«MEDICAL CARE IN THE WORKHOUSES IN BIRMINGHAM AND WOLVERHAMPTON, 1834-1914 by ALISTAIR EDWARD SUTHERLAND RITCH A thesis submitted to the University of ...»
purgatives. In the words of Warner, ‘the brandy bottle replaced the lancet’.76 A debate within the medical profession took place at that time over the pharmacological action of alcohol in disease, recorded in the pages of The Lancet and British Medical Journal. Physicians did not doubt that alcohol was an effective therapeutic agent, and used it as the stimulant of choice, but now required scientific validity of its mode of action. The therapeutic theories expounded included alcohol acting as a food and so being metabolised completely within the body; it being totally eliminated from the body unchanged and so having no nutritive value; and it being able to act as an antipyretic.77 Samuel Wilks, physician to Guy’s Hospital, suggested ‘the most important question in therapeutics at the present day is the value of alcohol in disease’.78 However, changing scientific views of the action of alcohol on the body had little influence on clinical practice.
Liebig classified alcohol with nutritional elements, but postulated that its greater capacity to become oxidised in the bloodstream meant it was more efficient in preventing tissue breakdown. Robert Todd, a physician at King’s College London, used this concept to promote the scientific basis and theoretical justification for the medicinal use of alcohol. He believed that all disease resulted in depression of vital power and disintegration of tissue, secondary to inflammation. Alcohol could protect healthy tissue from being used to generate body heat, but it was also capable of directly stimulating the nervous system.79 For Todd’s theory to hold true, alcohol had to be completely metabolised within the body and this effect was disputed following experiments by Lallemand and colleagues in the late 1850s. Attention now turned to Warner, ‘Physiological Theory’, p.236.
Ibid., p.235; an antipyretic has the ability to lower body temperature.
S. Wilks, ‘Indiscriminate Use of Alcohol Stimulants in Disease’, The Lancet, i (1867), p.505.
Paul, p.66; Warner, ‘Physiological Theory’, pp.240-42, 244.
the effect of alcohol on the body’s temperature. Rather than raise body temperature by the production of heat as had previously been postulated, it was observed that ingested alcohol could have the opposite effect in a healthy individual. This led to its widespread use in high dosage in the treatment of fevers and, by the early 1870s, it had become the mainstay of treatment for typhus and typhoid.80 The use of large doses of alcoholic stimulants in febrile illness was challenged by William Gairdner, professor of the practice of medicine at the University of Glasgow. In 1864, he reported a reduced mortality in typhus patients treated without alcohol and concluded that its use poisoned, rather than supported, the body.81 Historian Harry Paul has acknowledged that, by the 1880s, alcohol no longer played a major role in the therapeutic discourse of medicine, although it continued to be prescribed widely as a therapeutic agent until the 1920s.82 Wine was the commonest alcoholic beverage prescribed and its continued use could be justified as its many other constituents were thought to contribute to its therapeutic benefit.83 The majority of doctors recognised the harmful effects of alcohol on the body by the late nineteenth century, particularly cirrhosis of the liver, and were aware of the condition of alcoholism. This recognition and the influence of the growing impact of the temperance movement led to more moderate doses being used.84 By 1830, local temperance societies were present in all major British cities.85 Teetotallers strongly attacked the theories of alcohol’s medicinal qualities and were supported by a few S. E. Williams, ‘The Use of Beverage Alcohol as Medicine 1790-1860’, Journal of Studies in Alcohol, 41 (1980), p.551; these infections were very prevalent in workhouses and typhus was often referred to as ‘workhouse’ fever; see chapter 3 for further details.
W. T. Gairdner, ‘Facts and Conclusions as to the Use of Alcoholic Stimulants in Typhus Fever’, The Lancet, i (1864), pp.291-94.
Paul, pp.92, 134; Warner, ‘Physiological Theory’, p.256.
