was not wrong to sense that his leadership was under threat; a group of people was actively organizing a campaign to challenge the Itters’ control. This is revealed in a letter signed only with an “X” that is published in the Waterloo County Chronicle. The author describes how the Keeper turned the Ladies away at the Poorhouse after Council had given them permission to visit. The author also expressed disappointment that some councillors who had encouraged the Ladies and “in the charitable works they had undertaken and who furnished them with facts against the keeper are now stating that the Council not be led by ladies”. The anonymous author clarified that the women “have no desire to lead the Council,” but would “continue to work until a reform is brought about” (“The ladies and the poorhouse”, 1893, p. 4).

The Council strikes a Special Committee of five Council members to formally investigate the charges against the Keeper and Matron (Municipal Council of the County of Waterloo, 1894, p. 10). On June 24, 1893, the County of Waterloo issued a public notice calling for written complaints and summoning witnesses to appear before a Special Committee to investigate allegations against the Keeper and the overall management of the poorhouse (“County of Waterloo”, 1893).

Day One of the 1893 Investigation

The investigation began on July 3, 1893, at the Berlin Courthouse. Detailed accounts were printed in the daily newspapers which were the main sources for the events in court (“The County Poorhouse: Investigation into the charges against the management by the special committee”, 1893; “Yesterday’s meeting of the poorhouse investigation committee”, 1893). A five-man committee would review formal written and in-person testimonies from former staff, inmates, and community members. The committee began by reading sworn statements including those from former inmates Hattie Strassberger and Elizabeth Beight. Mrs. Beight’s affidavit was direct:

I saw Mrs. Itter whip with a horse whip, Flory McPhee, so it left marks; also Lucinda Potter, whipping her with a strap.... I was told by an inmate that Mrs. Itter kicked her and downed her on the floor, putting one knee on her and struck her on the eye, she nearly losing her sight through the effects of it. (“The County Poorhouse: Investigation into the charges against the management by the special committee”, 1893, p. 8).

A.B. McBride, a Waterloo lawyer, submitted nine separate allegations, ranging from physical abuse to wrongful confinement and medical neglect, to Itter’s refusal to obey Council orders and his alleged preoccupation with personal business. There was a claim that Mrs. Jemima Frame had suffered from neglect during a chronic illness, and that Henry Sand, who fell from a second-story window in 1891, had had no night supervision at the time of his death and that, as the result of an official inquest, a grand jury had recommended changes to observation and window safety.

McBride’s charges also highlighted that inmates were locked into their rooms at night without access to a nurse or watchman, and that food and clothing provisions were inadequate. The complaint further accused the Keeper of detaining residents who were able to work, thus preventing them from leaving the institution to support themselves.

The inquiry heard affidavits from several individuals with first-hand knowledge of the institution. Hannah May, a former servant at the House ten years prior, described observing violence toward an elderly woman by another staff member, Alvina Klem (then a servant and now Itter’s wife), with Mr. Itter present but passive. She testified that inmates were served poor-quality meals, lacked milk even when ill, and confirmed that all residents, sick or well, were locked into their rooms overnight.

Sophie Miller’s affidavit dated June 30, a servant for over two years, was shared where she claimed that she saw Itter “thrash and abuse” both Meinrod Oxner and “Blind Mike” (Michael McCarthy) and confirmed that women were denied permission to leave even when they requested it repeatedly. She noted that “no proper attention was paid to the sick” (“The County Poorhouse: Investigation into the charges against the management by the special committee”, 1893, p. 8).

Mrs. Hall described that a group of women had tried to visit the poorhouse after receiving permission from the Warden. Mr. Itter, learning of their plans, telephoned Mrs. Hall directly and refused to admit them, defying an agreement that the women could visit upon the Warden’s order.

Henry Moletzer, a former inmate with an injured arm, stated he was made to perform hard labour on the farm despite his disability. He reported that food rations were insufficient for working men and that he was locked in while sick, crying out in pain with no one to hear him until morning. He confirmed that “Schmitt” and Blind Mike were both beaten and that sick inmates were ignored.

