Under the Old Poor Law, parishes paid for medical attendance on a fee-forservice basis, but by the early nineteenth century, many found it more convenient to contract with a medical practitioner based on an annual salary. The latter arrangement was cemented after the Poor Law Amendment Act (1834) when the Poor Law Commissioners authorized boards of guardians to appoint medical officers for the provision of outdoor medical relief and for the attendance on sick inmates in workhouses. Consequently, guardians treated medical officers on the same basis as other officers or servants employed by them. For instance, William Sturrock, workhouse medical officer in Birmingham in 1900, complained that he was allowed only three weeks’ annual leave, whereas other first-class officers had four. He claimed that this “seems like a slur on Medicine that its representative should be ranked with subordinate officers.” Immediately after the New Poor Law, guardians appointed the doctors by utilizing the tendering process, usually choosing the lowest submitted. This arrangement was abolished after the General Medical Order of 1847 required a salary decided by the guardians to be stated at the time the post was advertised. Medical officers were usually appointed on an annual basis, despite the order directing that tenure should be permanent. It also required them to be qualified as surgeons and apothecaries. This was modified by an order in 1859 to require qualifications to practice medicine and surgery in England and Wales, thereby ensuring that poor law medical officers were better qualified than practitioners in private practice. However, the dual requirement could be circumvented if a doctor lived outside the district of his responsibility. Although salaries were set by guardians prior to appointment, they remained very low, varied greatly, and were a cause of frequent complaint. Despite this, medical officers were the one common denominator within a patchwork of welfare practices and fundamental to medical welfare.

This chapter will consider the conditions under which the workhouse medical officers of Birmingham and Wolverhampton labored and will provide an estimate of their workload. The questions it attempts to answer include to what extent the New Poor Law influenced the institutional medical care of paupers and how the development of infirmaries affected medical staffing.

Medical Relief in Birmingham Workhouse for Selected Weeks, 1851–56

Prevalence of Selected Infectious Diseases in Birmingham Workhouse on the Last Day of the First Week of Each Quarter for the Years 1877–80 and 1894–1911

The traditional narrative of poor law medical care emphasized a sharp divide between the old and new poor laws that has allowed historians to make broad-brush comparisons of the quality of care before and after 1834. Those who regard care as better under the Old Poor Law focus mainly on outdoor medical relief, whereas those who favor New Poor Law medicine concentrate on workhouse care. However, a new appreciation of workhouse medicine has emerged that stresses the continuity from the old to the new forming a continuous line of development throughout the nineteenth century. Utilizing letters written by paupers requesting relief, Steven King has demonstrated that medical welfare was a significant call on poor law resources. While the workhouse was a relatively small element, it was the single most important form of institutional provision for the sick poor. By the end of the Old Poor Law, there had grown a substantial patchwork of support for sick paupers and this core function of the old continued to grow under the new. Assessing quality of the care from a single parameter is problematic as care is multifactorial, involving adequate staffing levels of suitably trained personnel, the provision of adequate facilities, nourishment and treatments, and safety from harm. Thus, it is from these perspectives that the standard of care in Birmingham and Wolverhampton workhouses will be examined.

The preceding chapters clearly demonstrate that both workhouse infirmaries played an important part in the provision of medical care for paupers after the New Poor Law. This included those with short-term acute illnesses and those who had sustained accidents, the type of patients that historians have suggested were not to be found in workhouses. In Birmingham this also took place before 1834 and changed little afterwards as the parish continued as before under its local act. In Birmingham and Wolverhampton, almost one third of patients had acute medical and surgical conditions in 1869, a greater proportion than in inner London workhouses. Another group of patients who needed admitting urgently were those with disturbed behavior due to mental illness. Both Wolverhampton and Birmingham arranged transfer to asylums for the majority of these patients as best they could against a background of the lack of availability of local institutions and a lack of available beds within them. There is no evidence that financial considerations were implicated in preventing asylum admission.

