I

WHILE the mental health branch of the Board’s work could not escape the repressive power of the poor law, the MAB services for the infectious sick encountered forces which resulted in State intervention in the field of medical care outside the poor law. These devel­opments altered the traditional criterion of hospital admission from lack of means to need of treatment, and evolved in four progressive phases.

During the relapsing fever epidemic of 1869-70, the only MAB hospital in use was the hurriedly-erected structure at Hampstead. While the Asylums Managers were dealing with this unexpected visitation, building operations were being accelerated on the new smallpox and fever hospitals at Homerton and Stockwell. In July 1870, when the four units—two for fever and two for smallpox—were approaching completion and plans for staffing them had been submitted to the central authority, the Asylums Board learned with frustrated amazement that the Poor Law Board considered it `expedient that the Managers should open one fever and one smallpox hospital only, in the first instance, and defer appointing staff for the other two institutions until the number of patients renders it necessary that these should be made use of.’ Only eighteen months had elapsed since the ill-timed suspension of hospital building at Hampstead. The Board had already appointed, from among its own members, a management committee for each of the four hospitals. The committees straightway combined to study the situation. ‘ Compliance with the Poor Law Board’s suggestion would not only stultify the exertions of the Asylums Board over the past three years’, they affirmed, ‘but it would be entirely contrary to the spirit of the intentions of the Legislature in passing the Act of 1867.’ The committees’ joint report re­capitulated the rationale upon which the planning had been based, and emphasized the danger to which patients would be exposed if obliged to travel from one side of the metro­polis to the other to reach the only available fever or smallpox hospital. Early in the autumn of 1870, this report was sent to the Poor Law Board, supported by the information that some 250 pauper cases of typhus and typhoid had been admitted recently to the London Fever Hospital; that smallpox was already threatening the East End of London; and that the voluntary smallpox hospital at Highgate was rapidly filling.

As an anti-climax to this warning plea for effective action, the Asylums Board re­ceived two voluminous sets of Poor Law Board regulations governing the administration of the MAB isolation hospitals and mental institutions. They were almost identically worded and were suggestive of the regimen of a penitentiary. The functions of each officer were set out with minute precision. Of the fifteen articles specifying the duties of the medical superintendent, one prescribed that he was to govern and control all the officers, servants and other persons employed in the “asylum” (The central authority referred to all the MAB hospitals as asylums’, while the MAB reserved this term only for its institutions for the chronic insane.) The ‘house superintendent’, whose functions were explained in twenty-three articles, was ‘required to be over twenty-five years of age and qualified to keep accounts’. The matron, whose duties were those of a housekeeper, was to be responsible for female domestic staff on and off duty, and for nursing staff only off duty. Nurses, while on the wards, were to be directly responsible to the medical superintendent.

While the Asylums Board was considering these regulations, the smallpox epidemic, which had been sweeping Europe, was gaining on the metropolis. Since early in 1868, extensive outbreaks had occurred in such widely separated places as Vienna, St. Petersburg, Hamburg and Dublin. Early in the autumn of 187o Paris was invaded and by the beginning of November two hundred cases were reported in the East End of London. In the absence of hospital accommodation, these remained in workhouses and crowded dwellings.

When a major visitation appeared inescapable, the Poor Law Board sanctioned the opening of all four hospitals at Homerton and Stockwell, and the temporary building at Hampstead, and urged the Asylums Managers to act in this instance with the same promptitude as was shown with so satisfactory a result in the case of the outbreak of re­lapsing fever ‘. The Managers thereupon made direct contact with Sir John Simon, Chief Medical Officer of the Privy Council; and his assessment of the situation confirmed their worst fears.

. . . The mortality from smallpox in London has been steadily increasing during the present year [wrote Sir John Simon]. Whether its further extension can be prevented depends to a large extent upon the special measures, vaccination and isolation, which shall now be taken, but, from the sanitary condition .. . of some of the districts of London where smallpox is most prevalent, there is a great reason to fear that the disease will increase, and that the epidemic will equal that of 1866-67.

The MAB immediately appointed a management committee for the Hampstead Hospital—the only institution yet available—and authorized it to make all necessary arrangements. The Poor Law Board was asked to authorise the committee to proceed in the matter without adhering to the regulations prescribed in ordinary cases. On 1 Decem­ber 1870, the Hampstead Hospital was re-opened and very soon it was filled with small­pox cases from every part of London. The East Grinstead Sisterhood again came to the Board’s assistance and supplied all the nursing and domestic staff. Initially, the outbreak was most prevalent among women and children. Wards were allocated accordingly, and the eighteenth-century practice of encouraging mothers to accompany and nurse their sick children was revived. When further accommodation was required, the makeshift building behind the London Fever Hospital (formerly used for the relapsing fever out­break) was transferred to the Hampstead site, where the main structure was extended. By this means, a total of 450 beds was achieved at a cost of £13,000. For two months this was the only isolation accommodation available to the MAB. Irate boards of guardians descended upon the Managers and described the appalling conditions in their districts, where the stricken were crowded in workhouses, chapels and vestry houses. The Shoreditch guardians upbraided the Board for the insufficiency of its isolation accommodation and demanded that it should receive immediately one hundred smallpox cases and two hundred imbeciles.