Mrs. Margaret Young of Galt submitted a detailed emotional letter, recalling her visit to Jemima Frame in 1888, where she found the woman lying “in a state of filth” (“The County Poorhouse: Investigation into the charges against the management by the special committee”, 1893, p. 8). When Mrs. Young and a companion offered to send a nurse at their own expense, they were refused. “In a few days,” she wrote, “word was received from Berlin, not that she was better, but that she was dead” (“The County Poorhouse: Investigation into the charges against the management by the special committee”, 1893, p. 8).

The committee then reviewed the Sand inquest, led by Dr. Lackner, which found that Henry Sand had died from a fall and the grand jury recommended window bars and a night nurse, measures still unimplemented by 1893.

When called to explain himself, Peter Itter requested legal counsel. The morning focused on his refusal to release Annie Watson, despite County orders after securing her a position as a servant. Itter admitted defying the County, claiming he acted to protect his reputation amid damaging rumors and arguing that Watson preferred to go to Buffalo rather than the arranged placement, dismissing the visiting women as merely “looking for servants” for themselves (“The County Poorhouse: Investigation into the charges against the management by the special committee”, 1893, p. 8). Mr. Wilkins, a committee member, rebuked him sharply, calling Itter’s behavior of holding Annie Watson until an investigation was held was a “blooming farce” (“The County Poorhouse: Investigation into the charges against the management by the special committee”, 1893, p. 8). With tensions high, the committee adjourned for lunch, to convene again at the poorhouse to speak directly with inmates and reconvened in the courtroom later in the evening.

The Waterloo County Chronicle reported that Annie Watson was released that night from the poorhouse and there was “just a little scene” before she was permitted to leave but does not offer details (“Local News”, 1893, p. 5).

The committee met privately with current inmates to explore the claims against the Keeper and Matron. The Berlin Daily Record reported the press was excluded from the meetings (“Yesterday’s meeting of the poorhouse investigation committee”, 1893). Back at the courthouse at 5:30 p.m., the committee reported that the testimonies they heard from inmates were “conflicting” yet provided no further detail about the content of these interviews (“The County Poorhouse: Examination of the Keeper and Physician”, p. 8). In their final Special Committee report, they would recount that the visit found the poorhouse to be “clean and orderly,” and that inmates “expressed themselves as satisfied with the treatment they received” (County of Waterloo, 1866-1923, August 1893 entry).

Next, Miss Miller, a former servant, testified in person that Blind Mike, Oxner, and Lucinda Potter had been mistreated. Blind Mike was punished through confinement to an unlit cell for wanting to attend church, Oxner was chased after scratching Itter’s face, and Potter was whipped by Mrs. Itter for disobedience. Under cross-examination by Itter’s legal representative, Miller clarified she had seen Itter restrain Blind Mike with a knee to his chest and handcuffs but had not witnessed him striking him. She believed Mike had spent no more than 24 hours in the dark cell. She was asked to acknowledge that Miller herself had complained about Lucinda Potter’s disobedience in the past (“The poorhouse investigation”, 1893). Itter’s lawyer was developing a thread for the committee that Lucinda Potter was problematic and deserves harsh discipline.

Peter Itter was summoned to respond to the accusations, offering a lengthy and defensive testimony framing his actions as necessary discipline. He admitted handcuffing and briefly confining Blind Mike but denied solitary confinement or prolonged punishment. He minimized his treatment of Oxner and Schmitt, insisting he did not “make a practice of beating inmates” (“Mr. Itter’s reply”, 1893b). Regarding Jemima Frame, Itter described routine care challenges and denied neglect. He recounted Henry Sand’s fall in 1891, noting that room-locking procedures were introduced afterward. Itter also denied any shortages of clothing or food, dismissing complaints as unfounded. In Annie Watson’s case, Itter admitted refusing her release despite orders from the Warden and committee, claiming he needed her as a witness to defend his reputation. However, both the Warden and committee chair testified that he had not given this explanation at the time. Itter defended his wife, Alvina, claiming she had not neglected her duties but was simply “working too hard” (“The County Poorhouse: Examination of the Keeper and Physician”, p. 8). He justified strapping kitchen staff as necessary discipline and insisted he and his wife suffered more abuse than the inmates. He also denied that his private business interests interfered with his management of the farm, asserting it had his full attention.