List of Drugs Kept in the Wards of Birmingham Infirmary in 1896

Pauperism Rates and Institutionalization Rates for Birmingham Parish, Wolverhampton Union, and England and Wales, 1840–1911

Nineteenth-century Britain was characterized by epidemics and the widespread prevalence of infectious diseases. They were the most common causes of morbidity and mortality and with the exclusion of bronchitis and pneumonia accounted for 33 percent of deaths in the years 1848‒72 in England and Wales. When these respiratory diseases are included, infection was the cause of 48 percent of deaths nationally in 1851‒60. Communicable diseases were more prevalent in areas wherever people were crowded together and rapid urban growth occurred in the early nineteenth century, and its associated problems of sewerage and water supply multiplied the risk of infection. Thus, urban environments became more unhealthy and allowed diseases to become endemic. According to Anne Hardy, there grew up within these areas “fever nests,” from where the Victorians feared that epidemics could escape and spread to the rest of the population. For example, Whitechapel was considered the “nucleus of the metropolitan fever field,” while Southwark held the same status within the cholera field in London.

The mortality rate from infectious diseases declined markedly in the second half of the nineteenth century, both in absolute terms and in relative importance among all causes of disease. In 1901‒10, they accounted for only 19 percent of all deaths. This mortality decline was accompanied by an epidemiological transition, with degenerative diseases such as cardiovascular disease and cancer replacing pandemics of infection as primary causes of morbidity and mortality. This shift in disease patterns, with a progressive decline in infectious diseases, began in the mid-eighteenth century, but a more marked fall in overall mortality rate in England and Wales took place from the middle of the following century. The reasons for the mortality decline have long been a contentious issue among historians and epidemiologists. Abdel Omran, who first proposed the theory of “epidemiologic” transition, ascribed the decline of infection in western European societies to socioeconomic factors, augmented by the sanitary revolution in the late nineteenth century. The work of Thomas McKeown has been influential in stressing the primary reason as the improving nutritional status of the population. However, Simon Szreter argues that preventive public health provision and services were more important in explaining the mortality decline. Hardy's view is that no one factor was of overriding importance in reducing death rates, but the measures taken by the preventive authorities made a fundamental contribution.

This chapter is primarily concerned with certain groups of patients whose behavior was challenging or difficult to control within the institution. For those with mental illness or epilepsy, it was beyond their control. Patients who contracted venereal disease did so as a direct result of their actions, but they were prone to misbehave when residing in the workhouse. However, mentally ill patients were not completely absolved of blame for their condition because of the links between insanity and bodily disturbance; for example, one strongly held theory by many doctors was that it was caused by masturbation and other acts that were regarded as immoral. A number of questions will be addressed in relation to these groups of paupers and the workhouses in the two towns. As the treatment of mental illness in asylums changed throughout the nineteenth century from the widespread use of mechanical restraint to moral management, what effect did this have on the treatment of lunatics in workhouses? With their lower staff-to-patient ratios than asylums, how did workhouses cope with behavioral disturbances? To what extent were physical treatments for mental disorders also used for punishing any type of misdemeanor and how frequently were workhouse staff at risk of sustaining injury from disturbed patients? Patients with epilepsy posed a particular problem for staff as they were at risk of injuring themselves during a seizure. How frequently were they subjected to forms of mechanical restraint after these were no longer allowed for mental illness? How disturbing was the frequency of epileptic fits to both sufferers and other inmates? What implications did the development of epileptic colonies in the early twentieth century have for epileptic patients in the workhouse? A significant proportion of inmates with mental disability suffered from epilepsy, and as a result lunatics and epileptics were usually accommodated in the same wards in the workhouse. So it is not always possible to identify them discretely, although attempts will be made to do so as much as is possible. Workhouse provision and dedicated facilities for patients with venereal disease will be covered in respect of the scarcity of specialist care. The types of treatment they received will be analyzed and the extent to which they were subject to discrimination on moral grounds will be explored.

The nature of medical care in workhouses and of the clinical treatment inmates received after the New Poor Law is not well understood. Neither is it certain how representative it was of nineteenth-century therapeutics. This chapter analyzes the therapies that medical officers utilized in the management of patients in Birmingham and Wolverhampton workhouses and attempts to reconstruct the treatments they prescribed. Because workhouse medical officers were often required by boards of guardians to pay for the drugs they used from their salaries, historians have accused them of withholding effective treatment. Joseph Rogers recounts that, when he was appointed medical officer to Westminster workhouse in 1872, the retiring physician expressed pride in the fact that the only medicine he gave inmates was peppermint water. Was this true of other workhouses, or just an unrepresentative anecdote? At the beginning of the nineteenth century, medical treatment was much as it had been for many centuries, with the emphasis on depletive therapies, and it was not until the end of the century that the production of effective treatments in the form of the first vaccines for infectious diseases took place. However, from the perspective of twenty-first-century pharmacology, the only really effective drugs were opium and aperients, and the only one that could cure disease was, arguably, quinine for malaria. One advance in therapeutic technique was Edinburgh physician Alexander Wood's introduction of the hypodermic syringe for subcutaneous administration of drugs in 1855. Despite the lack of apparent ineffectiveness in the drug armamentarium, medical historians agree that nineteenth-century medical therapeutics worked in the context of the culture of the time and that patients had visible evidence of the effectiveness of the regimens employed.

