CHAPTER 1 of England’s First State Hospitals, by Gwendoline M Ayers 1971, published by the Wellcome Institute of the History of Medicine. Reproduced by permission.

A Nightingale Ward

A Nightingale Ward

STATE direction in the sphere of medical care in modern England may be traced from 1867, when the Metropolitan Poor Act of that year led to the founding of special hospitals for the indigent sick of London.(Public provision for the care of the sick and needy was universal throughout the countries of Greece and Rome. In his Linacre lecture, 1914, on ‘Public Medical Service and the Growth of Hospitals’, Sir T. Clifford Allbutt produced evidence of Roman municipal hospitals staffed by salaried doctors; of publicly financed iatreia where doctors received patients; and of the management of these services by regional health committees. (Sir T. Clifford Allbutt, Greek Medicine in Rome (1921), pp. 443-71).) For some sixty years, these institutions were managed by a statutory authority confusingly known as the Metropolitan Asylums Board. This study seeks to define the forces which influenced the creation of this body and to follow its development as a link between the nineteenth-century poor law and the twentieth century welfare revolution.

The advent of the Metropolitan Asylums Board was closely bound up with the hapless lot of ailing paupers during the middle nineteenth century. Before 1867, no statutory provision existed for the destitute sick who needed institutional care. The Royal Commission of 1832-34, which studied the administration of the poor laws, was concerned mainly with the problem of able-bodied destitution. The one positive recommendation that can be extracted from its report concerning other categories of the poor was the repeated demand that, where they required indoor relief, they should not be placed in a single ‘mixed’ institution but in separate buildings under quite independent management. It was suggested that distinct institutions should be provided for at least four classes-the aged and impotent, the children, the able-bodied females and the able-bodied males’. (Report from His Majesty’s Commissioners for Inquiring into the Administration and Practical Operation of the Poor Laws, 1834 )

But the report contained no clarification of the term ‘impotent’ and offered no clear alternative to the current practice of providing the sick poor with outdoor relief. Notwithstanding the emphatic recommendations of the 1834 Report and their statutory endorsement by the Poor Law Amendment Act of 1834, general mixed workhouses were allowed to persist by the Poor Law Commissioners of 1834-47 and by the Poor Law Board which succeeded them.

The purpose of the 1834 Act was not so much to create a new system of poor laws as to restore. the scope and intention of the Elizabethan statute of 1601 by establishing a two tier administrative structure for controlling the dispensation of poor relief and thereby remedying the abuses which had resulted in the rapid growth of the poor rate. In each parish or union of parishes, all classes of the needy were placed under a single local authority known as a ‘board of guardians of the poor’. The function of these elective bodies was to administer relief in accordance with rules laid down by the three Commissioners appointed under the Act as representatives of the central government.

As the guardians were dependent for their position on their ratepaying electorates, they were more concerned to save the ratepayers’ money than to provide for the separate needs of the poor. One institution was as much as most boards were prepared to maintain. In many rural areas, the number of the poor in each class would have been too small in any case to justify the expense of separate buildings. All categories of the poor thus came to be accommodated together under one roof. The Assistant Commissioners (responsible for the twenty-one districts into which the country was divided under the 1834 Act), finding these establishments easier to inspect than several buildings under separate management converted their official superiors to the practical nature of these institutions. The general mixed workhouse thus became established with all its attendant evils. As an instrument for testing destitution, it was administered with the object of making life inside less tolerable than employment in field or factory-the principle of ‘less eligibility’, as it was called. While this policy might deter the work-shy, it inflicted undeserved hardship upon sick and aged inmates, since no alternative system was provided by law for regulating their relief according to their special needs. The following indictment by a learned lawyer in 1852 embodied the essence of much that has been written concerning the effects of this drift in poor law administration.

