«MEDICAL CARE IN THE WORKHOUSES IN BIRMINGHAM AND WOLVERHAMPTON, 1834-1914 by ALISTAIR EDWARD SUTHERLAND RITCH A thesis submitted to the University of ...»
following year. In December 1884, Simpson was called before the guardians for using ‘improper language’ to a nurse in one of the wards, which he explained was done in ‘moments of irritation’. He was found to have interfered with the ‘perfect harmony’ required for the efficient running of the infirmary and requested to refrain from such language in future.166 At this time, there were around 1,200 patients in the infirmary, cared for by three resident officers and one visiting physician.
The final enquiry arose after an outbreak of puerperal fever in the lying-in wards in April 1885. Simpson’s re-organisation to transfer the accommodation to the female infirmary and later to the infectious wards, because of a further outbreak, was approved by the guardians. As the infectious wards were small, the guardians reopened the girls’ school as lying-in wards on 30 October.167 Elizabeth Wood, aged 31 years, was admitted to the lying-in wards in the girls’ school on 12 November and, later that day, was delivered of twin boys by nurse Rebecca Williams, after a labour lasting three hours and ten minutes (Appendix D). She had a two-year history of pulmonary tuberculosis. Her temperature was higher than normal on admission, but increased markedly after four days and remained at this level until her death on 6 December.168 Simpson was of the opinion that she was not suffering from puerperal fever, although the two AMOs were not in agreement.169 He requested a second opinion from Dr Edward Malins, Obstetric Physician to the General Hospital and Vice-President of the Obstetric Society of London, who confirmed the diagnosis of ‘puerperal septicaemia’, whose origin was intrinsic to the patient, but which was BCL, VGPC, GP/B/2/8/1/9, 5 December 1884.
BCL, Infirmary Sub Committee (hereafter ISC), GP/B/2/4/1/2, 16 October 1885; BPP, 1886 (19Sess. 2), pp.3-11.
BPP, 1886 (19-Sess.2), pp.3-11, 24, 27, 29, 31; her initial temperature was 37.8º Centigrade, as opposed to the normal upper limit of 36.8ºC, and increased to 39.4ºC and then to 39.8ºC.
The raised temperature at the start of the illness was not in keeping with a diagnosis of puerperal fever, although the increase after a few days would suggest the onset of septicaemia (see Appendix D).
communicable to other lying-in patients.170 When the lying-in wards were moved to the girls’ school, the members of the Infirmary Sub-committee were concerned that no-one involved in the wards up to that date should have any further attendance on lying-in patients. This included Simpson and they resolved that Henry Cook, one of the AMOs, should have sole charge of these wards. Simpson was informed of this on his return from a four-day stay in Ireland on 3 November. However, he continued to examine patients in the lying-in wards, including Elizabeth Wood, and perform deliveries until Malins confirmed Wood’s diagnosis.171 The guardians referred the matter of Simpson’s conduct to the LGB, with a request that the enquiry would be limited to whether he had disobeyed orders.172 At the enquiry, Mr Price, chairman of the Infirmary Sub-committee, stated that he had informed Cook on 30 October that he was in ‘sole charge’ of the lying-in wards and, three days later, told Simpson of Cook’s position and that the guardians wished to release him (Simpson) from attending cases in the girls’ school. Both Cook and Simpson denied that Price had said Cook was to have ‘sole and entire’ charge. In addition, Simpson denied that Price had forbade him to enter the wards, and pointed out that he had not received any written confirmation of such an order. While the members of the enquiry, J. J. Henley and Dr F. Mouat, criticised the guardians for not making the order explicit and for failing to ensure all officers concerned were aware of it, they took the view that ‘in charge’ implied complete professional control as the only MO. They concluded that Simpson had disobeyed an important order and failed to justify his disobedience; the guardians were justified in their opinion that he had forfeited their confidence; and the Birmingham board should request his BCL, ISC, GP/B/2/4/1/2, 1 December 1885; BPP, 1886 (19-Sess. 2), p.24.
BPP, 1886 (19-Sess. 2), pp.3-11.