On 31 January 1871, the MAB smallpox hospital at Stockwell was opened, followed the next day by that at Homerton. Questioned in the House of Commons shortly after­wards, the President of the Poor Law Board (Mr. Goschen) was obliged to admit that there were then well over 1,200 known cases of smallpox in the metropolis and that only about half of these were isolated in the MAB hospitals. Although the Homerton and Stockwell smallpox hospitals were officially open, they were unable to function adequately owing to the difficulty of recruiting staff at the rates of pay stipulated by the Poor Law Board; and it became necessary to revert to the scales originally recommended by the Asylums Board. These included 10s. 6d. a week for nurses, a rate considered excessive by the central authority. By the beginning of March 1871, the Board was obliged to ask the London Fever Hospital to receive all its fever cases in order that the two fever hospitals at Homerton and Stockwell might be used for smallpox patients. The disease was of a particularly viru­lent type with a 17 per cent case fatality rate. With 1,200 smallpox beds, the Board now hoped to keep pace with the demand, but the epidemic raged unabated.

There were now signs of concern at the Poor Law Board. Dr. John Henry Bridges, FRCP, was sent to confer with the MAB hospital management committees. This was the beginning of an association which was to prove long and fruitful. Formerly a factory inspector, Dr. Bridges had been persuaded in 1869 by Mr. Goschen, friend of his schooldays, to accept the post of medical inspector at the Board. An apostle of the philosophy of Comte and the religion of Humanity, he was integrated into the machine which controlled the lives of the helpless poor. To his duties he brought dedicated energy and reforming zeal. If such a class as ‘hereditary paupers’ really existed, he blamed the system. Among members of the Asylums Board he found men after his own heart; but his position at the Poor Law Board was not a happy one. He was hampered by `the necessity of educating his official superiors, by the deadening futilities of red tape and by the undercurrent of opposition provoked by his religious views’.

In accordance with Dr. Bridges’ advice, the Asylums Managers set about finding additional sites for temporary isolation accommodation, and negotiated with the parochial authorities for the loan of some seven hundred supplementary beds. Meantime, the lay administrators of the Poor Law Board were invoking their powers under section 18 of the 1867 Act. Taking independent action, they ordered the appropriation of an old building belonging to the Islington guardians. Further, without consulting the Asylums Board or their medical inspector, they negotiated with the Commissioners of Works to make avail­able a six-acre site at Battersea and arranged with the War Department to erect a hospital for four hundred smallpox patients. The Asylums Board was then assured that these arrangements have not been actuated by any wish to interfere in the general discharge by the Managers of their responsible duties but merely by the desire to render them every possible assistance in the present emergency’. ‘ One of the main objects’, it was asserted, `has been to save as much time as possible.’ To this, the Managers replied that they were unable to enter into any engagement to take over a building, of which the plans—altogether unknown to them—might be unsuitable for the purpose and involve a very large charge upon London ratepayers for a very short period of time.’ After inspecting the site and the plans with representatives of the Poor Law Board and the War Depart­ment, the Managers declared that they wished to have nothing whatever to do with the project. The cost of erecting the building was estimated at £20,000. At the rate of £50 a bed, it was considered ‘very inferior in all respects to the Hampstead Hospital which, despite its piecemeal construction, had cost no more than £45 per bed.’ The catalogue of inadequacies concluded with a critical comment on one of the more peculiar features—the dead-house’, which the War Department planners had designed as an appendage to the main building! A very angry reply was received, emphasizing that the Poor Law Board had gone out of its way to facilitate the operation of the Managers and to save time, an object of such extreme importance.’ The communication ended with a threat to take action under section 15 of the 1867 Act. This was tantamount to resorting to a man­damus and forcing the Asylums Board to proceed with the projected hospital at Battersea. On taking legal advice concerning the powers of the central authority in this connexion, the Managers were fortified in the opinion at which they had themselves arrived’.

The MAB, although not convinced of the need for additional accommodation, offered to build a 200-bed hospital on an alternative site; but efforts to purchase land at Peckham and West Brompton belonging to two of the dissolved sick asylum districts ‘— Newington and Kensington—proved unsuccessful, and the Managers were obliged to charter from the Admiralty the hospital ship Dreadnought, (formerly used as the Seamen’s Hospital) lying off Greenwich. Next, the Islington guardians refused the Managers access to the building which the Poor Law Board had ordered them to appropriate. Shortly afterwards, without prior notice, it was abandoned with some seventy unattended patients in it. Twenty-four hours later, the MAB had transformed it into a 300-bed convalescent annex to the Hampstead Hospital, which was now accommodating five hundred acute cases.

