«MEDICAL CARE IN THE WORKHOUSES IN BIRMINGHAM AND WOLVERHAMPTON, 1834-1914 by ALISTAIR EDWARD SUTHERLAND RITCH A thesis submitted to the University of ...»
admitted, 201 were men, 62 women, 5 boys under 15 years of age and 3 girls of similar age. Only six women were admitted for a second time, but of 40 men who took their own discharge, as they wished to resume work to provide for their families, 25 were admitted for a second time, 9 for a third time, 5 for a fourth time and one had six admissions.262 Over the next few years, the number of admissions remained constant, except for the third quarter of 1911, and the number of phthisis patients present in the infirmary (Table 3.7) was similar to that at the turn of the century at 80 and in 1906 at 85 men and 10 women.263 The high mortality rate reflects the severity of the disease in patients admitted who were frequently in the terminal stages, but compares favourably with an estimated mortality rate of around 20% at the City of London Hospital for Chest Diseases in the 1880s.264 When Edinburgh City Hospital opened in 1906, the death rate of the first 104 admissions was as high as 46% because many of the patients were in the later stages of the disease. Of the 48 who died, 11 did so within 10 days of admission.265 Phthisis was responsible for the largest number of deaths in Birmingham infirmary in the years 1905 to 1908 inclusive, causing 16% of the 1,707 who died.266 It was the BCL, WIMC, GP/B/2/4/4/5, 10 January 1910.
Ibid., 11 January 1909.
BCL, WIMC, GP/B/2/4/4/2, 29 July 1901; GP/B/2/4/4/4, 21 May 1906.
BCL, WIMC, GP/B/2/4/4/5, 14 December 1908.
commonest reason for admission in the year ending 31 May 1910, affecting 246 patients and accounting for 7% of the 3,338 admitted.267 This is in stark contrast to Smith’s estimate, based on extrapolating data from Liverpool, that 60% of admissions to workhouse infirmaries in England and Wales were of consumptive patients.268 Table 3.7: TB Patients in Birmingham Infirmary for Specific Time Periods, 1909-11
Source: BCL, WIMC, GP/B/2/4/4/5-6, 1909-11.
An alternative to open-air treatment that became popular in Britain in the early twentieth century was a model of occupational therapy or graduated labour. It was pioneered by Marcus Paterson, medical superintendent at the Brompton Hospital Sanatorium at Frimley in Surrey. Patients started with walking and after they were able to do ten miles, carried baskets, which gradually were made heavier, and finally they progressed to digging.269 Paterson claimed that it prepared patients for an immediate return to work on discharge. This was one of the reasons given by Thomas Ibid., 11 July 1910.
Bynum, Spitting Blood, p.142; Condrau, pp.74-75.
Galbraith, WMO at Wolverhampton, for implementing a similar scheme of graduated exercise for men. They started with walking for half-a-mile daily after their temperature had returned to normal on bed rest. After they could manage six miles daily, graduated labour was begun. This consisted of very light work, such as carrying a basket, weeding, potting, watering plants, and was increased to heavier carrying, planting out, cutting vegetables after about one week. Further stages included sweeping paths, cutting edges, hoeing; then light digging, mowing grass; and finally digging, trenching, sawing, until fit to resume their previous occupations.
Galbraith estimated this would take 14 to 17 weeks and that 15 male patients in the workhouse would benefit from the scheme. Its other advantage would be overcoming the demoralising effects of long periods of mental and physical inactivity. The guardians agreed to proceed and delegated the newly appointed male charge nurse to provide close supervision of the men who would be taking part.270 They decided not to erect dedicated buildings for the men to sleep at night, but chose to add balconies to the existing wards. Once again, they made alterations to the doorway in the male surgical ward to enable patients to be taken out into the open air in their beds.271 Galbraith did not think that there were a sufficient number of female patients to justify instituting the same arrangements. It was agreed that the ward in which they resided should be portioned so that their part could be provided with as much ventilation as possible.272 Strict adherence to the exercise programme was considered necessary for success. The MO in Reading Union workhouse found it difficult to persuade patients to remain for the full course of treatment, as the regulations for phthisical patients were so detailed and so tedious. However, patients were notified that the programme would be of ‘no use to them’, if they did not ‘co-operate heartily… in every detail of WALS, HC, PU/WOL/E/4, 27 August 1913.
