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The Development of the London Hospital System,

1823 - 2013

Geoffrey Rivett

homeshaping the systemvoluntary hospitalspoor law infirmariesmedical schoolsfever hospitalsproblems & solutionsshaping the futureInter-war yearsregions & districtsthe EMSBevanhospital developmentrationalisationstringencydistricts to trustsoverview

 

The Poor Law Infirmaries

An excellent website on Poor Law Infirmaries exists, with much detail about individual institutions.  See Peter Higginbotham's web site: www.workhouses.org.uk.

The framework of the voluntary hospital system in London had been established by the middle of the nineteenth century. The hospitals aimed to care for those of the poor who could be restored to honest independence, but for many this was not likely to be possible. The poor but destitute had a second and traditional claim to relief under the poor law, dating back to the 43rd Act of the reign of Elizabeth. Many of the destitute were also sick or infirm. Whilst the hospitals might use moral judgments in determining who were ‘proper objects for charity’, merit had nothing to do with assistance under the poor law. The provident and improvident, the virtuous and the vicious were equally entitled to it. The principles of this relief had evolved over many centuries, and their application varied from area to area. The system was reviewed by the Royal Commission on the Poor Law (1832-4)1 whose recommendations were given substance by the Poor Law Amendment Act of 1834. This was a compromise between central control and local administration by boards of guardians formed by uniting parishes too small to run an independent workhouse efficiently. The formation of the unions was often a matter of contention. Parishes objected to the loss of long standing powers and the existence of private acts in a number of London parishes reduced the authority of central government.

The new principles, established by the 1834 Act, were logical if severe. In theory every detail of the help to be given was laid down by central regulation. The pauper was not to be allowed to enjoy the standard of living attainable by the independent labourer, otherwise he would rely on the guardians for support. The pauper’s lot had to be made ‘less eligible’, both in appearance and reality, than that of the worst paid employee outside the workhouse. The assistant commissioners who monitored the implementation of the Act discouraged the giving of ‘outdoor relief’, the workhouse test was applied more rigorously, and the life of the pauper became tougher. The Royal Commission on the Poor Laws had suggested some degree of classification within work­houses and the separation of the sick and old from the able-bodied. The Poor Law Commissioners published architectural plans providing for this to help local boards of guardians1 but classification was seldom effective. Neither was any real consideration given to the position of orphans, deserted children, the ill or the elderly, probably because nobody had previously objected to their being given outdoor relief in the form of rent, food or money. Was the principle of less eligibility also to be applied to them? For some thirty years after the poor laws were tightened the answer was ‘Yes’. The hardship endured by the destitute sick was criticised by the Medical Times which asked ‘where is the mischief which can spring from generous medical relief to the sick? Men will feel no anxiety to be ill because illness entitles them to careful medical attention. Our Commissioners act as if they have an insupport­able horror of a poor patient getting too good attendance.’ 2

The great social evil of pauperism was considered to lie neither in the poverty nor the social conditions but in the need to give relief to the pauper and the moral consequences for the individual and society which flowed from this. Honest independence would be undermined and the birth rate might increase amongst those unable to support themselves. The Act was also designed to reduce abuses amongst those adminis­tering relief, for many had shown ‘both a desire and an ability to extract from it a profit to themselves’.1 As a result of the laxity and inconsistency with which relief was given the cost had risen alarmingly. Giving outdoor relief made it easier for tenants to pay their rent — and the landlords might be guardians. The Act was designed to reduce costs, and almost certainly did so, even though it did not achieve the national uniformity of practice for which many had hoped.

The local boards of guardians retained considerable freedom of action and in London the members were usually small tradesmen or shopkeepers. The system of election was archaic and plural voting of owners and occupiers was in proportion to the rateable value of their premises. Representation therefore related to the burden borne by the taxpayer. Few exercised the right to vote and rigged elections were not uncommon. Local politics might intrude into the affairs of the guardians, for the press reported the meetings and to be a guardian might be a springboard to greater things. At the very least it could sometimes be turned to financial advantage.

The crisis of the sick in the workhouses

In earlier days most of the inmates of the workhouses had been able-bodied and under the age of sixty. Between 1845 and 1862, a period of comparative prosperity, the proportions changed. The able-bodied found employment more easily and were in any case loath to seek relief on the new, harder terms. The aged and infirm entered the workhouses in greater numbers and in 1857 the medical officer of health for St Giles in the Fields and St George’s Bloomsbury said that most of those in the infirmary were exhausted by the burden of their years, by chronic bronchitis or by incurable diseases like paralysis or consumption. One out of every four or five admissions died - twice the rate of the hospitals.3

Then a rise in the level of destitution occurred, increasing the pressure on the workhouses. More of the inmates were clearly sick and in need of medical and nursing care. A new trend, encouraged by the Poor Law Board, became apparent. Increasingly paupers were classified into groups and accommodated separately. Children were removed from the workhouses and placed in district schools. Dangerous lunatics were not retained unless all the asylums in and around London were full.4 ‘Quiet lunatics and imbeciles’, when present in considerable numbers, were placed in separate wards or buildings. By common consent, cases of infectious or dangerous character were grouped in separate wards if practicable, or transferred to voluntary hospitals set apart for such diseases, like the London Fever Hospital or the Highgate Smallpox Hospital. For one shilling a day guardians could dispose of a difficult problem. Sometimes indeed the guardians would subscribe to a voluntary hospital to facilitate the transfer of a sick pauper needing attention more readily available in a hospital than a workhouse infirmary.  As the patients requiring separate accommodation increased in number, the infirmary or sick wards no longer formed the smaller part of the institution, nor did the older workhouses provide the type of accommodation the new conditions required.

