«MEDICAL CARE IN THE WORKHOUSES IN BIRMINGHAM AND WOLVERHAMPTON, 1834-1914 by ALISTAIR EDWARD SUTHERLAND RITCH A thesis submitted to the University of ...»
Birmingham was a good example of the dichotomy of care between the workhouse and its infirmary. By contrast, in Wolverhampton, the workhouse and infirmary remained integrated and no separation between acute and chronic care appears to have taken place. The process of the division of patients according to the nature of their illness continued through the next two decades, with increasing reluctance of the infirmaries to admit patients with chronic illness.259 Concern has been expressed that in the early 1900s acute medicine ‘was subordinating the needs of the aged and chronically ill patients’ and that it hampered the later development of care for a number of disadvantaged groups, including ‘the chronically sick, the elderly, the poor, D. Thomson, ‘Workhouse to Nursing Home. Residential care of elderly people in England since 1840’, Ageing and Society, 3 (1983), p.46; D. Thomson, ‘The Welfare of the Elderly in the Past: A Family or Community Responsibility’ in M. Pelling and R. Smith (eds), Life, Death and the Elderly, London, 1991, pp.207-8.
N. Goose, ‘Workhouse Populations in the Mid-nineteenth Century’, Local Population Studies, 62 (1999), p.67.
For a discussion of the role of the workhouse in the care of older paupers, see A. Ritch, ‘English Poor Law Institutional Care For Older People: Identifying the “Aged and Infirm” and the “Sick” in Birmingham Workhouse, 1852-1912’, Social History Medicine, 27 (2014), pp.64-85.
R. Means and R. Smith, From Poor Law to Community Care, Bristol, 1998, p.19.
the disabled’.260 This chapter has contributed a rare positive view of the character of medical care in the workhouse and of its role within the medical provision of local communities. In 1866, Birmingham’s WMO considered that the majority of patients who died had been under medical treatment at home or in the local voluntary hospitals and had been sent in to the workhouse to ‘have comfort in their last moments’.261 However, a significant proportion (7%) of inmates remained in the workhouse for more than five years around that time, while the majority of deaths in Wolverhampton workhouse twenty years earlier were in children and young adults.262 Although the workhouse did function as a locus for end-of-life care, acute medical treatment was a significant part of the medical activity that took place within the institution. One important aspect of that acute care was the management of patients with communicable diseases and this constituency will be addressed in the following chapter.
R. White, Social Change and the Development of the Nursing Profession, London, 1978, p.120; C.
Lawrence, Medicine in the Making of Modern Britain, 1700-1920, London, 1994, p.87.
BCL, BBG, GP/B/2/1/33, 23 May 1866.
BPP, 1861 (490), pp.194-95.
THE SEGREGATION OF COMMUNICABLE DISEASE‘the workhouse…is the receptacle for all classes of disease.’1 Nineteenth-century Britain was characterised by epidemics and the widespread prevalence of infectious diseases, which were the commonest causes of morbidity and mortality.2 Infectious diseases, excluding bronchitis and pneumonia, accounted for 33% of deaths in the years 1848-72 in England and Wales and one-third of those deaths were due to respiratory tuberculosis.3 With the inclusion of non-tuberculous respiratory disease, Graham Mooney and colleagues calculated that 48% of deaths nationally in 1851-1860 were infectious.4 Communicable disease was more prevalent in areas where people were crowded together. Rapid urban growth in the early nineteenth century, with its associated problems of sewerage and water supply, multiplied the risk of infection. Thus, urban environments became more unhealthy and allowed disease to become endemic.5 According to Anne Hardy, there grew up within these areas ‘fever nests’, from where the Victorians feared that epidemics Birmingham Central Library (hereafter BCL), Birmingham Board of Guardians’ Minute Book (hereafter BBG), GP/B/2/1/33, 23 May 1866.
