«MEDICAL CARE IN THE WORKHOUSES IN BIRMINGHAM AND WOLVERHAMPTON, 1834-1914 by ALISTAIR EDWARD SUTHERLAND RITCH A thesis submitted to the University of ...»
K. Siena, ‘The Moral Biology of “The Itch” in Eighteenth-Century Britain’, in J. Reinarz and K.
Siena (eds), A Medical History of Skin: Scratching the Surface, London, 2013, pp.71, 77, 234; this is the only contemporary text, but it does not extend beyond the eighteenth century.
eggs, usually in the hands of those infected. Intense itching follows, with a rash, which spreads up the arms. The disease is transmitted by direct skin contact and was accepted as contagious by the nineteenth century. The mite was identified in the midseventeenth century, but was not accepted as the cause of the disease until two hundred years later because doctors found it difficult to comprehend how a localised infestation could result in wide spread pathology and the mites were considered secondary to the infection.136 Many workhouses had dedicated wards for sufferers, for instance, in the mid-1860s, 52% of 48 provincial workhouses had itch wards or cutaneous wards.137 However, they were often in detached buildings, such as an outhouse, and were dirty and repellent, partly due to ‘a sense of disgust’ at the nature of the condition.138 For example, the two rooms used for the ‘cure of the itch’ in Birmingham workhouse in 1842 were described as in a filthy and disgusting state and alternative rooms were found.139 Around the same time, patients with itch in Wolverhampton workhouse were being placed in the same ward as venereal patients.140 The itch was very prevalent in workhouses, which led to it being perceived as a disease of the ‘immoral’ poor. There were more cases in Birmingham workhouse in the late 1870s (between 1% and 2% of inmates) than after 1894 (less than 1%), although the absolute numbers increased in the early twentieth century (Appendix B).141 An outbreak of skin disease occurred among the children in Wolverhampton workhouse in the autumn of 1858, with 53 out of about 130 affected at its peak. The MO stated the cause as their L. C. Parish, ‘History of Scabies’, in M. Orkin and H. Maibach (eds), Cutaneous infestations and insect bites, New York, 1985, pp.4-8; Siena, ‘ Moral Biology’, pp.72-73.
BPP, 1867-68 (4), pp.26-157.
BCL, HC, GP/B/2/3/1/1, 2 August 1842.
WALS, Master’s Journal (hereafter MJ), PU/WOL/U/2, 5 November 1842.
BCL, LGB Returns, GP/B/5/1/1-8, 1877-1911.
debilitated constitution and treated them with a full diet plus a small quantity of ale.
By the following February, the number had reduced to 13.142 However, a further outbreak took place 21 years later, affecting 22 children, caused by the admission of children with the disease.143 Children appear to have been particularly susceptible.
When Mary Kitson and her five children were transferred to Walsall workhouse from Wolverhampton in 1893, they were noted to be suffering from the itch and the heads of two of the children were in a ‘filthy condition’.144 The traditional treatment was with sulphur, which was made into an ointment by mixing it with butter or hog’s lard and had an offensive odour.145 It was applied to the
Wilmshurst, MO at Birmingham workhouse, requested permission to use a new method imported from Belgium, using a solution of sulphur and lime. This required only one application to achieve a cure and he pointed out it would allow more rapid discharge of patients and create more space in the infirmary for urgent cases.
Wilmshurst introduced this treatment to Birmingham ten years before it became standard treatment in other workhouses and this is one example of the introduction of innovative treatment by a MO in a workhouse.146 WALS, WC, 22 and 29 September, and 13 October 1858; 9 February 1859.
Ibid., 1 September 1880.
WALS, WBG, PU/WOL/A/24, 3 March 1893.
Sulphur continues to be recommended as the treatment of choice for children and second line for adults.
BCL, BBG, GP/B/2/1/19, 24 June 1857; BPP, 1867-68 (4), p.8.
