I

THE next eight years saw radical changes in the epidemiological work of the MAB. These stemmed mainly from the revelation of deficiencies in the 1867 Metropolitan Poor Act which left the Board unprotected from the exigencies of common law; and from the investigations which ensued concerning the local impact of the MAB hospitals, their limitations and the demands made upon them. From these emerged improved measures of smallpox control and the prospect of escape from the grip of the poor law.

Despite the recession in the recent epidemic, the Board’s isolation hospitals received some 3,600 smallpox patients during the years 1879 and 1880. During this period the number of London deaths from the disease reached nearly one thousand. This level of mortality was attributed in the main to three factors: the lax administration of the metro­politan public health authorities; legislative anomalies which limited the class of patient legally admissible to the MAB hospitals; and the apparent disinclination of the govern­ment to remedy these defects.

The local authorities were constantly asking the MAB to accept their infectious non-pauper patients, and when informed by the Board that it was not legally empowered to do this, they suggested that the MAB should set up a separate department for the reception of such cases. On soliciting the views of the metropolitan vestries and district boards, the MAB learned that all but four were in favour of such an arrangement. A summary of these replies was sent to the Local Government Board, with the suggestion that an investi­gation should be made into the causes and conditions which had protracted the recent smallpox epidemic. No reply was received, but the Poor Law Amendment Bill, introduced into Parliament in the summer of 1879, included the provision—inserted three years before into the aborted Public Health (Metropolis) Bill—for empowering metropolitan sanitary authorities to contract with the MAB for the reception of their non-destitute patients. The Asylums Managers, who had not been consulted beforehand, represented to the Local Government Board, as they had done repeatedly in the past, that a more precise and obligatory directive to the local authorities was required in order to ensure that adequate provision could be made for their patients. Beyond an acknowledgment, no further notice was taken of the Managers’ protest, and the permissive provision passed into law.

Responsibility for the destitute was clearly laid down in numerous statutory instru­ments under the poor law, but there was some ambiguity concerning the legal obligations of local authorities towards their independent poor when sick. Infectious non-pauper patients were not admissible into the sick wards of a workhouse except upon a Justice’s Order under the 1875 Public Health Act. However, if an infectious patient, though not utterly destitute, was without the means of obtaining medical attendance and nursing, it devolved upon the poor law authorities to supply `the requisite relief’. If the patient had the necessary means and required to be removed to a hospital for isolation only, it devolved upon the sanitary authority, and not upon the guardians, to provide the accommodation. But, if the means of that patient became exhausted while he was isolated and the sanitary authority was unwilling to bear the cost of his maintenance in hospital, the ‘non-pauper patient’s new state of destitution obliged the guardians to play their role under the poor law and to reimburse the sanitary authority from the poor rate. This procedure—appli­cable to voluntary and local authority hospital admissions—varied slightly in the case of admittance to the MAB institutions, since no payment was exacted on entry, even if the patient was in a position to pay. The poor law guardians of the patient’s locality were notified, and it was for them to use their legal machinery to investigate his means and to recover maintenance costs where possible. In the stress of an epidemic, it was obviously impossible to discriminate between the non-destitute who could not afford medical necessities and those who could afford them and required isolation only. Practical diffi­culties thus impeded the satisfactory outcome of contractual or statutory provision for the care of the non-destitute suffering from infectious disease.

Having already estimated, by direct enquiry or by census returns, that between 70 and 90 per cent of their patients during the two earlier epidemics were not habitual paupers, the Asylums Managers made another attempt to assess the proportion of non-pauper admissions in 188o, when there was a recrudescence of smallpox. Local guardians were asked to report on the cases in which they had managed to recover all or part of the main­tenance costs. On this basis, the proportion of ‘non-paupers ‘ was very low, ranging from 0.5 to 3.6 per cent, according to the locality of the hospital. Nevertheless, the proportion of patients who had not previously received public assistance was still substantial, varying from 78 to 93 per cent in the different institutions. In the existing state of the law, however, once these self-supporting citizens entered the MAB hospitals for isolation and treatment, they were relegated to the pauper class and deprived of their civil rights. So far as the sanitary authorities were concerned, the law allowed them every means for evading their responsibilities. The only non-pauper cases which the MAB hospitals were legally em­powered to accept, apart from the `emergency’ cases, were those for whom contracts were concluded at the voluntary instigation of the local authorities under the 1879 Poor Law Act. But, as the current irregular practices involved them in no financial commit­ments, the sanitary authorities made no contracts. The MAB hospitals, therefore, con­tinued to treat, without statutory sanction and as a charge on the poor rate, a substantial number of patients who were legally the responsibility of the local authorities. Although the Board’s position concerning this class of patient was slightly modified in legal theory, in practice it remained unchanged.

