England’s First State Hospitals for Infectious Diseases

THE Metropolitan Asylums Board embarked on its pioneering venture on 22 June 1867, when its sixty members met at the headquarters of the Metropolitan Board of Works in Spring Gardens, near Admiralty Arch. These premises – `cavernous and tavernous’, as Lord Rosebery later described them—were lent during weekends to the Asylums Board until it was able to find accommodation of its own. In accordance with the 1867 Act, fifteen members of the new hospital authority had been nominated by the Poor Law Board and the remaining forty-five had been elected by the metropolitan guardians, on the instructions of the Poor Law Board, to represent the thirty-nine unions and parishes ‘included in the Metropolis, as defined by the Metropolis Management Act, 1855. This comprised the thirty-six registration districts used for the census of 1851. The Registrar-General’s district had its origin in the Bills of Mortality which, since the sixteenth century, had been kept for parishes in the City and neighbouring populous areas, largely so that the Court and others might be warned of the coming of the plague and seek a safer retreat. As London grew, the Bills had been extended to more and more parishes, and when the Registrar-General was appointed, he continued the practice, using the area covered by the Bills as the basis of his metropolitan district. In 1867, there were thirty-nine metropolitan poor law districts. The six largest were allowed to have two representatives on the MAB, while the remainder each had one. By 1871, these districts had been reduced to thirty as a result of re-grouping following the dissolution of most of the ‘sick asylum districts’ referred to in Chapter 2. This new ‘ Asylum District’, covering about 118 square miles and embracing a population of some three millions, was identical with the area within the jurisdiction of the Metropolitan Board of Works, and subsequently of the London County Council.

At this first meeting, a chairman was elected and five standing committees were set up. Of the five standing committees first appointed three were for the management of the three classes of patients —those suffering from`fever’, smallpox, and insanity—and the other two were general purposes and finance committees. A close contest resulted in the office of chairman being conferred on Dr. William Henry Brewer, JP, MD, MRCS, a coroner and one of the two representatives of the union of St. George’s, Hanover Square, in John Stuart Mill’s parliamentary constituency of West­minster. For the next fourteen years, the most crucial in the Board’s history, its fortunes were to depend in large measure on the dynamic leadership of its first chairman.

For some months, the Board deliberated from Spring Gardens before moving into No. 6, Westminster Gardens, SW1, where it had acquired four rooms at a rent of £250 a year. The Poor Law Board, when notified, curtly reminded the MAB that such an arrangement was irregular without prior sanction. This early repression of the Board’s aspirations towards a measure of autonomy presaged the relationship which was to develop during the next few years between the Asylums Board and the central authority. The MAB was recruited from an elite accustomed to arbitrary leadership, free competition of ideas and opinions, and intolerance of all but a minimum of State interference in the social and economic life of the country. Now, for the first time, a central department was entering the field of civilian hospital management, hitherto the monopoly of voluntary effort. Despite its extended powers for the purpose, the Poor Law Board was ill-equipped for its new role, since public health was entirely outside its province.

At the outset, the MAB was endowed with neither charter nor terms of reference beyond the provisions of the 1867 Act and the brief Poor Law Board order constituting the Metropolitan Asylum District. The members of the new hospital authority assumed that they would be serving as governors of the projected establishments and that they would be granted ample latitude to govern, but the tone of the central authority’s communi­cations, in which they were referred to as ‘Managers’ left no doubt that their role was in­tended to be of a purely executive nature and subject to detailed control from Whitehall.

Undaunted, the pioneers began to study the fundamental problems of siting and design­ing the new institutions. For the fever and smallpox hospitals, they aimed to select localities which would be easily accessible to patients from every part of the capital, but without compulsory powers of purchase this was not easy. Concentrating on the neighbourhoods of Regent’s Park, Victoria Park and Clapham Common, the Board eventually found three sites of about eight acres each in Hampstead in the north-west, Homerton in the north­east, and Stockwell in the south-west, at prices ranging from £12,000 to £15,000. It was decided to build a 200-bed fever hospital and a 1oo-bed smallpox hospital on each site, with a view to providing for an estimated annual intake of from 4,200 to 4,500 `fever’ cases and from 2,600 to 3,200 smallpox cases. On submission to the Poor Law Board, however, these projects were severely pruned, and it became necessary to limit the building at Hampstead—on the property known as ‘Old Bartrams’ off Haverstock Hill—to one fever hospital for one hundred patients. For mental cases, the Board decided to build two large institutions outside London, one north and one south of the Thames. A site of seventy-two acres was found at Caterham, Surrey, for £6,000, and one of eighty acres at Leavesden, Hertfordshire, for £8,600.

