«MEDICAL CARE IN THE WORKHOUSES IN BIRMINGHAM AND WOLVERHAMPTON, 1834-1914 by ALISTAIR EDWARD SUTHERLAND RITCH A thesis submitted to the University of ...»
medicine, the Act changed the relationship between the poor and the doctor, who no longer thought of himself as a local contractor.4 Nevertheless, guardians treated MOs on the same basis as other officers or servants employed by them. For instance, William Sturrock, workhouse medical officer (hereafter WMO) in Birmingham, complained in 1900 that he was allowed only three weeks’ annual leave, whereas other first-class officers had four. He claimed, this ‘seems like a slur on Medicine that its representative should be ranked with subordinate officers’.5 However, the terms of employment of MOs differed in that the majority had part-time contracts and continued with private practice. Immediately after the New Poor Law (hereafter NPL), guardians appointed the doctor offering the lowest tender. This arrangement was abolished after the General Medical Order of 1847 required a salary decided by the guardians to be stated at the time the post was advertised. MOs were usually appointed on an annual basis, although the Order had directed that tenure should be permanent. It also required them to be qualified as surgeons and apothecaries.6 This was modified by an Order in 1859 to require qualifications to practise medicine and surgery in England and Wales, thereby ensuring that poor law MOs were better qualified than practitioners in private practice. However, the dual requirement could be circumvented if MOs lived outside the district of their responsibility.
BCL, House Sub Committee (hereafter HSC), GP/B/2/3/3/20, 24 July 1900.
Hodgkinson, ‘Poor Law Medical Officers’, pp.301, 306.
Ibid., p.302; Brand, ‘Parish Doctor’, p.100.
C. Lawrence, Medicine in the Making of Modern Britain, 1700-1920, London, 1994, pp.42-43.
those who failed to acquire sufficient income from private practice.9 They were seen as third-rate practitioners, who had failed to succeed in private practice, because they were poorly paid, worked for a state service, which did not attract ambitious doctors, and were subservient to public officials in the form of the boards of guardians.10 The patients they treated suffered from diseases that were considered uninteresting and from the stigma of pauperism. Their places of work, the workhouse infirmaries, were less prestigious than the voluntary hospitals. Their status reflected the level of their remuneration and the class of their patients and their professional position remained unsatisfactory throughout the nineteenth century.11 Despite this, they were the one common denominator within a patchwork of welfare practices and fundamental to medical welfare.12 This chapter will consider the conditions under which the MOs of Birmingham and
questions it attempts to answer include to what extent the NPL influenced the institutional medical care of paupers and how did the development of infirmaries affect medical staffing? A comparison between the arrangements in Birmingham and Wolverhampton has allowed exploration of possible differences in the performance of resident and non-resident MOs. For instance, was the greater continuity of medical care that occurred with the appointment of non-resident staff a positive advantage?
How they came into conflict with guardians and other poor law officers over patient care and why MOs were at times exonerated, but at others were charged with medical I. Loudon, Medical Care and the General Practitioner 1750-1850, Oxford, 1986, p.228.
Crowther, ‘Paupers or Patients?’, p.40.
Loudon, Medical Care, p.227; Flinn, p.54.
K. Price, ‘A regional, quantitative and qualitative study of the employment, disciplining and discharging of workhouse medical officers of the New Poor Law throughout nineteenth-century England and Wales’ (unpublished PhD thesis, Oxford Brookes University, 2008), p.335.
negligence, will be explored. To what extent did the imposition of charges reflect the approach of MOs to their patients? The chapter will commence with details of the MOs, followed by an analysis of their conditions of employment and the number of patients they cared for. It will question whether the MOs’ workload compromised their management of patients.
Appointment and Duties of the Workhouse Medical Officer The duties of the WMO were prescribed in Article 78 of workhouse regulations in the Second Annual Report of the PLCs in 1836. These required him to attend at times stated by the guardians and in emergency at the request of the master; to visit the sick as their condition necessitated; to examine all lunatics; to give directions for inmates’ diets; to provide and dispense all medicines; to keep a register of morbidity and mortality; and to provide the guardians with regular reports on the inmates treated.