Despite their tireless efforts in the public interest, the Asylums Managers were incurring opprobrium and loss of prestige. A letter appeared in The Times charging the Hampstead management committee with maltreatment of patients and insufficient food supplies at the hospital. The writers were three assistant medical officers whom the committee had recently dismissed for irresponsibility. Not only had they kept unlicensed fighting dogs on the premises, but they had neglected their duties to frequent the George Inn at the hospital gates, after their daily issue of strong ale had been reduced by the committee from six to two pints. The central authority ordered an enquiry into the charges made against the management committee. On the completion of the evidence produced by the former AMOs, the hearing was suspended, as the young doctors’ funds were insufficient to enable Counsel to continue with the cross-examination of the Board’s numerous witnesses. In order that the enquiry might be completed, the central authority was obliged to sanction the cost from public funds. Most of the charges were proved to be grossly exaggerated and to derive from the exceptional circumstances of the epidemic. There were, for instance, only thirty-four ordinary nurses to look after some eight hundred patients. Eventually, the Board was absolved as a result of the investigation.

Meantime, Hampstead ratepayers continued to harry the MAB concerning the small­pox hospital in their midst. The Managers, however, were resolved to stand their ground, come what may. In an effort to reduce the incidence of infection in the locality, they attempted—possibly with memories of the Broad Street pump—to organize the yielding of communal pumps in Hampstead on Sunday mornings, only to be confronted with complaints from the poorer residents.

III

As the four hospitals at Homerton and Stockwell were now filled to capacity, with beds in the corridors, tents were hired from the War Department. With an admission rate of about five hundred a week, the number of cases under treatment at the height of the epidemic reached two thousand. By the middle of 1871, however, the outbreak appeared to be under control, and the fever hospitals at Homerton and Stockwell were returned to their original use; the Islington workhouse was restored to the guardians; and the Dread­nought was handed back to the Admiralty. Thereafter, the outbreak persisted spasmodi­cally until January 1873. It was estimated that, for the period of the epidemic, the MAB hospitals had been able to admit only about one-third of London’s smallpox victims and that twice as many had died from the disease at home as in hospital. The smallpox mortality rate in 1871—the worst year of the epidemic—was the highest ever recorded for the capital. Of every million of the metropolitan population, 2,421 died from the disease, compared with a rate of 1,012 per million for the whole of England and Wales. This loss of life was attributed mainly to neglect of vaccination and to excessive gin-drinking. Urban areas on the continent, however, were even more severely ravaged. In Vienna, the 1871 rate of death from smallpox was 5,369 per million, while that in Hamburg reached 10,750 per million.

The 1870-73 epidemic had brought into relief the nineteenth-century trend of small­pox to concentrate on the capital while receding from the provinces. It had also emphasized the changing age-distribution of the disease. Formerly, children had been the chief victims of smallpox. During the latter half of the eighteenth century, between 8o and 90 per cent of smallpox deaths were of children under five. But from about the time when death registration was introduced (1837), the disease began to kill many more older people. Free infant vaccination from 184o and its statutory compulsion in 1853 and 1868 almost certainly reduced mortality from smallpox amongst infants. At first, the change was gradual, and then it became more rapid during the 187o-73 epidemic. Of the 16,000 smallpox cases admitted to the MAB hospitals during this period, less than 1,000 (approxi­mately 6 per cent) were under five years, while, of the 3,000 fatalities, less than 500 (about 16 per cent) were in this age group.

IV

In July 1871, the Poor Law Board had been superseded by the Local Government Board. Merged into the new ministry were three scattered departments: the Public Health Division of the Privy Council; the Local Government Act Division of the Home Office; and the Poor Law Board itself. The office of Permanent Secretary had been given to John Lambert, formerly assistant to Gathorne Hardy. Lambert was meticulous and dogmati­cally ‘poor law-minded’. To him, the new asylums were not so much therapeutic insti­tutions, as gambits in the poor law policy of deterrence. They would, he believed, facilitate the segregation of able-bodied paupers in disciplined deterrent workhouses.

Although reduced to a division, the old Poor Law Board dominated the new Depart­ment, and relations with the MAB remained unchanged. Despite the efforts of the Asylums Managers to keep in check the worst epidemic of the century, no word of appro­bation was received from the central authority. When, towards the end of 1872, the out­break began to subside, the Managers intimated that they `would have been gratified if the Local Government Board had more specially recognized the manner in which hospital staffs had performed their duties under unprecedented difficulties during a long and severe strain upon their powers’, and forthwith addressed a tribute to their personnel.

V

The management committees had worked strenuously throughout the epidemic period. One or more meetings were held each week at the hospitals, while individual members supervised day-to-day administration. This visitation of unprecedented severity had created problems which demanded immediate resolution and had rendered impracticable the precise application of the Poor Law Board hospital regulations. The management committees accorded the medical superintendent supremacy in all medical matters and freedom to pursue his clinical duties, while the house superintendent, whom they preferred to call the ‘steward’, was given responsibility, under their general direction, for all the non-medical aspects of the establishment. Although the matron came within the spheres of responsibility of both the medical superintendent and the steward, the Managers found it convenient to deal with her direct as if she were head of an independent department.

