«MEDICAL CARE IN THE WORKHOUSES IN BIRMINGHAM AND WOLVERHAMPTON, 1834-1914 by ALISTAIR EDWARD SUTHERLAND RITCH A thesis submitted to the University of ...»
Typhoid, a type of enteric fever, was not identified in annual registration reports as a separate disease distinguishable from typhus until 1869, although the clinical differentiation between the two had been widely accepted in Britain by the medical profession following Jenner’s studies of the disease in the 1840s.106 Like typhus, it presents with fever, headache, a rash and diarrhoea.107 The disease is contracted by ingestion of food or water contaminated by human faeces; hence its reputation as the ‘filth disease’ was due to its association with faecal pollution. Despite this, it affected all social classes as the houses of the wealthy had private wells and poor drainage, as was the case in Birmingham.108 The responsible bacterium was discovered by Karl WALS, WBG, PU/WOL/1/15, 24 March 1842; MJ, 26 March 1842 and 26 October 1844.
BPP, 1870 (468-I), pp.52, 63, 82, 86, 233, 286.
Anonymous, ‘Reports on the Old Cholera Haunts and Modern Fever Nests of London’, The Lancet, ii (1865), p.656.
Creighton, p.213; Worboys, p.132.
The rash is typically rose-coloured and spotted and appears later in the course of the disease. It is associated with the diarrhoea and may be followed by intestinal ulceration.
Wohl, p.278; Pelling, pp.197, 283; R. Woods, Mortality and sanitary conditions in late nineteenthcentury Birmingham’, in R. Woods and J. Woodward (eds), Urban Disease and Mortality in Nineteenth-century England, London, 1984, pp.197-98.
Eberth, a German bacteriologist, in 1880.109 However, its acceptance as the definitive cause of typhoid was not universal in Britain until the emergence of a diagnostic test in 1896 and a vaccine the following year.110 Although endemic in England, outbreaks
Birmingham Registration District, it was halved between the decades 1871-80 and 1901-10, falling from 788 deaths and a death rate of 0.33 per thousand to 351 and
0.15 respectively; figures similar to the national picture.112 The major factors in achieving this change were improved domestic water supply and better individual hygiene, but the more stringent hospitalisation of patients was also important.113 The MOH for Birmingham attributed the decline in cases of enteric fever predominantly to the provision of isolation accommodation.114 An outbreak of typhoid occurred in a house in Oxford Street, Wolverhampton in 1869 and the 11 sufferers who survived were admitted to the workhouse. They joined five existing patients with the disease, causing the female fever wards to be fully occupied.115 However, typhoid does not appear in the poor law records of Wolverhampton and Birmingham until the 1880s. An outbreak occurred in the town of Bilston in the Union of Wolverhampton in 1885, and the guardians arranged for infected paupers to be admitted to the local isolation hospital. Despite this, two inmates died from typhoid in the workhouse the following year, as well as four in the Known as Salmonella typhi, it is excreted in human faeces.
Worboys, pp. 268-69.
Smith, p.245; Luckin, p.107.
Woods, p.181; Hardy, p.152.
Hardy, pp.152-53, 159, 165; Wohl, p.128.
The Lancet, ‘Reports of Medical Officers of Health’, ii (1902), p.178.
WALS, WC, 24 November 1869.
General Hospital.116 In 1892, when Elizabeth and Ellen Brooks arrived at the workhouse suffering from typhoid, it was the General Hospital that the guardians turned to for their admission, agreeing to meet the cost of their care.117 Despite this, patients with typhoid continued to be admitted to the workhouse, as there were four present three years later in March.118 A small number of inmates with typhoid were also present in Birmingham workhouse throughout the 1870s, 1880s and 1890s (Appendix A). Prior to 1882, they were being treated in the general sick wards, but, in that year, the guardians decided they should be isolated from other patients and agreed to convert the room over the ‘old swimming bath’ for this purpose.119 Three years later, the bed provision for typhoid patients was eight for men and, surprisingly, none for women, although they would have been able to reside in the 12-bedded, female infectious ward.120 Only one inmate is recorded as having typhoid after midsummer 1899 (Appendix A), but, as the figures are based on one-day counts, it might reflect the reduced prevalence of the disease rather than its non-existence in the workhouse. However, there were no cases of typhoid between October 1906 and the same month two years later. The opening of a second isolation hospital in the city at Little Bromwich in 1895 may be a further reason for the lack of patients admitted to the workhouse. Furthermore, patients with typhoid did get admitted to the infirmary in the early twentieth century. Jordan Lloyd, visiting surgeon to the infirmary, complained in 1908 that two or three cases of the disease had been transferred from the workhouse into his wards and he believed that the visiting physician had had the WALS, WBG, PU/WOL/A/20, 21 and 28 August 1885; WALS, L614, Report on the Health of the Borough of Wolverhampton, for the year 1887, p.12.