“…I have visited many prisons and lunatic asylums, not only in England, but in France, and Germany. A single English workhouse contains more that justly calls for condemnation than is found in the very worst prisons or public lunatic asylums that I have seen. The workhouse, as now organised, is a reproach and disgrace to England; nothing corresponding to it is found throughout the whole continent of Europe. In France, the medical patients of our workhouses would be found in ‘hopitaux'; the infirm aged poor would be in ‘hospices'; and the blind, the idiot, the lunatic, the bastard child and the vagrant would similarly be placed in an appropriate but separate establishment. With us, a common malebolge is provided for them all. . . . It is at once shocking to every principle of reason and every feeling of humanity that all these varied forms of wretchedness should thus be crowded together into one common abode; that no attempt should be made by law. . . to provide appropriate places for the relief of each.”

There were, however, some exceptions to the general absence of discrimination in the treatment of the unfit. A few parochial boards provided separate wards where the sick and insane were tolerably well treated, while others subscribed to the voluntary hospitals in order to secure admission for their infectious and surgical cases. In the Sheffield and Eccleshall workhouses, separate wards were provided after 1834 for the sick and insane, with special accommodation for infectious cases and lunatics. In Chorlton, the guardians established a model infirmary in the early 1860s where the nursing was supervised by Anglican nuns. In London, not all the workhouses were mismanaged. At the Islington institution, the system worked reasonably well. (B. Abel-Smith, A History of the Nursing Profession (1960), p. 13.) At the vast City of London workhouse, ‘a great deal appeared satisfactory’ to one Poor Law Board President on a visit in 1866. ‘The wards were, in my judgment, well ventilated,’ he reported, ‘and the imbeciles, especially, carefully tended.’ (A. E. Gathorne-Hardy (ed.), Gathorne-Hardy, First Earl of Cranbrook-a Memoir (1910), pp. 192-3.)

It took more than thirty years to convince the central authority that it had made a mistake in merging the sick in the general mixed workhouse. Meantime, the numbers in receipt of poor relief continued to increase, particularly in urban areas, where the pressure of population growth was aggravated by the influx from the country. This provoked the guardians to maintain even more rigorously the’ less eligibility’ principle. They economized to the utmost and spent the minimum on medical and nursing services.

The post of workhouse medical officer was normally a part-time appointment. Sometimes one practitioner combined the duties of workhouse and district medical officer, as was the case in sixteen of the forty London unions. Only a few of the largest institutions employed resident medical officers. Four of these were in London. Emoluments varied considerably. By the middle ‘sixties, they ranged from £50 p.a. in some rural areas to the exceptional rate of £950 p.a. at the St. Marylebone workhouse. Medical officers personally bore the cost of drugs out of their salaries and sometimes paid for an assistant or dispenser. The position of the workhouse medical officer was rendered even more untenable by the fact that he was subordinate in status to the lay workhouse master, who was usually of a lower social class. Most of the nursing was done by elderly and illiterate pauper inmates of the ‘Sairey Gamp’ type. By 1866, some 21,000 sick and aged patients in the London workhouses were being attended by only 142 paid non-pauper nurses, very few of whom had received any hospital training.4 Most of the provincial institutions suffered from similar deficiencies.

With the general improvement in economic conditions which had set in during the late 1840s, more of the able-bodied poor found employment, and the proportion of the sick and aged in workhouses began to increase. In some cases, they were so numerous that they occupied the greater part of the institution. By 1863, some 50,000 sick paupers throughout the country were receiving indoor relief, but no coherent policy had been formulated by the central authority concerning the care of these helpless dependants of the State. At times, the Poor Law Board positively discouraged progressive guardians from introducing medical improvements. In 1850, for instance, it forbade the Croydon board to employ additional nurses in its infirmary.

“… Three at least of the paid servants in this hospital must be discontinued [wrote the PLB]. In the greater number of country unions there is no paid nurse and in none, it is believed, more than one. In pronouncing upon this point, the Poor Law Board attach more weight to the results of experience than to the opinion of the medical officer of the Croydon Workhouse, though supported by that of three of his professional friends. If for instance, the infirmary of the Wandsworth and Clapham union workhouse can be, as it is, perfectly well managed under one paid nurse, why should the medical officers say that five paid nurses are required in the much smaller infirmary of the Croydon workhouse?”

