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that, by the end of the nineteenth century, the clinical management of disease and hospital treatment were a positive benefit to patient care.164 From the 1860s, these changes and the development of clinical instruments such as the thermometer, microscope and ophthalmoscope added to the importance of the clinical examination.165 However, therapeutics failed to progress accordingly and the medical armamentarium remained very similar to that of the eighteenth century, with a range of drugs limited to opium, hyoscine, ephedrine, atropine, ergotamine, quinine, cocaine and digoxin.166 The middle of the nineteenth century was also the watershed in the history of surgery, with the move into the post-anaesthetic era and the start of antiseptic wound management.167 Despite the fact that anaesthetics were used in hospitals from the 1860s, the LGB did not approve their use in the treatment of inmates until the 1890s and in many unions pauper patients underwent operations without anaesthesia.168 Surgical procedures with a mortality rate of around 25% or less were limited to amputation, hernia repair, removal of tumours, lithotomy and the deligation of arteries.169 However, surgery offered the possibility of cure, whereas medical treatment remained either symptomatic or palliative in nature. The main curative methods were seen as good hygiene, adequate ventilation and sanitary reform.170 They were more likely to be adopted in workhouse infirmaries, as new treatments W. F. Bynum, Science and the Practice of Medicine in the Nineteenth Century, Cambridge, 1994, pp.100, 130, 160, 226; Abel-Smith, The Hospitals, pp.1-2; K. D. Keele ‘Clinical Medicine in the 1860s’, in F. N. L. Poynter (ed.), Medicine and Science in the 1860s, London, 1968, p.57.

Keele, pp.1, 4.

M. Weatherall, ‘Drug Therapies,’ in W. F. Bynum and R. Porter (eds), Companion Encyclopaedia of the History of Medicine, London, 1993, p.920.

G. Lawrence, ‘Surgery (traditional)’, in Bynum and Porter (eds), p.982; U. Tröhler, ‘Surgery (modern)’, in Bynum and Porter (eds), p.984.

Price, p.233; Brand, ‘The Parish Doctor’, p.120.

Woodward, pp.l74, 165.

For a discussion of the role of ventilation in medical treatment, see Pickstone, pp.110-12.

were introduced into poor law practice only some time after their use in the large London hospitals. In addition, the assumption that therapeutic treatment was ineffective, and so a waste of money, was prevalent.171 This study will demonstrate whether such a viewpoint operated in Birmingham and Wolverhampton workhouses.

Summary of Thesis While this study will analyse a variety of aspects of the institutional poor law medical service, it will attempt to bring to the fore the experiences of sick paupers and their medical attendants. The next chapter will consider those inmates who required medical treatment, what proportion they constituted of the total inmate population, the nature of their illnesses, and the medical services provided for them. It has been generally accepted that the workhouse catered almost exclusively for patients with chronic diseases, but this study will challenge that assumption by showing that a significant proportion were admitted with acute illness in the early nineteenth century and their number increased as the century progressed. However, for those inmates suffering from chronic disease, the chapter will reveal the diverse range of diseases affecting them and, uniquely, the nature and extent of their disabilities. It will demonstrate that for most of the period studied they received good quality care, ensured by a sympathetic approach from guardians. Birmingham and Wolverhampton guardians differed in how they managed arrangements for their welfare, both over

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Whiggish interpretation of the history of disability as one underpinned by the Brand, ‘The Parish Doctor’, p.110; Kidd, p.41.

portrayal of those with impairments being pushed to the physical margins of their community and of gradual progress toward increasing social participation.172 Borsay argues that the exclusion of disabled people from the full rights of citizenship was not challenged until the mid-twentieth century and Victorian society practised the ‘ultimate form of exclusion’ by depositing disabled people into ‘carceral settings’, such as workhouses.173 The finding in this study that disability based on impairment was constructed differently in two workhouses located in geographical proximity challenges Borsay’s simpler model of exclusion. Guardians considered they were providing the most appropriate care available at the time for infirm paupers, though Borsay condemns this attitude as ‘benevolent paternalism’.174 However, within the context of services for the care of dependent paupers in the nineteenth century, their residence in workhouses and their infirmaries provided them with a degree of care that would not have been otherwise available. Furthermore, at that time, only a minority of citizens had the right of full social participation, which was denied to paupers of all types, and the exclusion of disabled inmates has to be seen within the context of varying degrees of exclusion of many individuals and groups within Victorian society.

One aspect of acute care, namely fevers and infectious disease takes up chapter three, which shows the considerable part the poor law authorities played in providing facilities for such patients and in containing the spread of infection within the community. In Birmingham, this extended to a jointly managed isolation hospital, in contrast to the more usual strained relationships between guardians and local A. Borsay, Disability and Social Policy in Britain since 1750: A History of Exclusion, Basingstoke, 2005.

Ibid, pp.197-98.


authorities over the provision of isolation facilities.175 The extent of this medical role beyond the workhouse’s poor law function has not previously been acknowledged in the secondary literature. Although it was unusual for children to be admitted to hospital when unwell, the workhouses in Birmingham and Wolverhampton did regularly contain children with infectious disease prior to the instigation of isolation policies. The arrangements for the care of smallpox patients have not been recorded in as much detail as this study presents, demonstrating how significant they were in containing the spread of infection within the community, in addition to providing care to individual sufferers. The chapter also contains one of the few detailed accounts of the implementation within the workhouse of the same methods of treatment for patients with tuberculosis as employed in sanatoria.

