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infection. After advice from the LGB that the care of such patients was the responsibility of the sanitary authorities, the guardians gave notice to Bilston sanitary authority that they would rescind the contract to pay for paupers admitted to its isolation hospital.185 When the master reported an outbreak of smallpox in the workhouse in February 1896, Esther Gubby was transferred to the Borough Hospital and Ellen Faulkner, another infected inmate, was transferred the following month.186 In the winter of 1902-3, two cases of smallpox arrived in the casual wards.187 The tramp wards were also where an outbreak began in Birmingham in January 1893, at the time of the epidemic. It spread within three months to the infirmary and six months later to the workhouse, as a result of which all visiting was suspended.188 During the epidemic in 1902, five patients were admitted to the infirmary suspected of having smallpox as they all lived in a lodging house where the disease had been present, but they had been misdiagnosed. However, the next year John Russell was found to have the infection after his admission to the infirmary by the WMO, who claimed there had been no sign of smallpox when examined in the ambulance.189 Hardy makes the point that guardians were reluctant to admit smallpox patients into the main workhouse or additional buildings during epidemics.190 However, the provision of isolation wards and hospitals by the sanitary health authorities was slow to develop and only 20% of authorities had any such facilities by the 1890s.191 During the 1872 epidemic, Wolverhampton guardians were considering erecting a WALS, WBG, PU/WOL/A/24, 23 September 1892; WC, 28 June 1892, 8 March 1893.

WALS, WBG, PU/WOL/A/25, 7 February 1896, Workhouse Visiting Committee, PU/WOL/H/2, 17 March 1896.

WALS, House Committee, PU/WOL/E/1, 31 December 1902, 15 January 1903.

BCL, WMC, GP/B/2/3/2/1, 13 January 1893; WIMC, GP/B/2/4/4/2, 28 April 1893; WMC, GP/B/2/3/3/2, 27 October 1873.

BCL, WIMC, GP/B/2/4/4/4, 17 February 1902; WMC, GP/B/2/3/2/3, 10 July 1903.

Hardy, p.123.

Wohl, p.138.

new building as a smallpox hospital, but deferred it in preference to using the recently built receiving wards for convalescent smallpox patients and utilising the old receiving wards for their previous purpose.192 Three months later, the guardians agreed to a request from Wolverhampton Town Council to accept non-pauper patients in the infectious wards of the workhouse on a payment per case basis.193 Conversely, during the epidemic in the early 1880s, arrangements were made for pauper patients to be admitted to Bilston infectious hospital for payment of 3s per removal, 15s per week and the cost of the funeral. When the LGB questioned this arrangement, the guardians responded that it was the duty of the sanitary authorities to provide isolation facilities in order to keep the workhouse from the danger of a large number of smallpox sufferers in the infirmary wards.194 Ten years later during the next epidemic, Willenhall Local Board were informed that the isolation wards at the workhouse were not for the admission of out-door paupers.195 The arrangements for the isolation of smallpox sufferers in Birmingham involved greater collaboration between the guardians and the Town Council. Admissions of paupers with contagious diseases into the workhouse, including smallpox, only took place after 1864.196 Because of the threat of cholera around that time, two straw sheds and several stone-breaking sheds at the rear of the workhouse had been converted into wards and they had subsequently been used for smallpox cases. During the 1871 epidemic, they had become overcrowded within ten months of the first admission. In co-operation with the Borough authorities, an additional ward was to be built, but before it was ready, there were more than enough cases to fill it, so a further one was WALS, WBG, PU/WOL/A/15, 8 January 1872.

Ibid., 5 April 1872.

WALS, WBG, PU/WOL/A/19, 3 August, 7 September 1883.

WALS, WBG, PU/WOL/A/24, 10 February 1893.

BCL, BBG, GP/B/2/1/33, 23 May 1866.

agreed with the same result. The two buildings to hold 30 acute cases were completed and occupied within one week, although several of the workmen contracted smallpox.