The final testimony that day came from Dr. Lackner, the poorhouse physician for 12 years, who offered a generally favourable view of its operations (“The County Poorhouse: Examination of the Keeper and Physician”, p. 8). He recalled no visible trauma in the Sand case and believed Sand died from shock or cold. Lackner stated that patient care orders were always followed and that he never filed complaints, though he noted occasional foul smells attributed to wooden pails. He described Mrs. Frame’s condition as difficult to manage and reported that hiring a trained nurse was deemed too costly. He suggested local care would improve with a hospital. As the session closed, the committee announced it would be reconvened on Saturday, July 15th to continue its investigation.

Day Two of the Poorhouse Investigation

Before day two proceedings began, the Chair asked Mr. McBride, the lawyer, submitting affidavits and leading the questioning of participants if he had more evidence; McBride confirmed he did. Mr. W.H. Bowlby, counsel for Keeper Itter, objected, citing that Henry Moletzer had made a retraction of his testimony, proof that previous affidavits were fraudulent. Moletzer’s retraction was read aloud, denying any knowledge of abuse. McBride countered that Moletzer had been sane when signing the original affidavit and that “no sane man would believe the Mr. Culqhoun [Justice of the Peace] had concocted the charges” (“The County Poorhouse: The investigation concluded on Saturday last”, 1893, p. 8). Despite objections that new evidence would prolong the inquiry and bias public opinion, the committee voted to hear McBride’s additional declarations.

McBride read Selina Dietrich’s declaration describing the 1888 visit to Jemima Frame. Dietrich recalled finding Frame on a dirty straw mattress under a ragged quilt, in a room with an unbearable stench. Frame said she survived mainly on bread and water, unable to tolerate the regular inmate meals (“The County Poorhouse: The investigation concluded on Saturday last”, 1893, p. 8).

Bergman testified about how, while recovering from a broken shoulder and collarbone, Itter forced him to saw wood before he had healed. He witnessed Itter and a farmhand knock down Michael McCarthy for wanting to attend church and described being confined on a cold March night with only a thin sheet, leaving him too chilled to eat the dry bread provided. Former servant Minnie Kirchinski claimed that she saw Itter grab an elderly man by the neck and shove him so hard he was nearly pushed down the stairs after the man hesitated in a hallway instead of joining the others (“The County Poorhouse: The investigation concluded on Saturday last”, 1893, p. 8).

Reverend Hubert Aeymans, a Catholic priest serving as chaplain to poorhouse inmates, gave a declaration that reported being forced to hear confessions in a dirty washroom due to the lack of a private and dignified space for religious rites. He attended the deathbeds of two Catholic inmates and found them clothed in rags, lying in a room pervaded by an “offensive and sickening stench” (The Investigation: Another letter”, 1893). The only food available to these dying individuals was dry bread and black molasses.

Margaret Young submitted a second letter disputing Itter’s claims that Jemima Frame’s lack of bedding was temporary, insisting there were no linens to remove and that the neglect was prolonged. She added that Frame’s eagerness to eat highlighted her physical deprivation and inadequate nourishment (“Mrs. Young’s Second Letter”, 1893).

Following the submission of Mrs. Young’s rebuttal letter, the committee proceeded with oral testimony from witnesses who had either worked at or interacted with the House of Industry and Refuge. The first to appear was C. Eby, a former poorhouse butcher, described witnessing Mrs. Itter push an elderly man from the washhouse, causing him to strike his head on a post and bleed. Eby claimed that Mrs. Itter had laughed and closed the door on the elderly man (“Witnesses examined”, 1893).