Ibid., 31 July 1913.
Ibid., 22 August 1913; WOL/PU/E/5, 17 April 1914.
the routine’ by ‘cheerfully acquiescing in every direction given to them’.273 They were also informed that the average length of stay was three months, which was similar to the time that tuberculous patients were required to commit to treatment in Birmingham infirmary.274 Summary It has been claimed that workhouses were efficient at preventing admission of paupers with infectious diseases, but this conclusion was based on mortality data.275 This chapter has demonstrated that the contribution of workhouse infirmaries in Birmingham and Wolverhampton to the care of children with infectious disease, to patients with endemic diseases such as typhus and typhoid and to victims from the cholera epidemics was substantial. Their role in isolating patients with infectious conditions assisted greatly in preventing the spread of infection within their communities. The guardians’ attempts in mid-century to prevent admission or seek alternative institutions for paupers were based mainly on the concern that infection introduced into the workhouse might affect the incumbent inmates. Workhouses had a reputation as ‘contagious spaces’, but whether spread of infection within them due to overcrowding and unhygienic conditions took place is, according to Ruth Hodgkinson, ‘a moot point’, but she gave one example of a serious outbreak of Railton and Barr, pp.143-44.
Ibid., p.144; BCL, IHSC, GP/B/2/4/5/3, 23 December 1902.
G. Mooney, B. Luckin and A. Tanner, ‘Patient Pathways: Solving the Problem of Institutional Mortality in London during the later Nineteenth Century’, Social History of Medicine, 12 (1999), p.244.
cholera in Leeds workhouse in 1834, at a time where there were few cases in the town.276 Poor law facilities were used extensively in Birmingham to cope with smallpox epidemics, as happened in Wolverhampton to a lesser extent and mostly during the epidemic of the 1870s. In both towns, access by non-pauper patients to workhouse accommodation was permitted. Until the end of the nineteenth century, institutional provision for smallpox patients in Birmingham was in poor law buildings and on workhouse land, leased by guardians to the corporation. It was not unusual for workhouse infirmaries to be utilised in this way. 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 until the 1890s, although the smallpox epidemics gave a degree of impetus.277 Fever hospitals that existed were small, usually containing around 70 beds, until the 1880s.278 John Pickstone notes that arrangements for fever in the Manchester region other than provided by guardians were present only in Manchester, Preston and Lancaster in the 1860s.279 Until the 1890s, it was still possible for smallpox patients to be admitted to general workhouse wards.280 Both Birmingham and the borough of Wolverhampton had an isolation hospital by 1892, the one in the latter town accommodating around 36 patients. It had only been available for one year, although some beds had been available for the previous ten years. However, the K Siena, ‘Contagion, Exclusion and the Unique Medical World of the Eighteenth-Century Workhouse’, in J. Reinarz and L. Schwarz (eds), Medicine and the Workhouse, Rochester, 2013, p.28;
R. G. Hodgkinson, The Origins of the National Health Service: the Medical Services of the New Poor Law 1834-71, London, 1967, p.161.
Pickstone, pp.156, 158; Wohl, p.138; Currie, pp.13, 125-26.
lack of isolation facilities in all districts making up Wolverhampton union meant that poor law accommodation continued to be utilised. Furthermore, the question of who should pay for paupers admitted to isolation hospitals within the union created conflict between guardians and sanitary authorities. Satisfactory arrangements were not in place in Wolverhampton as late as 1912. When Annie Birch was admitted to the infectious diseases hospital, the guardians accepted liability for the charges, but warned that, in future, they would only do so if they had requested the admission.281 In Birmingham, the new infectious hospital had 300 beds, but buildings, which were still being leased from the guardians, could accommodate a further 100 patients.
While there had been no cases of smallpox in the Wolverhampton hospital from 1888 to 1892, 89 patients had been treated in Birmingham; for scarlet fever, the numbers treated were 1,217 and 7,206 respectively.282 The extent of co-operation between the poor law and sanitary authorities in Birmingham, with joint management of facilities for infectious disease, was exceptional.