He was required to inform the guardians of defects in sanitation, ventilation and heating and the conduct of the nursing staff. All admissions to the workhouse were to be examined by him and classified into the appropriate group. In particular, he had the task of separating the ‘able-bodied’, who could be assigned work, from the ‘nonable-bodied’. This and his duty to decide the fitness of inmates for punishment meant that he was seen as much a part of the disciplinary system as the provider of medical care.13 In 1847, the task of vaccinating all children entering the workhouse was added to his list of duties.14 According to Kim Price, his workload must have been ‘immense’, making it almost impossible for him to carry out his duties Crowther, ‘Paupers or Patients?’, pp.47-49.
For further information on the management of smallpox, see chapter 3.
conscientiously.15 As he was able to appoint an assistant, without medical qualifications, it was often left to that individual to attend to those in the workhouse, while the MO devoted his time to his private patients.16 This was possible as the most usual arrangement for medical care for inmates of the workhouse was for guardians to engage a private practitioner, whose contract may have included duties as a district medical officer (hereafter DMO) in addition. Jeanne Brand is of the opinion that the regulations relating to MOs were so general that they allowed not only considerable variation in performance, but ‘outright abuse’.17 Less frequent practice was the appointment of a whole-time MO specifically for the
employment within workhouses was a controversial issue, opposed by The Lancet and Dr Edward Smith, MO to the Poor Law Board (hereafter PLB).18 Joseph Rogers, a reformer and WMO in the 1860s, was instrumental in getting the requirement for the infirmaries in London to have resident MOs supervised by visiting physicians included in the Metropolitan Poor Act of 1867.19 Over the following four years, the number of WMOs who were resident in the capital increased from three out of a total of 12 to seven of 13.20 By the early 1880s, a majority of metropolitan MOs served full-time and no longer carried out private practice.21 In the provinces, they were most likely to be appointed in large urban workhouses, such as Liverpool, Price, ‘Quantitative and qualitative study’, p.154.
Ibid, p.21; M. A. Crowther, The Workhouse System, 1834-1929, London, 1981, p.163.
Brand, ‘Parish Doctor’, p.105.
A detailed discussion of the two sides of the argument appears in Hodgkinson, ‘Poor Law Medical Officers’, pp.317-19.
Rogers T. (ed.), Joseph Rogers, MD, Reminiscences of the Workhouse Medical Officer, London, 1889, pp.xviii-xix, 60-61.
Hodgkinson, Origins of NHS, pp.399-401.
Brand, ‘Parish Doctor’, p.110.
Table 4.1: Resident Workhouse Medical Officers in Birmingham Workhouse, 1830-1914
Nottingham, Manchester and Birmingham (see Table 4.1).22 Although whole-time contracts became more usual from the 1870s, 93% of the 625 unions in England and Wales still had no resident MO in 1900. Birmingham was unusual in appointing a resident MO to the workhouse as early as 1823, but was not unique for a provincial workhouse as Nottingham had one from 1822.23 Hodgkinson, ‘Poor Law Medical Officers’, pp.319-20; BCL, LGB Returns, GP/B/18/2/1, 15 October 1856.
Legacy of the Old Poor Law After 1834, there was a marked reduction in the number of MOs’ posts in the new unions. In seven examples given by Irvine Loudon, the extent of the removal of medical men ranged from 50% to 81%.24 Birmingham, at the time of the NPL, employed six surgeons who received £30 per annum, were each allocated to a district, with responsibility for attending patients in their homes and at the town dispensary.
They all had duties in the Town Infirmary, where the medical staffing also consisted of one resident house surgeon (hereafter HS) and apothecary, plus two assistant apothecaries. The HS was paid an annual salary of £70 and received free accommodation and board (Table 4.1). His duties, prescribed prior to the NPL, included visiting each ward twice daily and providing a list of necessary drugs, plus responsibility for cleanliness and ‘good order’ of the sick wards and ‘superintendence’ of the nurses.25 The assistants were non-resident and had an annual salary of £50; their duties were not stated, but would have included dispensing drugs.