Respiratory Disease The invention of the stethoscope in the early 1800s by René Laennec, one of the greatest physicians of the French school, permitted him to identify normal from abnormal breath sounds and, as a result, to differentiate a variety of pulmonary diseases.147 Respiratory disease was one of the commonest reasons for admission to hospital, accounting for 11% of admissions to the Royal Infirmary of Edinburgh in the late eighteenth century.148 The mortality attributed to bronchitis, pneumonia and influenza increased in the second half of the nineteenth century, but declined sharply thereafter.149 In December 1869, 8% of patients in workhouses in England and Wales were suffering from a non-tuberculous respiratory illness. However, in Birmingham they constituted 39% of patients and, in Wolverhampton, 27%, reflecting the industrial nature of those towns.150 Respiratory diseases other than tuberculosis accounted for between 18% and 22% of deaths in Birmingham borough in the 1880s.151 Cornelius Suckling, Physician to the Queen’s Hospital, Birmingham and Visiting Physician at Birmingham workhouse, published an account in September 1884 of his treatment of lobar pneumonia in 100 workhouse inmates over the previous 16 months.
The disease is the commonest bacterial cause of community-acquired pneumonia, affects only one lobe of the lungs and is known now to be caused by Streptococcus pneumoniae. The overall mortality was 43%, rising with the increasing age of the Bynum, pp.37-38.
Risse, Hospital Life, p.146.
R. Woods, ‘Mortality Patterns in the Nineteenth Century’ in R. Woods and J. Woodward (eds), Urban Disease and Mortality in Nineteenth Century England, London, 1984, p.67.
BPP, 1870 (468-I), pp.56, 57, 63, 327, 329.
patients. Patients he treated for pneumonia at the voluntary hospital were fitter premorbidity and had better outcomes than those at the workhouse. He pursued a stimulant plan of treatment in most of these cases, starting with cinchona and ammonia, and was convinced he had saved several lives by ‘free stimulation’ with alcohol. Quinine and occasionally a cold pack were used to treat a raised temperature.
Pain was alleviated by ‘morphia injections’, hot poultices and a few leeches. He believed bloodletting to be dangerous in most cases of pneumonia and, on the only occasion he used it, the patient, who had marked cyanosis, had died. In four cases, he had seen early after the onset of the illness, he believed that he had aborted the disease by one dose of ten grains of quinine.152 Early in the twentieth century, pneumonia was one of the commonest causes of death in Birmingham infirmary, declining from 14% (55 patients) in the first six months of 1905 to 6% (31) for the same period three years later. The guardians credited the decrease in morbidity to the change in the treatment of pneumonia that had taken place over those years, but, unfortunately, did not elucidate what that alteration had been.153 Dr Suckling’s usual treatment for cough in patients with chronic bronchitis and emphysema, and chronic phthisis was a mixture of ammonia and senega.154 He added a few grains of iodide of potassium if expectoration was difficult and a small quantity of lobelia if dyspnoea was marked. Most patients were also given cod-liver oil, as he considered it one of the most useful drugs in these conditions. Of 100 cases he treated in the winter of 1885, 28 were discharged well, with the chest examination being clear, and 68 discharged relieved. After reports of the benefit of pure terebene for C. W. Suckling, ‘Lobar Pneumonia’, The Lancet, ii (1884), p.407.
BCL, Infirmary Management Committee (hereafter IMC), GP/B/2/4/4/5, 14 December 1908.
Senega was the dried root of Polygala senega, a plant of the milkwort family. It was in common use as an infusion to treat pneumonia, probably for its perceived action as an expectorant.
winter-cough, he gave it a trial in a further 100 patients, giving five drops orally every four hours initially and increasing the dose to ten drops, whereas his previous mode of administration had been to let patients inhale it.155 Oral administration resulted in 72% of patients with chronic bronchitis and 67% of the 6 cases of chronic phthisis being relieved, although the beneficial effect was mainly on their breathing as many requested an anti-tussive in addition. Suckling concluded that oral terebene was very effective in relieving the dyspnoea of chronic bronchitis.156 Venereal Disease The poor law medical service was responsible, by default, for the management of the majority of patients with venereal disease. Those suspected of suffering this condition were frequently denied admission to voluntary hospitals, often on moral grounds, although the South Staffordshire General at Wolverhampton was an exception.157 Specialist hospitals, often called ‘Lock’ or Skin Hospitals, were not established outside London until the later part of the century; for instance, the Skin Hospital in Birmingham (founded in 1881) first took inpatients in 1886 and then only twelve.158 Kevin Siena found it difficult to estimate the general prevalence of sufferers of venereal disease in eighteenth-century workhouse infirmaries in London, as their proportion varied over time, for instance, from almost 4% in 1733 to 12% the Terebene is a mixture of dipentene and other hydrocarbons, distilled from oil of turpentine.