Following the epidemic, the Managers continued the system to which they had become accustomed. Not only were the central authority’s regulations found to be unworkable in practice, but they involved two fundamental principles which were questioned by the Managers. The first concerned control. Was the Asylums Board to be a mere tool of the central authority? Or was it to be allowed to manage the hospitals with due latitude for discretion? The second concerned the sick for whom the hospitals had been created. Were they patients or paupers? A number of incongruities were pointed out to the Local Government Board, with the suggestion that it should ‘make the regulations more appli­cable to hospitals of the nature of those under the charge of the Asylums Board’. Nine months elapsed. At the end of 1872, the Managers received, with some consternation, an extensive schedule of amended regulations’, in which `some additional provisions of an important character have been inserted’. Resentment mounted when it was realized that, if adhered to, these regulations would completely undermine the system of management which had been built up since the opening of the hospitals. Based on the assumption of remote control by management committees, the re-issued regulations retained the principle of medical superintendence. Assistant medical officers were to work under the direction of the medical superintendent in the wards, and the steward likewise in the administrative offices. The tenor of the regulations suggested that the Local Government Board was intent on placing the MAB establishments on the same footing as workhouse infirmaries and of reducing the power of the hospital Managers.

After two years of acrimonious correspondence, the MAB requested the central authority `so to frame its regulations that they would not be at variance with existing practice’. It was made clear that ‘regulations applicable to workhouse infirmaries would not be found suitable for the hospitals of the Managers, as some differences must occur consequent on the varying circumstances of the several institutions’, and it was suggested that the central authority’s regulations might be replaced by one order empowering the management committees to prescribe their own rules, subject to the sanction of the Asylums Board. The MAB communication continued:

… The Board believes that in all the large London hospitals the duties of the medical men are strictly confined to those of a medical character and they are sure that such an arrangement is a wise one; . . . in some other institutions where a contrary plan has been tried, it is well known that the medical superintendent has become to all practical purposes a medical steward, leaving the treatment of the patients to the assistant medical officers.

The next move was the issue by the Local Government Board, on 10 February 1875, of an order embodying revised ‘General Regulations’. This was accompanied by a note declaring the unacceptability of the Managers’ views upon the relative positions of the medical superintendent and the house superintendent’, but deferring to their wishes to the extent of referring to the latter as the `steward’. Concerning the term ‘pauper’, the Local Government Board affirmed that as all the persons admitted into the asylums are persons maintained at the expense of the poor rates, the term “pauper” is the correct one, and there is not sufficient reason for substituting “patient”. Thereafter, the Asylums Board always referred to the ‘patients’ and the Local Government Board persisted for the next twelve years in using the term ‘paupers’.

In the exchanges which followed the 1875 order, the MAB declared that, if the Local Government Board ‘insist on maintaining these regulations in their integrity, the Managers must definitely repudiate for themselves and throw upon the Local Government Board the responsibility for any failure that may occur in the management of the hospitals’.’ Eventually, some of the regulations were modified by an admixture of ambiguity. For instance, in an attempt to clarify the duties of the chief executive officers, the Local Government Board decreed that, while authority was to be divided between the medical superintendent and the steward, the former was to assume overall responsibility ‘for the good order of the asylum’, although ‘it was not necessary for the medical superintendent to interfere with the departments of other officers’.

The voluminous correspondence which grew up around the ‘amended’ regulations resulted in the Managers’ working ‘bible’ becoming a vast compendium of mandatory commands, prohibitions and advisory injunctions. The Board accordingly detailed its general purposes committee to compile a consolidated version of these fragmentary and sometimes conflicting ‘regulations’. Meanwhile, the acceptance of personal responsibility by committee members became even more deeply entrenched in the administrative sys­tem, and each hospital continued to be governed by an oligarchy—the management committee—and operated by a triumvirate—the medical superintendent, the steward and the matron.

VI

In view of the potential need for additional accommodation, the MAB acquired reserve sites for emergency use in Fulham (West Brompton) and Deptford (Old Kent Road). By the middle of 1875, however, these were still unused. The existing hospitals had sufficed for the increased demand for scarlet fever beds during the outbreak of the previous autumn and for the relatively few smallpox cases since the 1870-73 epidemic. The makeshift building at Hampstead, which for a while had housed the Board’s sub­normal children, was being prepared for eventual use as a permanent smallpox and fever hospital. This aroused local opposition in renewed strength. Numerous memorials were addressed to the MAB and to the Local Government Board. Residents of Haverstock Hill, near the hospital, found an alternative site in Mill Lane, and tried to impress the Managers and the President with its superior merits. This led to hostilities between two opposing factions of Hampstead ratepayers. One or other, or both, descended periodically upon the President of the Local Government Board, Mr. Sclater-Booth, who remained unimpressed. Towards the end of 1874, The Times reported that one such deputation

. . . was headed by six Members of Parliament and included representatives of residents and local bodies and the Provost of Eton, who was interested in property in the neigh­bourhood. After several hours, there were some who still desired to say ‘a word or two’, but even the excited deputation had grown weary of the repetitions, and loud hushes met some who still attempted to intervene between the chief of the department and his visitors. After the President had made a statement, some others wanted to speak but the President said the subject was exhausted, and the deputation then retired much dissatisfied.’