The major texts on non-tuberculous infectious diseases as a group include M. Pelling, Cholera, Fever and English Medicine, 1825-1865, Oxford, 1978; A. S. Wohl, Endangered Lives, Public Health in Victorian Britain, London, 1983; R. Woods and J. Woodward (eds), Urban Disease and Mortality in Nineteenth-Century England, London, 1984; A. Hardy, The Epidemic Streets, Infectious Disease and the Rise of Preventive Medicine, 1856-1900, Oxford, 1993; M. Worboys, Spreading Germs, Disease Theories and Medical Practice in Britain, 1865-1900, Cambridge, 2000; M. Dobson, Disease, the Extraordinary Stories Behind History’s Deadliest Killers, London, 2007.
W. P. D. Logan, ‘Mortality in England and Wales from 1848 to 1947’, Population Studies, 4 (1950), pp.138-40.
G. Mooney, ‘Infectious Diseases and Epidemiologic Transition in Victorian Britain? Definitely’, Social History of Medicine, 20 (2007), p.600.
Wohl, pp.3-4, Woods and Woodward, p.20.
could escape and spread to the rest of the population.6 For example, Whitechapel was considered the ‘nucleus of the metropolitan fever field’, while Southwark held the same status within the cholera field in London.7 The mortality rate from infectious diseases declined markedly in the second half of the nineteenth century, both in absolute terms and in relative importance among all causes of disease. In 1901-10, they accounted for only 19% of all deaths.8 This mortality decline was accompanied by an epidemiological transition, with degenerative diseases replacing pandemics of infection as primary causes of morbidity and mortality, a theory first proposed by Abdel Omran in 1971.9 This shift in disease patterns, with a progressive decline in infectious diseases, began in the mideighteenth century, but showed a more marked fall in overall mortality rate in England and Wales from the mid-nineteenth century. The reasons for the mortality decline have been a contentious issue among historians and epidemiologists. In western European societies, Omran ascribes the decline to socioeconomic factors, augmented by the sanitary revolution in the late nineteenth century.11 The work of Thomas McKeown has been influential in stressing the primary reason as the improving nutritional status of the population.12 However, Simon Szreter argues that preventive public health provision and services were more important in explaining the Hardy, p.1.
The Lancet, ‘Reports on the Old Cholera Haunts and Modern Fever Nests of London’, ii (1865), p.656.
A. Omran, ‘The Epidemiological Transition’, Milbank Memorial Fund Quarterly, 49 (1971), pp.509Detailed discussion of the epidemiological transition can be found in: G. Mooney, ‘Infectious Diseases and Epidemiologic Transition in Victorian Britain? Definitely’, Social History of Medicine, 20 (2007), pp.595-606; A. Hardy, The Epidemic Streets, Infectious Disease and the Rise of Preventive Medicine, 1856-1900, pp.1-11; T. McKeown and R. G. Record, ‘Reasons for the Decline of Mortality in England and Wales during the Nineteenth Century’, Population Studies, 16 (1962), pp.94-122.
For example, in McKeown and Record, pp.94-122.
mortality decline.13 Hardy’s view is that no one factor was of overriding importance in reducing death rates, but the measures taken by the preventive authorities were of fundamental importance.14 Indeed, the historiography of infectious diseases is most often set in the context of the general development of the public health movement, to the detriment of local studies of death and disease.15 An integral component of preventive policy to combat infectious disease was the development of fever and smallpox hospitals to provide facilities for isolation.16 Although the Public Health Acts of 1866 and 1875 empowered sanitary authorities to build hospitals and permitted compulsory isolation of patients, the development of isolation hospitals by local authorities was slow. Only one-fifth had made any provision by the 1890s, although the smallpox epidemics gave a degree of impetus.17 For instance, arrangements for fever in the Manchester region other than provided by guardians were present only in Manchester, Preston and Lancaster in the 1860s.18 Additionally, until the 1880s, fever hospitals were small, usually containing around 70 beds.19 The task of coping with patients with infectious disease fell to the poor law authorities and this provides the theme for this chapter. As the Edmund Robinson, medical officer (hereafter MO) at Birmingham workhouse, succinctly put it in 1866 ‘the workhouse as a matter of course is the receptacle for all classes of disease’.20 S. Szreter, ‘The Importance of Social Intervention in Britain’s Mortality Decline c.1850-1914’, Social History of Medicine, 1 (1988), p.2.