Then, the lawyer advocating on behalf of the complainants, requested that Lucinda Potter be brought before the committee to testify about allegations that she had been whipped. He emphasized the difficulty of securing testimony from current inmates, many of whom, he believed, had been “terrorized into silence (“Witnesses examined”, 1893, p. 8.). Mr. Wilkins supported the motion and added that it was his firm conviction the inmates had been coached on what to say. He insisted that if Lucinda were to be brought forward, it must be by someone independent of the Itters, to avoid any opportunity for manipulation. Despite this call for procedural fairness, the matter was quickly dropped after brief discussion (“Witnesses examined”, 1893). The justification offered was that Lucinda had already been interviewed during the committee’s earlier visit to the poorhouse, though no transcript or summary of that testimony is available publicly.

Then, Jacob Shelly, a former farm worker, testified that he saw no mistreatment at the poorhouse and believed it was well managed. Dr. Bowlby, the Itter family’s personal physician, described Mr. Itter as mild-tempered and fit for his role. Former County Warden Randall praised Itter as a “good man,” but had not visited the poorhouse in years (“Witnesses examined”, 1893, p. 8). Lewis Kribs, former Reeve of Waterloo and Hespeler, testified in support of Itter, recalling he had sent Lucinda Potter to the poorhouse: “She was the worst girl I ever saw. Don’t think you could get along without using the strap on her. I approve of using strap in family and it would be proper to use it in the poorhouse in the same way” (“The Investigation: Friendly efforts to save the Keeper’s head, 1893; “Witnesses examined”, 1893, p. 8).

Israel Bauman's Testimony: "The Inspector is Heard"

The poorhouse archives for the first 25 years are written by the hand of Israel D. Bauman. Bauman, County Clerk and Inspector of the House of Industry and Refuge from 1869 to 1896. Mr. Bauman portrayed himself as a neutral administrator, stating that “The principal part of my duty is to keep books and look after accounts” (“Witnesses examined”, 1893, p. 8). In reality, Bauman played a significant role in the institution’s governance, including admissions, discipline, and child indenture placements, with archival records showing he was aware of abuse allegations and actively attempted to influence committee decisions (e.g. County of Waterloo, 1881-1888, March 16, 1881 entry; 1888-1894, July 29, 1893 entry). What we are able to see in the archives and what we cannot see are based on Bauman’s decisions. In court, Bauman described the House as a “first-class institution,” stating he visited often, especially at mealtimes, and had “always considered the poorhouse well managed” (“The inspector is heard”, 1893). He defended the quality of food, the purchasing practices, and noted tobacco was provided as one of the few “solid comforts” for inmates. While conceding that Mrs. Itter could be “sharp,” he argued a softer Matron would be ineffective and explicitly defended corporal punishment: if the Keeper used the strap, it was because inmates “deserved it” (“The inspector is heard”, 1893). Regarding Meinrod Oxner, he supported Itter’s treatment, stating Oxner was difficult and that “his relatives would not keep him” (“Witnesses examined”, 1893, p. 8). In discussing Lucinda Potter, Bauman called her “a bold, bad girl” (“The inspector is heard”, 1893) and went further to pile on shame and blame by sharing that he knew that one of the girls in the poorhouse had “three children in the House and another out of it” (“The inspector is heard”, 1893).

A Series of Other Witnesses to Close the Inquiry

Several witnesses offered generally positive views of the poorhouse, including Louisa Vogel (seamstress), Mrs. Vogel (laundress), Joseph Carl (former sick waiter), and Louis Schroer (farm worker). They described the institution as orderly, the food adequate, and blamed inmate misconduct, not staff, for conflict. Lucinda Potter and Annie Watson were often portrayed as quarrelsome, with Carl calling Lucinda “crazy,” “not right in her head,” and “the worst girl in the poorhouse,” claiming she deserved frequent punishment (“Afternoon session”, 1893, p. 8). Carl, who once sought admission as a paying patient, insisted he would have known if abuse occurred. Mrs. Vogel described Lucinda as having a “quick temper” and deserving punishment, though she had not witnessed mistreatment (“Afternoon session”, 1893, p. 8). Schroer testified that inmates were well fed, though not served the same food as staff, and described Lucinda as having a “fresh mouth” (“Afternoon session”, 1893, p. 8). Additional statements from local businessmen spoke favourably of the Itters’ characters and the institution’s financial management (“Afternoon session”, 1893, p. 8). The committee adjourned to reconvene in a private session on July 24 to draft their final report.

