«MEDICAL CARE IN THE WORKHOUSES IN BIRMINGHAM AND WOLVERHAMPTON, 1834-1914 by ALISTAIR EDWARD SUTHERLAND RITCH A thesis submitted to the University of ...»
patients in both wards all had breakfast in bed, but some did get up for dinner. In contrast, inmates in the wards for aged men and women were able to do ward cleaning and washing-up.189 By 1911, the levels of dependence had increased significantly as 68 of 71 women in two of the wards in the female bedridden department were described as ‘actually bedridden’. In one of the wards, all of the 35 patients were bedridden except for one and were being cared for by a nurse and three inmates. Mr E. B. Wethered, Local Government Board (hereafter LGB) inspector, considered that this ward required two trained nurses.190 One reason for the increasing dependency levels was that the guardians had agreed that patients could be transferred from the infirmary to the workhouse for convalescence.191 However, this resulted in the chronic and convalescent wards taking patients with severe disability and the workhouse medical officer (hereafter WMO) commented in 1893 that these wards ‘were practically the same as the bedridden wards’.192 Following his appointment as Medical Superintendent in 1913, Dr Frederick Ellis devised a scheme to improve the classification in the infirmary and workhouse, based mainly on physical ability.
Inmates unable to work because of infirmity were classed as ‘The Infirm’, but men between 60 and 66 years were allocated to this group only if ‘so physically crippled to merit infirm’. ‘The Bedridden’ group contained those who found it necessary to be in bed part of the day or at least part of some days during the week, as well as those who were in bed continuously and with no hope of improvement or where skilled nursing was unnecessary.193 BCL, HSC, GP/B/2/3/3/22, 9 April 1907.
BCL, WMC, GP/B/2/3/2/6, 16 June 1911.
BCL, BBG, GP/B/2/1/57, 19 June 1888.
BCL, HSC, GP/B/2/3/3/15, 21 March 1893.
BCL, BUB, GP/B/2/1/83, 23 September 1914.
The majority of inmates in the sick wards in the mid-nineteenth century suffered from chronic diseases such as consumption, bronchitis, paralysis and debility.194 The nature of the medical condition of the inmates in the workhouse infirmary prompted the Birmingham Daily Mail to comment, following a visit in 1885, that ‘there are comparatively few really sick. It is not so much disease as decrepitude that has to be treated here; and not so much physic as food and nursing that is required’. The article
includes a description of the patients in one of the bedridden wards:
Take for example the largest of female bed-ridden wards. It is a long apartment with 81 beds in it, 80 of which are now occupied.
No measurement can give any idea of it, but imagine a room, not over lofty, with 81 beds as close as they can possible be packed to allow room to pass between them, all filled with decrepit, withered, and haggard specimens of humanity in all stages of senile helplessness. Some are lying in their beds asleep, with the clothes drawn over their faces, inert and seemingly lifeless. Some are sitting crouched up in bed poring over scraps of periodicals. One or two are creeping about the room, getting about a bit.
In this ward the beds run in four rows, with a low wooden partition between the two centre rows, and here are these people herded close together, with nothing to do but to gaze at one another, to grow callous to one another’s sufferings, to see one by one their fellow inmates grow stiff and cold in their beds, and speculate upon whose turn it will be next.195 The patients transferred from the infirmary to the convalescent wards in Birmingham workhouse in 1911 suffered mainly from paralysis, blindness, deafness and bronchitis.196 However, specific diseases were now being recognised as a cause of dependency, rather than age per se, as was the case in 1852, when the WMO reported that two or three inmates were ‘disabled by age and removed to the bedridden BPP, 1867-68 (4), p.5; 1870, (468-I), pp.53-54, 57.
Birmingham Daily Mail, 20 July 1885.