The conditions in the workhouses

The quality of the care and the accommodation provided by the workhouses came to interest the reformers and following the Crimean war there was an upsurge of interest in sanitary problems. William Farr had shown that the death rate of the pauper inmates of the workhouses was higher than that of the districts from which they came, figures which Wakley had used with some effect in The Lancet. One of the first actions of the newly established General Board of Health in January 1849 was to ask Dr Arthur Farre and Mr R D Grainger, of the Webb Street School, to report upon the general state of the inmates of workhouses, particularly in respect of cholera and bowel complaints. They visited 38 of the metropolitan workhouses, reporting on the sanitary conditions. With a few exceptions a good average state of health was observable. However the descriptions of the buildings revealed grave deficiencies and the surveyors recommended improved sanitary facilities, better ventilation (a minimum of 500 cubic feet of space per inmate) and the use of paid nurses.5 In 1856 Dr Robert Bence Jones submitted a report on the St Pancras Workhouse at the request of the Poor Law Board. It revealed a level of overcrowding which he believed could not be tolerated by the government. One of the worst areas was a bedroom used by lying-in women at night and night nurses by day. On analysis, the air contained 2.5 per cent carbon dioxide and the superintendent of nurses said that the smell was ‘enough to knock you down.’6

The following year the Poor Law Board asked its Metropolitan Inspector, Mr H B Farnall, for a report. Farnall was a sound civil servant whose opinion was sought on the policy issues of the day by his superiors. He might be asked to comment on proposed legislation and was sent on two occasions to report on conditions of ‘exceptional distress’, as at the time of the cotton famine in Lancashire. Farnall was asked to obtain information about the sanitary conditions, ventilation, occupancy and death rate of a number of London workhouses and infirmaries. He selected those of Bethnal Green, Hampstead and Bermondsey. In general his report was reassuring. Tuberculosis was the chief cause of death, followed by cholera and the fevers. In a fuller report on all of the London workhouses prepared in 1858 he maintained that most of them were well managed and in a satisfactory state. There were a few exceptions, however, like the St Marylebone and the St Martin’s-in-the-Fields institutions which were ‘indifferent and in­adequate’.

Louisa Twining, who was active in a number of charitable move­ments, sought formal permission from 1853 onwards to visit patients in the workhouses and eventually this was granted by the Poor Law Board. In 1857 she addressed the newly established Social Science Association on workhouses and was subsequently responsible for the formation of the Workhouse Visiting Society, an offshoot of the Association. The overt aim of the Workhouse Visiting Society was to provide comfort to individual residents. However, the basic motive was to influence public opinion. Many of the visitors were wives or daughters of members of parliament and men of high position.7 The society submitted unsolicited reports to the boards of guardians, who sometimes acted upon them, and to the Metropolitan Inspector, Mr Farnall, who was known to be sympathetic to the society’s aims. In 1859 Louisa Twining wrote to The Times about the poor quality of workhouse nursing. What else could be expected, she wrote, for to be the lowest scrubber in a hospital was considered a higher post than to be in sole charge of a workhouse ward.8,9 The evidence she gave to the Select Committee on Poor Law Relief told the same story of crowded wards, inadequate supervision of pauper nurses and a failure to classify patients adequately. Quite apart from humanity, she said that the sick would recover more rapidly if properly nursed and treatment would therefore be more economical. Reformers frequently maintained that money spent on better health care would save on the rates in the end. Miss Twining considered that it was important for there to be at least one trained and efficient person to superintend the nursing. If, in addition, medical men would visit workhouses with their pupils as they did hospital wards, many mischiefs would cease and medical training improve. However, when medical periodicals referred to the workhouses and their infirmaries the problems with which they were concerned were generally those of the poor law medical officers, rather than their patients.11

Between 1862 and 1865 widespread unemployment in London increased the pressure on the workhouses and led to crowding.12 The workhouses were coming to provide more beds for the sick than the hospitals, although there was little public recognition of the change. Hospital statistics were poor — Simon, Bristowe and Holmes lamented the inadequacy of the records when examining the question of the healthiness of hospitals.13 But when the London workhouse scandal broke, Dr Sibson of St Mary’s was able to compare the case-mix of the St Marylebone and Kensington Infirmaries with St Bartholomew’s and Guy’s.

‘A large proportion of Chronic cases are received into the Infirmary, where they amount to one-third of the inmates. These form only one-tenth of the medical cases in the Hospital. Aged persons are three times more numerous in the Infirmary than in the Hospital. More than two-fifths of the Medical cases in the Hospital are of an active and acute character, requiring ample air-space, close medical supervision, and careful nursing, whilst in the Infirmary such diseases form only 1 in 15 of the same cases in the Infirmary and one in twenty of the total number of inmates.

‘Finally, and this is the most important point of difference, the open sores, many of them of great gravity, including 175 amputations, besides 399 other cutting operations in a total of 6,227 surgical patients, amount to two-fifths of the surgical cases in Hospitals whilst in the Infirmary they form a fifth part of the same class of patient and a twentieth of the whole number of inmates.’

‘The proportion of Medical to Surgical cases is three to one in the Infirmary, and two to five in the Hospital. Cases of fever, including typhus, enteric fever and scarlet fever, which are usually admissible in limited numbers, into the General Hospital, are excluded from the Infirmary, being sent to the Fever Hospital.