II

While the 1879 Poor Law Act was ineffective in extending the availability of the MAB hospitals to patients outside the pauper class, it nevertheless gave to the Board new powers to provide for patient transport. As early as 1818, a Select Committee had recommended a system for conveying infectious patients in the metropolis which would prevent the use of coaches or sedan chairs’.’ Apart from the use of a hand litter by the ‘House of Recovery’ (as the London Fever Hospital was then called), no special means for removing the infectious sick existed in the metropolis, and the spread ofinfection remained unchecked. By 1867, nothing had been done to improve the situation. When the Metropolitan Poor Bill was being debated, it was proposed that provision should be made in the Bill for the allocation of a ‘ hospital carriage’ to each of the projected asylums’, but Gathorne Hardy expressed his belief that `this most excellent suggestion’ would be carried out under the clause providing for `all necessary fixtures, furniture and conveniences’. His successors, it seems, had not shared this assumption. Since the opening of the MAB hospitals, poor law patients had been moved in vehicles owned or hired by the parochial authorities. Old street cabs were frequently used and when not required these were often kept in mews alongside traders’ carts. On occasion, the guardians arranged for discharged fever patients to be brought back from hospital in vehicles which had been used for smallpox admissions. Sometimes relatives accompanied the patient and made the return journey by public transport. For nearly a decade, the Asylums Managers protested to the guardians and to the central authority concerning these practices. Although the Board had refrained from suggesting that it should operate an ambulance service of its own, the Local Government Board made it clear that the MAB had no legal right to undertake the conveyance of the sick. In reply, the MAB described the unfortunate conditions which resulted from the lack of an organized system of patient transport during the current prolonged epidemic, and concluded:

. . . This is not the way to stamp out the epidemic. . . . Unless more energy is dis­played, the unspeakable miseries inflicted by it, not only on individuals but on whole families, will continue to be a scandal to the metropolis.’

A year later, the MAB was empowered under the 1879 Poor Law Act `to provide and maintain carriages suitable for the conveyance of persons suffering from any infectious disorder ‘.

III

Such hopes of improvement in the Board’s status as the 1879 Act had raised were over­shadowed at this juncture by anxiety concerning the outcome of the Hampstead Hospital law suit. In May 1879, however, after a three days’ hearing, the Queen’s Bench Division made an order dissolving the injunction to close the hospital and granted a new trial, with a direction that the costs of the first suit—in November 1878—should abide the result of the new trial. By this time, Sir Rowland Hill was in failing health and in August 1879 he died His son, Pearson Hill, rallied the Hampstead plaintiffs, who appealed against the granting of a new trial. The Asylums Managers, on their part, appealed against the payment of costs. On 18 December 1879, the Court of Appeal set aside the ruling of the Queen’s Bench Division and issued an order dismissing the Hampstead plaintiffs’ appeal if, within a specified time, the Board paid the costs of the first trial. If that were not done, the plaintiffs’ appeal was to be allowed. The following April, another writ of injunction was served on the Board, restraining the use of the Hampstead Hospital for the treatment of infectious diseases. The Asylums Managers then brought the order of the Court of Appeal to the House of Lords, where it was decided that the appeal should be heard on the question of the right of the Board, in point of law, to maintain the Hampstead Hospital in its existing state.