Paul, pp.167, 171, 308; J. Sournia, A History of Alcoholism, Oxford, 1990, p.70.
medical men, such as Benjamin Ward Richardson, who later became a physician at the London Temperance Hospital.86 Some influence on medical practice was achieved as practitioners subsequently limited their use of alcohol, although this occurred in the context of a reduction in the general consumption of spirits of 80% and of beer of 38% between 1831 and1931.87 Workhouse inmates were supplied with alcoholic beverages for a variety of reasons.
Beer was provided in the dietary for able-bodied inmates in some workhouses, more often in the early years of the NPL. For instance, the ordinary dietary in Birmingham in 1834 included beer at dinner on five days each week and, four years later, it was increased to one pint of beer every day for both men and women. However, paupers in the infirmary were restricted to one half pint daily, but, six years later, beer had been withdrawn from those on the ‘half sick’ diet.88 Patients in West Ham Union Infirmary were also given beer at dinner and supper, with those on the full diet allowed one and a half pints and on the half diet one pint, but patients on the low and fever diets were not permitted alcohol.89 Voluntary hospital patients were also allowed regular alcoholic beverages; for instance, in the Royal Infirmary of Edinburgh in the eighteenth century, a ‘house’ beer of low alcoholic content of 1.2% was served during breakfast and supper.90 Alcoholic beverages were frequently provided to inmates who carried out tasks within workhouses, including the pauper nurses. Edward Smith, MO to the PLB, in his report on Metropolitan Workhouses in Ibid., pp.298-99; J. Reinarz and R. Wynter, ‘The Spirit of Medicine: The Use of Alcohol in Nineteenth-Century Medical Practice’, in B. Schmidt-Haberkamp and S. Schmid (eds), Drink in the Eighteenth and Nineteenth Centuries, London, 2014, p.138.
Lucia, pp.161-62; B. H. Harrison, Drink and the Victorians: the Temperance Question in England, 1815-72, Keele, Staffordshire, 1994, p.38.
J. Lane, A Social History of Medicine: Health, Healing and Disease in England, 1750-1950, London, 2001, p.62; BCL, BBG, GP/B/2/1/4, 17 October 1838; HC, GP/B/2/3/1/1, 14 November 1844.
R. G. Hodgkinson, The Origin of the National Health Service: the Medical Services of the New Poor Law 1834-71, London, 1967, p.154.
Risse, Hospital Life, p.224.
1866, noted that paupers, in many workhouses, were given a daily allowance of either one pint or one and a half pints of strong porter, plus one or more glasses of gin for carrying out disagreeable work.91 MOs could prescribe alcohol on an individual basis, as part of ‘medical extras’ paid for by the guardians, for both pauper nurses and patients. As the majority of contracts held by MOs stipulated that they were required to pay for drugs they prescribed, guardians were suspicious that medical extras were frequently substituted for drugs in order to avoid this expense. Both they and the central authority strove continually to control the cost of alcohol consumption in workhouses, but this proved difficult due to alcohol’s status as a medicine, although this was challenged in the latter part of the nineteenth century. Jonathan Reinarz and Rebecca Wynter assert that a decline in the prescription of alcohol in institutions had more to do with cost than a change in prevailing theories.92 They give as an example the marked difference at the General Hospital in Birmingham between the years of 1865-1867 and 1881-1884, when the consumption rate of wine reduced from 0.09 to 0.02 bottles, spirits from 0.07 to 0.03 bottles, beer from 0.55 to 0.01 quarts, and ale from 0.58 to 0.09 quarts.93 A similar situation with increasing costs leading to restrictions in the prescription of wine and beer at the Royal Infirmary of Edinburgh in the 1790s has already been mentioned.94 At the time when alcoholic beverages were more freely prescribed at the General Hospital, Edward Smith considered that the quantities of ‘spirituous liquors’ ordered in provincial workhouses and ‘the length of time’ during which they are ordered, are ‘sufficiently astonishing’, and will, I do not doubt, ultimately engage the attention of BPP, 1866 (372), p.25.
Reinarz and Wynter, pp.136-37.
Risse, ‘Therapeutics’, p.52.
the Poor Law Board’. 95 This issue was the only one he had encountered where there was widespread disagreement between the views of guardians and MOs. Smith’s assumption proved correct and the first of a number of returns relating to the consumption of alcoholic beverages by paupers was issued in 1872.