Sibson found that the length of stay and the outcome of comparable cases was much the same in the hospitals and the workhouse infirmaries, with similar numbers of ‘cured’, ‘relieved’ and ‘unrelieved’. The infirmaries were assuming the functions of true hospitals, rather than workhouse institutions.14

This progressive change in function was reflected in the design of the more recently constructed infirmaries, like the Mile End workhouse which ‘consisted of a whole village behind boundary walls.’ The architects retained the main design features of earlier buildings, but enlarged the accommodation for the aged and infirm. Detached infirmaries were built, with larger rooms and additional facilities. These separate infirmaries were still dependent upon the central facilities of the workhouse, such as kitchens, and under the general control of the workhouse master. The pursuit of the policy of removing all the sick and infirm from the main building had a major effect on the design, since the accommodation for the sick became the dominant part of the complex.

Pressures for reform

These improvements were slow and patchy. Conscientious inspectors like Mr Farnall might attend the meetings of the boards of guardians, keep closely in touch with their officials and recommend improvements. But the Poor Law Board did not have the power to insist that the improvements should be carried out. Many workhouses were adminis­tered under private Acts of Parliament, and an excuse for inaction could always be found. When times were bad guardians would say that the ratepayers could not find the money necessary for improvements; when times were good it would be said that pauperism was so reduced that there was no need for new building. Better conditions for paupers were not amongst the most appealing of causes.15

Matters came to a head with the death of an Irish labourer, Timothy Daly, in St Bartholomew’s Hospital in December 1864. Daly had developed bed sores whilst in the Holborn Workhouse Infirmary. His friends removed him to private lodgings and eight days later he was admitted to St Bartholomew’s where he died the following day. The jury brought in a verdict of death from exhaustion from bed sores and rheumatic fever, adding that Daly had received inadequate care from the poor law medical officer. Critical articles appeared in The Times and Spectator, and Florence Nightingale wrote at once to Mr Villiers, the President of the Poor Law Board, to ask for an enquiry into the whole question of hospital nursing in workhouses. She maintained that when a pauper became sick he ceased to be a pauper and ‘became a brother, and as a brother he should be cared for.’ ‘If you could only get to know’, she wrote, ‘how many poor have died because they were not nursed you would be shocked. Could you help by having a searching enquiry made into the nursing system of all workhouses?’16 Mr Villiers wrote back pointing out that there was a shortage of trained nurses and that the guardians could not compete successfully for staff with the rival attractions of the public hospitals and private sickness.

The Poor Law Board’s enquiry into Daly’s death exonerated the medical officer, Mr Norton, and suggested that two paid nurses should be employed and the medical officer’s salary increased. Shortly after a second death from neglect occurred in another infirmary, that of Richard Gibson. This time the enquiry led to the resignation of the assistant medical officer and the paid nurse.17 Miss Nightingale saw Mr Villiers in February 1865 about nurses for the workhouses. The British Medical Journal and The Lancet, had supported the campaign of the poor law medical officers for higher pay, more authority within the infirmaries, and more medical assistants. Now a new campaign began on behalf of the patients. The Medical Times and Gazette suggested the separation of the sick wards from the rest of the infirmary, so that they could be conducted on different principles, and commended to ‘the various Sisterhoods which are springing up around us the union hospitals of London as a most fitting field for their exertions’.18 In May 1865 the Workhouse Visiting Society organised a large and influential delegation to Mr Villiers at the Poor Law Board, seeking increased medical and nursing staff and better facilities for the infirmaries. In July 1865 Miss Nightingale drafted her ‘ABC of Workhouse reform’: separation of the sick, insane and incurable from the usual pauper population, a general metropolitan rate for this purpose with central administration, and the continued care of the paupers and casual poor by the guardians.19 Her ideas were hardly original.

The Lancet Commission

The Lancet took up the new cause, supporting a campaign which was a classic example of the use of publicity to work for reform. Not only did the journal’s activities culminate in a major legislative measure, but its reports as published led boards of guardians to make rapid improvements in their services. The campaign followed the usual formula of the day for unofficial action — information, agitation, the parent society, the local branch and the handbill, a method which had been used with great effect by the evangelicals in their campaign against slavery.
20 At James Wakley’s request, Mr Ernest Hart* approached Dr Anstie of the Westminster Hospital, and Dr Carr, a member of the panel which had enquired into Daly’s death, for their help. In April 1865 The Lancet announced the establishment of a commission to enquire into all the metropolitan workhouses to which it could obtain admission.21

‘The workhouse hospital system is a disgrace to our civilisation. Compare it with our public hospitals ... workhouse hospitals sin by their construction, by their want of nursing, by their comfortless fittings, by the supremacy which is accorded to questions of expense,
by the imperfect provision made for skilled medical attendance on the sick, by the immense labour imposed on the medical attendants, and the wretched pittances to which they are ground down.’22