These demonstrations culminated in the appointment in June 1875 of a House of Commons Select Committee, headed by Mr. Sclater-Booth, to report upon the action of the MAB with regard to the establishment of a fever and smallpox hospital at Hampstead. Exhaustive evidence was received by the Committee from the Managers and the inhabi­tants of Hampstead. In its report, the Committee affirmed that the action of the Asylums Managers had been strictly in accordance with their duties, powers and responsibilities, as derived from the 1867 Act and from the sanction and control of the Local Government Board, so far as it was incumbent on them to be guided by that department. Furthermore, the Committee saw no reason why Hampstead should claim the interference of Parliament for the removal from it of an inconvenience to which it had become subject by reason of the due execution of the provisions of a wise and beneficent law’. The Committee, which warmly commended the Managers for the great services they had rendered to the metro­polis, submitted, for the consideration of the House, whether compulsory powers of pur­chase, with corresponding powers of compensation, should not be conferred upon the Board. All the London Members of Parliament voted against the report.

VII

As the Select Committee had suggested that administrative offices should be erected on the two unused sites owned by the Board, so that there should be no ground for com­plaint that Hampstead was unduly made use of for the cure of paupers coming from the south and west of London, the sites in Fulham and Deptford were accordingly prepared for the erection of hospitals when required. The demand was manifested sooner than was expected. By the autumn of 1876, about 150 cases of smallpox were admitted to the Homerton and Stockwell hospitals. At Hampstead, the conversion of the temporary structure into a permanent building had been started. The Local Government Board, nevertheless, ordered that it should be opened forthwith for the reception of smallpox cases. For the third time, the East Grinstead Sisterhood took over the nursing and domestic work of the hospital. No sooner had the central authority’s instructions been acted upon, than legal proceedings were taken against the Asylums Board by Sir Rowland Hill, and other Hampstead residents, to recover damages ‘ for a nuisance arising from the use of the hospital at Hampstead for smallpox and other infectious diseases, and for causing the assemblage in the neighbourhood . . . of large numbers of persons suffering from such diseases. . As the epidemic spread, it became necessary once more to use the fever hospitals for smallpox patients and to erect huts in the grounds of the Homerton and Stockwell establishments. In Dod Street, Limehouse, a private factory was taken over to accommodate severe cases occurring in the locality. This and other thoroughfares were marked off with plague flags as infected areas.

In August 1876, as the demands upon the Board’s accommodation were mounting in a menacing manner and problem after problem presented itself, the Local Government Board sent a lay inspector to visit the hospitals. He discovered the consolidated version of the central authority regulations, which had been issued to recently appointed staff. The verbal exchanges which ensued between the inspector and members of the manage­ment committees were followed by an official reprimand.

The [Local Government] Board learn from their inspector [it read] that the officers of the asylums . . . have been supplied with certain rules printed by the Managers . . . purporting to be a consolidation of the regulations in force, but differing in many important respects from those issued by the [Local Government] Board. . . . The re­marks of the committee to the effect that `they can hardly believe that the Board will treat their Managers with such scant courtesy and so little confidence as to upset the system of management which they are desirous of perpetuating’ appear to the Board to have no real foundation when regard is had to the concessions which were made in deference to the wishes of the Managers. . .

The Asylums Board retorted that the Local Government Board, in issuing its recent regu­lations, had acted unwisely for the public interests and that unless the policy which has dictated this line of treatment is altered, it will be impossible for the Managers to act with the Local Government Board in the same spirit of harmony as they have hitherto done’. The communication concluded by pointing out that, if the central authority

… initiated what was to be done, the Managers merely giving effect to its directions, the result will probably be that this Board, hampered by the misguided regulations laid down by the Local Government Board, will be far less efficient for the good service of the inhabitants of the metropolis, and the public will learn how impossible really good work is when it is subject to the centralizing influence which the Local Govern­ment Board, through its officials, is so constantly exerting.

In November 1876, a reply, signed by Sir John Lambert, reminded the Managers that the Legislature has imposed on the Local Government Board the duty and respon­sibility of issuing such general regulations as they may deem proper for the good government of the Metropolitan District asylums, as well as of other Poor Law establishments; acting under a sense of this responsibility, the President regrets that he cannot sanction the perpetuation by formal orders of a dual system of government, but must maintain the principle of unity of authority and the general supremacy of one superintendent.

The Asylums Managers replied that they. . . certainly do not wish for a dual system of government in their institutions. They have hitherto had unity of management, but that unity has consisted in the Managers themselves, by their several committees, being the real governing power. . . . For a series of years this system has worked in all respects well and it must be a source of regret that the Local Government Board should now insist on its alteration.

Sir John Lambert reiterated that. . . the [Local Government] Board are distinctly of opinion that they would not be justified in sanctioning . . . the principle of co-ordinate officers acting under the direc­tion of the committee of management as it is obvious that gentlemen who may at any time seek to withdraw from their voluntary work cannot be held responsible for the order and discipline of the asylums in the same manner and degree as paid officers.