The criticism by historians that WMOs ordered extras, including alcohol, to avoid the cost to themselves of prescribing drugs did not apply in Birmingham as the guardians continued to meet the cost of drugs ordered in the workhouse under the NPL, as they had previously. Wolverhampton guardians did not agree to pay for medicines until 1874, but before this time, there had been no concerns raised in Wolverhampton over the cost of extras, despite the consumption of alcoholic beverages rising significantly between 1842 and 1846, while the number of inmates stayed the same (Table 5.1).96 Although the number of patients increased in 1843, it remained static thereafter and the increased consumption most likely reflected increased prescription and possibly the opening of fever wards. Wolverhampton guardians discussed the cost of alcohol consumption in 1867, as it had risen eightfold compared to a few years earlier. For the quarter year ending 1866, they had spent nearly £85 at a cost of 2s and 3d per inmate, while Birmingham spent above £134 at only 1s and 3d per head. The matter was raised by Mr Barker, who was denounced as a teetotaller by the other guardians, one of whom, Mr Willcock, was proud that the MO gave the ‘sick poor’ those stimulants he considered necessary, as he felt they did more good than all the medicines that were prescribed.97 BPP, 1867-68 (4), p.16.
WALS, WBG, PU/WOL/A/16, 20 November, 24 December 1874.
WALS, WC, 3 July and 14 August 1867.
The amount spent on wines and spirits to treat sick inmates in Birmingham workhouse increased from a weekly average of approximately £43 for the year 1832to nearly £80 for 1842-43, but declined to annual costs of just under £57 in 1849 and nearly £39 in 1871. Over the same period, the number of patients rose from 122 to around 700.98 The guardians did not raise the issue of cost at that time and the mostly likely reason for the reduction in the prescription of alcohol was a change in medical practice. Nevertheless, when the guardians were presented in 1876 with details of alcoholic ‘liquors’ prescribed over the previous five years, they instructed the MO to revise the list of inmates for whom it was allowed with a view to reducing consumption. This was despite considering the return as satisfactory.99 At this time, Birmingham was already frugal in the amount of alcohol consumed in its institution, compared with Wolverhampton workhouse and the national average (Table 5.2). This is re-affirmed by the cost per patient, which is available for 1871 only. Birmingham spent 4s and 5d per patient, while Wolverhampton was more spendthrift at over £1, BCL, BBG, GP/B/2/1/3, 2 April 1833; GP/B/2/1/6, 24 April 1849; BPP 1872 (391), pp.24-25; BPP, 1870 (468-I), p.21; TNA, MH12/13286, MH12/13288.
BCL, House Sub-committee (hereafter HSC), GP/B/2/3/3/5, 25 July 1876.
although this was two-thirds less than the national average, despite the WMO having to meet the cost of the drugs he prescribed.100 A national return on alcohol consumption in workhouses for 1881 was brought to the attention of Wolverhampton guardians. Birmingham had spent less, but could obtain ale and brandy at a lower cost and port wine at half the price per gallon.101 When a Table 5.2: Quantity and Cost of Alcohol Consumption in Wolverhampton, Birmingham and all English and Welsh Workhouses, 1871-1892
1871 8,675,337 168,700 232,711 48,362 11,231 22,962 140,000 0.60 1881 6,541,128 114,497 183,233 33,839 7,148 19,316 170,566 0.35 1892 3,643,504 38,597 124,367 16,951 4,256 14,428 182,000 0.20 Sources: BPP, 1872 (391), pp.22-25, 36; 1883 (108), pp.4, 14-15; 1895 (44), pp.4, 25;
Census data for 1871; Williams, From Pauperism to Poverty, p.159.
further return from the LGB was considered at the request of the chairman of the Workhouse Drink Reform League in 1888, the cost of consumption of wine and spirits had dropped to £8 and £42 respectively and the cost per inmate had fallen to 3s and 5d and to 8s and 7d per patient. Out of the 423 patients in the infirmary, only 14