In addition, two wards for convalescent smallpox patients were erected.197 The guardians requested payment from Birmingham Corporation for the maintenance of 599 cases sent to the ‘smallpox hospital’ by the Sanitary Commission between 7 December 1871 and 8 February 1873, an amount totalling £1,388 for 11,101 days at 2s and 6d per day. However, they requested no further cases to be sent.198 The following year they agreed to let the buildings containing the smallpox wards to the Town Council, who decided to build additional wards for patients with infectious diseases on land in the workhouse grounds.199 However, over the next 10 years, there was continual haggling over the length of tenure of the lease and for the majority of the time it remained on annual renewal, despite the guardians agreeing in 1878 that it would be for seven years. In the discussions, the Health Committee requested an extended tenure of the smallpox hospital and declared it would be impossible to find another site for it within Birmingham Borough if the lease was not renewed. The Committee pointed out that the hospital needed ‘extensive rebuilding’ and that the guardians would also need to provide a separate building for paupers with scarlet fever. As the Committee had purchased a piece of land from the Asylum Committee for the erection of wards for scarlet fever cases, the building in the workhouse grounds would only be for smallpox.200 The guardians agreed the Corporation could purchase the smallpox buildings and have tenancy of the land as long as it was required. However, they requested that paupers requiring admission should have BCL, HSC, GP/B/2/3/3/3, 28 January 1873.

BCL, VGPC, GP/B/2/8/1/6, 31 January, 14 February 1873.

BCL, BBG, GP/B/2/1/43, 19 August, 9 December 1874.

BCL, VGPC, GP/B/2/8/1/9, 9 November 1883.

priority over all others.201 In 1888, the Town Council demolished several of the wooden buildings used for smallpox as they had become ‘unfit for human habitation’.202 However, the epidemic in 1893-94 was more severe in Birmingham than the one in the previous decade and consequently the Town Council had to request the use of the stone yard sheds at the workhouse for treating smallpox cases.203 Six months later, they were asked to vacate the buildings as soon as possible as the guardians felt that the proximity of the sheds to the workhouse constituted a ‘great danger’ to the inmates.204 Anxiety over the danger to the public of isolation hospitals as foci of infection had been growing from the 1870s and protest over the siting of these hospitals was more forceful in London, where every locality voiced opposition to their erection.205 A challenge by local residents resulted in intermittent closure (1872-75 and 1879-82) of the Metropolitan Asylum Board’s first infectious disease hospital in Hampstead and a decision to stop admitting smallpox patients in

1884.206 When Birmingham Health Committee requested a renewal of the lease for the smallpox hospital in 1896, they indicated that they would no longer use it for smallpox patients, who would be admitted to the Borough Hospital in Lodge Road.207

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Birmingham Registration District, deaths had fallen from 1,042 in the 1870s to 253 in the 1890s, with only one person dying from the disease between 1901 and 1910.208 The last outbreak of Variola major in England occurred in 1901-2, confined mainly to BCL, VGPG, GP/B/2/8/1/7, 25 July 1878; GP/B/2/8/1/9, 7 December 1884; BBG, GP/B/2/11/52, 19 March 1884.

BCL, WMC, GPB/2/3/2/1, 17 March 1888.

Hill, ‘Epidemic of Small-pox’, p.5.

BCL, BBG, GP/B/2/1/62, 15 November 1893, 4 April 1894.

M. N. Kerr, ‘Sites of complaint and complaining’, in J. Reinarz and R. Wynter (eds), Complaints, Controversies and Grievances in Medicine, London, 2014, pp.205-6.

Kerr, p.208; Worboys, p.240.

BCL, BBG, GP/B/2/1/64, 1 July 1896.

Woods, p.181.

London, and endemic smallpox disappeared from England in the 1930s. The World Health Organisation declared its eradication worldwide in 1979, the only disease where this has been achieved by immunisation.209 Tuberculosis Mortality from pulmonary tuberculosis (hereafter TB) also declined throughout the nineteenth century, although the reason for this has been a matter of considerable debate. Raised standards of living, better nutrition, sanitary improvements, legislation to control the disease and greater institutionalisation have all been proposed as factors.210 However, the argument is far from being settled in favour of any one cause.211 The MO of the LGB in his report for 1905-6 dismissed the proposition of Dr Arthur Newsholme that segregation of tuberculosis patients in workhouse infirmaries had played a dominant role in the decline. He did so on the grounds that TB was not such a highly infectious disease that it would be influenced by isolation, when diseases with greater infectivity had not been controlled in this way. In addition, he felt the average length of stay of TB patients in workhouses was too short to prevent Hopkins, pp.303, 317.