BCL, WMC GP/B/2/3/2/6, 28 April 1911.
wards’.197 The failure to recognise the importance of multiple pathologies as a reason for disability in old age was due to the practice of making a single diagnosis for each patient and this was reflected in the lack of diagnostic depth on death certification in workhouses.198 At the turn of the century, the bedridden wards in Birmingham could include younger disabled adult inmates, such as ‘chronic cripples and paralytics’, as the MO reported that it was no longer the age of 60 years which determined whether ‘a man’ was ‘able-bodied or infirm’, but his physical condition. The change was prompted by the issue of a LGB Order relating to the dietaries of the various classes of inmates, in which the classification of inmates according to age was superseded by one based on their physical condition.199 This meant that older inmates with a disability, but not dependent, could reside in the wards for able-bodied or older inmates. For instance, 70-year-old Michael Hussey who had a ‘wooden leg’, requested to be discharged from the workhouse, as he felt sure he could obtain work.200 This may not have been an unrealistic view, as over 60% of adult males with a disability were in work in the 1860s.201 In the 1890s, Ebenezer Teichelmann, resident WMO, reported that a considerable part of his time was spent treating women in the bedridden wards.202 In 1906, Mr Herbert, LGB inspector urged the Birmingham guardians to transfer the bedridden patients to the infirmary as he felt their quality of life would be improved by the more highly skilled infirmary nurses.203 Five years later, the Workhouse Management Committee BCL, BBG, GP/B/2/1/11, 5 June 1852.
G. Mooney, ‘Diagnostic Spaces: Workhouse, Hospital, and Home in mid-Victorian London’, Social Science History, 33 (2009), pp.357-90.
BCL, WMC, GP/B/2/3/2/3, 7 December 1900.
BCL, WMC, GP/B/2/3/2/4, 14 April 1905.
Ibid., GP/B/2/3/2/1, 11 April 1890.
BCL, HSC, GP/B/2/3/3/22, 27 February 1906; see Chapter 6 for discussion on nursing staff in Birmingham infirmary.
were concerned that some of the bedridden cases required the attention of two nurses and would be better served by the nursing care provided in the infirmary.204 Despite their concerns, the bedridden wards remained in the workhouse and were no longer considered part of the medical provision. In a national return of inmates occupying the wards for the sick in June 1896, Birmingham guardians declared 917 sick and bedridden patients in the separate infirmary, but none in the workhouse. However, there were 818 non-able-bodied adults in the workhouse at that time and some of those would have been in the bedridden wards, as they had not been transferred to the infirmary.205 Nevertheless, it is clear they were no longer regarded as requiring medical care, an attitude that prevailed elsewhere. The WMO at Battle workhouse in the first decade of the twentieth century attributed overcrowding in the infirmary to the number of infirm inmates who needed attention, but not medical treatment or skilled nursing.206 This viewpoint was also reflected in the decision by the Birmingham guardians to change the designation of officers employed in the workhouse wards from nurses to attendants. However, they were forced to rescind this a few months later because of the difficulty in retaining sufficient staff.207 The bedridden wards remained in the workhouse and, from early in the twentieth century, the movement of patients was from the infirmary to the workhouse, where the chronic and convalescent wards became occupied by inmates who suffered from severe disability. At times, the infirmary was required to take bedridden patients from the BCL, WMC, GP/B/2/3/2/6, 28 April 1911.
BPP, 1896 (371), p.28; BCL, LGB Returns, GP/B/5/1/2, 30 May 1896.
Railton and Barr, pp.132-33.
BCL, WMC, GP/B/2/3/2/1, 10 July 1891; HSC, GP/B/2/3/3/13, 8 September 1891; see chapter 6 for more detail.
workhouse when it was overcrowded, but always on the understanding they would return in due course.208 In Ellis’ scheme for classification of the indoor poor in 1914, he considered essential for the economic administration of the infirmary that ‘chronic cases’ not requiring medical or nursing skill should be removed to the workhouse. He gave examples of patients with leg ulcers and ‘chronic sores’. There were three male and three female wards in the infirmary for ‘chronic cases’, where patients could receive treatment for a ‘fair length’ of time, namely for several months. He estimated that up to 55 of such patients could be transferred at that time.209 The transfer of chronically disabled patients from acute hospitals and infirmaries became standard practice nationally.
According to Weisz, as hospitals became more medicalised, they frequently denied admission to ‘chronics’ on the grounds that there was nothing medically that could be done and beds should be reserved for those who might benefit from medical treatment.210 Poor law infirmaries could not refuse admission to paupers and so needed to make transfer arrangements. For example, Leicester poor law infirmary at North Evington transferred patients to the local workhouse, despite the infirmary having infirm wards for patients not requiring ‘sick nursing’. Bedridden patients and those suffering for paralysis were among those sent to the workhouse, where the MO described their move as inappropriate.211 One of the reasons in defence of this practice given by the Chief Medical Officer in 1930 was that the continued presence of such patients in a hospital would lower medical and nursing standards throughout BCL, Workhouse Infirmary Management Committee (hereafter WIMC), GP/B/2/4/4/3, 18 March 1898.