The article went on to summarise the results of the vast and meticulous enquiry, detailed reports of which appeared fortnightly in The Lancet for the next year. The medical press was not united about the need for reform. The Medical Times and Gazette said that the ratepayers should not be ignored. Long suffering and themselves impoverished, were yet heavier burdens to be placed upon them?
23 In areas of destitution the increased poor rates during years of ‘distress’, enforced by law, could be the final burden which bankrupted a family.  Thirty six of the 39 metropolitan workhouses readily agreed to inspection by The Lancet, two more agreed later and only St Margaret and St John, Westminster refused admission. Guardians were sometimes oblivious of the state of affairs in their workhouses and would find to their surprise that the visiting committee they had appointed had never in fact visited and that reports from their medical officer had been ignored. Commissioners might be given information by people who were interested in reform but were hesitant about making a public complaint. The Lancet’s reports were written in astringent terms, supporting the medical officers where possible but castigating without mercy boards which were not providing a tolerable level of care. In a few places, it was noted, attempts had been made to provide simple and cheap comforts, but taken as a whole the commission was a massive indictment of the system. Infirmaries were classified in three groups: the very worst which were ‘entirely improper as residences for the sick or even the ablebodied’; those which with certain necessary improvements might be satisfactory for chronic disease and infirmity; and those built on sound principles ‘which might be developed into first-rate hospitals capable of serving the needs of large districts for the treatment of the more important and acute diseases, both surgical and medical’.24 The infirmaries were treating more cases than the voluntary hospitals and had become, in truth, ‘the great state hospitals of the metropolis’. Their management and staffing should be arranged on a ‘modified hospital system’. The commissioners criticised the frequent failure to separate the sick wards from the rest of the workhouse. They commented on the widely varying standard of nursing, from a small but efficient staff with paid help to the employment of ‘ignorant, drunken or decrepit paupers with few if any hospital trained nurses to supervise them’. The medical officers were few in number, overworked, on a low salary, and often had to supply drugs from their stipend. They were seldom able to challenge the decisions of the workhouse master or the guardians. The small size of some of the wards and their ventilation and sanitary condition, beggared description. Patients with undressed sores were lying in filth. Guardians might protest that the reports were unfair, but they could seldom refute the statements which had been made and sometimes a second visit revealed worse scandals. Individual guardians joined the campaign, some feeling that the system of which they were part forced them to act as the persecutors rather than the guardians of the poor. The Lancet’s commissioners were treated with goodwill by the Poor Law Board and its officials, particularly by Mr Farnall who began to behave somewhat indiscreetly for a civil servant, engaging in an informal correspondence with Miss Nightingale.25 In June 1866 he took Ernest Hart with him to see the male sick wards at the Whitechapel Infirmary. Hart’s subsequent account of the visit, published in the Daily News and The Times, led the guardians to protest to the Poor Law Board that Mr Farnall had behaved improperly towards them and to their medical officer.26


In May 1865 the Poor Law Board sent the guardians a circular letter discouraging the use of paupers as assistant-nurses, and pointing out the desirability of employing a sufficient number of paid nurses. The Strand board appointed ‘a young and respectable-looking woman as a superintendent-nurse’.12 Replying to a parliamentary question, Mr Villiers said that on the basis of information supplied by Miss Nightingale there was no difficulty in finding the staff which were needed. There were no fewer than 93 paid nurses in the metropolitan workhouses, and only eight infirmaries had none at all. The following December Ernest Hart published an article in the Fortnightly Review on ‘The Condition of our State Hospitals’.27 His article, which was later reprinted as a pamphlet, was addressed to a wider public and accused guardians of failing to understand their duties as the governors of state hospitals. He felt that there were not enough men of ability to perform such an exacting task and that parishes should combine to make better use of the most suitable buildings. In these amalgamated hospitals something like a true hospital system should be introduced.


A second article published in the Fortnightly Review of April 1866 suggested more detailed remedies. Each infirmary might be reconstructed or remodeled, but this policy would throw an impossible burden on the poorer parishes where the demand was greatest and where it was most difficult to raise the poor rate. Alternatively the existing workhouses might be taken over by a central authority, though this was probably too large a reform to succeed. The voluntary hospitals could themselves be expanded, but the extent of development necessary to produce an additional 6,000 beds would imply a complete revolution in their character. The solution Hart favoured was to build six new hospitals, each of a thousand beds, and support them from a common rate fund. He was aware of fears which the voluntary hospitals were expressing that large new infirmaries might drain them of their patients and decrease their income, but he felt that the dangers were exaggerated. His proposal did not involve the admission of more patients, or patients of a different class — just better and more economical care.28
 

Hart’s main proposals were adopted by the Workhouse Infirmaries Association which had been founded early in 1866 and numbered among its members Louisa Twining, the Archbishop of York and two earls. It organised a large and influential delegation to Mr Villiers which was followed on 2 April 1866 by the setting up of a special enquiry by the Poor Law Board. ‘Having had their attention drawn to the alleged inadequacies of provision made for the sick poor in the metropolitan workhouses’ Mr Farnall and Dr Edward Smith were asked to inspect them carefully, paying particular attention to the size and ventilation of the wards, the medical staffing and the provision of nursing. Farnall discussed with Miss Nightingale the questions to be asked about the nurses.29 The inspectors were to suggest alterations in the existing system, and in each infirmary, to secure the satisfactory treatment of the sick poor.30,31,32 Dr Edward Smith had joined the Board in June 1865 as an inspector and had been appointed, in addition, medical officer to the Board in February 1866. Two months later the inspectors submitted separate and detailed reports to the Board. Both admitted that deficiencies existed, but excused many of them. Dr Smith pointed out that the poor, having been accustomed to old and low buildings and deficient light and air, did not like the large and lofty rooms, the bright light and ventilation, the rigid cleanliness and order of the newer workhouses.33