Although the Poor Law Board was fully entitled, in legal theory, to issue such dictatorial edicts to local boards, it was unable to enforce its will on reluctant guardians. The 1834 Act had endowed it with legal power but had provided it with no effective instrument of control. In the metropolis, the Act applied only in limited measure to a number of poor law authorities (incorporations) which had been established previously under special Local Acts.

The ‘new’ Poor Law had never lacked critics. Many of them had directed their attacks particularly to the general absence of suitable provision for the indigent sick. By the late 1850s, when the spate of protesting publications had failed to arouse the central authority from its complacency, concerted action was organized. An effective rostrum was provided by the National Association for the Promotion of Social Science (NAPSS), which included on its Council some progressive members of the aristocracy. At its inaugural conference in 1857, a paper on pauperism was read by Miss Louisa Twining, daughter of an Anglican clergyman. She disclosed the unsatisfactory state of the Strand Workhouse and other poor law institutions, which she and her friends had visited during the previous four years. Her revelations led to the formation the following year of the Workhouse Visiting Society under the auspices of the NAPSS. The Visiting Society grew; well over one hundred of its members penetrated the workhouses of the metropolis and the provinces; and individual members published their impressions, with demands for the release of the sick from penal conditions appropriate to the able-bodied, work-shy pauper.

The Health Section of the NAPSS became a centre where poor law medical officers voiced their own grievances and pleaded the cause of their pauper patients. Dr. Richard Griffin, medical officer of the Weymouth union, in particular, read papers at sectional meetings, wrote letters to the medical journals, and founded a provincial Poor Law Medical Reform Association. The improvements he advocated included the establishment of pauper dispensaries, a parliamentary grant for the provision of medicine, and the appointment of medical men to the Poor Law inspectorate.

The hostility and suspicion with which the public and guardians alike had regarded the central authority since its inception in 1834 reached a climax in the severe winter of 1860-61, when widespread unemployment and distress overtaxed the already crowded workhouses. The guardians received no directive from the Poor Law Board to aid them in their unprecedented difficulties. Instead, they were plagued, they alleged, by vexatious regulations which hampered their attempts to make effective arrangements for the relief of the destitute. The general impression prevailed that the poor law had broken down. Demands were made that the Poor Law Board should be shorn of its powers or discontinued altogether.

This led in 1861 to the appointment of a Select Committee of the House of Commons to study the question of poor relief throughout the country. Charles Pelham Villiers, Liberal President of the Poor Law Board since 1859, was appointed chairman. In 1864, the Committee presented its final report. Despite the evidence of such witnesses as Miss Twining and Dr. Griffin, it concluded that ‘there are not sufficient grounds for materially interfering with the present system of medical relief. . . which appears to be administered with general advantage’. The Committee did recommend, however, that ‘cod liver oil, quinine and other expensive medicines’ should be provided at the expense of the guardians and not, as previously, by the medical officers. This, the only improvement in regard to medical relief, resulted from the testimony of Dr. Joseph Rogers, the persistent and courageous medical officer of the Strand Union. The Committee conceded that in many cases the union workhouses were insufficient for the purpose of the proper classification of the inmates, and voiced the opinion that wider powers should be given to the Central Board. . . to require the guardians to make adequate arrangements for such classification.

In December 1864, a few months following the publication of this report, a pauper – an Irish navvy named Timothy Daly – died in the Holborn Workhouse. The inquest revealed that death had resulted from gross neglect. The Times printed the inquest proceedings in full and led the attack on the whole structure of poor law medical relief. Some weeks later, in February 1865, another pauper, named Gibson, died in the St. Giles Workhouse in similar circumstances. Deplorable as these deaths were, they proved to be not in vain. For the poor law critics, they provided fresh ammunition. For Miss Florence Nightingale, in particular, they served to strengthen her plea for nursing reforms.