Wohl, p.138; J. V. Pickstone, Medicine and Industrial Society: a history of hospital development in Manchester and its regions 1752-1946, Manchester, 1985, pp.156, 158; M. Currie, Fever Hospital and Fever Nurses: A British Social History of Fever Nurses: A National Service, London, 2004, pp.13, 125Pickstone, p.160.
F. B. Smith, The People’s Health 1830-1910, London, 1979, p.241.
BCL, BBG, GP/B/2/1/33, 23 May 1866; this quote appears in the heading to the chapter.
This chapter will consider the arrangements for admitting paupers with infectious diseases to either the workhouse infirmary or the local isolation hospital and will explore the extent of co-operation between the guardians and the sanitary authorities or town councils. How local outbreaks of epidemic disease were managed and how many patients with infectious disease were admitted to the poor law facilities will be analysed. It will address the following questions: how important was the medical role of the workhouse within the local communities; to what extent did Birmingham and Wolverhampton follow national developments in the prevention of infection; were poor law medical facilities an essential component of the management and treatment of communicable diseases in the nineteenth and early twentieth centuries? They will be considered from the standpoints of the impact of a number of childhood infections;
the outbreaks and epidemics of cholera, typhoid and smallpox; and the prevalence of endemic diseases, such as typhus and tuberculosis. However, it is first necessary to consider the issue of fever in general.
Isolating Fever Patients The most striking manifestation of infectious disease was fever, which remained acceptable as a diagnosis in the late nineteenth century. Cullen in the later part of the eighteenth century identified three stages of fever, as debility, chill and heat, and defined it as a disease in itself when it was not associated with another identifiable disease process.21 In the 1860s, it was classified clinically according to the temperature pattern into acute, intermittent or continuous types, while the presence of W. F. Bynum, ‘Cullen and the Study of Fevers in Britain, 1760-1820’, Medical History, Supplement, No. 1 (1981), p. 138.
a rash would aid a more precise diagnosis.22 In English and Welsh workhouses in 1870, a one-day survey of inmates under the care of MOs revealed that 25% of those with infectious disease were identified by the type of fever only.23 Furthermore, 12% of sick inmates suffered from a communicable condition.24 The need for isolation facilities for inmates with infectious disease was recognised from the early eighteenth century and some workhouses set aside special wards for the isolation of infectious cases.25 However, it was not until the late 1860s that provincial workhouses provided a detached building for the isolation of inmates with infective conditions.26 For example, Battle workhouse in Reading, erected in 1867, could accommodate fever cases in a small, detached building, which was enlarged three years later to hold 24 patients. Although the guardians agreed that non-paupers with infectious diseases could be admitted to the workhouse fever wards, a girl aged 25 with smallpox refused admission in 1876 because of the stigma of pauperism. The local sanitary authorities did not erect an isolation hospital until after a smallpox outbreak in 1880, while the guardians erected an additional isolation facility, the ‘Infectious Hut Hospital’, in 1881, consisting of two wards, each with three beds.27 However, the significant role of provincial workhouses in caring for patients with infectious disease and in providing additional facilities to cope with epidemics has been largely neglected. The historiography of institutions for infectious diseases is sparse and has concentrated on isolation hospitals, especially those established in K. D. Keele, ‘Clinical Medicine in the 1860s’ in F. N. L. Poynter (ed.), Medicine and Science in the 1860s, London, 1968, p.7.
By contrast, only 2% of patients in Birmingham had fever and all were grouped under the generic term; there were no fever patients in Wolverhampton workhouse. British Parliamentary Papers (hereafter BPP), 1870 (468-I), pp.52, 82, 86, 232, 236.
Ibid., pp.3, 52-53, 57.
K. Morrison, The Workhouse A Study of Poor-Law Buildings in England, Swindon, 1999, p.156.
M. Railton and M. Barr, Battle Workhouse and Hospital 1867-2005, Reading, 2005, pp. 57-59.