By this time, Sir John Lambert had subjugated the medical element at the Local Government Board and was wielding undisputed power. ‘The office blunders on in the same dull, groping way’, wrote Dr. J. H. Bridges in a personal letter in 1876, while remaining a frustrated outsider in this controversy. Dr. William Brewer, who had earlier denounced the central poor law authority in the House of Commons as ‘practically irresponsible’ and its policy as ‘notoriously fitful’, refused to be coerced by Sir John Lambert. And the system of personal supervision by committee members and day-to-day administration by the executive trio persisted unchanged in the MAB hospitals for many years to come.

Meantime, the Board had been planning the erection of hospitals on the two new sites in Fulham and Deptford to keep pace with the increasing demand for smallpox beds. Once again, after official approval of plans had been tardily granted and construction was in progress, the Local Government Board decided to limit the building programme to one hospital. The end of 1876 found the MAB hospitals with some five hundred smallpox cases and no sign of the outbreak receding. The Managers accordingly decided to proceed with building on both sites and to press meantime for permission to complete the two units. The central authority eventually relented, and in March 1877 the Deptford and Fulham hospitals were opened, the former with thirteen, and the latter with ten, thirty-bed pavilions.

London was now at the height of the second smallpox visitation of the ‘seventies. Characterized by an unprecedented proportion of haemorrhagic cases, it was regarded as the strongest analogy to the Black Death of the fourteenth century which had been witnessed since that time. During the epidemic period—from the second half of 1876 until the end of 1878—the MAB hospitals treated some 13,000 smallpox patients with a case fatality rate of about 19 per cent. Outside the hospitals, the metropolitan rate of mortality from smallpox during 1877, the worst year of the outbreak, was 709 per million, compared with 2,421 per million for the record year of 1871. The fact that about half of the deaths occurred in hospital, compared with about one-third during the previous outbreak, sug­gested that the traditional fear of hospitals was giving place to an appreciation of institu­tional medical care, despite the pauper stigma and disenfranchisement which entry to an Asylums Board institution entailed.

When founded, the MAB asylums had been intended solely for the destitute sick. But during periods of pestilence, the wage-earning poor, as well as patients of other social classes, applied direct to the hospitals for admission. On medical and public health grounds, it was obviously inadvisable to turn them away. Many were dying and all were potential centres of infection. The medical superintendents admitted them. The Managers, appreciating the practical difficulties and futility of discriminating between the destitute and other patients, supported their medical staff, and then sought legal sanction for their action. Their representations eventually resulted in a modification of the official regulations, and medical superintendents were empowered to admit any patient who arrived without the required documents ‘in such a condition that a refusal to admit him . . . might be attended with dangerous results’. No poor law requirement could override the wisdom of defend­ing both patient and public from the dangerous consequences of non-admission. Every case of fever or smallpox applying to the hospitals direct, instead of through the poor law authorities, was therefore regarded as an emergency under the modified regulations. When it became apparent that a large proportion of patients were not of the class habitually relieved from the rates, the question of statutory provision to cover non-pauper main­tenance charges had to be considered. An ingenious form of words was, therefore, inserted into the Divided Parishes and Poor Law Amendment Act of 1876 which made it possible, by implication, for such charges to be waived. In the case of a non-pauper being admitted into an MAB hospital under stress of urgency, the Board was authorized to exercise `in respect of the recovery of all reasonable charges incurred’, the ‘like powers . . . as are conferred by the Poor Law Acts upon guardians over a pauper for the recovery of relief given . . . by way of loan. . .’. For the first time, non-paupers were provided for under the poor law. The initial statutory step was thus taken towards the provision of free isola­tion accommodation for all in need of treatment.

The proportion of non-pauper patients treated in the MAB hospitals during the 1876-78 smallpox outbreak was even higher than it had been during the earlier epidemic. In the hospitals’ first eighteen months—up to mid-1872—of 16,459 admissions, only 4,792 had been in receipt of poor relief when sickness had overtaken them. Some 71 per cent therefore, were not paupers on admission. Of these, it was known that at least 235 had been admitted without the necessary relieving officers’ orders; and the cost of maintenance—one shilling and threepence a day—had been recovered from 191. When the 1871 census was taken, it was found that 82 per cent of the 223 male patients in the Hampstead Hospital were in regular gainful employment when admitted. Of these self-supporting patients, more than one-half were skilled artisans and well over one-fifth were white-collar workers. During the second smallpox epidemic, all MAB patients were asked (15 February 1877) whether they had ever before received poor relief. Only 10 per cent admitted that they had. It appeared, therefore, that the vast majority were paupers in legal theory only.

Report of Dr. Robert Grieve, Medical Superintendent of Hampstead Hospital, 15 April 1871 (MAB Mins., vol. v, pp. 39-41). The occupations of male patients were classified as follows:

NonPaupers: Paupers:
Professional

6

Labourers

35

Master Tradesmen

2

Costermongers

3

Railway and Post Office No occupation

2

Officials, etc.

8

Shopmen and Clerks

24

Domestic Servants

3

Barmen, Waiters, etc.