The MOs responsible for looking after sick inmates form the subject of the following chapter. Issues covered include their working conditions and the extent to which their heavy workload affected the level of direct patient care they practised. Despite the constraints imposed by guardians, some managed to provide good quality and innovative care. There is no doubt that the practice of conscientious MOs benefited patients even when staffing levels were low, challenging the assertion that an

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detailing the day-to-day work of MOs, this chapter reveals what it was like to practice medicine in the workhouse, an aspect that has not been the subject of historical study.

It explains why they found it difficult to avoid conflict with guardians who wished to control costs. The context in which charges of medical negligence were made is explored, revealing that the lack of good communication between MOs and guardians S. Sheard, ‘Reluctant Providers? The politics and ideology of municipal hospital finance 1870, in M. Gorsky and S. Sheard (eds), Financing Medicine: The British experience since 1750, London, 2006, p.117.

was a critical factor. The treatment of patients is taken up in chapter 5, which demonstrates that MOs managed to prescribe the full range of treatments that were in current use in the nineteenth and early twentieth centuries and contradicts the current viewpoint that inmates were denied medical treatment. Despite guardians paying for the cost of drugs in both Birmingham and Wolverhampton, they made very few attempts to control costs or interfere with the treatments prescribed, again contrary to the prevailing opinion on medical treatment in workhouses. The one exception was their attempts to limit the use of alcohol by MOs, but these met with limited success.

In some instances, MOs instigated recently introduced remedies, both pharmaceutical and surgical, and provided the same standard of treatment as they did in voluntary hospitals.

One aspect of treatment, namely giving pills and potions to patients, was the duty of the nurses, who are described in chapter 6. It gives the first detailed account of the reality of poor law nursing, revealing that their reputation of total incompetence in the early days of the NPL is demonstrably unjust. Their standards of conduct were those of the working-class in general in the nineteenth century. However, the proficiency with which they carried out their duties improved as training was introduced and nursing developed as a profession, but the high turnover rate and considerable proportion that failed to complete training were common to workhouse infirmaries and voluntary hospitals. Working conditions and salaries for nursing staff were similar in both types of institution so that nurses moved between the two. As the nineteenth century progressed, the standards of nursing care in poor law infirmaries became not dissimilar to that in voluntary hospitals. Poor law nurses are usually portrayed in the secondary literature as less efficient, more intoxicated, less well paid, provided with less satisfactory accommodation and having longer hours of work than those in voluntary hospitals.176 The model of poor law nursing in Birmingham and Wolverhampton workhouses contradicts this paradigm of inferior quality and quantity. Similarly, poor law infirmaries are usually depicted as providing nursing staff with less experience of acute medical care and surgery, but the large number of patients admitted to Birmingham and Wolverhampton infirmaries with infectious disease counteracts the former claim and the surgical operations listed in chapter 5 modifies the latter. They did provide greater exposure to patients with chronic conditions than voluntary hospitals, but this form of nursing is usually, but incorrectly, dismissed as requiring a lesser degree of skill.

The concluding chapter analyses the overall standards of care provided for sick inmates in Birmingham and Wolverhampton workhouses. It demonstrates that care is multi-factorial and its quality cannot be judged solely on the adequacy of medical staffing, as advocated by Price.177 By demonstrating the positive side of NPL medical care and showing that inmates did, for the most part, receive humane care, workhouse medicine is seen as more complex than previously appreciated and as more important in the lives of sick paupers in the nineteenth and early twentieth centuries than is generally acknowledged. Thus, it challenges the accepted viewpoint that the importance of workhouse medicine was merely as a locus for the development of state medical facilities with steady progression to the founding of the National Health Service in 1948.

C. Helmstadter, ‘Building a New Nursing Service: Respectability and Efficiency in Victorian England’, Albion: A Quarterly Journal Concerned with British Studies, 35 (2003), p.593; White, pp.82Hawkins, p.11; Baly, p.96; Lorenzton, pp.5-7.

Price, p.237.

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Under the Old Poor Law, relief could be provided for medical assistance and treatment, including admission to voluntary hospitals. Workhouses provided sick wards for inmates who became ill during their stay in the institution. It was never envisaged that acute illness would be a reason for admission, but ill health turned out to be a major cause of destitution, giving rise to the need for relief under the poor law system.2 Edwin Chadwick, Secretary to the Board of Poor Law Commissioners (hereafter PLCs), recognised that disease could be ‘caused by destitution’ and that greater longevity was associated with ‘expensive modes of living’ and considered the remedy to be sanitary improvement.3 However, this was not until four years after the Poor Law Amendment Act (1834), which had concentrated on the problem of able

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Pickstone has suggested that this concentration on able-bodied paupers helped to disguise the extent to which workhouses catered for the sick.4 The PLCs enabled Wolverhampton Archives and Local Studies (hereafter WALS), Wolverhampton Chronicle (hereafter WC), 2 December 1846.

The main studies of the poor law medical services are: E. G. Thomas, ‘The Old Poor Law and Medicine’, Medical History, 24 (1980), pp.1-19; R. Hodgkinson, The Origins of the National Health Service: the Medical Services of the New Poor Law 1834-71, London, 1967; M. W. Flinn, ‘Medical Services under the New Poor Law’ in Fraser (ed.) The New Poor Law in the Nineteenth Century, London, 1976; J. V. Pickstone, Medicine and Industrial Society, Manchester, 1985; H. Marland, Medicine and Society in Wakefield and Huddersfield 1780-1870, Cambridge, 1987; J. Reinarz and L.

Schwarz (eds), Medicine and the Workhouse, Rochester, 2013; A. Gestrich, E. Hurren and S. King (eds), Poverty and Sickness in Modern Europe, London, 2012.

British Parliamentary Papers (hereafter BPP), 1842 (006), pp.xvii-xviii.

Pickstone, p.35.

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