During the greater part of 1864, Miss Nightingale had been engaged in organizing the introduction of trained nurses into the Brownlow Hill Infirmary in Liverpool. In January 1864, William Rathbone, the Liverpool philanthropist, renewed his contact with her. Three years before, she had collaborated with him in establishing in Liverpool a training school for District Nurses. Now, concerned at the wretchedness of the twelve hundred sick paupers in the Liverpool workhouse, he had offered to recruit and finance a staff of trained nurses to attend them. To Miss Nightingale he appealed for help in organizing the scheme. A year of battling with the local authorities in Liverpool had convinced her of the impossibility of correcting workhouse abuses by piecemeal methods. An entirely new system of finance and administration was needed, and this would require fresh legislation.

Immediately after Daly’s death, Miss Nightingale wrote to Mr. Villiers at the Poor Law Board. She knew that there was nothing as effective as a death on a departmental doorstep to galvanize Whitehall into action. Emphasizing the overwhelming need for nursing reform in workhouse infirmaries, which the Daly case had so patently proved, she invited Mr. Villiers to visit her, ostensibly to describe the nursing experiment in Liverpool. He came away from his talk with Miss Nightingale in January 1865 convinced of the necessity for instituting a full-scale enquiry into the treatment of the sick poor. ‘I was so much obliged to that poor man for dying’, she wrote to a friend a month later.

Early in February 1865, Mr. Villiers sent Mr. H. B. Farnall to see her. He was Poor Law Inspector for the Metropolitan District. The outcome of the interview was a draft ‘Form of Enquiry’ drawn up by Miss Nightingale and Mr. Farnall for use in an investigation of every workhouse infirmary and sick ward in London. Mr. Villiers approved and the questionnaires were sent out at the end of February. In the course of the next few weeks, Mr. Villiers directed that a circular should be sent to all metropolitan boards of guardians calling on them to appoint trained nurses and to discontinue the employment of untrained inmates for attending the sick. As this was not in the nature of an Order, it had little immediate effect, but it served to suggest to an angry public and an impatient Miss Nightingale that an official awakening might be expected.

Other forces entered the lists for reform. In July 1865, at the instigation of Dr. Ernest Hart, a physician attached to the staff of the Lancet, its radical proprietor, Dr. James Wakley, appointed a special commission to investigate all the unions of the metropolis. Consisting of Drs. Hart, Anstie and Carr, the commission visited and reported on every workhouse in the London area. Week after week in the Lancet, for the greater part of a year and a half, the detailed accounts appeared, with demands for poor law medical reform. They revealed a bleak and ugly picture of insanitary conditions, inadequate nursing, defective appliances, insufficient ventilation and overcrowding. Concerning the sick wards, the Commission declared that ‘these accidental excrescences of the workhouse are not, and never can be, either in government, arrangement or service, fully used as hospitals-nevertheless, they are great hospitals-the great hospitals of London.”

When the allegations of two former workhouse nurses were investigated the following year by Poor Law Board inspectors, the Lancet Commission’s findings were substantiated in horrifying detail. Charges made by Nurse Matilda Beeton concerning the Rotherhithe Workhouse Infirmary included:

the absence of night nurses; ‘many sick patients were dirty, their bodies crawling with vermin'; ‘no waterproof sheets, no air cushions, no bed-rests, no night-stools and but one bed pan . . .'; sheets changed once in three weeks-‘ soiled sheets had to be washed in the infirmary at night'; ‘a bad supply of towels used for every clean and dirty purpose'; beds of flock-‘maggots would crawl from them by hundreds'; ‘sick diet was a mockery-milk was not heard of'; ‘patients were allowed to wear their own nightdresses if they could afford to pay for the washing of them and they often had to sell their nourishment to do this. . .’ This enquiry was conducted after two deputations to the PLB by the Workhouse Visiting Society. Similar allegations were made by Nurse Beeton of the Strand Union Workhouse and by Nurse Jane Bateman concerning the Paddington Workhouse. At its 1865 annual conference, the British Medical Association supported the initiative of the Lancet and followed with another committee of enquiry, which included Drs. Anstie and Griffin.

