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Birmingham and Wolverhampton were exclusively female and from that time men were retained only on the male lunatic wards. Historically, male nurses have been relatively neglected by researchers as a source of study, possibly because they have been regarded as a ‘social anomaly’.227 In the workhouses of Birmingham and Wolverhampton, they had a prominent place in the nursing complement and participated in general nursing prior to the introduction of training. Thereafter, their numbers dwindled, so that there was only one male nurse among a nursing staff of 33 in Birmingham workhouse in 1883.228 Consequently, their contribution to general nursing prior to the reforms has not been given due recognition.229 There is no doubt that nurse training improved the standard of nursing in the late nineteenth and early twentieth century, but it is more difficult to judge if it influenced the caring nature of nurses. The MO in Wolverhampton in 1860 was in no doubt that poor law nurses showed no sympathy toward their patients. On the other hand, two patients in Birmingham expressed their gratitude at the ‘extreme kindness’ and ‘every

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instances of maltreatment of patients and nurses were rare in both institutions.

Murray Browne, a LGB inspector, was very complimentary about the quality of nursing in Birmingham infirmary in 1893, stating that ‘he could not see how rich E. Gamarnikow, ‘Sexual division of labour; the case for nursing’, in A. Kuhn and A. Wolpe (eds), Feminism and Materialism, London, 1978, p.114; Mackintosh, p.233.

C. Hart, Nurses and Politics: the Impact of Power and Practice, Basingstoke, 2004, p.102.

R. Dingwall, ‘The place of men in nursing’, in M. M. Colledge and D. Jones (eds), Readings in Nursing, Edinburgh, 1979, pp.199, 202.

BCL, BBG, GP/B/2/1/51, 12 December 1883.

Hart, p.101.

BCL, VGPC, GP/B/2/8/1/9, 26 September 1884; Workhouse Infirmary Management Committee, GP/B/2/4/4/4, 15 December 1902.

people in sickness would be any better off’.231 However, those patients who remained in the workhouse did not fare as well. In conclusion, the standard of nursing care varied at different times and in different parts of the workhouses, although the general trend was one of improvement, but not always a steadily progressive one. Important events in this narrative were the appointment of paid nurses (in Wolverhampton in 1839); trained nursing superintendents (in Wolverhampton in 1893 and Birmingham workhouse in 1878) and a trained matron in Birmingham infirmary in 1889; the introduction of probationer nurses in place of inmates (in Wolverhampton in 1894 and Birmingham in 1883); and the guardians’ agreement to increase nurse staffing to meet increasing workload at various times during the study period. The overall quality of care provided under the NPL, which did not depend solely on nursing care, will be addressed in the next and final chapter.

BCL, BBG, GP/B/2/1/61, 1 February 1893.

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This detailed microstudy examining and comparing the medical provision and care in two west midlands workhouses has contributed to the debate over the standard of medical care provided by the poor laws. In assessing the standard of medical care, it has demonstrated that Birmingham and Wolverhampton guardians took markedly different approaches to the provision for sick paupers. However, the assessment of standards of care is complicated and Guenter Risse reminds us that care is a ‘complex transaction involving a variety of individuals in distinctive sick and caring roles’ and that healing services can provide a number of distinct functions.1 Thus, several of these aspects in relation to the range of institutional medical services provided by the guardians in the two towns will be considered, in response to the questions raised at the beginning of each chapter.

One of the important medical roles of the workhouse was the care and treatment of paupers suffering from chronic illness and disability, as they had access to few other avenues of institutional care. They were rarely identified as a distinct group of inmates, and Wolverhampton workhouse was typical in this respect. The opportunity to discern their nature and care needs arose in Birmingham due to its designation of some wards as ‘the bedridden wards’. Disabled inmates were found to form a sizeable proportion of workhouse inmates, have a range of disability levels and require considerable medical and nursing attention. The majority were in the older age group, resulting in the workhouse gaining the reputation as the institution of the aged by the late nineteenth century. The inclusion of disabled paupers among those in G. Risse, ‘Medical Care’, in W. F. Bynum and R. Porter (eds), Companion Encyclopaedia of the History of Medicine, Vol. 2, London, 1993, pp.45-46.

the care of the workhouse medical officer in the early years of the NPL demonstrates how disability became medicalised. However, later in the century, those requiring less in the way of direct medical care, for example, needing few or no drug prescriptions, were seen as requiring less medical care and thus acquired a lower status in medical eyes. For older and disabled inmates, the quality of care they received declined toward the end of the nineteenth century and did not alter until medical interest in the care of older people arose in the 1930s.2 This comparative neglect of sick inmates with chronic medical conditions developed as acute medical treatment became more predominant within the institution. However, Birmingham and Wolverhampton workhouse infirmaries played an important part in the provision of medical care for paupers with short-term acute illnesses from early in the study period. For instance, almost one-third of patients in these workhouses had acute medical and surgical conditions in 1869, similar proportions to the average for Warwickshire and Staffordshire, but greater than the four-fifths in Middlesex and Surrey, which included inner London workhouses.3 A significant element of that acute care was provided for patients with infectious and epidemic diseases. These patients, like those with chronic disability were usually ‘unwanted’ by non-poor law institutions. Indeed, for patients in Birmingham and Wolverhampton with a wide range of communicable disease, there was little alternative to admission to the workhouse infirmaries. In the earlier part of the century, they were either excluded from admission to voluntary hospitals or could not For the development of the specialty of geriatric medicine, see M. J. Denham, ‘The History of Geriatric Medicine and Hospital Care of the Elderly in England Between 1929 and the 1970s’, (unpublished PhD thesis, University of London, 2004); A. Ritch, ‘History of Geriatric Medicine: from Hippocrates to Marjory Warren’, Journal of the Royal College of Physicians of Edinburgh, 42 (2012), pp.368-74.