The appeal was heard the following January, and judgment was given on 7 March 1881. On behalf of the Asylums Board, it was claimed that the smallpox hospital in Hampstead had been erected near the properties of the respondents under statutory authority. The question raised was whether the appellants were not, in law, completely protected from liability. The 1867 Metropolitan Poor Act was invoked as evidence that the MAB had been constituted a public body by statute; that its duties were of a public nature; and that it was commanded by the Local Government Board to perform them.’ Everything the Asylums Board had done had been done under statutory authority; every detail in the 1867 Act, it was asserted, showed that the legislature had contemplated the carrying into execution of a public work for the health and safety of the community. It was, therefore, impossible to apply to this case considerations of possible private inconvenience that might occur in the execution of that work. It was to be assumed that the legislature had antici­pated such inconvenience and determined that it must be endured in consideration of the great public benefit that would result from it. Counsel for the respondents based their case on the fact that the 1867 Act conferred no compulsory powers on the Asylums Managers and contained no authority to act if action constituted a nuisance. The Lord Chancellor, Lord Selborne, re-affirmed that the Metropolitan Poor Act, so far as it related to an infectious hospital, contained nothing mandatory or imperative. He pointed out that the class of poor persons for which the hospital was to be provided was not specified in the Act. No compulsory power was given to acquire land for any asylum purposes. Included in the section of the Act specifying the objects chargeable to the Common Poor Fund was, he admitted, a reference to ‘patients suffering from fever or smallpox’, but, except for this and the fact that the general category of sick’ necessarily included patients suffering from any kind of disease, there was no provision in the Act relating to infectious disorders. ‘If express words, or necessary implication and intendment, must be shown in order to authorize the Poor Law Board or any managers of an asylum to create a nuisance in the exercise of the discretionary powers given to them, I can find none in this statute’, declared the Lord Chancellor. The only sense in which the legislature could be properly said to have authorized the exercise of any of these powers, he argued, was that it had enabled the Poor Law Board to order certain things to be done, and the Asylums Managers to carry out their instructions ‘if, and when, and where, they could obtain by free bargain and contract the means of doing so’. If the legislature had authorized some compulsory interference with private rights of property for the purpose of establishing the Hampstead Hospital for the treatment of infectious patients and had made provision for compensating those who might be injuriously affected by it, the case might have been judged otherwise. As the law stood, neither the Poor Law Board nor the MAB had any statutory authority to do anything which might be a nuisance to the plaintiffs without their consent. The Lord Chancellor, therefore, moved that the appeal should be dismissed with costs.

In May 1882, the Law Lords heard the appeal concerning the rule for a new trial. This was unanimously granted. About £40,000 of ratepayers’ money had been spent on litigation. Nothing had been achieved except a ruling that a new trial should take place. This was to be based, not on the statutory rights of the Board to create a nuisance, but on the question of fact—whether or not the treatment at the hospital of two to three hundred patients constituted a nuisance to neighbouring residents. By this time, these conditions no longer existed. The Hampstead Hospital had been closed since the end of 1878.
During the autumn of 1882, a serious outbreak of scarlet fever prompted the Asylums Managers to take legal advice concerning the possibility of using the Hampstead Hospital for fever cases. It was opened; and Mr. Pearson Hill immediately sued the Board for damages, once again. There were now two actions pending. £20,000 had originally been raised by the plaintiffs with the support of the Hampstead vestry, but by now the guarantee fund was £6,000 in debt and further appeals for public support were unproductive. As legal costs of both sides had fallen directly and indirectly on the residents of Hampstead, they finally threatened the Local Government Board with refusal to pay rates if litigation continued, and appealed to both parties to call a halt to legal proceedings. A settlement was effected out of court in 1883. The conditions included the purchase by the Board, from the executors of the late Sir Rowland Hill, of his residence, Bartram House, and adjoining property for £13,000; the payment of £9,000 in full settlement of the two pending actions, and of £500 towards the cost of constructing an entrance at the opposite end of the hospital site and closing the approach from Haverstock Hill. There was also an undertaking to limit the number of smallpox cases under treatment in the hospital at any one time to forty.
IV
While the Hampstead case was sub judice, the Managers decided to defer the acquisition of new hospital sites, although the appearance of numerous malignant smallpox cases early in 188o had presaged another serious outbreak. The MAB strongly urged the Local Government Board to take statutory action to enable it to deal with a possible epidemic without being hampered by the deficiencies of the law. This plea was met with the suggestion that the Managers might erect huts or tents in the vicinity of their mental institutions in Kent. A canvas camp was accordingly established at Darenth. Such cases as could tolerate the journey were collected at the Board’s Deptford Hospital and taken by road in hired four-in-hand horsed vehicles, which covered the distance of eighteen miles in three hours. This arrangement began in May 1881. Although third- and fourth-rate cities in America already had regulated ambulances in use, this was the first occasion on which a systematic transport service for hospital patients had ever been operated in London.

