«MEDICAL CARE IN THE WORKHOUSES IN BIRMINGHAM AND WOLVERHAMPTON, 1834-1914 by ALISTAIR EDWARD SUTHERLAND RITCH A thesis submitted to the University of ...»
treatments, in the form of the first vaccines for infectious diseases took place.4 However, from the perspective of twentieth-century pharmacology, the only really effective drugs were opium and aperients, and the only one that could cure disease was, arguably, quinine for malaria.5 One advance in therapeutic technique was the introduction of the hypodermic syringe for subcutaneous administration of drugs by Edinburgh physician Alexander Wood in 1855.6 Historians agree that nineteenthcentury medical therapeutics worked in the context of the culture of the time and that patients had visible evidence of the effectiveness of the regimens employed.7 Four approaches will be used to uncover therapeutic practice in the workhouses.
First, therapies, such as natural and physical medical treatments, the use of food and alcohol as treatment for disease and the drugs prescribed, will be described. Alcohol was an important and widely used therapy in the nineteenth century, but its
alternative approach to aid the understanding of therapeutic practice will investigate the management of specific conditions, such as respiratory disease, venereal disease and epilepsy. Third, the management of individual patients and their perspective on the treatment they received will be addressed through the complaints they made to the guardians. Finally, an exploration of surgical practice will trace the increasing number and the nature of operations within the workhouses. The chapter will also J. H. Warner, Therapeutic Perspective: Medical Practice, Knowledge, and Identity in America, 1820Cambridge, Massachusetts, 1986, p.1; C. E. Rosenberg, ‘The Therapeutic Revolution: Medicine, Meaning, and Social Change in Nineteenth-Century America’, Perspectives in Biology and Medicine, 26 (1977), p.485.
N. M. Goodman, ‘Medical Attendance on Royalty’, in F. N. C. Poynter (ed.), Medicine and Science in the 1860s, London, 1968, p.134; W. F. Bynum, Science and the Practice of Medicine in the Nineteenth Century, Cambridge, 1994, p.223.
K. D. Keele, ‘Clinical Medicine in the 1860s’ in F. N. C. Poynter (ed.), Medicine and Science in the 1860s, London, 1968, p.9.
address the question of the extent to which guardians limited the treatments that inmates could receive and over-ruled medical officers’ prescriptions and advice.
Therapeutic Principles Before considering individual treatments, it is necessary to understand the principles on which they were prescribed. The antiphlogistic, depletive regimen of the eighteenth century remained the mainstay of medical treatment at the beginning of the nineteenth. Bloodletting, purgation, a debilitating diet, sedating drugs and bed-rest were employed to relax the state of excitement that was thought to be induced in the body by disease. However, by the middle of the eighteenth century, a stimulant regimen was also used when the physician considered the illness was producing a debilitating state in the patient. One of the major proponents of this system was the Edinburgh physician, John Brown (1735-88), who postulated that all diseases were due to an excess or deficiency of natural energy or ‘excitability’.8 The condition with excess, he called sthenia, while deficiency resulted in asthenic disease. He did not believe in the healing power of nature to overcome disease, but considered all maladies required a stimulant. Sthenic conditions required antiphlogistic regimens of bloodletting, purging, cold applications and physical rest, which were all weak stimulants to reduce excessive excitement. Strong stimulants were required to increase deficient excitement in asthenic conditions and these included wine or spirits, gentle exercise, increased mental activity and the drugs, opium, camphor, musk and ether. The choice of stimulant for any individual patient depended on the speed of G. B. Risse, ‘Brunonian Therapeutics: New Wine in Old Bottles?’, Medical History, Supplement No.
8 (1988), p.48.
action and level of stimulation required.9 Brunonian therapeutics were not taken up enthusiastically in Britain, because judging the degree of bodily excitability and distinguishing asthenia from sthenia were problematic. Nevertheless, the importance of his theory lay in providing an alternative form of therapy to the exhausting
components of the stimulant regimen were a fuller diet containing meat, hot-baths rather than cold, exercise, alcohol and tonics. However, whichever regimen was chosen depended on the physician’s judgement as to the effect of the disease on the patient. On some occasions, an initial depletive regimen would be replaced by a more stimulating one as the patient’s condition improved.11 Natural and Physical Therapies Medical practitioners employed therapies utilising the natural environment to aid the body’s natural healing process or to combat the spread of disease as understood at the time. One of the more important environmental measures in institutions was efficient ventilation and the duties of the workhouse medical officer included advising on the adequacy of ventilation and sanitary arrangements. The miasma theory of disease dates back to around the sixth century and has been termed one of the earliest of the more ‘scientific’ theories of the spread of infection.12 According to this theory, disease could arise spontaneously in rotting matter, human waste and stagnant water Ibid.
