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«MEDICAL CARE IN THE WORKHOUSES IN BIRMINGHAM AND WOLVERHAMPTON, 1834-1914 by ALISTAIR EDWARD SUTHERLAND RITCH A thesis submitted to the University of ...»

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who were destitute.126 Their workload was immense, for instance, The Lancet commented in 1867 that Bethnal Green Workhouse had only one for 600 patients, while a similar sized voluntary hospital in London would have had 15 doctors.127 Pressure at national level achieved little as the central authority remained reluctant to become involved in medical matters and most of the problems remained unresolved throughout the existence of the poor laws.128 By 1871, poor law MOs were seen as an important branch of the medical profession and their status within the profession had risen. Within the workhouse, it gradually changed from a subordinate role to one of great influence by 1914.129 Nevertheless, Crowther considers that they remained at the bottom of the medical hierarchy.130 They were in the forefront of the pressure to reform the service, but there is controversy among historians as to their motivations and achievements. This ranged from the view that they had little success and the improvements they demanded would only have benefited their own interests to Hodgkinson’s assertion that the improvements they achieved furthered the interests of their patients.131 She considers that poor law MOs stand out as ‘particularly good public servants’, striving for ‘positive health measures’, and Brand concurs that they repeatedly urged for improvements in medical care to the poor. Instances of WMOs carrying out innovative procedures, particularly in surgery, have been recorded in the literature.133 Crowther, Workhouse System, pp.167, 181; M. A. Crowther, ‘Paupers or Patients?’, Journal of History of Medicine and Allied Sciences, 39 (1984), pp.33-34, 53; Brand, Doctors and the State, p.85.

Hodgkinson, p.356.

Flinn, p.61.

Crowther, Workhouse System, p.173; Brand, Doctors and the State, p.88.

Crowther, Workhouse System, p.167.

Crowther, ‘Paupers or Patients?’, p.37; Brand, Doctors and the State, p.234; Hodgkinson, pp.680Hodgkinson, pp.xv-xvi; Brand, Doctors and the State, p.234.

Flinn, p.61; R. G. Hodgkinson, ‘Poor Law Medical Officers of England, 1834-1871’, Journal of History of Medicine and Allied Sciences, XI (1956), p.312; Negrine, ‘Medicine and Poverty’, p.232.

Crowther considered that they were not in a position to make more than minor changes, but she concedes that little was known about the situation of local doctors.134 Alternatively, Michael Flinn contended that individual MOs brought about piecemeal improvements locally by means of ‘perpetual guerrilla warfare’.135 Price describes poor law MOs as a ‘fractious heterogeneous group’ with only a few as ‘prescient reformers’. He considers the historiography of these medical men to be contradictory and incomplete, especially with regard to the nature of their day-to-day practice; what he refers to as the ‘reality of poor law doctoring’.136 Nevertheless, there is general agreement among historians that poor law MOs were the key figures in the poor law medical welfare system, and Lynn Hollen Lees asserts that they ‘turned paupers into patients’.137 This detailed, intensive local study of two workhouses provides the opportunity to determine whether local WMOs were able to bring about improvements in patient care and introduce new forms of treatment.

Workhouse Nursing Care The historiography of the nursing profession prior to 1980 has been written for the most part as a conventional, congratulatory discourse and only since the late 1980s has it developed into a more critical and reflective area of scholarship. The major exception is Brian Abel-Smith’s A History of the Nursing Profession, published in 1960, although it dealt primarily with the structure of the profession, rather than Crowther, ‘Paupers or Patients?’, p.53.

Flinn, p.61.

Price, pp.2, 336.

Lees, p.279.

nursing as an activity and what it was like to perform nursing tasks.138 Celia Davies’ ‘mould-breaking’, edited collection in 1980 exhibited a more reflective narrative and set up a revolution through the writing of nursing history over the next decade.139 The most recent accounts place the history of nursing within a wider historical context and focus on the reality of practising as a nurse in the nineteenth century and the nature of the women who chose to be nurses.140 Little research has been carried out on the period before the nineteenth century or in its early decades.141 The majority of the literature has concentrated on the reforms since then in terms of the development of training according to the Florence Nightingale School, established in 1860. However, there were earlier initiatives to offer training to nurses, one of which was the Institution of Nursing Sisters, set up by the Quaker philanthropist, Elizabeth Fry, in