The largest number of smallpox cases which could be treated at the Darenth camp was 64o. There came a time when no more could be admitted. Sir Edmund Hay Currie, Vice-Chairman of the Board, had a brilliant idea. Two old wooden battleships were chartered from the Admiralty. A 90-gun ship, the Atlas, for acute cases, and a 50-gun frigate, the Endymion, for administrative purposes, were adapted at a cost of £11,000, and moored off Greenwich. The removal of patients to the ships direct from their homes and work­houses was then organized. A house in London Fields, East London, was rented to serve as an ambulance depot. A resident staff was installed; horse ambulances were provided; and the station was connected by telephone direct with the Board’s head office. Fierce local opposition followed. A writ was issued against the Board for recovery of possession. This was successful, but an arrangement was arrived at to enable the station to function until alternative accommodation could be found.

It was now mid-1881, and the epidemic, which had raged for nearly a year, had reached alarming proportions. The Board insisted on getting its legal position regularized. In view of the unfavourable House of Lords judgment in the Hampstead case in March 1881, the Managers renewed their representations to the Local Government Board and pressed for the immediate introduction of a Bill to define, and if requisite enlarge, the powers of the Asylums Board to enable it to perform in the present and any future epidemics, in a successful and satisfactory manner and without molestation, the duties which the Act of 1867 contemplated it should perform. In reply, the Managers were asked to suggest specific amendments to the law which, in their judgment, would be best calculated to resolve the difficulties in which they were placed. The Managers suggested that an Act should be passed making it compulsory for the Asylums Board to provide hospital accom­modation for all persons in the metropolis suffering from disease, infectious and other­wise. . .’. They also urged that legislation should be introduced to ensure that `the same consequences should follow from the acts of the Asylums Board as if the hospitals now in existence, or to be erected in the future by the Board, had been expressly sanctioned by Act of Parliament.’ Finally, the Asylums Managers emphasized the need for legislation which would make it obligatory for all cases of infectious disease to be notified to local authorities throughout the country. The Local Government Board did not reply.

Meanwhile, encouraged by the decision in the Hampstead case, a number of Fulham residents took steps to prevent the Board’s Fulham Hospital from being used for smallpox. An injunction was applied for in August 1881 but was refused. On appeal the following month, an interlocutory injunction was granted restricting the use of the hospital to small­pox admissions from a mile radius. The judgment was appealed against by the Board. But it was affirmed, despite evidence prepared by the medical superintendent to demonstrate from over 150 histories of cases occurring within a mile of the hospital, that infection was derived from contact with non-isolated cases and not from the hospital by aerial convection. Shortly afterwards, the Board was pressed for fever accommodation and directed that scarlet fever cases should be admitted to the Fulham Hospital. Again the Board was sued for damages. The case was settled out of court for £6,000.

Concerned by now at the cost and inconvenience of public opposition, the Local Government Board instructed its inspector, Dr. W. H. Power, to make a detailed study of the incidence of smallpox in the vicinity of the Fulham Hospital. From his conclusions, it appeared that when smallpox cases were freely admitted into the hospital, the number of houses invaded in a special area within a mile radius of the hospital was four times greater than in other parts of the adjoining districts; and that, in the area itself, a regular and progressive increase of invasion existed as the centre of infection—the hospital—was approached. Such being the case in connexion with one hospital, it was assumed that it was the same for the others. The hypothesis on which Dr. Power had worked was that infection had been conveyed through the air. As he dealt only with statistics of incidence and did not concentrate to any extent on human lines of communication, his conclusions did not prove one way or the other how the infection was conducted.

V

The Asylums Board had reached a critical stage in its development. Its hospitals at Hamp­stead and Fulham were severely restricted under legal injunctions, and similar proceedings were likely at Stockwell, Deptford and Homerton. As the law now stood, the hospitals existed merely on the sufferance of the neighbourhoods in which they were located, and might be summarily closed at the height of an epidemic, leaving the disease to run its course uncontrolled. The health of the community was being endangered by an insufficiency of isolation accommodation which it was the statutory duty of the Board to provide. Yet the efforts of the Managers to carry out that duty were paralysed by the inadequacy of the powers conferred upon them by the legislature. Although thwarted by public opposi­tion and official apathy, the Managers were in no doubt that their thankless task must continue.

At a plenary meeting of the MAB at the end of October 1881, Dr. Brewer rallied his colleagues to take the firmest possible line with the Local Government Board. Statutory action had to be taken, and taken without delay. Since the beginning of the year, the most horrible of all the ministers of death’ had been stalking the streets of London uncontrolled,and the number of the stricken was mounting day by day.’ A letter from Dr. Brewer was addressed to the central authority insisting that

. . . the time has arrived when the general purposes committee of the Asylums Board should seek an interview with the President … and ascertain whether the Local Govern­ment Board is prepared to take steps and, if so, what steps to enable the Asylums Managers to carry out their duties according to the spirit and intention of the Metro­politan Poor Act under which they were constituted. . .