D. Hamilton, The Healers: A history of medicine in Scotland, Edinburgh, 1981, p.138.
G. B. Risse, Hospital Life in Enlightenment Scotland: Care and Teaching at the Royal Infirmary of Edinburgh, Cambridge, 1986, p.181.
G. A. J. Ayliffe and M. P. English, Hospital Infection: From Miasma to MRSA, Cambridge, 2003, p.2.
and was spread in the emanations given off into the atmosphere from these sources.13 Many physicians continued to cling tenaciously to this mode of disease transmission late in the nineteenth century. It followed that, to combat cross-infection in hospitals and infirmaries, adequate ventilation was required and the pavilion system of building these institutions was devised to ensure this. Although wards with windows placed opposite to each other were first suggested in An Essay on Parish Workhouses in 1867 by Gillingwater, it was not adopted generally until the Poor Law Board (hereafter PLB) issued a circular a century later stating that all new infirmaries must adopt the pavilion principles.14 These involved long wards with opposing windows, built in separate blocks. A few years before this circular, Edmund Robinson, WMO in Birmingham, suggested that new infectious disease wards should be built so that the walls with the windows would not be restricted by other buildings, so enabling as much fresh air as possible.15 Both the new Birmingham infirmary in 1889 and the new Wolverhampton workhouse in 1903 were erected according to the pavilion plan.
Robinson, like many of his contemporaries, held a strong belief in the curative power of fresh air: ‘Pure air is the very life and blood, so to speak, of the sick and without it, the most consummate skill in medical or surgical treatment is of little or no avail’.16 However, twenty years before Charles Smith, house surgeon at the infirmary, cautioned against the excessive use of fresh air in the sick wards in the winter as the patients suffered mainly from ‘pulmonary, bronchial, rheumatic affections’. He pointed out that the result would be an exacerbation of pain in those with rheumatism G. Rosen, A History of Public Health, New York, 1958, p.288; C. F. Brockington, A Short History of Public Health, London, 1966, p.40.
K. Morrison, The Workhouse, A Study of Poor-Law Buildings in England, Swindon, 1999, pp.20, 105.
BCL, Visiting and General Purposes Committee (hereafter VGPC), GP/B/2/8/1/4, 17 June 1864.
Ibid., 17 June 1864.
and coughing and dyspnoea in those with lung conditions. He emphasised that these patients were susceptible to sudden changes of temperature, which could worsen their condition.17 The therapeutic benefit of fresh air was one of the basic principles behind open-air treatment for tuberculosis.18 However, at the beginning of the twentieth century, the quality of the air in Birmingham was felt to be too impure to treat inmates suffering from tuberculosis by the open-air method, as the infirmary was by then surrounded by many factories contaminating the atmosphere.19 Around this time, Arthur Foxwell, physician to the Queen’s Hospital, introduced an open-air ward on the top floor of the building, but it was used for the treatment of non-tuberculous patients.20 The medicinal use of water dates back as far as ancient Greece, when water was thought to both stimulate and tranquillize the nervous system and its healing properties could restore harmony to bodily humours.21 The therapeutic benefit of cold baths were promoted in England by Sir John Floyer, an eminent physician from
nineteenth century, Vincenz Priessnitz, an Austrian layman, developed a new system of treatment, of which the main tenets were that disease resulted from attempts by the body to expel foreign matter and only cold water, used internally and externally, BCL, House Committee (hereafter HC), GP/B/2/3/1/1, 7 February 1843.
F. Condrau, ‘Beyond the Total Institution: Towards a Reinterpretation of the Tuberculosis Sanatorium’, in F. Condrau and M. Worboys (eds), Tuberculosis Then and Now, Montreal, 2010, pp.80-81; a discussion of the nature of this treatment appears in chapter 3.
BCL, Workhouse Infirmary Management Committee (hereafter WIMC), GP/B/2/4/4/5, 9 March 1908.