This was a beginning, but obstacles soon intervened. Not least of these resulted from local opposition at Hampstead, where the Board became involved in a dispute with Sir Rowland Hill of postage fame, who owned the property adjoining the MAB hospital site. The true agents of infection were not yet commonly understood and the 3,000-year ­old miasmic theory still persisted. Sir Rowland Hill, with other local residents, fearful of fever-stricken paupers in their midst, sued the Board. The costly and protracted litigation which followed had far-reaching effects, not only for the fortunes of the MAB, but also for the development of public isolation hospitals in the country generally.

Further frustrations followed the submission of hospital plans to the Poor Law Board. These had been selected from designs invited from experienced architects. After retaining the plans for months, the central authority would return them with reduced dimensions and ill-advised criticisms. The Managers became restive. Nearly two years had elapsed since the legislature had sanctioned the strengthening of London’s inadequate defences against pestilence by the erection of infectious disease hospitals for the London poor. To the Managers’ consternation, a communication was received from the Poor Law Board advising them that ‘instead of erecting the whole of the three hospitals immediately, the more expedient course would be to erect only two of them in the first instance’. The Homerton and Stockwell institutions were considered sufficient. Only ‘if further perma­nent accommodation should be found necessary’ was the Hampstead hospital to be built. Supported by medical opinion, the Managers voiced their concern at the unwisdom of this proposal and at the Poor Law Board’s persistent quibbling on points of detail in con­nexion with the plans for the Homerton and Stockwell hospitals. Time-consuming correspondence continued until October 1869, when panic seized the Poor Law Board. The Lords of Her Majesty’s Council had discovered threatenings of a serious epidemic of so-called relapsing fevers in London.

Dr. Charles Murchison, writing in 1862 (A Treatise on the Continued Fevers of Great Britain, Chapter III), described relapsing fever, or famine fever, as a contagious disease chiefly met with in the form of epidemics during seasons of scarcity and famine. It was propagated by over-crowding, and prevailed in the most crowded localities of large cities, and, in the seventeenth and eighteenth centuries, was often confounded with typhus and enteric fever or incipient smallpox. It was characterized by an abrupt onset of feverish symptoms which disappeared about the fifth day. After a complete apyretic interval, the patient relapsed about the fourteenth day, the sickness running a similar course. This might be repeated twice or even five times. Before 1826, relapsing fever and typhus were regarded as modifications of the same disease, but after that date a distinction was drawn between the two. Epidemics of both often occurred simultaneously, the proportion of relapsing cases being greatest at the beginning of the epidemic.

The Privy Council impressed upon the Poor Law Board that ‘this evil can scarcely fail to attain very large proportions unless . . . steps are taken for ensuring that sufficient hospital accommodation may be provided for poor per­sons attacked with the disease ‘. With the MAB hospitals still in embryo, the Poor Law Board appealed in desperation to the London Fever Hospital. The Privy Council reminded the vestries and district boards of the proceedings to be taken by them under the Sanitary Acts’. The Poor Law Board reminded the MAB of its duties under the 1867 Metropolitan Poor Act, and urgently ordered that it should take the requisite steps for providing temporary accommodation to meet the present emergency . . .’

The Asylums Board thereupon convened a special fever committee with full powers to act as considered expedient and necessary. Forthwith a plan was formulated, and on 10 November 1869 it was presented personally by the committee to the President of the Poor Law Board, Mr. (later Lord) Goschen. The committee suggested, and he agreed, that the Asylums Managers should negotiate with the Governors of the London Fever Hospital, Islington, for the erection of a temporary structure in the hospital grounds, the Board to pay rent and the cost of erecting and equipping. The committee impressed upon the President the need for utilizing the Hampstead site in anticipation of a serious epidemic. It lost no time in calling for designs and estimates for a temporary 90-bed structure which could be extended to 180 beds, if required, and erected within one month. Provisional assurances were secured in advance from the Poor Law Board that the requisite orders for equipping and staffing the hospital would be issued as soon as necessary. The Poor Law Board was asked to keep the fever committee informed of the accommodation being provided by the metropolitan poor law unions, while the Privy Council Office was requested to report regularly on the state of the epidemic. Both central departments readily deferred to the demands of the MAB fever committee, which had assumed complete control of the situation. Financial obstacles were removed and loans were made available by the Metropolitan Board of Works.