Four approaches will be used to uncover therapeutic practice in the workhouses. First, therapies, such as natural and physical medical treatments, the use of food and alcohol as treatment for disease, and the drugs prescribed, will be described. Alcohol was an important and widely used therapy in the nineteenth century, but its prescription in workhouse infirmaries has not previously been investigated. An alternative approach to aid the understanding of therapeutic practice will investigate the management of specific conditions, such as respiratory disease and skin conditions. Third, the management of individual patients and their perspective on the treatment they received will be addressed through the complaints they made to the guardians.

In July 1841, Charles Hodgkins reported to the Board of Guardians of Wolverhampton Union that Anne, the wife of John Walford, was suffering from a disorder of her liver and bowels that was likely to last for six or seven weeks and resulted in her being “unable to follow any employ.” He added that both her sons required constant attention: John, aged two years, was “labouring under water on the brain,” and George, seven weeks old, also had a bowel disorder. Hodgkins, who had been appointed by the guardians as medical officer for Wolverhampton Union, arranged for them to receive four pounds of mutton and four loaves of bread per week for two weeks and planned to admit Anne after that time to the union workhouse, which had opened only two years previous. However, at the end of the two weeks, her condition had deteriorated to such an extent that Hodgkins regarded her recovery as very doubtful and removal to the workhouse as not prudent. The rations were continued for a further four weeks. Whether she recovered or not, we shall never know, but Hodgkins clearly saw the workhouse as a suitable place for treating a sick pauper.

Yet many poor law historians have claimed that workhouses did not develop a significant medical role until the late nineteenth century and emerged as the most important institutions for medical care only in the early twentieth century. Some have been highly critical of the standard of medical care provided in the early years after the New Poor Law, claiming a significant deterioration in the provision of medical services. As evidence, they point to the restriction of funding, the understaffing of infirmaries, and the undermining of medical officers’ decisions by guardians, who sought to treat patients as cheaply as possible. The conventional viewpoint denigrates medical care after the act as of such poor quality as to bring little benefit to sick paupers. However, the traditional history of the Poor Law Amendment Act (1834), usually referred to as the New Poor Law, as a watershed in the provision of medical services is now being challenged in favor of one of continuity of care across the eighteenth and nineteenth centuries.

The prevailing picture of the Victorian workhouse infirmary is of an institution filled with inmates suffering from chronic diseases and disabilities, a place where almost no treatment of acute illness was practiced. According to welfare historian Samantha Shave, it was the most reviled institution among the British working class. However, we have already seen in relation to the illness of Anne Walford at the beginning of the introduction that it was regarded as an appropriate setting for acutely ill paupers in Wolverhampton in the first decade after the New Poor Law, and this chapter will provide further evidence to demonstrate that acute care was an integral part of workhouse medical officers’ work. It will also provide an in-depth analysis of the characteristics of those inmates classified as “aged and infirm,” who did make up the majority of patients, but who have been largely neglected within the historiography of the poor laws.

Sick inmates formed a substantial group within the workhouse population, the proportion increasing from 10 percent in 1843 to between 34 percent and 48 percent in the mid- to late 1860s, with the higher figure in London and the lower in provincial workhouses. By the end of our period of study, 32 percent of inmates of poor law institutions in England and Wales were accommodated in sick wards or separate infirmaries. Illness and injury accounted for a substantial proportion of admissions to workhouses; for instance 62 percent of adult males and almost 44 percent of adult females were admitted to Medway Union workhouse between 1876 and 1881 because of sickness. Workhouses had begun to adopt the role of hospitals by 1870 and those in large towns became transformed into “infirmaries for the sick,” widely regarded as the first public hospitals. By 1891, the public sector provided about 83,000 beds, compared with only 43,000 by voluntary hospitals. The greater number of sick inmates in poor law infirmaries resulted from the recognition of the benefits of institutional medical care for those who could not be cared for at home, the poor state of health of many paupers prior to illness, and the growing popularity of hospitals among the poor. The policies of the central authority also contributed to the increasing admission of sick paupers.