C. W. Suckling, ‘Pure Terebene in the Treatment of Winter-Cough’, British Medical Journal, i (1886), p.541.
Hodgkinson, pp.300-302; T. J. Wyke, ‘Hospital facilities for and diagnosis and treatment of, venereal disease in England, 1800-1870’, British Journal of Venereal Diseases, 49 (1973), pp.78-79.
Reinarz, Health Care in Birmingham, p.110.
following year in St Margaret’s parish.159 Venereal disease was the term in common use in the nineteenth century to cover a host of sexually-transmitted diseases, the major ones being syphilis (or ‘Great Pox’) and gonorrhoea. However, Siena has cautioned against assuming that those diseases were exactly similar to the ones that are known by the same names at the present time.160 Syphilis first appeared in Europe in Italy at the close of the fifteenth century and rapidly spread as an epidemic, thereafter remaining endemic throughout the continent.
The disease goes through three distinct phases after an incubation period varying from 10 days to 10 weeks. It first presents as a local infection, with a painless genital ulcer, or chancre, which heals. Secondary syphilis develops six to eight weeks later with fever, a rash of variable character, though usually maculopapular. Mouth ulcers may be present, as well as condylomata, which are warty lesions on the perineum. There follows a latent period of many years before late symptoms become manifest, with abscesses, destruction of the bones and face, as well as cardiovascular and neurological defects. The disease can be transmitted to the foetus from an infected mother, resulting in deformities in the child, such as the diagnostic ‘peg-shaped’ teeth, blindness and deafness.161 Advances in aetiology and diagnosis did not take place until early in the twentieth century, with the isolation of the causative bacterium, called Trepenonema pallidum since 1906. The same year a diagnostic blood test, the Wassermann reaction, was developed, based on detecting antibodies to the bacterium.
The test proves positive between five and eight weeks after infection has been K. Siena, Venereal Disease, Hospitals and the Urban Poor: London’s “Foul Wards”, 1600-1800, Rochester, 2004, p.150.
M. Dobson, Disease, the Extraordinary Stories Behind History’s Deadliest Killers, London, 2007, p.32.
contracted.162 In 1914, Wolverhampton guardians agreed to make the test available at a cost of 15s per case, so that the MO could make an accurate return of the number in the workhouse for the Royal Commission on Venereal Diseases.163 The mainstay of treatment from the sixteenth century onwards was mercury, either ingested as a pill or applied locally as an ointment, although they were not curative.
One of the most popular forms was the blue pill, which also contained confection of roses and powdered liquorice.164 However, as the massive doses prescribed were not always effective and produced side effects, a non-mercurial plan of treatment, known as the ‘simple plan’ and based on the antiphlogistic regimen and local bloodletting, came into favour in the early nineteenth century.165 Langston Parker, a surgeon at Queen’s Hospital, Birmingham and an expert on venereal disease, recommended that treatment with mercury be withheld in primary syphilis until the patient had been prepared for it by means of the simple method.166 However, he preferred to start it immediately for secondary manifestations.167 The most important of the many alternative forms of treatment that were tried was iodide of potassium, introduced in 1836, but it became restricted to the treatment of tertiary disease. Powerful caustics such as nitric acid were used to treat sores and other local manifestations.168 Although both mercury and iodine are treponemacidal, it is likely that they were only suppressive of clinical symptoms rather than curative.169 In 1910, Paul Ehrlich, a German medical scientist, developed salvarsan, an arsenical compound as an effective BPP, 1913 [Cd. 7029], pp.11-12.
WALS, HC, PU/WOL/E/4, 29 January 1914.
Ibid., p.81; L. Parker, The Modern Treatment of Syphilitic Diseases, Birmingham, 1840, paragraphs 1-15.
Parker, paragraph 29.
Ibid., paragraph 208.
J. D. Oriel, The Scars of Venus; A History of Venereology, London, 1994, pp.88-89.
curative treatment, although it was subsequently amended to neo-salvarsan because of toxic side effects of the earlier preparation. It had to be administered with caution by intravenous injection and a number of injections were required until evidence of healing of lesions took place.170 Gonorrhoea is a bacterial infection that results in urethritis with a urethral discharge in the male and cervicitis, vaginal discharge and urethritis in the female. In both, a systemic reaction may occur with arthritis and a vasculitic rash. It was not clearly differentiated from syphilis until 1837 and the causative organism, Neisseria gonorrhoea, was identified in 1879. The major complications are urethral stricture in men and infertility in women due to infection ascending to the uterus and ovaries.