In January 1866, Drs. Hart, Anstie and Rogers met to plan a means of mobilizing public support for their reform campaign. They convened an open meeting on 3 March 1866, with the Earl of Carnarvon in the chair. Supporters, rallied by the convenors, included eminent men of both political parties and such well-known figures as Charles Dickens and John Stuart Mill. ‘The Association for the Improvement of the Infirmaries of London Workhouses’ was formally established and the reforms at which it aimed were discussed. These had been outlined already by Dr. Hart in an article published in the Fortnightly Review in December 1865. They included the provision of six Poor Law hospitals in London of one thousand beds each; the re-classification and re-housing of the workhouse population; and the grouping of all the metropolitan poor law districts into one hospital region which would collectively bear the cost of the sick poor. The meeting finally resolved that a deputation be sent to the President of the Poor Law Board to determine his willingness to introduce a suitable Bill. If he resisted, it was recommended that the Association should ‘take independent means to bring forward an appropriate measure in Parliament during the present session’. Dr. Hart elaborated the London reform scheme in a further article in the Fortnightly Review and, as part of the campaign, published the collected Lancet reports in one volume. Appended, was a brief statement over the names of seven leading medical men, including the President of the Royal College of Physicians, Sir Thomas Watson. Drafted by Hart and Anstie, who had solicited the signatures, this recapitulated the reforms already advocated, in particular, ‘consolidated infirmaries’, with trained nurses, resident medical officers, and medicines financed from the rates.

Meantime, Miss Nightingale had been working on similar lines. She was intent on pressing for immediate legislation for the fundamental reorganization of workhouse administration. Dubious concerning Mr. Villiers’ capacity to carry it through, she approached the Prime Minister, Lord Palmerston, family friend of her early days. He promised that, if she would draft a Bill, he would use his influence to get it through the Cabinet. She discussed her scheme with Dr. John Sutherland, old associate of the Crimean Sanitary Commission, and began to work with Mr. Farnall. But before she was able to submit her plan to Lord Palmerston he become ill, and in October 1865 he died. This was a cruel blow. Up to now, her hopes had been rising, as replies to the questionnaires coming in from the workhouse authorities consistently revealed deficiencies which even the Poor Law Board could not ignore. ‘So long,’ she wrote, ‘as a sick man, woman or child is considered administratively to be a pauper, to be repressed and not a fellow creature to be nursed into health, so long will these shameful disclosures have to be made. The sick, infirm or mad pauper ceases to be a pauper when so afflicted.’ Miss Nightingale, utterly opposed to ‘poor law-mindedness’ in the treatment of the destitute sick, was determined that reorganization should be based on her personal philosophy that suffering was sufficient claim to raise the sick individual beyond the realm of normal values, moral judgments and social class.

She completed the draft of her recommendations and sent it to Mr. Villiers in December 1865. This ‘ABC of Workhouse Reform’-as she called it-was based on three main principles: (A) the sick, insane, incurable and children should be dealt with separately in appropriate institutions; (B) the ‘medical relief of London’ should be under one central management; and (C) the system should be financed by ‘consolidation and a general rate’ and not out of parochial rates. ‘The care and government of the sick poor is a thing totally different from the government of paupers’, she emphasized. ‘Once acknowledge this principle and you must have suitable establishments for the care of the sick and infirm.’ On receiving her communication, Mr. Villiers agreed at once to press for a new London Poor Law Bill.

Miss Nightingale’s proposals were basically similar to those outlined by Dr. Hart in the article which had just appeared in the December issue of the Fortnightly Review. It is probable that she was in touch with Dr. Hart and his associates-possibly through Mr. Farnall. Nevertheless, it would seem that she had given them no hint of Mr. Villiers’ promising attitude. From the wording of the March resolution of the Association for the Improvement of London Infirmaries and the weight of the deputation which it sent to Mr. Villiers in April 1866, it is obvious that opposition was anticipated. The petitioners included the Earls of Carnarvon and Shaftesbury, the Archbishop of York and Drs. Hart and Rogers. Mr. Villiers received them cordially, however, and promised that their proposals would be given ‘favourable consideration’. In a letter of 2 May to Harriet Martineau, Florence Nightingale identified herself with the Association by describing how ‘we’ have been sending ‘our Earls, Archbishops and MPs to storm him [Villiers] in his den’.