The Unseen and Unheard Lucinda Potter and Michael McCarthy

The figures of Lucinda Potter and Michael McCarthy (“Blind Mike”) were frequently named in abuse allegations at the poorhouse. Though absent from the inquiry’s archival record, both spent most of their lives institutionalized (Waterloo House of Refuge Project, 2016b; 2016c). Lucinda Jane Potter was born in 1866 in Wellesley Township, Ontario. At age nine, she was sent to the poorhouse with her two-year-old brother, Daniel, by Reeve Kribs due to their parents’ alcoholism. Daniel was adopted, a common fate for younger children, while older children like Lucinda were placed as domestic servants. Over eight years, she was repeatedly sent out to work and returned, indicating instability, likely exploitation, and a reputation for being “difficult.” By 1880, records described her simply as “deserted by parents” (WCHIR, 1869a, entry 862). Fragmentary documentation suggests her father was Daniel Potter, a plasterer, and her mother, Catharine Louisa Hilts, likely died in 1874. Lucinda’s sister had also died young—one of many losses in her life. Lucinda gave birth to a son, Robert William, at the poorhouse in 1899, and Lucinda dies there in 1932 (Waterloo House of Refuge Project, 2016b).

Official accounts of Lucinda portray her as problem child, a fallen woman; “crazy,” bold, and immoral, and deserving of discipline. To justify the reported abuse at the poorhouse, Itter’s lawyer strategically used the image of Lucinda Potter as a wayward, disobedient girl to rationalize the harsh treatment before the Council. Yet another story emerges: that of a child abandoned by a system with no social safety net, forced into domestic labour, often sites of abuse, and navigating life with little autonomy. Whether her pregnancy was a result of consensual sexual relations is unknown. Her so-called defiance may have been a survival strategy, acts of resistance in the face of relentless indignities.

Michael McCarthy, or “Blind Mike,” was born in Ireland in 1843 and immigrated to Canada before 1860. By 1861, he was living with the Hennin family in Berlin, Ontario, and attending school (Waterloo House of Refuge Project, 2016b). He was admitted to the poorhouse at age 26, where he was recorded as a laborer and the cause for his confinement was listed as “blindness.” (WCHIR, 1869a, entry 16). A transfer request to the Ontario Institution for the Blind in 1873 was denied, and he remained institutionalized for life. McCarthy died at 61 from “paralysis” at the poorhouse in 1904 and was buried in Berlin’s Roman Catholic cemetery by a half-brother (WCHIR, 1869b, entry 450).

After the 1893 Investigation: Reform and Resistance in the Wake of Exposure

In the wake of testimonies exposing abuse and neglect at the poorhouse, the Waterloo County Chronicle and the Berlin Daily Record demanded a transformation for the Poorhouse grounded in decency and accountability. The Chronicle declared that “an acquittal is entirely out of the question” and urged decisive action (“The investigation”, 1893, p. 4). Editorials throughout August 1893 emphasized that humane reform was a Christian moral duty, calling for qualified leadership, a skilled nurse, regular inspections, and independent oversight to ensure public trust (“Poorhouse appointments”, 1893). The Berlin Daily Record challenged fiscal restraint, arguing that true compassion required meaningful investment in care and institutional reform (“Poorhouse appointments”, 1893; “The County Poorhouse”, 1893b).

Following the investigation, the Standing Committee met in a three-hour closed session on July 24, 1893. The committee’s final report cited “contradictory” evidence and accepted the resignations of Peter and Alvina Itter with little censure (“The Special Session of County Council”, 1893). Itter’s July 21 resignation letter framed his departure as voluntary and the charges as “trivial” (“The Special Session of County Council”, 1893). In private correspondence, Inspector Bauman confirmed the plan to clear Itter of major wrongdoing and discreetly offered his support of preferred candidates for his replacement (County of Waterloo, 1888-1894, July 29, 1893 entry).