Sir John Lambert, who had played a substantial part in assisting Gathorne Hardy to draft the 1867 Act, was now in the difficult position of having to advise his President, J. G. Dodson (later Lord Monk Bretton), on how to remedy its defects. The only possible way out of the impasse appeared to be the appointment of a Royal Commission. A fort­night after receiving Dr. Brewer’s letter, Sir John Lambert replied that

. . . the Government, having in view the difficulties attending this subject, have advised the issue of a Royal Commission to enquire into the whole matter and advise as to what further legislation is required. . . .

Dr. Brewer never learned of this significant development. He died suddenly on 3 November 1881, four days following the despatch of his letter. After leading the Board valiantly through fourteen years of vicissitudes, he was deprived of witnessing this turning of the tide.

The Commission, which included a number of eminent medical men, was appointed in December 1881. The main items in its terms of reference were: the nature, extent and sufficiency of isolation hospital provision by the MAB and the local authorities; the relative advantages of centrally- or locally-provided isolation accommodation; the expedi­ency of continuing the existing isolation hospitals; the protection of the community; the operation of relevant legislation; and the protection of hospital authorities from liability to legal proceedings. The Asylums Managers took a prominent part in the sub­mission of evidence.

The report, a significant contribution to the literature of public health, was presented to Parliament in August 1882. Reviewing the past, the Commission declared despairingly that for many years London had been grappling with an evil influence’ which ‘is fitfully and sensibly gaining ground. . . .’ Its main concern was the alleged ability of the Fulham Hospital to spread infection in the neighbourhood, and the possibility that the Board’s other smallpox hospitals shared this power. It was accordingly urged that smallpox should be treated in isolated positions on the banks of the Thames or in floating hospitals and not in populous areas. Between fifteen hundred and two thousand smallpox beds, it was estimated, would be required for treatment outside London. Severe cases, which could not be moved so far, should be accommodated in the Board’s London fever hospitals in a few small, isolated wards of annular design, rigorously separated from the fever wards and the administration. In any case, no urban institution should treat more than forty smallpox patients at any one time. The hospitals hitherto used for smallpox cases could provide about fifteen hundred additional fever beds; while a similar number of beds for convalescent fever cases in the country was also recommended. Concerning the legal position of the Asylums Board, the Commission urged that the power of arresting the Managers’ opera­tions by injunction should be removed; and that powers of compulsory purchase should be conferred upon the Board. The Managers’ perennial plea for general compulsory notification of all infectious cases was also affirmed by the Commission. All London isola­tion hospitals, it was suggested, should be under the control of a central hospital authority composed for the most part of the existing MAB and reinforced by representatives of the local authorities. This body should also maintain a central ambulance service. Although unwilling to accept definitely the conclusions of the Fulham Hospital enquiry, the Com­missioners evidently based their recommendations upon them. However, despite further detailed studies, they reached no definite conclusions concerning the means of spread, and merely recapitulated the reasoning of those who believed in aerial convection and of those who inclined to the hypothesis of contact infection. Both means, they cautiously recommended, should be eliminated in a sound administration.

The Commission’s most fundamental proposition was that the provision of hospital accommodation for infectious diseases should be entirely disconnected from the poor law and treated as part of the sanitary arrangements of London. Emphasizing the view that preventive practice and poor law principles were incompatible, the Commissioners affirmed that provision for the infectious sick was

. . . not to be treated solely with reference to the periodic relief of the indigent sick but as a question also of public safety, with primary reference to the extirpation of epidemic infectious disease, subject to the obligation of doing all that humanity demands for the benefit of individual sufferers. . . .

Particularly noteworthy was the Commission’s recommendation that poor law patients and others should be treated alike. Separate wards might be made available for paying patients, but the Commissioners were doubtful whether, in cases of ordinary accommoda­tion, payment should be claimed even from those who could afford to pay without difficulty. This was the first time that Parliament had been presented with a scheme of public hospital provision for the free use of all in need of treatment, irrespective of class or ability to pay.