Immediately following the April deputation from the Infirmaries Association, Mr. Villiers instituted an enquiry into the arrangements for the care of the sick in the metropolitan workhouses. For this task, he deputed his poor law Inspectors, Mr. Farnall and Dr. Edward Smith. The latter had been appointed the previous year and was the first physician to hold the office of Inspector. Mr. Villiers’ attempts to institute improvements, however, were short-lived. By the late spring of I 866, the Whig Government was tottering. Mr. Villiers was afraid to introduce so controversial a subject as workhouse infirmary reform. On 18 June 1866, the Government fell and with it the reformers’ hopes of the new infirmary Bill.

Although ill during most of the summer, Miss Nightingale persevered with her scheme. She sent a copy of her ‘ABC’ to John Stuart Mill, who was then sitting on the select Committee of the House of Commons on the Local Government of the Metropolis. At his suggestion, she sent another copy to Edwin Chadwick, the only surviving member of the 1832-34 Poor Law Commission. In so doing, she successfully resuscitated a powerful voice in the cause of the sick pauper. A few weeks later, Fraser’s Magazine published an article by Edwin Chadwick on ‘The Administration of Medical Relief to the Destitute Sick in the Metropolis’. If not a concerted effort, it had all the signs of being Nightingale inspired. Chadwick confirmed that the current evils concerning medical relief in London were condemned at the time of the 1832-34 inquiry and had continued in contravention of the 1834 Act. ‘The leading administrative principle made out by our enquiry as specially applicable to the metropolis’, he wrote, ‘was that of making the largest aggregation of cases practicable for the purpose. . . of segregation, or the most full and complete classification for distinct and appropriate treatment in separate houses. . . .’ Chadwick, the onetime vigorous champion of central administration on the model of France, went on to emphasize ‘the great advantages derived from the unity of local administration of Paris in having all the public hospitals under one direction with a central bureau d’admission’, and urged its applicability to the administration of medical relief in the metropolis.

Determined to recover the infirmary Bill, which twice had been so nearly within her grasp, Miss Nightingale watched her opportunity with the new Tory administration. In July 1866, Lord Derby appointed Mr. Gathorne Hardy to succeed Mr. Villiers at the Poor Law Board. Known as ‘an admirable House of Commons man’, Mr. Gathorne Hardy hitherto had held only one junior ministerial post. Recently, he had won a seat for Oxford University in an exciting election contest against Mr. Gladstone. In Lord Derby’s judgment, Gathorne Hardy was ‘one of the fittest men in Her Majesty’s dominions to put things straight’.

After only a few days in office, the new President of the Poor Law Board received a long and urgent letter from Miss Nightingale, enclosing her scheme of reform which she offered to expound personally. He suspected that, in the heat of her crusading fervour, she regarded God and Ministers of State alike as her private secretaries. An ambitious man, Gathorne Hardy intended to ‘put things straight’ in his own way. He had no wish to add the finishing touches to a project begun by his Liberal predecessor. His gracious reply to Miss Nightingale some three weeks later’ hastened ‘to assure her that he would bear in mind the offer she had made and in all probability avail himself of it to the full. He never did. Miss Nightingale was shut out of the Poor Law Board. A post in Yorkshire was found for Mr. Farnall.

The results of Miss Nightingale’s labours, however, had been insinuated into the archives of the Board. The reports of Mr. Farnall and his medical colleague, Dr. Edward Smith, had been completed before Mr. Gathorne Hardy took office, but no action had been taken on them. When questioned in the House of Commons on his first appearance as President of the Poor Law Board, Mr Gathorne Hardy seemed confident that he could deal with the workhouse evils ‘under the powers. . . now possessed by the Poor Law Board’, which he believed to be ‘sufficient in the main’. He thereupon set about discovering the extent of these powers. From Mr. Farnall’s report, he learned that his Board had ‘no power to compel boards of guardians to build infirmaries for the sick poor, or to oblige guardians to elect and pay resident medical officers, or to enforce the paying for drugs out of the rates.’ The report strongly urged that the Poor Law Board should acquire legal powers to enable it to order guardians to provide sufficient wards for the sick poor and to require these to be adequately staffed with resident officers and trained nurses, and supplied with drugs and medical appliances. ‘Hospitals’, the report insisted, ‘should be built wholly apart from the metropolitan workhouses. . . and the cost of building and maintenance be defrayed by a common rating of the metropolis.’ For a number of years, Mr. Farnall’s. routine reports on the London workhouses had been such as to occasion no concern. It is, therefore, not unsafe to assume that Miss Nightingale was behind his expansive recommendations. Some of the more insistent and synoptical passages of his report displayed a curiously apt imitation of her style and embodied themes already elaborated in her Notes on Hospitals.