Although it has been acknowledged that poor law infirmaries provided the larger share of accommodation for patients with TB, they have not been given credit for instituting current methods of treatment. Both Birmingham and Wolverhampton guardians began taking steps to provide dedicated accommodation and access to fresh air for patients early in the twentieth century, whereas many urban workhouses had not done so by the end of that decade.283 Following this, they adopted the regime carried out in sanatoria, which has been described as being ‘the bedrock of treatment’ for nearly one hundred years.284 That it did not succeed in Birmingham may have WALS, HC, WOL/PU/E/4, 18 January 1912.
BPP, 1895 (28), pp.352-55, 400-3.
BPP, 1909 [Cd. 4573], p.92.
been because the environmental conditions were not conducive. Within the historiography of TB, the poor law sanatorium set up at Heswall at the start of the twentieth century gets a brief mention.285 The intention was to provide treatment for those at an early stage to return them to employment. However, it had the disadvantage that all patients had to be admitted via the workhouse. As happened in Birmingham, patients were reluctant to enter the workhouse until in the later, nonambulant stages and Heswall became ‘a staging post of the dying’.286 Perhaps it was because poor law infirmaries were seen to cater mainly for TB patients who were terminal, that they have received so little attention from historians. The initiative in instigating current methods of treatment for TB patients was taken by the MOs in both workhouses and their part in providing general care for sick inmates will be considered in the next chapter.
Ibid., pp.166-67; Smith, pp.104-5.
Under the Old Poor Law, parishes paid for medical attendance on a fee for service basis, but by the early nineteenth century, many found it more convenient to contract
Amendment Act (1834), the Poor Law Commissioners (hereafter PLCs) authorised boards of guardians to appoint medical officers (hereafter MOs) for the provision of outdoor medical relief and for the attendance on sick inmates in workhouses. From this directive, there developed a new branch of the medical profession, poor law MOs.3 In shaping this new kind of practitioner, with a broader interest in social Birmingham Central Library (hereafter BCL), Birmingham Board of Guardians (hereafter BBG), GP/B/2/1/15, 28 February 1855; GP/B/2/1/19, 8 April 1857.
E. G. Thomas, ‘The Old Poor Law and Medicine’, Medical History, 24 (1980), p.7; A. Crowther ‘Health Care and Poor Relief in Provincial England’ in O. P. Grell, A. Cunningham and R. Jütte (eds), Health Care and Poor Relief in 18th and 19th Century Northern Europe, Aldershot, 2002, p.209.
The major narratives concerning poor law medical officers are R. G. Hodgkinson, The Origins of the National Health Service: the Medical Services of the New Poor Law 1834-71, London, 1967; M. W.
Flinn, ‘Medical Services under the New Poor Law’, in D. Fraser (ed.), The New Poor Law in the Nineteenth Century, London, 1976; J. L. Brand, Doctors and the State: The British Medical Profession and Government Action in Public Health, 1870-1912, Baltimore, 1965; R. G. Hodgkinson, ‘Poor Law Medical Officers of England, 1834-1871’, Journal of History of Medicine and Allied Sciences, XI (1956), pp. 299-338; J. L. Brand, ‘The Parish Doctor: England’s Poor Law Medical Officers and Medical Reform, 1870-1900’, Bulletin of the History of Medicine, 35 (1961), pp.97-122; M. A.
Crowther, ‘Paupers or Patients? Obstacles to Professionalisation in the Poor Law Medical Service Before 1914’, Journal of the History of Medicine, pp. 39 (1984), 33-54; A. Negrine, ‘Medicine and Poverty: A Study of the Poor Law Medical Services of the Leicester Union 1876-1914’ (unpublished PhD thesis, University of Leicester, 2008). These officers are also included in the discussion of poor law medical services in E. Bosworth, ‘Public Healthcare in Nottingham 1750-1911’ (unpublished PhD thesis, University of Nottingham, 1998); J. Reinarz and A. Ritch, ‘Exploring Medical Care in the Nineteenth-century Provincial Workhouse: a view from Birmingham’, in J. Reinarz and L. Schwarz (eds), Medicine and the Workhouse, Rochester, 2013; A. Negrine ‘Practitioners and Paupers’, in J.
Reinarz and L. Schwarz (eds), Medicine and the Workhouse, Rochester, 2013.