VI

Immediately following the issue of the Royal Commission’s report, the MAB took steps to carry into effect the internal reforms suggested. These included the construction of separate hospital entrances for patients and tradesmen; longer periods off duty for nurses; and stricter visiting and disinfection regulations. But the Board could do little else until the central authority initiated statutory action. Three months passed without any move on the part of the Local Government Board. Becoming restive, the Managers urgently enquired what steps it intended to take on the Commission’s report. In reply, the MAB was informed that the Government cannot at this time undertake to state what measures they may be able to bring forward during the next session of Parliament ‘. The Asylums Board thereupon directed its general purposes committee to seek an interview with the Prime Minister, Mr. Gladstone, with a view to discussing the advisability and practicability of the MAB taking immediate steps to put into effect the Commission’s recommendations concerning the provision of country hospitals and the organization of London ambulances. A communication was despatched to the Prime Minister at the end of 1882 emphasizing the Board’s difficulties—the impediments, the harassing conditions, the heavy costs to ratepayers, the absence of statutory protection, the lack of local authority hospital pro­vision and, finally, `the very unsatisfactory announcement’ made by the Local Govern­ment Board. Voicing the Managers’ sense of urgency, the MAB communication concluded:

. . . It is impossible to conceive any question more pressing or requiring more immedi­ate consideration, or one more likely to be fraught with serious and complicated consequences than that which the Asylums Board desires to have dealt with, seeing that it affects not only directly the health and lives of a large portion of the population of this vast metropolis, but also indirectly the health and lives of the community at large.

In January 1883 , a member of the Prime Minister’s staff was directed to reply that:

. . . Mr. Gladstone regrets that he is not able to receive a deputation on a matter which is beyond the province of his own department. Indeed, he could not undertake at the present time to receive any deputation whatever, having been enjoined to abstain from all business other than that which is absolutely necessary.

Mr. (later Sir) Edwin Galsworthy, who had succeeded Dr. Brewer as chairman of the MAB, insisted early in February 1883 on seeing the President and senior officials of the Local Government Board. At the close of the interview, he was under the impression that the Managers’ problems had been understood and that legislation would be promoted forthwith to safeguard their position. He asked that the outcome of the discussion should be embodied in a confirmatory letter, but when he received this communication, it revealed an insufficient appreciation of the essence and magnitude of the difficulties dis­cussed. Concerning legislation, the Local Government Board referred to a Bill ‘promised during the current session for the extension of municipal government to the metropolitan area’ and assured the chairman that ‘it would not interfere with the action of the MAB in providing additional accommodation. . .  The only question affecting the MAB which might arise in connexion with the Bill was whether the care and management of patients of the non-pauper class should not be clearly shown to devolve on the sanitary authorities rather than upon the Asylums Board’.’ This was quite irrelevant to the recom­mendations of the Royal Commission, which had envisaged one central hospital authority in London for infectious patients of all social classes. In regard to additional accommoda­tion, however, the Local Government Board agreed that floating hospitals might be established in the Thames some distance down river for the less acute smallpox cases. Buildings for convalescent cases, it suggested, could be erected on land at no great distance from the ships which could probably be secured without compulsory powers of purchase’. Concerning the conveyance of patients, the Local Government Board assented to Mr. Galsworthy’s suggestion that the MAB should acquire paddle steamers and trans­form them into river ambulances. In the last resort, the central authority agreed to consider legislation for the compulsory purchase of riverside sites for wharves.

The Asylums Managers were not satisfied. The acquisition of a few hospital ships would not provide the 1,50o fever beds and 2,000 smallpox beds recommended by the Royal Commission. However, they began their extra-metropolitan system of smallpox treatment by purchasing from the Admiralty the Atlas and the Endymion, which had been on charter. In addition, they acquired the Castalia, a disused cross-Channel steamer, and equipped her as a hospital ship. The floating hospitals were moored in Long Reach, some seventeen miles below London Bridge. In addition to the 350 beds which the ships would provide, and the 200 beds for severe cases left in the five London hospitals, at least another 1000 smallpox beds would be needed outside the metropolis to meet future epidemics. Additional land was therefore purchased at Darenth and prepared with roads, gas and water. It was planned to erect ten 100-bed blocks at a rate of £100 per bed. The cost of acquiring and equipping the hospital ships totalled some £96,000, a rate of nearly £275 per bed. Next, two paddle steamers were bought for £10,000 and fitted up as ambulance ships. A pier was constructed at Long Reach and wharves were established at Blackwall, Rotherhithe and Fulham at a cost of £42,000. Each wharf was equipped with an examination room, an isolation ward for patients found unfit to make the journey, and other wards for cases of doubtful diagnosis. Plans were also put in hand for extending the land ambulance service which had been inaugurated during the 188o-81 smallpox epidemic. Finally, a site was acquired at Winchmore Hill in north London on which to erect a 500-bed convalescent fever hospital. Like the Darenth project, this was designed for partial opening to meet the state of demand.