British Parliamentary Papers, 1870 (468-I), pp.12-14, 19-21, 29.

be accepted because of the small number of beds available. Later in the century, sanitary authorities were slow to erect isolation facilities, even after isolation hospitals were considered to be one of the ‘major weapons’ in containing the spread of infection and the Public Health Act (1875) allowed compulsory isolation of infectious patients.4 This is surprising since, as Paul Weindling points out, combating epidemics and endemic infectious disease was a major concern of nineteenth-century medicine.5 However, the need for isolation was met by workhouse facilities and was one area where the principle of less-eligibility did not apply. When epidemics struck, it was boards of guardians who had to respond by erecting temporary facilities, such as sheds or tents in the workhouse grounds or by vacating wards and transferring inmates to other workhouse accommodation in defiance of the classification system.

They also had to employ additional medical and nursing staff. As demonstrated by events in Wolverhampton, this pressure resulted in co-operation between guardians and the local sanitary authorities on some occasions and conflict on others. Isolation assisted in the prevention of the spread of disease and, in this regard, guardians were providing a beneficial service to the local community that went beyond the

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Birmingham, where co-operation between the poor law and sanitary authorities resulted in the joint management of facilities for infectious disease. This study has demonstrated that poor law medical facilities were an essential component of the management and treatment of communicable diseases in the nineteenth and early twentieth centuries. Unfortunately, the records do not reveal the medical therapy that patients with fevers received.

J. V. Pickstone, Medicine and Industrial Society: a history of hospital development in Manchester and its regions 1752-1946, Manchester, 1985, p.178.

P. Weindling, ‘From infectious to chronic diseases: changing patterns of sickness in the nineteenth and twentieth centuries’, in A. Weir (ed.), Medicine in Society, Cambridge, 1992, p.304.

Throughout the nineteenth century, there were few drugs available to medical practitioners that would provide a cure, other than sulphur for scabies, and in the early twentieth century, salvarsan for syphilis. Alcohol in one form or another was the most popular remedy for many acute illnesses and its cost was a substantial proportion of the guardians’ budgets in Birmingham and Wolverhampton. The increase in the amount consumed in Wolverhampton workhouse in the 1840s was attributed by the medical officer to the opening of fever wards, suggesting that it was being prescribed for infectious diseases. The evidence from the expenditure on alcohol in both workhouses suggests that it was given in the same manner and to the same extent as in voluntary and isolation hospitals. With regard to tuberculosis, guardians did more than merely provide accommodation for isolation, although this role was still important as they provided more beds than the local authority as late as the 1920s.6 The workhouse medical officers in both Birmingham and Wolverhampton instituted similar methods of medical management to those in use in sanatoriums. Moreover, despite the constraints imposed upon them, medical officers kept control of pharmaceutical treatments and medical extras, even when guardians were paying the drugs bill. Chapter 5 questioned whether Birmingham and Wolverhampton guardians were able to limit the treatments that inmates could receive and over-rule medical officers’ prescriptions and advice. The incontrovertible answer is that they were not. The change in Wolverhampton in the 1870s, when the medical officer no longer had to meet the cost of drugs out of his salary, appeared to have no effect on prescribing, confounding the general assumption that medical extras were ordered in preference to drugs to protect the medical officers’ salaries. At times, workhouse medical officers introduced new treatments, both medical and surgical, Pickstone, p.213.

and new forms of care within the workhouse, such as open-air therapy for tuberculosis. Patients appeared satisfied if they received from the medical officer the type of treatment they expected and within a reasonable time. The one area that guardians managed to restrict was surgery within the workhouse, but their preference was to transfer patients to a local voluntary hospital, where they paid an annual subscription or were prepared to pay on an individual basis. The restriction gradually lessened toward the end of the nineteenth century as the number of medical officers increased and facilities improved with the provision of an operating room.

Furthermore, anaesthetic agents were used for operations on inmates soon after they became available, with the guardians paying an additional doctor for administering them.

Some of the medical officers employed in both towns strove to provide as high a standard of medical care as was possible and at times succeeded despite their heavy workload. On the other hand, others were content to carry out their duties in a manner that satisfied the guardians and were content to accept increases in salary as patient numbers increased, rather than request additional professional assistance.

Birmingham’s example indicates that sufficient medical staffing was provided at times, in the early period after the NPL as a legacy of the previous system, and later when the infirmary was aligned with voluntary hospitals. The workhouse infirmary attracted medical officers of high quality at times throughout the century and visiting physicians and a surgeon who also had honorary appointments at the local voluntary hospitals. At least one of the physicians tailored his treatment of sick inmates to match that offered to patients in hospital. Birmingham’s medical culture, that included the establishment of medical training and education, was, no doubt important in attracting medical men of standing to take up poor law posts. The establishment in Birmingham of an infirmary under the management of officers distinct from the workhouse was an impetus to improve the level and quality of medical staffing.

Nothing similar occurred in Wolverhampton, where the workhouse and infirmary remained integrated. Throughout the nineteenth century, the single, part-time medical officer in a town such as Wolverhampton could hardly be expected to provide more than basic attention because of the excessive workload.

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