BCL, ISC, GP/B/2/4/1/2, 22 January 1886.
resignation.173 However, he refused to do so, protesting to the LGB that there was no evidence that Price informed him not to attend the lying-in wards. He received support for his retention from the Medical Defence Union, local newspapers and some of the Birmingham guardians. At a special meeting of the Birmingham board on 15 June, there were sufficient guardians present who wished Simpson to be removed from office, to confirm his dismissal, despite strong support from some of the others.174 The previous enquiries into Simpson’s conduct were taken into
Simpson’s continued refusal to resign, the LGB declared him ‘unfit for the office of Medical Officer’ and ordered him to cease to perform the duties of the office. He left the workhouse on 3 September 1886.176 It is obvious from the records that Simpson engendered strong feelings both toward and against him among the guardians and other officers, creating tension within working relationships in the workhouse. The matron, in 1877, was overheard to say he was not fit to be MO and, if he had been in Liverpool, would have been quickly dismissed. However, she and her husband, the master, were under investigation at that time and resigned before it could be concluded.177 Price claims that, as a council member of the Poor Law Medical Officers Association, Simpson was a reforming poor law surgeon, but there is no evidence for this in the local records, in which he appears to have carried out his duties as required and no more. Likewise, Price’s opinion that he repeatedly asked for more staff is not borne out in the guardians’ BPP, 1886 (19-Sess. 2), pp.3-11.
Birmingham Daily Post, 16 June 1886.
BCL, BBG, GP/B/2/1/54, 4 August 1886.
BCL, LGB Orders, GP/B/1/1/4, 2 August 1886; Incident Book, GP/B (Acc 2009/109), Box 15.
BCL, Workhouse Inquiry Sub-committee (hereafter WISC), GP/B/2/3/11/1, 15 November 1877.
minute books, in which there is not one instance of him complaining of overwork.178 Although he did admit to finding the work stressful, he denied that he found it
addition, he did not concur with the guardian who suggested that patients had suffered as a result of his workload.179 He ought to have been aware of the possibility of the transmission of puerperal infection and sought clarification of his position, when, as he claimed, he was not given precise verbal instructions. In not doing so, perhaps he
professional conduct seems to have been less satisfactory after he had medical help, rather than during the period when he was on his own and suffered ill health. Nor was he in the vanguard of nursing reform. When the guardians asked his opinion on the appointment of a trained nursing superintendent, he replied that a professional nurse was not necessary, only ‘a clever woman’.180 Summary This study confirms the heavy and increasing workload of the WMOs. Although this caused some to resign or to request medical help, others merely used it as a tool to increase their salaries. By doing so, part-time MOs could employ their own assistants, and it is surprising that some full-time officers were content with extra payment only. An example is Edmund Robinson in Birmingham, who denied he needed assistance, despite the presence of between 600 and 700 sick inmates on his wards. He subsequently became one of the most highly paid poor law MOs (Table Price, ‘Quantitative and qualitative study’, pp.300, 315-17.
BCL, WISC, GP/B/2/3/11/1, 24 January 1878.
BCL, WISC, GP/B/2/3/11/1, 24 January, 22 March 1878.
4.1).181 There is a marked difference between the employment of resident MOs in Birmingham, supported at times by visiting medical personnel, and the single parttime doctor in Wolverhampton. Part-time officers offered more continuity of care as they served for longer periods, but difficulties could arise if they suffered poor health or as they aged. As Birmingham’s resident officers could spend most of the day and evening on the wards and be called during the night at times, it is difficult to imagine that Wolverhampton’s officers could be providing adequate care with a visit of a few hours each day, even with a smaller number of sick inmates. Birmingham’s medical staffing levels were exemplary in the early years of the NPL, but as the central authority imposed its rules governing medical duties, the reduction to one resident MO was highly unsatisfactory. To give some credit to the LGB, it was at their insistence that the number of MOs was increased and the new infirmary built.
However, as the result of the infirmary being separately managed from the workhouse, medical cover in the latter was again reduced to one lone officer. The changes to the medical arrangements in Birmingham after the NPL resulted in the MOs losing the right to admit urgent cases directly to the infirmary without the permission of the guardians or an overseer and so imposed more completely the principle of less-eligibility. Nevertheless, it has been possible to draw out the characters of these previously unknown MOs, but not do likewise for the guardians, as their opinions are rarely identified as pertaining to named individuals.