The Waterloo Chronicle, involved in exposing abuses, published an editorial on August 17, 1893, reminding readers that the movement for change had been driven “entirely out of a feeling of sympathy for the aged, infirm and sick inmates” (“The new Keeper and Matron”, 1893, p. 4). The Chronicle concludes that Mr. Itter’s autocratic behaviour was unacceptable (“The new Keeper and Matron”, 1893, p.4). The editorial insisted that future appointments must be based on “integrity and fitness” alone and lamented a system in which incompetence was tolerated due to political favouritism. Further the editorial gives credit to the advocacy efforts of Mrs. Kumpf and “the ladies” for “their agitation under great difficulties and now that their efforts have been crowned a success, we may expect better and humane treatment be given the inmates…” (“The new Keeper and Matron”, 1893, p.4).

On August 15, 1893, the council met in special session to accept the Itters’ resignations, authorized hiring a nurse, required access for clergy, and recommended an improved process for checking sales of farm products (“The Special Session of the County Council”, 1893). There was also an argument and an eventual rejection about a recommendation to appoint the Inspector and Physician yearly. A committee member placed some blame on Bauman and the Physician for not addressing the issues sooner. The heated debated ended with a vote to remove and reject this clause from the Special Committee report (“The Special Session of the County Council”, 1893). Joseph A. Laird was appointed Keeper. By September, routine management resumed, and Itter was publicly thanked for his “kind and civil manner” (Municipal County of Waterloo, 1869, Sept 2, 1893 entry). By 1894, some changes began to materialize: a chapel was built, the sewer system modernized, fire safety improved, and a nurse authorized. However, key reforms like annual reviews and depoliticized appointments were only partially fulfilled. The investigation led to infrastructure upgrades but little systemic change. Abuse was never formally acknowledged; instead, allegations were minimized or justified as discipline. No lasting mechanisms were established to monitor or prevent future harm, and daily life for residents continued under familiar structures of power and surveillance.

Conclusion

The 1893 investigation into the Waterloo County House of Industry and Refuge offers a revealing glimpse into the institutional beliefs and practices that governed the lives of socially marginalized people at the turn of the century. Our investigation shows the poorhouse offered practical, potentially lifesaving help for those with no other option, but was also a place of control, and at times neglect, shame, blame, and abuse. The investigation exposed how violence, whether through whipping, confinement, or verbal degradation, was legitimized as “discipline,” and how resistance was pathologized.

Yet there was resistance, as evidenced by the organized advocacy of the local community, including women reformers who attempted to bring forward the voices of those who lived and worked in the institution and those who testified to what they saw. The structural response was tepid: the resignation of the Itters, a nurse hired, a chapel built, a few windows screened. No enduring mechanisms were established to prevent future abuse. The institutional model itself remained untouched. Thousands more people would be institutionalized and abused in the 20th century in Ontario.

An absence of built-in accountability is a pattern that continues today. Reports by the Ontario Ombudsman (2024) and Ontario Human Rights Commission (2024) have repeatedly documented institutional failures, calling for stronger oversight, transparency, and responsiveness to complaints in carceral and care settings. These reports reinforce the essential role of independent monitoring in ensuring the dignity, safety, and rights of people in institutional systems. Without meaningful external accountability, harm is likely to be repeated, hidden, or normalized.

The policing and containing of "unproductive" bodies in the poorhouse remains in the modern "carceral pipeline" (Bergen & Abji, 2020). Today, social welfare systems, particularly the child protection system, continue to impose social control by punishing poverty and structural deprivation in marginalized communities. This results in the disproportionate funneling of racialized and Indigenous youth from state care into the criminal and immigration systems (Ontario Human Rights Commission, 2018). Today’s institutions often rely on antipsychotic medications to manage behaviour (Health Quality Ontario, 2015; Turnbull & Moore, 2024), modern carceral tools that poorhouses lacked, but both reflect a shared ethos: prioritizing cost control over the dignity and autonomy of those whom society deems less valuable.