WALS, WBG, PU/WOL/A/24, 12 August 1892.
WALS, WC, 20 March 1895.
BCL, VGPC, GP/B/2/1/8//1/8, 28 April, 12 May 1882.
BCL, VGPC, GP/B/2/8/1/9, 14 August 1885.
same experience.121 In the same week, Miss Emma King, assistant matron of the workhouse and a qualified nurse, contracted the disease, was admitted to the nearby City Fever Hospital, but died ten days later.122 These occurrences are suggestive of an outbreak in the workhouse at that time, but no cases of typhoid were recorded in the returns to the Local Government Board (hereafter LGB) for that month. Epidemics within workhouses could result in high fatality rates, such as the outbreak of enteric fever in Bridgewater parish workhouse in the winter of 1836-37 that killed one-third of inmates.123 From the available literature, it appears that, in contrast to Birmingham and Wolverhampton, workhouses had very few if any inmates suffering from typhoid.
However, inmates with severe infective diseases were more likely to die within the first month of admission.124 Their relatively short length of stay in the workhouse makes it likely that statistics collected on one-day counts may under-represent how many inmates had been admitted with infectious disease associated with a high fatality rate. This would also be the case for the other diarrhoeal disease, cholera.
Asiatic cholera first arrived in England from India in 1831 at Sunderland and spread throughout the country over the next eighteenth months, highlighting the insanitary conditions of industrial Britain.125 Further epidemics arrived in 1848, 1853 and 1866, although the virulence of the organism varied on each occasion.126 Bilston was one of the ‘worst hit’ places during the first epidemic in 1832, with 3,568 cases out of a BCL, IMC, GP/B/2/4/4/5, 13 January 1908.
BCL, WMC, GP/B/2/3/2/5, 10 January, 5 February 1908.
S. Shave, ‘“Immediate Death or a Life of Torture Are the Consequences of the System” The Bridgewater Union Scandal and Policy Change’ in J. Reinarz and L. Schwarz (eds), Medicine and the Workhouse, Rochester, 2013, 170.
J. Boulton, R. Davenport and L. Schwarz, ‘“These ANTE-CHAMBERS OF THE GRAVE”?
Mortality, Medicine and the Workhouse in Georgian London, 1725-1824’ in Reinarz and Schwarz (eds), Medicine and the Workhouse, p.77.
R. J. Morris, Cholera 1832. The Social Response to an Epidemic, London, 1976, p.17.
population of 14,500 and a fatality rate of 21%.127 On the other hand, Birmingham surprisingly escaped with only 31 cases reported.128 The second outbreak arrived in Wolverhampton Union in August 1848 once again at Bilston Brook, causing 550 deaths in a population of 22,000 within the first month.129 Like typhoid, it is spread by drinking water or eating contaminated food and can lead to rapid dehydration and death in about half of those affected.130 The account of John Snow’s epidemiological observations of the spread of the disease in Soho during the 1848 and 1853 outbreaks, leading to his ‘waterbourne theory’, is one of the most familiar in medical history.131 Although Koch first isolated the bacillus in 1882, it did not gain immediate acceptance as the definitive cause of the disease among British medical opinion.132 Strict isolation of the sufferers, with careful disposal of their excreta, was the most important preventive measure instituted after the first epidemic.133 Subsequent improvements in sanitation later in the century and the development of a vaccine in 1893 greatly reduced the impact of the disease.