A new administration

The efforts for workhouse reform were interrupted when the Whig government resigned in June 1866 as a result of political upheavals preceding the passage of the Second Reform Act of 1867. Florence Nightingale’s ‘side’ was replaced by a minority Tory administration. In place of Mr Villiers, Mr Gathorne Hardy became President of the Poor Law Board. A deputation of reformers immediately went to see the new Minister, who responded more rapidly than Mr Villiers who had taken little action for a year. In late July 1866 the Poor Law Board sent the reports of Mr Farnall and Dr Smith to all the metropolitan boards of guardians, asking them to remedy the defects which had been revealed. The guardians were to consider improvement in ventilation, the need for more space for each inmate, the separation of the aged and infirm from the sick and the provision of a higher standard of medical attention and nursing. Mr Gathorne Hardy rapidly discovered that the London workhouses would be a troublesome problem. After a rather difficult interview with Mr Farnall he announced to the House on 6 August 1866 that he had begun new enquiries which would be conducted by inspectors unconnected with the London district.
34 The problems of London, he said, were too much for one inspector and Mr Farnall was transferred unceremoniously to Grantham, far away from his family’s home in Kent, where he remained until 1870. He continued a regular correspondence with Miss Nightingale, attempted to obtain drafts of the reports of the inspectors who had replaced him, made caustic comments about both of them and the President of the Poor Law Board, and bemoaned his misfortune after all the diligent work he had performed for the Board.25 He was kept in the north for three years and then entrusted with the south eastern district. Dr Smith was also moved. On his own admission he had discussed matters with Ernest Hart, and the President of the Poor Law Board was reluctant ‘under the peculiar circumstances to place in charge of a district an inspector who was thought to be publicly committed to any particular scheme for the future management of the infirmaries. Smith protested, but in vain. His duties were changed and he was asked to undertake an inspection of the provincial infirmaries. He was also relieved of duties to a specific district and made full time medical officer to the Board.32 In the place of Farnall and Smith the Board appointed two new inspectors, Mr U Corbett and Dr W 0 Markham. Corbett was an experienced man, summoned from Derby at less than a day’s notice. His relocation was costly and the Poor Law Board had to seek special Treasury sanction for the reimbursement of the cost of moving him, his family, his furniture and his five servants to his new house in Onslow Square.35 Markham had been the editor of the British Medical Journal.

The inspectors were men of seniority. With salaries of around £600 per annum they earned many times the pay of workhouse masters, medical officers or matrons.  On 11 August 1866 a letter speedily drafted for the President of the Poor Law Board instructed Corbett and Markham to proceed at once to a further inspection of the workhouses. They were to suggest the immediate improvements required in the workhouses and in their medical and nursing attendance, and also the longer term and more extensive alterations required to ensure, permanently, the proper care and treatment of the sick poor. They were to begin with the infirmaries that Dr Smith had considered the worst, and with the assistance of Mr Savage, the Architect to the Board, to provide an estimate of the cost of the alterations they recommended. In selecting Mr Corbett, the Poor Law Board had made a good choice. Ten years later, when he came to retire, the Secretary to the Board said that the zeal, ability and energy with which Corbett discharged his functions ‘during the difficult years of 1867-8’ were highly appreciated by his seniors. Within a week of his appointment, Mr Gathorne Hardy wrote to ask him about the method he habitually adopted in examining a workhouse. Corbett replied that he would go immediately to the sick wards of the infirmary without forewarning, to ensure that no preparations were made for his arrival. Inspection of the sick wards was the heaviest part of his work and a part he did not wish to hurry. He would question some of the inmates quietly, to gain their confidence, for as a rule paupers were not disposed to make complaints. He would try to find out if they were treated kindly by the officers, whether any little amusement or occupation was afforded them, whether the doctor was patient with them, the chaplain came to read to them, and whether they were well nursed and attended in the night.35 ‘Cheerful looks and clean bed linen and nightdresses are things which cannot be put on at a moment’s notice, nor can rooms, closets and cupboards be readily furnished to order in the course of half an hour.’ By using his eyes and following these principles, Corbett thought that whilst an inspector might on occasions be deceived, he could not always be misled about the real state of affairs. 

Mr Gathorne Hardy also asked a group of eminent doctors including the President of the Royal College of Physicians and Captain Douglas Galton to visit the London infirmaries and advise on the cubic space to be allowed to each inmate. Galton, like Miss Nightingale, laid great stress on the need for good ventilation and the two were in constant touch with each other. Florence Nightingale felt that it would do ‘their side’ no good if the Cubic Space Working Party reached a unanimous conclusion, for that would assist Mr Gathorne Hardy of whom she disapproved.36 Several scientific papers were submitted to the group and Miss Nightingale herself was invited to submit a memorandum. Characteristically it went far beyond nursing matters into those of hospital design and management.37
Corbett and Markham assisted the Cubic Space Working Party, but were also hard at work on their own inspection. Writing from Yorkshire Mr Farnall asked for the draft, which was refused. The report of the new inspection made recommendations which could only be implemented if the Poor Law Board took powers of direction and maintained control over detailed matters.38

It recommended that:

1  The workhouse infirmary should always be as near as possible to the district to which it belonged.

2  The infirmary should be separated from the rest of the workhouse and under independent management, and that the treatment of sick paupers should be carried out under different principles from those to which the able-bodied were subject.

3  Attention should be paid to ventilation and space standards should be:

    chronic and infirm      500 cubic feet
    sick                         800 cubic feet
    lying-in women       1,200 cubic feet
    ‘offensive’ cases     1,200 cubic feet

4  Imbeciles, children, those suffering from smallpox and fevers, and possibly venereal disease should be excluded from the infirmaries and treated elsewhere.

The medical officer should have entire control of the infirmary, be independent of the workhouse master and report annually to the Poor Law Board. He should visit every patient regularly and should make notes on the patients’ prescription boards, rather than relying on the nurses.

6  The nursing and the general management of the infirmary should be under the charge of a matron with some previous hospital training. Qualified nurses should take charge of the sick, the more menial duties being carried out by pauper nurses under their supervision. There should be one qualified nurse for every fifty patients by day and for every hundred at night. Drug administration should not be left to pauper nurses.

7  A system of uniformity in internal administration of infirmaries was desirable, especially in medical administration, ventilation, diet and nursing, for ‘the practice of uniformity in minor things naturally tended to bring about agreement in matters of more importance.’

The Metropolitan Poor Act (1867)

Once in possession of the evidence he needed, Mr Gathorne Hardy prepared a bill to meet the essential requirements, and which stood a fair chance of passage through the House. It involved the intervention of the state in matters which had previously been left to the guardians and the charitable, who had worked largely undisturbed. Opposition was therefore likely. The bill, which owed much to the ideas of Louisa Twining, Ernest Hart and Joseph Rogers, was mentioned in the Queen’s speech at the opening of the parliamentary session and was introduced at an early stage.