The inpatient workload of all the MOs in the three months of April to June 1834 consisted of between 116 and 123 patients, while that for the surgeons also included 2,722 seen in the dispensary, 1,385 seen at home and 108 midwifery cases to monitor in association with the poor law midwives.26 By comparison, the MO of Nottingham Union in July 1837 was responsible for 58 patients in the union hospital, 47 in the workhouse and 351 outpatients, with the help only of a dispenser in the institutions.27 One of the Birmingham surgeons was Edward Cox, whose son, Sands Cox, assisted BCL, BBG, GP/B/2/1/1, 11 March 1823; Bosworth, p.206.
Loudon, Medical Care, p.238; the unions were Derby, Lincoln, Bridgewater, Aylesbury, Eton, Shipston and Newbury.
BCL, BBG, GP/B/2/1/3, 3 June 1827.
BCL, BBG, GP/B/2/1/3, 8 July 1834.
him in the workhouse and later became honorary surgeon to the Queen’s Hospital, of which he was a founder.28 Ten years later, it was decided to separate the indoor and outdoor medical relief, as the HS was being ‘called out of the workhouse’ frequently, and six further surgeons were appointed for district work only. It was planned to reduce the existing surgeons (who were to work in the infirmary only) to four as vacancies arose, with a reduced salary of £10 per annum.29 At that time, the number of patients in the infirmary had increased to around 150, while that of dispensary patients had fallen by half.30 The following year, one of the surgeons, Thomas Green, took on the sole responsibility for the lunatic wards.31 Rather than a reduction, more surgeons were appointed, so that by March 1847 sixteen were in post, with annual salaries of between £10 and £20, except for Green who received £55.32 As Birmingham Parish had been established by an individual act of parliament, the guardians could resist aligning with the regulations of the NPL for many years.
However, the increasing influence of the central authority, exerted through the PLB inspectors, resulted in a radical reorganisation of medical staffing in 1849, with a substantial reduction in the number of MOs. The number of sick in the infirmary (160) had not shown an increase in recent years, but the new workhouse was in the planning stage with a proposed infirmary of just over 300 beds.33 Inpatients were to be cared for by only one resident HS at an enhanced annual salary of £150, plus Sands Cox also founded Queen’s College, which developed into the medical school and ultimately the University of Birmingham.
BCL, BBG, GP/B/2/1/4, 2 July, 18 December 1844.
Ibid., 8 October 1844.
BCL, BBG, GP/B/2/1/5, 22 July 1845. Thomas Green was appointed the first house surgeon to the infirmary in 1823, a post he held for three years, became one of the visiting surgeons in 1831, and was appointed superintendent at the Borough Asylum in 1850.
Ibid., 15 March 1847.
Ibid., 21 February 1848.
‘lodgings, coals and candles’.34 His duties would be governed by the workhouse regulations laid down by the PLB, and the guardians would continue to cover the cost of drugs. The salary may have been improved in the hope of obtaining a more experienced practitioner or it may have reflected the anticipated increase in workload.
The surgeons were reduced to six, with responsibility for only outdoor medical relief, at an annual salary of £150, which was to include the cost of all ‘drugs, medicines and surgical appliances’.35 Notice was given to the assistant apothecaries and surgeons that their services would not be required after Lady Day in 1850.36 Charles Smith, HS, did not apply for the redesigned post, although the fact that he was then aged 66 years may have influenced his decision. Fifteen candidates applied and John Humphrey was elected. Five of the pre-existing surgeons were appointed to the six new DMO posts, out of a total of 46 applications.37 The WMO was no longer supported by more senior colleagues, although the guardians allowed him to request a second medical opinion from physicians and surgeons in the town, who were paid a fee for their services. Despite the increasing medical role of Birmingham infirmary, the PLB had succeeded in reducing medical staffing and thereby the quality of patient care.
Meeting an Increasing Workload after the New Poor Law John Humphrey transferred to the new workhouse when it opened in March 1852.
Between then and 1914, 14 MOs held the office of resident surgeon, serving for BCL, BBG, GP/B/2/1/6, 27 June 1849.
Ibid., 11 December 1849.
BCL, BBG, GP/B/2/1/7, 15 March 1850.