Dr. Edward Smith’s report pointed to the numerous causes of defective workhouse management, which by now had become familiar reading. In particular, he suggested that certain categories of inmates should be warded separately. These were: scarlet fever and smallpox cases; ‘the noisy and dangerous lunatics who were admitted on occasion when the county asylums refused to receive them'; and the ‘far too many children too young to be removed to the district schools’.

These reports, based largely on subjective evaluation, suggested to Mr. Gathorne Hardy the need for quantitative data. Clearly, overcrowding was a basic cause of the evils to be eradicated; but what constituted overcrowding, he wished to know; and if, as was obvious, some classes of the sick had to be removed, how much accommodation would they require, and what space should be allowed for the inmates who remained? On these matters the reports were conflicting and confusing. Mr. Gathorne Hardy decided to make a fresh start and appointed two new Inspectors to the metropolitan area, Dr. W. O. Markham, formerly editor of the British Medical Journal and a sympathetic advocate of poor law medical reform, and Mr. Uvedale Corbett, ‘an inspector of much experience’. In September 1866, the President instructed them to visit the London workhouses with a view to procuring information which might assist him in drafting new legislation for the reform of workhouse infirmaries. Their report, which included statistical studies of the diseases and accommodation of the non-able-bodied, strongly urged the establishment of separate hospitals for the sick who would be removed from the workhouse, and dispensaries for the outdoor poor.

The system of out-patient clinics, or dispensaries, where the poor were attended by qualified medical practitioners, was already in operation in Paris and Ireland. To Ireland, then, Gathorne Hardy sent John Lambert, a senior civil servant at the Poor Law Board, . with instructions to report on how the system worked.

As for the new hospitals which his advisers and the leading reformers had advocated, Gathorne Hardy was not yet fully convinced of their need. He consulted the President of the Royal College of Physicians, Sir Thomas Watson, who immediately convened a committee of eminent medical and sanitary experts to examine the London workhouses and their provision for the sick. Early in February 1867, the Watson Committee presented an extensive report, which included recommendations on the construction of infirmary wards, ventilation and the amount of space for different classes of inmate. One of the report’s numerous appendices was a lengthy contribution on nursing, which Florence Nightingale had persuaded the committee to include. In this, she restated her case for the complete reform of workhouse administration. Undeterred by his apparent indifference to her suggestions, she sent a copy urgently to Gathorne Hardy and followed this by numerous letters. He refrained from giving her any hint of his intentions.

The Watson Committee, like Gathorne Hardy’s other advisers, urged that the workhouse sick should be provided with separate accommodation and special care; and, in particular, that those suffering from infectious fevers and smallpox, and the insane, should be removed from the workhouses and treated in specially erected hospitals.

At this time, isolation accommodation in the metropolis was limited to 182 beds in the London Fever Hospital in Islington (opened in 1802) and about one hundred beds in the Smallpox Hospital in Highgate (founded in 1746). These two establishments were supported mainly by voluntary contributions and intended primarily for paying patients but when beds were available, poor law patients were sometimes admitted. The guardians, like the general hospitals, were becoming increasingly reluctant to admit infectious cases to their institutions. Of London’s twelve leading voluntary hospitals-providing some 3,300 beds-none treated smallpox; and, while eight claimed to admit fever patients, they actually received very few. These were scattered among non-infectious cases in the general wards, for, although the germ theory was already well founded, it was not yet fully understood. During the middle 1860s, infectious fever cases represented about 4 per cent of the total admissions at St. Bartholomew’s Hospital and about 2 per cent at Guy’s Hospital. Other general hospitals in London received an even smaller proportion of infectious cases Sir John Simon, Medical Officer of the Privy Council, was particularly censorious of this discrimination against infectious patients. In the Scottish hospitals, every disease was admitted and the system of separate wards or blocks for fever and smallpox was universal. Many Scottish hospitals admitted a very large proportion of fever cases.