The bill had been carefully framed to attract support without appearing to involve revolutionary changes, for it was necessary to avoid alarming the richer parishes like St George’s, Hanover Square, ‘where Charity began and ended at home’. The maintenance of the destitute was traditionally a parish responsibility, and many parishes worked under private Acts of Parliament, the repeal of which would be necessary. However difficult it might be for the poor and over-burdened rate-payers of the East End to find money for improved services, the West End was not going to rush to their aid.39 Introducing the second reading of the bill, Viscount Enfield referred to the reports in The Lancet and ‘the very strong impression on the public mind that some sweeping reform was required’. He was however aware ‘of the sensitivity of the parochial mind on the subject of local self-government’. A new system must be just to those who find the funds and merciful to those who receive relief. There should be no unnecessary expenditure and existing buildings should be used where possible, but every justice should be done to the poor. The bill was restricted to London and a common metropolitan fund would only reimburse the cost of treating easily recognizable illnesses like smallpox, fever and lunacy.

Powers of direction would have to be obtained, for the guardians had taken little notice of the Poor Law Board’s circulars. Mr Gathorne Hardy told Parliament that ‘it is not of the slightest use to make orders or lay down rules unless you are in a position to carry them out, and enforce them if they are not complied with.’ Under the bill, the Poor Law Board would nominate up to a third of the guardians and they would select men of ‘influence, mind and heart’ to ensure that those entrusted with the supervision of the workhouses would undertake the necessary reforms. Boards of guardians would henceforth contain both members selected locally and nominees of central government.

Florence Nightingale did not approve of Mr Gathorne Hardy’s bill, describing it as ‘an abortion of Mr Villiers’ scheme’. She wrote to Sir Harry Verney on 1 March 1867 saying that in Mr Farnall’s view the bill would open the way to more medical and guardians’ jobbery. What was needed was a ‘central uniform management for the whole of the metropolis’ with all infirmaries managed by paid, responsible officers. These officers would be interposed between the hospitals themselves and the Poor Law Board.41

A few small amendments were made to the bill at the committee stage, but it was essentially untouched and the bill was welcomed both on the floor of the House and in the medical press. On 14 March the bill was read for a third time and passed ‘amid the cheers of the House’. ‘We have little to complain of in all this’, said The Lancet. Mr Gathorne Hardy had had his own way in almost everything and The Lancet suspected that, whilst he and not presented the measure as a radical reform, the extent of the changes would become rapidly apparent when the new system was working.39

Armed with its new powers the Poor Law Board began to reorganise the pattern of the workhouses. In principle, each parish or union, when sufficiently large and when it had the means to provide for its own wants, was allowed to remain distinct. Throughout 1867 Corbett and Markham produced a variety of proposals to unite the smaller parishes into unions with populations of 70—100,000, each providing for roughly 1,000 inmates. They were not in entire agreement. Markham favoured large all-purpose unions, whilst Mr Corbett preferred to deal with the problem, on occasion, by creating united sick asylum districts for the care of the sick poor, leaving the smaller parishes and unions to continue to provide for the able-bodied destitute on a separate basis. It was clear that the guardians were not going to take kindly to any change in their responsibilities, but on balance they preferred Corbett’s solution. This left boards with a continuing role, whilst placing the care of the sick and destitute in the hands of a separate body (the Sick Asylum District) which was responsible directly to the Poor Law Board and not to a board of guardians. Mr Corbett said that he regarded it as important to work with, and not in the teeth of, the existing boards of guardians, and the Poor Law Board agreed, believing it was ‘wise and right to adopt a course which involves the least disturbance to present arrangements and is least unpopular with guardians’. A favourable opportunity had presented itself for reconstructing the union map of London but this had not been a prime object of Mr Gathorne Hardy, neither had the possibility been brought prominently before Parliament during the discussions on the bill.42 The aim was to achieve adequate classification of the sick and infirm taking into account geography, the existing buildings and the land available for development not to disturb all the existing institutions.

In December 1867 the Poor Law Board asked Dr Markham and Mr Corbett if there were any wards in the metropolitan workhouses of such a character as to require immediate and direct interference by the Board to support or supplement the recommendations that the inspectors had already made. Dr Markham said that the defects had already been reported to the Board and to the guardians, who were prepared to remedy them at the earliest opportunity. Mr Corbett was more cautious and admitted that there was great overcrowding in some places, but he said that the guardians were often providing temporary accommodation and that the problems could not be wholly overcome until new building on an extensive scale had been completed. Only in the case of the Strand union had the inspectors’ proposals met with refusal, and this union proposed to give outdoor relief more freely. Direct and immediate interference was not necessary.35

In the same month Mr Corbett reported to the Poor Law Board that the level of distress was considerably higher than the previous year. In the East End it had reached the provident classes. To avoid ‘coming on the rates’, many people were pawning clothing and bedding and the Poplar union decided to lend bedding to the poor, taking the precaution of marking it with the union’s name.