9

Skilled Artisans

94

Omnibus Drivers, Carmen, Stablemen

26

Porters

9

Seamen

2

VIII

The illusion persisted at the Local Government Board, nevertheless, that the practice of admitting non-pauper patients to the MAB hospitals was altogether exceptional. The sanitary authorities were circularized at the beginning of 1877 concerning their responsibility for non-destitute patients, and it was emphasized that the MAB hospitals were exclusively for paupers. Replies from the local authorities showed that they could not, or would not, provide isolation accommodation for paying patients, which they were empowered to do under the 1866 Sanitary Act. The difficulty of obtaining sites, and fear of local opposition, were among their practical problems. Some of them appealed direct to the MAB, pointing out that, as the Board dealt with infectious disease among one class of the community and was supported out of the rates, an extension of its powers to enable it to deal with all classes would be more favourable to the sanitary and financial in­terests of London than would any separate action taken by the local authorities themselves.

A decade had passed since the creation of the MAB, and it now commanded some 2,000 isolation beds in five relatively equidistant units encircling the metropolis, but in an epidemic these would be quite inadequate for London’s 3.6 millions. Other hospital accommodation in the capital was still deficient, although it had increased to some extent during the past ten years. While the number of special beds of one kind and another re­mained about 3,000, the bed complement of the general (voluntary) hospitals had risen to about 5,000, and the workhouse infirmaries were providing more than twice that number.

The MAB realized that the local authorities were trying to divest themselves of their statutory responsibilities. Nevertheless, their suggestions were considered with more than objective interest. The Board appreciated the folly of restricting fever hospitals to one section of the community and hoped to be empowered to provide isolation accommoda­tion for the whole of the metropolis. Within the MAB system existed the means for merging poor law and public health requirements, but impediments to such integration persisted at the Local Government Board. The civil servants of the P.L. Division of the LGB assumed that control of the poor law was the most important of all the civil functions of the government. They even continued to file all documents on whatever matter—sanitation or poor relief—according to poor law districts, a practice which subsisted until the advent in 1919 of the Ministry of Health. During the last phase of the old Poor Law Board, however, a flicker of hope had been kindled in this direction by Mr. Goschen’s lip service to the wisdom of making medical services available to `the poorer classes generally as distinguished from actual paupers’. He expressed the view that ‘perfect accessibility to medical advice and free medicine at all times under thorough organization ought to be considered so important in themselves as to render it necessary to weigh with the greatest care all the reasons which might be adduced in their favour.’ These words were written into the Poor Law Board’s annual report for 1870, compiled while London was suffering near-paralysis from the greatest smallpox epidemic it had ever known—a situation which could have been mitigated, if not averted, by the operation of such a free health service. At this time, there were estimated to be some 173,000 poor law patients in the country, of whom 54,000 were actually under medical treatment in poor law institutions. This number was esti­mated by the Webbs  to be about one-fourth of all persons in England and Wales simultane­ously under medical treatment, either at their own expense or paid for by charity or the poor rate. The 1876-78 epidemic provided yet further evidence of the need for more comprehensive health services to protect the public from ill-controlled pestilence. In Ireland since 1851, all ‘poor persons’ who were sick had a right to free advice and medicine and it was not deemed poor relief. Under the Medical Relief Charities Act of Ireland, 1851, any ‘poor person’ had the right to free advice and medicine. Each poor law union was divided into Dispensary Districts under the board of guardians, and the dispensary medical officers acted ex officio as medical officers of health under the sanitary authorities. But in England it was held that ‘people must not be encouraged to be ill by the knowledge that they could be treated free at the expense of the State.’

The Asylums Board was determined to represent the need for encouraging all classes of the community to seek isolation when stricken with infectious disease. The reports of its management committees and medical superintendents urged that the central authority should be pressed to meet this need by providing a central hospital service for paying and non-paying patients alike, linked with a system of compensation for those who suffered financially by submitting to isolation for the benefit of the community. Typical of these reports, which were communicated to the Local Government Board with relentless regu­larity, was one from the management committee of the MAB Homerton Hospital in 1878, describing the impact of smallpox on the capital:

. . . Smallpox has very seriously disturbed the health and comfort of the dwellers of London twice during the past seven years; it has not only destroyed a large number of lives which might have been saved, but has put the ratepayers to an immense expense for the maintenance of patients in the hospitals. Notwithstanding these deplorable results, and the lessons they teach, the same state of things is allowed to continue, year after year; no measures of a comprehensive character suited to the wants of this vast metro­polis are being taken to arrest the ravages of the disease, beyond the mere sending of so or 6o per cent of the cases to the hospitals for paupers, while the remaining cases are permitted to stay in their own homes spreading the infection in every direction, and thus keeping the epidemic alive.

The medical superintendent of the MAB Fulham Hospital emphasized

. ..the need for encouraging the enormous class above the very poor to seek hospital treatment when suffering from disease, as well as the class of minor tradesmen who are focal centres of infection. Are the existing hospitals [he asked] to be utilised for all classes? Are the parishes to multiply infectious disease hospitals ad infinitum? Or are things to remain as they are, incompletely constituted?