For the mentally disordered, London was served by a number of institutions with varying standards of care. Some 300 charitable beds were provided by the Bethlehem Royal Hospital (Bethlem), of monastic origin, and a similar number by St. Luke’s, founded by voluntary subscription in 1751. Guy’s Hospital also admitted the mentally afflicted into its ‘lunatic ward’. Of the thirty-nine privately owned licensed houses functioning in the London area at this time, three (each with over 400 beds) entered into contracts with the parochial authorities for the reception of poor law patients. Hanwell (now St. Bernard’s Hospital) and Colney Hatch (now Friern Hospital)-the 2,000-bed county ‘lunatic asylums’ of Middlesex-were also available to the metropolitan community. These public asylums had not escaped the censure which the lunacy authority at this period levelled at a number of private, charitable and other mental institutions. Although private patients were subsequently admitted to the county asylums by arrangement with the visiting committees, they were intended originally for destitute persons who were severely disturbed, dangerous, or suffering from the more curable mental disorders ‘pauper lunatics’, as they were called. Congenital mental defectives-idiots and imbeciles and other harmless ‘incurables’ were, therefore, not strictly eligible for admission. Consequently, the vast majority of this preponderant section of the mentally disordered became the responsibility of the poor law authorities. Some were given relief in their own homes or were boarded out, but many were kept in the union workhouses. The distribution of mental cases between the asylums and the workhouses was, however, largely haphazard. As the poor law institutions were neither equipped nor staffed for the care of the mentally ill and subnormal, the ‘harmless chronics’ existed for the most part in wretched conditions, often deprived of adequate facilities, food and medical care. Furthermore, they aggravated the pressing problem of overcrowding.

Following Daly’s death in the Holborn workhouse, demands for poor law medical reform had become increasingly focused on London, and most of the investigations-both independent and official-had been centred on the metropolitan institutions. Miss Nightingale and Dr. Hart had formulated their schemes for immediate application to London. It was obvious that sweeping reforms could not be absorbed at once throughout the country. If first established in the capital, it was confidently anticipated that improvements would spread, sooner or later, to the provinces. Legislation for the metropolis was, therefore, the reformers’ immediate goal.

The reform movement had been motivated partly by humanitarian concern for the helpless poor, partly by the professional self-interest of poor law medical officers, and partly by Miss Nightingale’s crusade for improved workhouse nursing. These forces, however, were inevitably allied to the ever-present menace of disease and death in Victorian London. The ultimate arbiter of State intervention was fear lest the infectious destitute sick in crowded workhouses and insanitary dwellings should suscitate the uncontrolled dissemination of disease, with its toll of human life and economic dislocation. Fear of disease had led, for example, to the Quarantine Acts, which dated from the Great Plague; the first consultative Board of Health, appointed under the presidency of Sir Henry Halford in 1831; its successor, the General Board of Health, in 1832, and the’ cholera legislation’ of 1832; the first Vaccination Act of 1840 ; the first Public Health Act of 1848; and the Diseases Prevention Act of 1855.

Progenitor of State medicine in the past, fear of pestilence was now moving the Government towards a new area of social responsibility. Early in 1867, Gathorne Hardy and his assistant, John Lambert, embarked on the draft of a new poor law Bill. It was clear that a break with the past was essential; that the Poor Law Board must acknowledge and define its responsibilities towards the destitute sick; that the principle of ‘less eligibility’ must be revised; and that the central authority must acquire fresh powers for implementing a new policy. On 6 February 1867, in the Speech from the Throne, the Government announced its intention of introducing a measure’ for improving the management of sick and other poor in the metropolis’.

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