By the end of 1867, the estimated cost of the building work required had reached nearly £1 million. Included in the estimates were42:

    Two imbecile asylums @ £60 per head £200,000
    Three fever hospitals with sites
   
@ £80 per patient                                     £70,000
    Two small pox hospitals                            £50,000
    Bethnal Green Infirmary (for 500
   
@ £50 per head)                                       £25,000
    Clerkenwell Workhouse and Infirmary      £40,000

Including sites and fittings the cost of each of the new institutions was at least £40-50,000, and there were moments ‘in which even the calmest & most humane seemed to feel the problem to be insoluble and to wish that it were possible to sink the entire pauper population to the bottom of the sea and have done with them.’43 Classification there had to be, but with small unions that meant a number of small and separate establishments. The Sick Asylum District, bringing together the more acutely ill paupers from a number of unions, was more economic. It placed the sick under different management and avoided the need to erect many new and costly buildings. Mr Corbett considered that the Strand Union, St James’ Westminster, St Martin-in-the-Fields, St Giles’ and St George’s Bloomsbury might have a joint hospital for the acutely sick and the worst of the chronic sick, whilst the remaining chronic sick could go to the existing Strand workhouse. He discussed the proposition with Miss Twining, ‘the most practical woman I have ever known amongst the many who have taken an interest in the subject’. Miss Twining said she could provide two lady nurses who would be delighted to undertake the duties of nursing superintendent or infirmary matron, should his plan be adopted.42

Elections were held for new guardians, and the new brooms assisted by the centrally nominated members swept cleaner. Insubordinate staff were dismissed, paupers were classified more effectively and lunatics removed to county asylums. The St Pancras guardians, whose work­house was severely criticised by Dr Markham in February 1867, and in a number of respects by The Lancet on a repeat visit the following year,44 purchased land at Highgate and called for designs for a new infirmary.45 The Lancet claimed credit for many of the changes which were taking place in the infirmaries, but it defended Mr Farnell whose move to Yorkshire had been interpreted as a censure allegedly for failing to expose and remedy the abuses which had come to light. He was, said The Lancet, the only official who over many years broke the monotony of corrupt stupidity and inaction in the management of the London parishes by the Poor Law Board. The journal continued to publish reports by its staff on the improvements which were being made46, and commented helpfully on the architects’ plans for the new infirmaries which the unions were being directed to build.

The campaign died away almost as rapidly as it had started. Ernest Hart moved to the British Medical Journal as its editor. Although at an earlier stage Hart’s views had been sought by the authorities, now, wrote Miss Nightingale, they refused to admit him to their councils. Miss Nightingale believed that there was a conspiracy to keep things quiet. ‘The world is to be put to sleep, as Mr Hart has been stopped’ she wrote.24 Hart did not use the British Medical Journal, as The Lancet had been used, to run a campaign.

Early in 1868 it was agreed that Corbett’s proposals for central London should be accepted and he was invited to name the new joint board for the parishes and unions which were to be united for the purpose of providing accommodation for the sick. He suggested that it should be called the Central London Sick Asylum District, and the board of management was established in May 1868 to serve the Strand and Westminster unions, and the parishes of St Giles’-in-the-Fields and St George’s Bloomsbury. The board consisted of nominees of the parishes and unions concerned, together with four members selected by the Central department. Its first task was to determine the extent of the provision required, which in itself proved a difficult task, and the nature of the institutions available. After careful consideration, and in consulta­tion with Corbett and Markham, it was concluded that none of the existing workhouses was suitable for conversion into a hospital. Nor could a suitable site be obtained by advertisement. A solution was found the following year. The parish of St Pancras was added to the Sick Asylum District so the new infirmary under construction at Highgate could be used for the sick of the entire district. It opened at the end of 1870 with accommodation for 523 paupers and a matron recommended by the Nightingale Fund.47

In 1870 the Poor Law Board issued a circular to the metropolitan guardians specifying the cubic space allowance for the various classes of paupers, giving financial encouragement to guardians who were pre­pared to deal with overcrowding by erecting new buildings. It was the beginning of a major construction programme which gave London a system of separate infirmaries far in advance of other parts of the country. One after another was built from 1867 onwards and recorded in the annual reports of the Poor Law Board and the Local Government Board. Hospitals built on the pavilion plan were not cheap to construct, but the design was almost invariably chosen for the new infirmaries. The work of Douglas Galton on the cubic space working party was incorporated in the design guidance issued by the Poor Law Board, for while it was important to minimise public expenditure, the buildings had to be satisfactory for their purpose. In 1868 the board issued instruc­tions for the guidance of architects in the construction of workhouses and workhouse infirmaries. The board said that it did not wisWhittingtonh ‘unduly to fetter their discretion’, but in considering plans the guardians submitted for approval the Board would have regard to the guidelines.

Some architects came to specialise in poor law buildings. Henry Saxon-Snell was one of these. A Fellow of the Royal Institute of British Architects, he was a pioneer member of the Sanitary Institute, now the Royal Society of Health. In his early days he was an assistant to Sir Joseph Paxton, who designed the Crystal Palace. He wrote extensively on hospital design, debunking an emerging fashion for circular wards. His book, Charitable and Parochial Establishments, was presented to the Prince of Wales when he opened the St Marylebone Infirmary. He wrote a second book, Hospital Construction and Management, in associ­ation with a doctor, Frederick Mouat.48 His obituary in The Builder makes clear the extent of his contribution to London hospital architec­ture.49 Surviving examples include the Archway wing of the Whitting­ton, St Charles’, Paddington, St Olave’s and St Stephen’s, Fulham. His infirmaries were designed in a style which has been dubbed ‘Guardians’ Gothic’. With disarming modesty he commented upon the St Mary­lebone Infirmary, now St Charles’: ‘It must not however be supposed that I consider it to represent the model of a perfect hospital building; the limited extent of the site alone would render this impossible; nevertheless, it is allowed to be the most perfect building of its kind yet executed.’ It provided a cubic footage of 936 per patient, at a cost of £161 per bed. The Poor Law Board’s circular Points to be attended to in the construction of workhouses was modified by the architects to the Local Government Board over the next 30 years and determined the form and content of infirmaries in one of the most active periods of hospital building London has seen.50