One issue that has resulted from the WMOs heavy workload has been that of conflict with the guardians and resultant charges of medical negligence. Examination of Simpson’s dismissal brings to the fore the role played by poor communication, a Price, ‘Quantitative and qualitative study’, p.224, has calculated that only 0.4% of poor law medical officers received more than £300 annually throughout the nineteenth century; BPP, 1867-68 (4), p.45.
factor which continues to be one of the most important in current medical complaints made by patients against doctors.182 In Linda Mulcahy’s study of patients’ complaints in the late 1990s, the lowest incidence was in those medical specialties in which the patient was least empowered and of low social status.183 As the main objective of the NPL was the disempowerment of indoor paupers, it might be expected that they would not feel able to question a doctor’s practice. This study has demonstrated there were times when inmates complained about the treatment they received. On at least one occasion, it concerned the MO’s attitude during examination (by Mary Shaw in Wolverhampton in 1855), the second commonest type of complaint in Mulcahy’s study.184 In the case brought against Simpson, both his and Cook’s version of their conversation with Price was at variance with his and that of the master and nursing staff. Also the chairman of the board of guardians was not aware of the ruling to exclude Simpson from the lying-in wards. Poor communication was also an essential element in the incident of Galbraith and Buck, the tramp, in Wolverhampton. The majority of the other charges related to non-attendance at the workhouse and were not exclusive to non-resident officers. However, part-time officers in Wolverhampton were particularly guilty of this offence, although it was associated with ill health on more than one occasion. A low salary may have played a part in the frequency of attendance in the case of Cooper, but the others were paid an amount that was in the top 10% of the salary range throughout the nineteenth century.185 In Wolverhampton, however, the two WMOs who died in office were middle-aged. In addition, the fact P. Bark, C. Vincent, A. Jones and J. Savory, ‘Clinical complaints: a means of improving quality of care’, Quality in Health Care, 3 (1994), p.125; P. Kinnersley and A. Edwards, ‘Complaints against doctors’, British Medical Journal, 336 (2008), p.841; L. Mulcahy, Disputing Doctors: the socio-legal dynamics of complaints about medical care, Maidenhead, 2003, pp.45, 68-69.
Mulcahy, pp.68-69. The majority of cases of complaints quoted by Klein against general practitioners between 1949 and 1971 concerned children and older adults, Klein, pp.37-57.
Price, ‘Quantitative and qualitative study’, p.224.
that most charges took place before the onset of the crusade against outdoor relief is at variance with the national picture.186 MOs were often exonerated or given a caution when charges related to subjecting patients to degrading treatment, as in the matter of Cooper’s handling of children in Wolverhampton. Crowther has commented that guardians were prepared to defend an MO, whatever the charge, if they were subservient to the guardians’ standards.187 Whether subservience to the guardians had an influence on the medical treatment that WMOs prescribed for sick inmates will be discussed in the next chapter.
Crowther, ‘Paupers or Patients?’, p.40.
The nature of medical care in workhouses after the New Poor Law (hereafter NPL) and of the clinical treatment inmates received, as well as how representative it was of nineteenth-century therapeutics is not well understood.2 This chapter analyses the therapies that medical officers (hereafter MOs) utilised in the management of patients in Birmingham and Wolverhampton workhouses and attempts to reconstruct the treatments they prescribed. Because workhouse medical officers (hereafter WMOs) were often required by boards of guardians to pay for the drugs they used from their salaries, historians have accused them of withholding effective treatment. Joseph Rogers recounts that, when he was appointed MO to Westminster workhouse in 1872, the retiring physician expressed pride in the fact that the only medicine he gave inmates was peppermint water.3 Was this true of other workhouses, or just an unrepresentative anecdote? At the beginning of the nineteenth century, medical treatment was much as it had been for many centuries, with the emphasis on depletive therapies, and it was not until the end of the century that the production of effective Birmingham Central Library (hereafter BCL), Infirmary Sub Committee (hereafter ISC), GP/B/2/4/1/4, 25 November 1887.
S. King, ‘Poverty, Medicine and the Workhouse in the Eighteenth and Nineteenth Centuries’, in J.
Reinarz and L. Schwarz (eds), Medicine and the Workhouse, Rochester, 2013, pp.229, 234-35.
Rogers (ed.), Reminiscences of a Workhouse Medical Officer, London, 1889, pp.111-12.