The medical superintendent of the Board’s Hampstead Hospital wrote:

… I hope the time will come when admission to these hospitals shall be freely asked and as easily obtained and when the burden of pecuniary loss borne for the safety of others can be distributed among those who enjoy safety. . .. That coming generations will look upon smallpox as a matter of tradition is perhaps too much to expect. . . .

Lest it should escape the notice of the Local Government Board that the MAB lacked neither the willingness nor the vision to assume the role of London’s central hospital authority for infectious diseases, it detailed its general purposes committee to formulate specific recommendations in the light of the local boards’ attitudes concerning isolation hospital provision. It appeared that five of the thirty vestries and district boards had made some attempt to use their statutory powers to provide hospital accommodation; seven said they possessed no facilities; six advocated the creation of a central board for all infec­tious disease hospitals; and the remainder assumed, erroneously, that it was the duty of the Asylums Board to make provision for all cases.

As it was obvious that adequate provision for the isolation and treatment of epidemic disease in the metropolis did not exist, the MAB general purposes committee submitted the following recommendations :

That such provision could be best made in a comprehensive manner by one central authority acting for the whole metropolis, not only for pauper patients but for other classes desirous of hospital accommodation;

  1. That such central authority should not be merely a department of poor law adminis­tration, but should have the powers of the Sanitary Acts conferred upon it;

  2. That either the MAB should be merged into such central authority or should itself be that authority, in which case its constitution should be altered and adapted to its enlarged duties and responsibilities.

The central department was requested to give these suggestions urgent consideration, and local boards were invited to submit their views. It was clear from their replies that most of them were generally in favour of a central hospital authority, though some were averse to having the powers of the Sanitary Acts conferred upon it.

Evidence of response—albeit ineffectual—on the part of the central authority appeared in two clauses inserted into the Public Health (Metropolis) Bill, introduced into Parliament late in the 1876-77 session. These empowered, but did not compel, local authorities, either to combine for hospital purposes, or to contract with the Asylums Board for the reception of their non-pauper cases. The Bill was dropped; but in any case it would have done little to solve the problems of the MAB. While free from disease, the sanitary districts, as hitherto, would have done nothing to provide for their paying patients. In an epidemic the measure would have imposed on the Board the moral responsibility of providing for all classes, whilst, in the absence of prior knowledge of probable requirements, it would have been unable to make adequate arrangements. Meantime, the local authorities, only too willing to take advantage of medical ethics and legal loopholes, went on sending their infectious cases to the MAB hospitals.

The Board continued to plan for the role of metropolitan public health authority with special responsibility for isolation accommodation, but, as the second smallpox epidemic of the ‘seventies was subsiding, its aspirations suffered a temporary eclipse. On 29 November 1878, judgment against the MAB was given by Mr. Baron Pollock in the Hampstead Hospital law suit. After a trial lasting eleven days, the jury decided that the hospital as hitherto used, was a legal nuisance, both in its incidence and in itself; and an injunction was issued for its closure.’ With characteristic resilience, the Managers straightway proceeded to negotiate for a new trial.

This initial phase in the development of the MAB hospitals illustrated conclusively that the application of poor law principles and practice to infectious disease was a practical failure, even if it persisted as a legal fiction. Nevertheless, an initial—but as yet ineffective step had been taken towards uniting in the hospital ward the `two nations’ which poor law policy perpetuated in English society.

TABLE 1

Cases received into the MAB Infectious Disease Hospitals from the date of opening (between December 1870 and March 1871) up to 24 June 1872

Hospital

Date of
Opening

Total Number of cases received

Number of cases on the MOs’ list, or otherwise in receipt of relief immediately before orders for their admission were given

Number of cases admitted without an order from the Relieving Officer

Hampstead 1 Dec. 1870 (for smallpox)

7,276

78

Homerton Smallpox 1Feb. 1871

2,684

not known

Homerton Fever 15 Feb. 1871

1,706

37

Stockwell Smallpox 31 Jan. 1871

2,641

120

Stockwell Fever 6 March 1871

1,858

not known

(after reopen­ing for  smallpox)   294

Totals:

16,459

4,792

235

TABLE 2

Metropolitan Workhouse Infirmary Accommodation in the late 1870s

Parish in which the
Infirmary was situated

Parish to which the
Infirmary belonged

Number of patients for whom accommodation was
provided

Battersea Wandsworth and  Clapham

38o

Bromley (Middlesex) Poplar and Stepney

586

Camberwell Camberwell

232

Chelsea Chelsea

272

Chelsea St. George’s

776

St. George in-the-East St. George in-the-East

307

Greenwich Greenwich

247

Hackney Hackney

322

Islington Holborn

617

Islington Islington

540

Kensington Kensington

438

Kensington St. Marylebone

744

Lambeth Lambeth

622

St. Leonard, Bromley, and Mile End Old Town London, City of

645

Newington St. Saviour

1,010

Plumstead Woolwich

213

Rotherhithe St. Olave

18o

Shoreditch Shoreditch

470

St. Pancras Strand and Westminster

523

St. Pancras St. Giles and St.George   (Bloomsbury), and St. Pancras

281

Whitechapel Whitechapel

689

Total: 10,094

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