VII

In view of the difficulties which still beset the Board whenever it attempted to acquire land for a hospital, an ambulance station or a wharf, the Asylums Managers continued to press for compulsory powers of purchase. The Local Government Board was now per­turbed, however, with the prospect of an outbreak of cholera. When the Managers were approached concerning the reception of cholera patients, they firmly declined to accept an undefined responsibility in view of their experience with other infectious diseases. They made it clear to the Local Government Board that they did not intend to relieve the sanitary authorities of their responsibilities in this connexion unless their own commitments were precisely laid down. It was finally agreed that the MAB should be responsible for finding accommodation for up to fifty patients in the early stages of an outbreak. There­after, each local authority was to be responsible for providing its own hospital accommoda­tion. On this occasion the views of the Asylums Board were respected. A Bill was introduced setting out the arrangement agreed upon and decreeing that the MAB should be deemed a local authority under the Diseases Prevention Act of 1855 for the purpose of providing for cholera patients.

For the MAB, these provisions were, however, the least important of the innovations introduced by the new measure—the Diseases Prevention (Metropolis) Act of 1883. The Board was at last endowed with compulsory powers of purchase. Although these were limited to the acquisition of landing places for the ambulance ships and did not extend to hospital sites, their conferment represented a break-through in the legislative dilemma. Furthermore, the Act affirmed that no person should suffer disability or disqualification by reason of admission to an MAB institution for infectious diseases. MAB hospitals, nevertheless, remained poor law establishments, administered by a poor law authority and maintained out of the poor rates, but the stigma of pauperism had been removed from patients. These two provisions represented the only statutory implementation to date of the numerous recommendations made in the Royal Commission’s report. Nothing was included concerning compulsory notification of infectious disease. The Act was valid for one year only, but was renewed annually for another eight years. It would seem that qualms existed at the Local Government Board lest the long-term acceptance of this measure might undermine the punitive principles of the poor law.

VIII

Before the Asylums Board was able to complete its building programme, smallpox again invaded London—the fourth large-scale epidemic since the advent of the MAB. Now that treatment in the Board’s hospitals was no longer considered to be parochial relief, there was an unprecedented demand for admission, despite the liability to maintenance charges which non-pauper patients still incurred. The new site at Darenth was made into a huge hospital encampment in the spring of 1884. Soon it was taxed to the utmost. It was decided that a ‘lady superintendent’ was needed. Dr. Bridges, of the Local Government Board, offered to find a suitable candidate. Miss Isabella Baker, possessed of Nightingalian qualities, had already been induced by him to stand as first woman guardian for Holborn. Again, she responded to his persuasion, and in the summer of 1884, she found herself under canvas at Darenth in the midst of 1,100 smallpox patients from all parts of London. Nothing was ready when she arrived. She described how the patients came pouring in from the ships across the river with their goods and chattels like the children of Israel passing through the Red Sea’. The average number of arrivals was one hundred a day. Everything had to be provided for them, and one of her proud achievements was obtain­ing a separate brush and comb for each patient, a luxury hitherto unknown ‘.

During this epidemic, the Asylums Board was forced by the rapid influx of patients to dispense with all hampering restrictions. Non-pauper cases were accepted on the application of Medical Officers of Health. The only proviso was that a medical certificate should be handed to the ambulance nurse when the patient was collected. Pauper cases were received on the application of any poor law official and admission orders were sought later. In the past, the Asylums Managers had found it necessary to act in advance of legisla­tion, and they were now confident that, as they were serving the best interests of the public, their action would eventually receive statutory sanction. In the earlier development of preventive medicine, growth had nearly always been stimulated by expansion in methods of administration and then followed by legislation in the fulness of time.