BCL, HC, GP/B/2/3/14/1, 16 September 1914.
the institution.212 This policy cemented Birmingham workhouse’s role as the main provider of care for chronic illness and disability and it was no surprise that it became a specialised geriatric hospital in 1948. In that year, the Birmingham Chronic Hospital Survey reported that nearly half of the male patients and just below twothirds of the women in the hospital were bedridden.213 According to Weisz, poor law institutions such as Birmingham workhouse became seen ‘as a dumping ground for indigent elderly and chronically ill people’.214 The practice of removing long-stay patients from the acute hospitals gave rise to the division in British hospital medicine between a voluntary sector that dominated acute care and a public sector in which the older, ‘chronic’ patient was located.215 Dependent Patients in Wolverhampton The ability to identify severely disabled patients in the Birmingham poor law records has aided the understanding of the establishment of chronic hospitals within the National Health Service, but it has been more difficult to determine how smaller workhouses, such as Wolverhampton, managed these patients. In Wolverhampton, the wards, as recorded in master’s journal in 1842, were for able-bodied inmates or old men and old women, plus infirmary wards.216 However, the guardians’ minutes contain a reference to an ‘aged infirm’ women’s ward and, ten years later, to male and M. J. Denham, ‘The History of Geriatric Medicine and Hospital Care of the Elderly in England Between 1929 and the 1970s’, (unpublished PhD thesis, 2004), pp.60-61.
Denham, ‘Surveys of the Birmingham Chronic Sick Hospitals’, p.282.
M. Gorsky, ‘Creating the Poor Law Legacy: Institutional Care for Older People Before the Welfare State’, Contemporary British History, 29 (2012), p.442. Similarly, voluntary and municipal hospitals in the USA sought to eliminate patients with chronic disease, Weisz, pp.58-59.
WALS, MJ, PU/WOL/U/2, 16 April 1842.
female infirm wards, but it is uncertain how dependent inmates in these wards were.217 Around this time, Mr Dunn, and his children were allowed to leave the workhouse, but his wife, who was paralysed and partially disabled, remained, as she was in constant danger of falling into the fire. He was unable to earn sufficient money to pay for a nurse to take care of her at home, but he agreed a weekly payment to the guardians of 2s and 6d.218 Bedridden patients were first mentioned by the WMO in 1863, when he transferred them out of the cottages in order to use these buildings for patients with smallpox.219 As in Birmingham, overcrowding took place in the workhouse in 1866, when there were around 260 sick and infirm inmates (36% of the total), of whom 200 were considered by the MO to be chronic cases, unlikely ever to leave the workhouse.220 The lack of sufficient accommodation may have been the reason for 10 ‘crippled or infirm’ men residing in the able-bodied ward.221 When a correspondent from Wolverhampton Chronicle visited the sick wards 20 years later, one man aged over 80 years of age had been an inmate for more than 40 years, while some of the ‘very old’ women were bedridden.222 When Edward Smith, MO of the PLB, visited the infirmary in 1867, there was an eleven-bedded ward for ‘aged and incurable’ females, and two similar sized wards for paralytic males and females.223 However, the occupants of these wards get no mention in the guardians’ records.
Toward the end of the century, 83 of the 225 patients in the infirmary were described as requiring ‘everything done for them’ and 16 children were included in that WALS, WBG, PU/WOL/A/3, 24 March 1842; PU/WOL/A/8, 29 October 1852.
Ibid., PU/WOL/A/6, 14 August 1846.
WALS, WC, 18 November 1843.
Ibid., 28 November 1866.
Anonymous, ‘Wolverhampton Workhouse, Staffordshire’, The Lancet, ii (1867), p.555.
Ibid., 14 July 1886.
BPP, 1869-70 (14), p.153.
number.224 One of the children may have been Mary Ann Wilkes, an illegitimate child of 13 years, suffering from ‘Spinal Caries’ and hip joint disease. At the MO’s instigation, the guardians agreed to her transfer to the Royal Alexandria Children’s Hospital in Rhyl and pay 8s weekly toward her keep.225 On the first of January 1900, 725 (56%) inmates were over 65 years of age, with 275 (38%) of those over 70 years.