J. Reinarz, Health Care in Birmingham: The Birmingham Teaching Hospitals 1779-1939, Woodbridge, 2009, p.151.
R. Price, ‘Hydropathy in England 1840-1870’, Medical History, 25 (1981), p.270; R. Jackson, ‘Waters and Spas in the Classical World’ in R. Porter (ed.), ‘The Medical History of Waters and Spas’, Medical History Supplement, 10 (1990), p.1.
Ibid., p.271; F. D. Zeman, ‘Life’s Later Years’, in G. J. Gruman (ed.), Roots of Modern Gerontology and Geriatrics, New York, 1979, p.941.
could separate and remove it. His water cure became extremely popular and was brought to England in 1842 by Dr James Wilson.23 However, therapeutic bathing had been in use in hospitals prior to that time; for instance, just over 115 of patients in the Royal Infirmary of Edinburgh received some form of bathing as part of their treatment in the last quarter of the eighteenth century.24 The hospital provided separate hot and cold baths for patients’ use only, although they could also use portable tubs in the wards. Baths were thought to exert a tonic effect on the nervous system, to be useful in skin conditions, and the relaxing effect of a warm bath for fifteen to twenty minutes was used to help patients with chronic rheumatism and postparalytic muscular contractions.25 Vapour baths were in use in Birmingham Skin Hospital to treat a variety of dermatological diseases in 1882.26 Richard Nugent, MO at Wolverhampton workhouse, prescribed three warm baths per week for children with skin disease in 1858. Four boys and 30 girls over the age of two years were suffering from ‘impetigo’, which he put down to poor personal cleanliness and inadequate ventilation in the building.27 More than three decades later, Edward Watts, WMO at the time, was using large quantities of mineral water in the treatment of patients. One of the guardians, Dr Totherill, a hospital physician, considered it an ineffective therapy, but could not persuade Watts to discontinue its use. Totherill accepted that Watts had the authority to order it and the guardians were powerless to over-rule him.28 The MO in Birmingham workhouse also used Buxton water to treat a patient in 1855 with good effect.29 The Victorian period witnessed a profusion of Price, pp.271-73; H. Marland and J. Adams, ‘Hydropathy at Home: The Water Cure and Domestic Healing in Mid-nineteenth-century Britain’, Bulletin of the History of Medicine, 83 (2009), pp.500-1.
Risse, Hospital Life, p.203.
Reinarz, Health Care in Birmingham, p.110.
Wolverhampton Archives and Local Studies (hereafter WALS), Wolverhampton Board of Guardians (hereafter WBG), PU/WOL/A/10, 13 August 1858.
WALS, Wolverhampton Chronicle (hereafter WC), 14 June 1893.
BCL, VGPC, GP/B/2/8/1/1, 24 August 1855.
spas and mineral water hospitals, which specialised in the treatment of chronic rheumatic diseases.30 Birmingham guardians utilised such facilities for Thomas Regan, a young inmate suffering from chronic gout, by arranging his attendance at Droitwich Salt Baths in 1883.31 While water was thought to strengthen the body, bloodletting weakened the body as it affected a cure.32 The rationale behind its use was based on the causation of disease
understanding of human physiology from the seventeenth century onwards, it remained the mainstay of the antiphlogistic regimen. In the late eighteenth century, 25% of patients in the Royal Infirmary of Edinburgh were subjected to one or other forms of bleeding, despite a degree of popularity for John Brown’s stimulant treatment after 1780.33 In the early nineteenth century, the medical system proposed by François-Joseph-Victor Broussais, renowned as the leader of Paris medicine at the time and acclaimed as the inventor of ‘physiological medicine’, resulted in resurgence in the use of therapeutic bleeding.34 He considered that all diseases were due to over stimulation of bodily function resulting in local inflammation, most frequently in the
treatment for all disease was an antiphlogistic regimen of a debilitating diet and D. Cantor, ‘The Contradictions of Specialization: Rheumatism and the Decline of the Spa in Interwar Britain’ in R. Porter (ed.), ‘The Medical History of Waters and Spas’, Medical History Supplement, 10 (1990), p.127.
BCL, ISC, GP/B/2/4/1/1, 20 April 1883.
Marland and Adams, p.506.
Risse, Hospital Life, p.203.
E. H. Ackerknecht, Medicine at the Paris Hospital 1794-1848, Baltimore, 1967, p.61.