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Patient Management and Mismanagement A greater understanding of how treatments were utilised can be gleaned from consideration of the management of individual patients. Workhouse inmates had high expectations of treatment from MOs and would complain to the guardians if it was not to their satisfaction. Benjamin Lane, an inmate of Wolverhampton workhouse in April 1855, had initially been suffering from ‘white swelling’ of the knee, for which he was prescribed a flannel to wrap round the joint.205 Later, he developed a pain in his side and diarrhoea, for which he was given a mustard plaster and he subsequently recovered. However, he complained that it took three requests to the MO, Richard Nugent, before he received treatment for his bowel complaint.206 Joseph Freeman also complained of abdominal pain on admission in June 1894 and explained that it was four days since he had had a bowel movement. The MO gave him a ‘draught to relieve pain’. He was transferred from the old men’s ward to the infirmary as the doses of laxatives and castor oil were unsuccessful and his condition had deteriorated.

An injection of an analgesic and oral lime water and brandy produced a little improvement, but he died the next day.207 Patients were also critical of the type of treatment prescribed by MOs. William Stanley and John Dyer criticised Nugent’s practice of using the same medicine for BCL, VGPC, GP/B/2/8/1/9, 26 September 1884.

‘White swelling’ was the term used to denote tubercular infection of the joint.

WALS, WC, 4 April 1855; TNA, MH12/11682, 5 April, 27 October 1855.

WALS, WVC, PU/WOL/H/1, 15 June 1894.

between 20 and 30 different cases in Wolverhampton infirmary. They considered that not everyone’s sickness was alike and that therapy should have been prescribed according to individual complaints and constitution. Nugent dismissed their criticism by claiming that ‘this class of case’ would never be satisfied whatever treatment was used.208 An anonymous letter to the Birmingham Journal in 1857 complained that Birmingham guardians did not believe in any medicines more expensive than ‘epsom salts’, and restricted the MO’s use of drugs. The accusations, which had been made by Daniel Smith, who had been an able-bodied inmate, were denied by the MO, who stated that he treated inmates with the same drugs and stimulants as he would use for private patients.209 However, there were few complaints over eighty years and the most likely explanation is that patients usually received the attention they expected.

Inmates were also at risk of inadvertently being given the wrong medication, although only one incident has been recorded in the minutes of both boards of guardians. In 1898, probationer Nurse Stockwin in Birmingham workhouse infirmary admitted that she gave two patients a dose of lead lotion instead of ward mixture. She called promptly for medical attention and both patients recovered without incident. Both medicines were contained in identical bottles, although that containing lead lotion had the word ‘poison’ attached to it. It was usually kept in the poison cupboard, but had been lying out on the ward as it had been in use. The nurse was reprimanded for carelessness and the guardians took steps to provide distinctive bottles in future for poisons.210 The lotion in question was likely to have been lead acetate, also known as sugar of lead, which was used as an astringent. More hazardous than the incorrect drug administration was the need for surgical operation.

TNA, MH12/11682, 2 February 1855, 23 January 1856.

BCL, VGPC, GP/B/2/8/1/2, 4 September 1857.

BCL, IHSC, GP/B/2/4/5/1, 19 December 1898.

Surgery The practice of surgery was revolutionised in the middle of the nineteenth century with the development of inhalation anaesthesia and antiseptic techniques, which have been hailed by some as the greatest innovations ever made in medical theory or practice.211 Although they made more complex surgery possible, the most commonly performed surgical procedures were amputation, setting fractures and treating wounds. The period up to the First World War has been designated localistic, with the emphasis on resection of tumours, inflammations and injuries.212 The operations carried out in Birmingham workhouse are an accurate reflection of this period, although more complex surgery took place from the 1880s (Table 5.5). A few instances of minor surgery in Wolverhampton workhouse have been recorded. In 1855, Richard Nugent lanced Arthur Belcher’s lumbar abscess and applied poultices.

When George Roberts was admitted having cut his throat, Nugent sutured and bandaged it, later applying poultices with astringent lotions.213 Later surgery involved the removal of ‘gravel’ in the bladder of four-year-old Henry Weckman in 1861 and

–  –  –

Birmingham where there were 55 acute and 56 chronic surgical patients, each type corresponding to 8% of total patients, compared with the national figures of 6% and 10%.215 A similar position occurred in Reading union workhouse, with four acute A. T. Youngson, The Scientific Revolution in Victorian Medicine, London, 1979, p.212.