1842. The Institute’s nurses gained experience by means of short attachments in London voluntary hospitals. Thereafter, the majority went into private practice.142 Fourteen years later, the Anglican Sisters of St John’s House spearheaded reform of hospital nursing in England. They devised a system of training and took over the nursing at King’s College Hospital, London.143 On Nightingale’s return from Crimea in 1856, a national appeal raised sufficient funds to establish a training institution for nurses. Four years later, the first probationers from the school arrived at St Thomas’ C. Davies (ed.), Rewriting Nursing History, London, 1980, pp. 11-14; A. M. Rafferty, J. Robinson and R. Elkan (eds), Nursing history and the politics of welfare, London, 1997, pp. 1-3; B. Abel-Smith, A History of the Nursing Profession, London, 1960, p.xi.





Davies, Rewriting Nursing History; Rafferty, Robinson and Elkan, pp.1-2.

C. Hawkins, Nursing and Women’s Labour in the Nineteenth Century, Abingdon, Oxon, 2010; A.

Borsay and B. Hunter (eds), Nursing and Midwifery in Britain since 1700, Basingstoke, 2012.

S. Williams, ‘Caring for the sick poor; poor law nurses in Bedfordshire c. 1770-1834’, in P. Lane, N. Raven and K. D. M. Snell (eds), Women, Work and Wages in England, 1600-1850, Woodbridge, 2004, p.142. One of the few is C. Helmstadter and J. Godden, Nursing before Nightingale, 1815-1899, Farnham, 2011.

Helmstadter and Godden, pp.72-73.

Ibid., p.123.

Hospital, London.144 Although the Nightingale School achieved little in its first 10 years, the surrounding publicity encouraged other hospitals to copy the system.

Additionally, the School attracted motivated recruits, who carried the banner elsewhere.145 Throughout the second half of the nineteenth century, nursing developed as a profession and nursing registration was eventually achieved in 1919.

The dominance of the Nightingale reforms in nursing historiography has overshadowed improvements within poor law nursing.146 Indeed, studies of nursing within poor law institutions have been sparse, possibly because of the uncertainty surrounding the nature of those carrying out nursing duties.147 Accounts included in general studies of nursing history have concentrated on the improvement in conditions of service and the increasing involvement of poor law nurses with acutely ill patients.

Christopher Maggs’ chapter in Davies’ edited volume describes nurse recruitment in the late nineteenth century in one voluntary hospital and three poor law infirmaries and notes that the most significant quantitative change over the period was the rapid expansion in the number of nurses in the poor law sector.148 Hawkins’ study mainly utilises material from St George’s Hospital, London and, although brief mention is made of poor law nursing, there is no acknowledgement of the use of paid, untrained nurses in workhouses. Similarly in Borsay and Hunter’s collection, the poor law sector receives minimal attention, even in the section on midwifery, although the The establishing of the Nightingale School is described in detail in M. E. Baly, Florence Nightingale and the Nursing Legacy, London, 1986.

Ibid., pp.38, 219.

M. Lorentzon, ‘Lower than a scullery maid’, Nursing History Review, 7 (2003), p.7.

Abel Smith, pp.10-11; S. Wildman, ‘Changes in Hospital Nursing in the West Midlands 1841, in J. Reinarz (ed.), Medicine and Society in the Midlands 1750-1950, Birmingham, 2007, p.102.

C. Maggs, ‘Nurse Recruitment to Four Provincial Hospitals 1881-1921’, in Davies (ed.), Rewriting English History, p.23.

majority of births in institutions took place in the workhouse.149 Rosemary White has provided the one dedicated account of poor law nurses, in which she points out that, despite the lack of interest by historians and the nursing profession, they nursed 75% of all hospital patients.150 Moreover, the nature of the nursing tasks they performed and their interaction with the patients they cared for has been relatively neglected.

White has been praised for doing much to rehabilitate the image of the poor law nursing service by showing that its members often achieved relatively high standards of nursing care.151 Their status was on a par with those trained in voluntary hospitals as a substantial number of poor law probationers have been shown to have found employment in the voluntary hospital sector.152 Another account focussing on poor law nurses is the chapter on ‘Nursing in the Workhouse Infirmary’ in Negrine’s thesis, in which she describes how the nursing staff had to overcome the prejudices of the guardians to establish effective patient care.153 In contrast to the medical service, nursing was the weakest part of the care provided for patients and the lack of trained nurses was the greatest handicap for the developing poor law infirmaries.154 Nursing duties were initially undertaken by untrained female paupers, who were noted for being inefficient and unreliable. Their duties were mainly domestic as they gave minimal personal attention and they were frequently rewarded with extra rations and alcohol, which made drunkenness not uncommon.