When 267 cases were recorded in the Wolverhampton Union’s districts in one week in August 1849, the guardians considered converting the vagrants’ wards as isolation accommodation, but instead bought land to erect a cholera hospital in co-operation with the Committee for Health of Wolverhampton.134 One woman who tried to escape from the ‘contagion raging there’ by walking from Bilston to Birmingham was Smith, p.237; BPP, 1847-48 , p1.
Pelling, p.2; BPP, 147-48 , p.1.
WALS, WC, 3 October 1848.
The infecting organism is the bacillus Vibrio cholerae, which causes sudden severe watery diarrhoea, associated with abdominal pain and vomiting.
The debate surrounding the possible cause of cholera are discussed in Pelling, Cholera, Fever and English Medicine, 1825-1865, Oxford, 1978.
Worboys, pp. 248, 252; Pelling, p.305.
WALS, WBG, PU/WOL/A/2, 13, 18, 21, 28 August 1849.
admitted to the latter’s infirmary with the affliction.135 By the end of 1849, the epidemic had subsided and the guardians ordered the cholera hospital to be demolished. They agreed a joint plan with the town council in 1853 in anticipation of further outbreaks. The main emphasis was on attempting to keep cholera victims at home rather than admitting them to a cholera hospital, providing houses of refuge for healthy relations and organising dispensaries to give out anti-diarrhoeal medicines.136 Before the arrival of Asiatic cholera, the term cholera had been in use, denoting any disease characterised by intense diarrhoea and abdominal pain.137 Such a disease in infants was known as infantile cholera and in adults, English cholera, both of which were associated with unsanitary domestic conditions.138 When a case of choleraic diarrhoea occurred in Bilston during the last epidemic in 1866, the MO was able to reassure the guardians that it was the English type.139 Diarrhoeal diseases formed a substantial proportion of admissions with infectious conditions in the 1850s (Appendix B) and it is not surprising that outbreaks of diarrhoea took place from time to time within workhouses.140 For instance, several cases of dysentery occurred in Wolverhampton in 1901, requiring the employment of additional nurses.141 Many Birmingham inmates were affected by an outbreak of diarrhoea in one night in July
1865. Only adults were afflicted: 96 in the old men’s wards, 46 in the old women’s ward, 24 able-bodied inmates, 2 in the probationary ward, 8 epileptic men and 33 BCL, BBG. GP/B/2/1/6, 11 September 1849.
WALS, WBG, PU/WOL/A/8, 21 September 1853.
W. Bynum, Science and Practice of Medicine in the Nineteenth Century, Cambridge, 1994, p.74.
No specific organism has been identified with this disease.
WALS, WBG, PU/WOL/A/13, 14 August 1866.
TNA, MH12/13297-99, 13300.
WALS, WBG, PU/WOL/A/29, 22 November1901. Dysentery is caused by bacilli of the Shigella family and results in fever and bloody diarrhoea.
pauper nurses.142 Edmund Robinson, WMO, put the cause of the outbreak down to miasma from the unsatisfactory drains. However, the clinical pattern of many inmates affected at the same time for a short period, plus patients in the infirmary and children, who would have had a different dietary, being unaffected, suggests the culprit was a mild form of food poisoning. This is the only recorded incident of a major outbreak within either institution, and one presumes that many more must have occurred without being mentioned in the records.
Smallpox The need for additional facilities for isolation during epidemics meant that cooperation between the responsible authorities was essential. Smallpox was the only one of all the major epidemic diseases that was controlled by means of medical
presumed to have been smallpox have been traced as far back as antiquity, but the disease appears to have been more virulent in the early modern period, resulting in several epidemics across Britain in the nineteenth century. It is spread mainly by droplet infection and the disease is contracted in the immediate vicinity of an infected person, even after the death of the sufferer.144 There is no sign of illness until a week after infection, when symptoms of headache, fever and backache commence, and a rash appears as the fever abates. The patient is infectious from just before the rash until the last scab drops off, as the virus is shed from the rash. The average fatality BCL, BBG, GP/B/2/1/32, 19 July 1865.
Wohl, p.132; Hardy, p.149.
It is caused by a diminutive, brick-shaped virus, Variola major. The rash begins with flat, reddish spots, first on the face, then spreading throughout the body. It becomes raised with blisters, which dry to form crusts or scabs, accompanied with general swelling of the body.