U. Tröhler, ‘Surgery (modern)’, in W. F. Bynum and R. Porter (eds), Companion Encyclopaedia of the History of Medicine, London, 1993, p.980.

TNA, MH12/11682, 2 February 1855.

WALS, WBG, PU/WOL/A/11, 3 May 1861; HC, PU/WOL/E/1, 30 October 1900.

BPP, 1870 (468-I), pp.3, 19, 21.

(5%) and eight chronic (10%) surgical patients out of a total of 79. This was despite a ruling by the guardians the year previously that all paupers with fractures and all emergency cases should be directed straight to Royal Berkshire Hospital, for which purpose they increased their annual subscription from six to ten guineas.216 Birmingham guardians required the MO to seek their consent for inmates to have surgery and preferred them to be transferred to the General Hospital for the operation.

This ensured that the decision to carry out surgery was approved by more than one surgeon.217 When amputation of Mary Norton’s leg because of ‘disease of the knee’ was recommended to the guardians in 1851 and of the arm of the ‘man, Trafford’ for a diseased elbow in 1854, they suggested further surgical opinions.218 The guardians’ position was challenged by one WMO, Redfern Davies, when he amputated Edward Waite’s leg in the workhouse without permission, although he eventually had to concede he would only do so again in an emergency (Table 5.5).219 However, Davies had performed other surgical procedures in the workhouse prior to that time and published details in medical journals. The following decade, Davies’ successor, Edmund Robinson, declared that there were hardly any surgical cases in the workhouse and ‘capital operations’ did not take place there. 220 However, he found it necessary to amputate John Walsh’s leg for malignant disease in the workhouse in 1867, as he was too ill to be transferred to hospital (Table 5.5). By the mid-1880s, the number of operations in the workhouse had increased, but after the opening of the new infirmary at the end of the decade, details of the surgery performed there are mostly available from published case reports, which contain the more difficult and Ibid., p.4; M. Railton and M. Barr, Battle Workhouse and Hospital 1867-2005, Reading, 2005, p.44.

BCL, VGPC, GP/B/2/8/1/2, 8 January 1858; BBG, GP/B/2/1/22, 9 February 1859.

BCL, BBG, GP/B/2/1/9, 23 July 1851; GP/B/2/1/14, 24 February 1854.

BCL, BBG, GP/B/2/1/23, 22 June 1859.

BPP, 1867-68 (40), p.45.

Table 5.5: Operations Performed in Birmingham Infirmary, 1859-1892

–  –  –

Sources: BCL, BBG, GP/2/1/23, 8 June 1859, VGPC, GP/B/2/8/1/6, 10 May 1872; R.

Davies, ‘Birmingham Workhouse Infirmary’, British Medical Journal, i (1858), p.284; R. Davies, ‘Birmingham Workhouse Infirmary’, British Medical Journal, i (1859), p.677; J. R. Davies, ‘On the radical cure of Varicocele’, The Lancet, ii, (1861), p.60; R. Davies, ‘Remarks on the Operative and Mechanical Treatment of Prolapsus Uteri’, The Lancet, i (1864), p.407; J. Lloyd, ‘On Acute Intestinal Obstruction and its Treatment by Abdominal Section, with Illustrative Cases’, The Lancet, i (1890), pp.996, 844, 1891; Anonymous, ‘Birmingham Workhouse Infirmary. A Case of Peritonitis Following Parturition’ The Lancet, ii (1891), pp.1276-77; J. Lloyd, ‘Reports on Medical and Surgical Practice in the Hospitals and Asylums of Great Britain, Ireland, and the Colonies. Birmingham Workhouse Infirmary’, British Medical Journal, i (1892), p.16.

The outcome is as defined by the surgeon.

rarer cases, rather than routine surgical procedures.222 Nevertheless, Dr Stuart, assistant surgeon, performed 45 major and 10 minor operations over a three-month period in 1913.223 At that time, the surgeons had the benefit of X-ray apparatus, which proved invaluable in confirming a suspected kidney stone in a man admitted with vague abdominal symptoms. Jordan Lloyd successfully removed the stone and the patient was discharged cured. Another successful removal was possible after Xray confirmed the exact site and extent of tuberculous disease in the bone of a patient’s foot. The machine was also useful in the diagnosis of the large number of cases being admitted with suspected fractures.224 Wolverhampton WMOs did not publish case reports, but Woodward Riley, while acting as deputy to Henry Gibbons, did so in 1870. He repaired successfully a small femoral hernia in David B., a 90year-old inmate, after attempts at reduction had failed. He administered chloroform himself as he was ‘rather pressed for time’.225 In all the operations listed in Table 5.5, anaesthesia was used in the form of chloroform or ether and was administered by an assisting surgeon.