The status of nursing in general prior to the commencement of training in the 1860s R. Dingwall, A. M. Rafferty and C. Webster, An Introduction to the Social History of Nursing, London, 1988, pp.157, 160; they estimate 1% of the 1.3% of births in institutions in 1890 took place in workhouses.

R. White, Social Change and Development of the Nursing Profession, London, 1978, p.3.

R. Versluysen, ‘Old Wives Tales? Women Healers in English History’, in Davies (ed.), Rewriting English History, p. 181.

Lorentzon, p. 11.

Negrine, ‘Medicine and Poverty’, pp.98-122.

Flinn, p.56; Digby, Pauper Palaces, p.171.

was equivalent to that of domestic servants and the major source of recruits was working-class women.155 A few guardians did employ paid nurses, but this was rare before the mid-1860s, with only 248 paid nurses in workhouses in England and Wales in 1850.156 The first training scheme in a workhouse infirmary took place in Liverpool in 1865 and thereafter trained nurses began to be employed by guardians, although they always remained in short supply and turnover was high. Pauper nurses continued to be used until the LGB issued an order in 1897 prohibiting their use for specifically nursing duties.157 As training became more widespread, the number of poor law nurses increased, reaching 2,490 in the separate infirmaries in 1909, where they were responsible for nursing 40,000 patients.158 Although Abel-Smith and Digby contend that nursing staff disliked the tedium of caring for the chronic sick, White maintains that poor law nurses developed expertise in the nursing care of those with chronic illness and incurable disease and played a major part in retaining the caring role within nursing.159 Medical and Surgical Treatment Notwithstanding the limited coverage in the literature on poor law nursing, even less has been documented regarding the nature of the treatments that were used in the workhouse, the impact of these on the health of patients and the medicine practised Dingwall, Rafferty and Webster, pp.10-11, 33.

White, p.26.

Ibid., p.87; Hodgkinson, p.569.

White, p.131; Digby, Pauper Palaces, p.171.

Abel-Smith, The Hospitals, p.210; Digby, Pauper Palaces, p.172; White, p.198.

–  –  –

historiography contains little of the experiences of the poor law MOs and the ‘voice’ of the individual doctor has rarely been heard.161 Because of this, local MOs will be included along with patients, older inmates and nursing staff in the focus on presenting a ‘history from below’ in the qualitative aspect of this study.

As the nineteenth century progressed, the understanding of the aetiology of disease changed fundamentally through the influence of scientific research and created a new form of medicine, based on the ‘anatomico-clinical gaze’.162 The seminal paper on this subject is that of N. D. Jewson, who argued that the perception of the sick-man as a ‘person’ altered with the shift from ‘Bedside Medicine’ to that of a ‘case’ with the

–  –  –

concentrated on the unique pattern of bodily events of an individual while the latter saw the sick-man as a ‘collection of synchronised organs’ and turned him into a passive, uncritical patient. The establishment of ‘Laboratory Medicine’ in midcentury removed the patient further from the consultative relationship. With the development of the cell theory, disease was viewed as originating in the cell and the sick-man as a ‘cell complex’.163 This discovery of the cellular basis of pathology along with the germ theory of disease and the development of theories of cellular immunity in the late 1880s, laid the foundation of modern medicine. The result was Hodgkinson, Origins, and Crowther, Workhouse System, each devote a chapter to this topic. They discuss it in detail in Hodgkinson, ‘Poor Law Medical Officers’, pp.299-338, and Crowther, ‘Paupers or Patients?’, pp.33-54. The subject is also covered by Flinn, ‘Medical Services Under the New Poor Law’.

The exceptions were Joseph Rogers, who was President of the Poor Law Medical Officers’ Association and whose memoir is recorded in T. Rogers (ed.), Joseph Rogers MD Reminiscences of a Workhouse Medical Officer, London, 1889 and A. Sheen, The Workhouse and its Medical Officer, Bristol, 1890.

M. Harrison, Disease and the Modern World, Cambridge, 2004, pp.57, 118.

N. D. Jewson, ‘The Disappearance of the Sick-Man from Medical Cosmology 1770-1870’, Sociology, 10 (1976), pp.225-44.



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