The poorhouse mindset, rooted in the belief that some lives require surveillance and control and that good care is an undue tax burden, continues to shape the systems of care in Canada (Finkel, 2006; Wagner, 2005). Contemporary institutions still function along a carceral continuum (Mussell, 2023). The epistemic injustice evident in 1893, when the voices of residents were excluded from the official record, persists today, as the perspectives of people who collide with carceral spaces remain largely absent (Turnbull & Moore, 2024). If we cannot yet dismantle these systems, we support ideas such as Dumbrill and Lo (2020) who argue, in the context of child welfare, for the establishment of service users’ unions or associations as means to redress this epistemic injustice by giving those most affected the collective power to shape and challenge the systems that govern their lives.

In Canada, efforts toward deinstitutionalization have been ongoing since the impactful advocacy efforts organized during mid-20th century, yet they remain uneven and incomplete, often replacing confinement with neglect and failing to provide dignified, community-based alternatives (Spagnuolo, 2016). Emerging frameworks around decolonizing care represent meaningful shifts, but structural conditions remain largely unchanged, and carceral approaches in child welfare, justice, and other sites remain (Barker, 2025; Turnbull & Moore, 2024).

We are currently living in a second Gilded Age. As Piketty (2014) demonstrated, when left unchecked, capitalism concentrates wealth in the hands of a few, deepening social and economic divides and endangering democracy. Twain and Warner’s (1873) term, “The Gilded Age,” perfectly captured this hypocrisy: a surface glitter of wealth concealing deep inequality, greed, and corruption. In 1893, amid scandal at the Waterloo County Poorhouse, the Berlin Daily Record called for leaders to “remove the stigma that is sure, otherwise to attach itself to the County, one of the richest in Ontario, as being the most niggardly in the treatment of the poor” (“The County poorhouse,” 1893). This stigma of miserliness remains. Currently, Canada has never been wealthier, yet poverty, institutional violence, and housing insecurity persist (Statistics Canada, 2025). Then, as now, abundance was present, but systems of care prioritized the values of the ruling class over human need.

Perhaps it is not surprising then, that we see a return of eugenic attitudes among powerful voices and policy movement towards increased forced confinement for people with mental health challenges and violence towards people living in encampments (Canadian Press, 2024; CBC News, 2024; Smith, 2025). It is unclear whether there is a progressive path forward or we are in fact on a path of regression. Stories like this account from the poorhouse offer a warning that a regressive path will lead to increased suffering and abuse.

What is the barrier to a progressive path? We argue that scarcity discourse and a poorhouse mindset persist: one that devalues some lives and justifies inhumane systems built on containment and neglect. As Meadows (1999) argued, the most powerful way to change a system is to shift the paradigm that underpins it. We know another way, however political will is lacking and powerful forces support the status quo (Carroll, 2017; Willmott & Skillings, 2021). Decades of activism, advocacy, lived experience, and research offer a roadmap for a new paradigm and better systems (Ben-Moshe, 2014; O’Hagan, 2016). A future beyond repressive institutions is not only imaginable, but also necessary. Social policy must move toward prevention: addressing the structural roots of abuse, family separation, disability marginalization, and mental distress before they become crises. Authentic truth and reconciliation must be felt by those most harmed. The values absent from the 19th-century poorhouse: dignity, compassion, consent, and self-determination, can become the foundation of our collective care.

Endnotes

  1. The term “bound out” as a child labourer refers to a historical practice in which children - often poor, orphaned, or from marginalized families - were contractually placed with an employer or household to work, usually without pay, in exchange for basic necessities like food, shelter, and sometimes minimal education or training. This was common in the 18th, 19th, and early 20th centuries in North America and parts of Europe. This practice was common in the early decades of the Waterloo County Poorhouse.
  2. The term “inmate” is used in this article to reflect the historical language found in poorhouse records, government legislation, and contemporary media of the period. While today the word is more commonly associated with prisons and carries stigmatizing connotations, in the 19th and early 20th centuries it was a general term for individuals housed in institutions, including poorhouses, asylums, and hospitals. We use the term here to preserve historical accuracy while acknowledging its problematic legacy and the power dynamics embedded in institutional care.

References