In the autumn of 1884, the Board again approached the central authority concerning the situation which had resulted from the permissive powers of the local authorities to contract with the MAB for the reception of infectious non-pauper patients under the 1879 Act. Up to this time, no vestry or district board had entered into any such agreement with the Asylums Board. Patients above the pauper class were being admitted to the MAB hospitals on public health and humanitarian grounds. The Asylums Board strongly represented to the central authority that explicit legal sanction should now be given for the admission of all such patients. The practical effect of section 7 of the Diseases Pre­vention (Metropolis) Act of 1883, which abolished the pauper stigma, had been to remove the distinction between pauper and non-pauper cases. The Asylums Managers were informed in reply that no Local Government Board order was necessary to enable them to contract with the local authorities, but that any arrangement entered into would require central authority sanction. The Asylums Board thereupon submitted to the Local Govern­ment Board the draft of a circular which it proposed to address to the metropolitan vestries and district boards. This contained an offer to admit local authority patients into MAB isolation hospitals at a fixed fee of four guineas a case. This would be chargeable to the vestry or district board and recoverable from the patient, as the local authority saw fit. The Board made it clear that it could not undertake to make any class distinction in the treatment of patients in the isolation hospitals. The Asylums Board was informed by the Local Government Board that it could not make an open offer in this way and that it would have to enter into a separate contract with each authority. Thereupon, the MAB sent to each of the forty metropolitan vestries and district boards a form of contract, drawn up on the lines of its circular, and invited comments. Not one authority agreed uncondi­tionally to enter into a written agreement. Fourteen agreed in principle, with modifications ; fifteen disapproved; seven offered alternative schemes; and four did not reply. Most of them questioned the justice of exacting a fee and suggested that expenses should be a charge, either on the Metropolitan Common Poor Fund, or on a sanitary fund set up for the purpose. The Asylums Board sent a summary of these replies to the central authority, and declared that it could take no further action in the matter ‘unless and until the Local Government Board shall see fit to obtain from Parliament such additional powers as will render compulsory, instead of optional, the conditions of section 15 of the Poor Law Act of 1879’. No reply was received to this communication.

IX

So far the MAB had failed to move the central authority to secure its legal recognition as an isolation hospital authority for the whole of London. But it could look back from 1886 over two decades of substantial achievement. It now had 1,900 fever beds in its six London hospitals—the North-Western (Hampstead), the South-Western (Stockwell), the North-Eastern (Homerton), the Western (Fulham), the South-Eastern (Deptford) and the Northern (the new convalescent hospital at Winchmore Hill). On the Darenth camp site and the nearby Gore Farm estate, plans were well advanced for the provision of one thousand smallpox beds in permanent buildings to supplement the accommodation of the hospital ships, now modernized with electrical equipment. With its characteristic pioneer­ing spirit, the Board had never hesitated to break new ground. The banishment of large numbers of smallpox patients from populous areas to hulks on the river was a revolutionary experiment. It was as yet too soon to judge whether it would result in a significant advance in pestilence control. Since the inauguration of its ambulance service in 1881, the Board had established three permanent stations adjoining the hospitals at Deptford (1883), Fulham (1884) and Homerton (1885), at a total cost of £25,000. These depots were served by resident staff and equipped with ambulance vehicles and horses. Nurses for smallpox cases were quartered at the stations, but for fever cases they were drawn from the staff of the adjoining hospital in order to avoid cross-infection. The stations were maintained in readiness to transport patients at any time of the day or night from any part of London on receiving orders from the MAB head office in Norfolk Street, Strand, with which they were linked by direct telephone lines. The advent of the telephone in the early 1880s had materially increased the efficiency of the Board’s isolation hospitals. It became possible to arrange more promptly than previously for the removal of patients; and in times of pressure, the MAB head office, which was also in telephonic communication with all its institutions, was able to direct the allocation of patients to the nearest hospital with vacant beds. The Board’s centralized ambulance service was still the only organized system of patient transport in London, and its efficiency had already stimulated demands for a similar public service for the conveyance of accident and other cases in the capital.

Since the MAB hospitals were first opened, they had treated upward of 57,000 small­pox patients and borne the brunt of four serious epidemics. Some 30,000 fever cases had also passed through the Board’s hospitals. Of these, about 6o per cent were scarlet fever patients and the remainder were chiefly typhus and enteric cases. By now, the MAB hospital system for infectious diseases had become accepted as an essential part of London’s public health administration. But, at this very juncture of relative stability, forces were afoot to reform the municipal government of the metropolis. For the MAB, the future was enigmatic, but the past had witnessed a definite, if limited, step forward in preventive medicine.

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