The arguments are similar to those proposed for the mortality decline as discussed in the introduction to the chapter. TB was used by McKeown and Record to demonstrate their support for higher living standards. For more on TB specifically, see B. Harris, ‘Public Health, Nutrition and the Decline of Mortality: The McKeown Thesis Revisited’, Social History of Medicine, 17 (2004), pp.379L. G. Wilson, ‘The Historical Decline of Tuberculosis in Europe and America: Its Causes and Significance, Journal of the History of Medicine and Allied Sciences, 45 (1990), pp.366-96; M.

Worboys, ‘Before McKeown: Explaining the Decline of Tuberculosis in Britain, 1880-1930’, in F.

Condrau and M. Worboys (eds), Tuberculosis Then and Now, Montreal, 2010; G. Cronjé, ‘Tuberculosis and Mortality Decline in England and Wales, 1851-1910’, in R. Woods and J.

Woodward (eds), Urban Disease and Mortality in Nineteenth-Century England, London, 1984, pp.79G. Jones, ‘Social History of Medicine Virtual Issue: Tuberculosis’, 2013, pp.1-3, accessed 10 May 2013.

spread of the infection; for instance in Birmingham in 1897, it was only 74 days.212 Newsholme’s view gains support from Wilson, who argued that the influence of segregation was sufficient to be the decisive factor. He made the point that by 1905 workhouse infirmaries were being used very extensively for TB patients in England and Wales.213 Throughout the nineteenth century, there was no change in the medical approach to TB, nor was there any treatment available that could account for the decline.214 Deaths from pulmonary TB declined steadily throughout the second half of the nineteenth century and the annual death rate in England and Wales decreased by 71% between 1840 and 1905 (Table 3.4). The national rate for other forms of TB also fell, but only by 21% between 1858 and 1900.215 All types of the disease accounted for 13% of all deaths during the period, but for 33% of those aged between 15 and 34 years, making it primarily a disease of young adulthood.216 The mortality rate was greater in females until the mid-1860s, when it changed to become more predominant among males.217 The disease was more prevalent in urban areas, such as Birmingham, where the death rate was higher than the national average and the decrease between 1870 and 1910 was 5% lower than the country as a whole (Tables

–  –  –

dominated the causes of death among all sections of society and killed more people than any other disease throughout the Victorian era.219 Despite the mortality decline, TB was the commonest cause of death after heart disease at the end of the nineteenth century.220 BPP, 1907 [Cd.3657], pp.240-47.

Wilson, pp.383, 388; this view is supported by Cronjé, p.82.

Cronjé, pp.84-85.

BPP, 1907 [Cd.3657], pp.32-36.

Cronjé, pp.83, 78.

BPP, 1907 [Cd.3657], p.43, facing p.44.

Cronjé, p.97; Woods, ‘Sanitary Conditions’, p.180.

Cronjé, p.79.

Wohl, p.130.

TB has a long history dating back 20,000 to 35,000 years and evidence of its presence has been found in skeletons in ancient Egypt.221 Yet, attempts to control the spread of the disease and improve the condition of sufferers did not occur until the late nineteenth century. A major reason why the disease was not seen to be a public health issue in the nineteenth century was the belief that it was an inherited condition arising spontaneously within the body of susceptible individuals, possibly as a result of ‘bad living’.222 Although Koch in 1882 identified a bacterium as the cause of the disease, which he established as contagious, medical opinion in Britain was slow to change.

Table 3.4: Annual Number of Deaths and Annual Death Rates from Phthisis in England and Wales, 1840-1905

–  –  –

T. Dormandy, The White Death, London, 1999, pp.1-2; H. Bynum, Spitting Blood. The History of Tuberculosis, Oxford, 2012, pp.2, 5.

Bynum, Spitting Blood, p.91.

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