At the beginning of the twentieth century, the infirmary in Birmingham took on more acute medical work and became more akin to a general hospital. For the twelve months to May that same year, 1,137 surgical cases had been admitted, representing 34% of all admissions.226 The number of operations carried out in Wolverhampton workhouse at the beginning of the twentieth century can be estimated from the record of payment to a second surgeon for administering anaesthetics. It increased from 4 in BCL, Infirmary Sub-committee, GP/B/2/4/1/4, 25 November 1887.

BCL, Infirmaries Committee (Hospitals), GP/B/2/4/8/1, 9 July 1913.

BCL, IMC, GP/B/2/4/4/6, 23 October 1911.

J. W. Riley, ‘Operation for strangulated femoral hernia in a man ninety years of age; recovery’, The Lancet, ii (1879), p.110.

BCL, IMC, GP/B/2/4/4/5, 11 July 1910.

1901 to 42 in 1902, but decreased to 14 in 1903 as the appointment of an assistant MO for the workhouse in that year allowed the anaesthetic to be given by him without additional payment.227 Although surgical operations were uncommon in both workhouses in the mid-1880s, this form of medical care gradually increased in frequency and importance into the twentieth century.

Summary In 1887, Birmingham guardians considered that the medical care in the workhouse was of such a high standard that patients were treated according to current scientific knowledge.228 This chapter has provided some evidence to support this claim. The extent of medical prescriptions ordered by the MOs required the services of a dispenser at both workhouses, over most of the study period. Some of the MOs introduced therapies that were innovative, for instance, John Wilmhurst’s treatment for scabies and Suckling’s use of oral terebene for chronic bronchitis; or treated workhouse inmates more rigorously than patients in the voluntary hospital, as in the management of pneumonia. Redfern Davies attempted to introduce new surgical techniques and groundbreaking surgery, with some success in spite of the guardians’ objections. However, much of this innovative medical practice in Birmingham only comes to light because the medical practitioners were motivated to publish their practice to improve their standing in a competitive medical market. Birmingham workhouse is conspicuous because of the extent to which its MOs practised a high standard of medical care. Although there is no evidence of innovation in WALS, WBG, PU/WOL/A/29, 22 November 1901; 3 January, 6 June, 14 November, 5 December 1902; 17 July 1903.

BCL, ISC, GP/B/2/4/1/4, 25 November 1887.

Wolverhampton, it does not mean that the care provided was of an inferior quality.

New methods of treatment did occur in other workhouses, for instance, the WMO in Leicester treated leg ulceration by skin grafting in the early 1870s, only a few years after the method was published in The Lancet.229 Drugs in general use at the time, such as mercurials, made up the therapeutic armamentarium in workhouse infirmaries, in addition to a range of physical therapies. The workhouse provided care for the majority of sufferers from venereal disease, who were allowed access to newly introduced drug therapy in the early twentieth century.

WMOs provided a range of sick diets, tailored to specific conditions and the severity of the illness, as was the case in voluntary hospitals. With medical extras, additional nutrition, usually a form of meat, could be provided to suit individual patients.

Alcohol was regarded as one of the most potent forms of drug therapy in the nineteenth century. Despite becoming less popular towards the century’s end, few leading practitioners of the day advocated dispensing with it completely, since they believed it to be effective even if they were in dispute over its mode of action. It was used therapeutically in workhouse infirmaries, liberally in some, but more frugally in others, depending on where the MO stood in the alcohol debate. Whether guardians or the MO paid for drugs and whatever the degree of local influence of the temperance movement, these factors had only a limited effect. Historians’ allegation that the main reason for the prescription of alcohol was evasion by the MO of the cost of drug therapy does not appear justified. Rather, the evidence in this chapter suggests it was the strongly held belief in its power to affect a cure. There is some evidence from Wolverhampton that guardians also believed in the therapeutic benefits A. Negrine, ‘Medicine and Poverty: A Study of the Poor Law Medical Services of the Leicester Union 1876-1914’, (unpublished PhD thesis, University of Leicester, 2008), pp.80-81.

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