In December 1869, when it was apparent that the disease was gaining rapidly on the capital and that only two poor law unions had made any attempt to provide isolation accommodation, the M A B fever committee decided to erect the projected temporary hospital at Hampstead. By this time, the London Fever Hospital and the adjacent emergency structure were filled to capacity with over 400 cases, and many of the staff were stricken down. Building operations at Hampstead were speeded up and the fever committee set about staffing the temporary hospital within the month. Almost daily the Poor Law Board urged upon the Asylums Managers the necessity for hastening the completion of the structure. Christmas intervened, and the task of finding nurses and domestic staff at short notice became increasingly difficult. The chairman, Dr. Brewer, a devout churchman, tackled the problem personally. In Newport Market, Soho, in his poor law district, was a vagrants’ refuge managed by nuns of the Anglican Society of St. Margaret. The mother house of the Sisterhood at East Grinstead had been founded in 1855 for the purpose of nursing the poor, and the nuns had considerable experience of fever cases. The East Grinstead Sisterhood, an Anglican religious community of the Society of St. Margaret, founded in 1855 by the Rev. John Mason Neale, was one of several such Orders established about this time for nursing the sick poor. In 1848, the St. John’s Sisterhood, the first purely Nursing Order in the Church of England, was founded. This Order was the first to take over the entire nursing of a London hospital—King’s College Hospital—while a sister Order, the All Saints Sisterhood, performed the same service at University College Hospital. At first Guy’s, then the London and the Westminster Hospitals, were the sources of practical training.  Anglican nuns also nursed at the Chorlton poor law infirmary when it was established in the early 1860s. The practical experience of the nuns after training was gained in nursing the poor in their own homes. The great work, historically speaking, of these nursing Orders was the part they played in bridging the gap at the London hospitals between the ousting of the earlier uneducated, unreliable Sairey Gamp  type of nurse and the establishment of the new type of trained nurses drawn from the better-educated classes.

Dr. Brewer appealed to them for help and they readily responded. In order to maintain their essential community life, they stipulated that all the nursing and domestic staff of the hospital should be members of the Sisterhood. This was eminently satisfactory to the fever committee, and the nuns were engaged at the rates offered to temporary lay workers. The monthly rates of pay offered to the nursing nuns at Hampstead were: matron, £10; head nurse, £3; superintendent of night nurses, £4; ordinary nurses, £2.10s. In one month, the 90-bed hospital had been erected, equipped and staffed. The cost of the temporary structures at Hampstead and Islington had totalled £12,000. On 25 January 1870, the Hampstead Hospital was opened for the reception of patients, the first of whom were Polish refugees from the East End of London. England’s first State hospital was functioning. The epidemic was under control. Upon Old Bartrams Hampstead, site of the first State hospital in this country, now stands the North-Western Branch of the Royal Free Hospital.

Panic at the Poor Law Board now gave place to qualms concerning expenditure. The Asylums Managers were informed that `the salaries at Hampstead appear to be very high.. . . In the London Fever Hospital the salaries for similar services are very much lower ‘. This provoked the Asylums Managers to reply:

. . . Although the salaries . . . are undoubtedly on a liberal scale, the Poor Law Board must remember that the engagements are entirely of a temporary character . . . and the employment is not without considerable personal risk to those engaged. The Managers would be glad to be informed if the Poor Law Board has ascertained whether the London Fever Hospital is able at a lower price to secure the services of servants who prove themselves in all respects efficient for the duties required of them. . . . The Managers believe it is true economy to provide their establishments with thoroughly efficient officers.

The medical press supported the Asylums Managers, and when the Poor Law Board objected to a wage of thirty shillings a month for a hospital kitchen maid, the Lancet recorded with relish the Managers’ unanimous resolve to resign if their views were not respected, and commented:

. . . If the Poor Law Board wish to carry out their control to such details, they had better manage the whole affair. The fact is that the staff at Gwydyr House have been so accustomed to interfering with boards of guardians and have so frequently sanctioned contemptible expedients for saving money, that they have been tempted to try it on with gentlemen of intelligence and common sense, who know how wretchedly every sort of poor law officer is paid and how badly the public is served by them.

No official regulations concerning hospital management existed at this stage and ad hoc orders were issued by the central authority when considered necessary. The MAB fever committee decided that the medical certificate and form of admission prescribed by the Poor Law Board ‘were more detailed than was convenient’, and drastically abbreviated them. When an infectious pauper arrived in a public cab, it reported the incident direct to the Home Secretary and reprimanded the guardians who sent him. The Poor Law Board did not intend the fever committee’s emergency powers to continue indefinitely and impressed upon the Asylums Board that the legislature had intended the central authority to exert active, and not mere nominal, supervision over the new hospital services. The Managers, however, regarded Poor Law Board interference in organizational detail as obstructive and superfluous, and from now on took a firm stand.

In May 1870, the relapsing fever epidemic began to recede. Later in the year, the tem­porary structure at Hampstead was vacated and the London Fever Hospital resumed the reception of pauper cases, pending the opening of the new MAB isolation hospitals, which were still under construction.