Improvements in the infirmaries 

Improvements were not restricted to the buildings. Florence Nightin­gale had expressed a desire to assist where possible with poor law nursing. After the St Pancras guardians had been criticised by the coroner for the poor standard of nursing in their infirmary51, the first poor law school of nursing in London was established at the new Highgate Infirmary in association with the Nightingale Fund. The school only lasted until 1878 but another, also associated with the Nightingale Fund, was subsequently established at Snell’s St Marylebone Infirmary. There the guardians took a novel step and erected a building for forty probationers, including lecture rooms, at a cost of £12,000.St Leonard's

In 1870 Dr Dudfield reported on the reduction of mortality which had accompanied the introduction of trained day and night nurses into the St Margaret’s Workhouse, Kensington. Expenditure on wines and spirits had also fallen, the savings being more than the cost of employing the eight nurses. ‘Much has been done by your Board,’ reported Dr Dudfield, ‘to ameliorate the condition of the sick, infirm and the aged, without in any way making the establishment attractive to that class of poor for whom the workhouses were originally intended.’52

The London guardians were increasingly men of vision, but the supervision of the Poor Law Board remained essential.53 The represen­tatives of the various unions and parishes which made up the Central London Sick Asylum District did not always see eye to eye, and in its first year the Westminster guardians tried to break away. The Poor Law Board made it clear that it did not envisage a further reorganisation. Instead, one of the board’s nominees, Sir Sydney Waterlow,* became chairman in 1870 to pull the authority together. Sir Sydney had been one of the more active guardians of St Pancras. He became Lord Mayor of London in 1872, treasurer of St Bartholomew’s in 1874, and was the first president of the Hospital Sunday Fund. Under his leadership the Central London Sick Asylum District opened its first infirmary at Highgate in 1870, and a second one in Cleveland Street in 1874—5 which contained a further 211 beds.

Steady and unobtrusive work by Louisa Twining and the Workhouse Infirmary Nursing Association also began to show results. In 1880 a second Lancet commission on workhouse infirmaries reported on the ‘distinct advance in the treatment of the sick pauper’ as a result of the new separate infirmaries and congratulated the guardians on ‘the noble manner in which they have carried the scheme into effect’  The Lancet said that the new infirmaries were the equal of any hospital it had visited, both in accommodation and equipment. Only in the size of the medical and nursing staff to deal with the ‘overwhelming amount of sickness and suffering had the guardians been niggardly’. The Lancet suggested that assistant medical officers should be appointed and that medical students should attend the infirmary for six months. Great advances had been made in nursing and to the journal’s astonishment the ignorant, rough, well-meaning pauper nurse was being replaced by a class of intelligent, trained, paid nurses who performed their onerous duties skillfully. A matron or lady superintendent controlled a staff of head nurses, one to two or three wards, with an assistant nurse in each ward. The Lancet felt that the staff should be increased and suggested a fixed proportion of nurses to sick, not less than one nurse to eight to ten patients, and an increased number of probationers, ‘for there could be no better training school than an infirmary.

The development of the infirmaries into true hospitals was taken a step further in 1886 when their superintendents met at the Lambeth hospital. They petitioned the guardians and drew attention to the increasing degree of specialisation in medicine. They recommended the appointment of ‘specialists of eminence’ as honorary consultants to the infirmaries.” Slowly and patchily the infirmaries were developing into true hospitals.

 *Sir Sydney Waterlow (1822-1906); stationer and printer; Lord Mayor of London 1872-3; Liberal MP 1868-1885; founder of the Improved Industrial Dwellings Company to provide dwellings for the poor, which came to house nearly 30,000 people.

References

For more information on the history of the workhouse, see Peter Higginbotham's web site: www.workhouses.org.uk.

1     Brundage A. The making of the new poor law. London, Hutchinson, 1978; Royal Commission inquiring into the Administration and Practical Operation of the Poor Laws. London, Fellowes, 1834; and Fifth annual report of the poor law commissioners, pp 132—5. London. Clowes and Sons. 1839.

2     The new poor law regulations. Medical Times, 1842, vi, p 24.

3     Smith E. Report to the poor law board on the metropolitan infirmaries etc. House of Commons, 1866; and Buchanan G. St Giles in 1857—8, the annual report of the medical officer of health, London, 1858.

4     PRO MH 3 2/24.

5     Farre A and Grainger R D. Report to the General Board of Health on the metropolitan workhouses. London, House of Commons, 1850.

6     Bence Jones R. Report on the accommodation in the St Pancras Workhouse. London, Eyre and Spottiswoode, 1856.

7     Twining L. Workhouses: transactions of the National Association for the Promotion of Social Science, 1857, pp 571—4. London, Parker. 1858; and

Recollections of workhouse visiting and management, London, Kegan Paul and Co, 1880.

8     Twining L. Metropolitan workhouses and their inhabitants. London, Longman Brown and Co, 1857.

9     Twining L. Letter to the President of the Poor Law Board on workhouse infirmaries. London, William Hunt and Co, 1866.

10    Twining L. Evidence to the select committee on poor relief 1861. Paras 11619, 11965 et seq.

11    The administration of the poor laws. Lancet, 1847, ii, pp 236—7.

12    Rogers J. Reminiscences of a workhouse medical officer, London, Fisher, 1889.

13    Bristowe J S and Holmes T. Appendix 15 to the report of the medical officer to the Privy Council. London, HMSO, 1863.

14    Sibson. Appendix to the report of the committee to consider the cubic space of metropolitan workhouses. London, HMSO, 1867.

15    Farnall H B. Report on the infirmary wards of the metropolitan workhouses. London, House of Commons, 1866.

16    BM Add Mss 45787 f 54 & 56.

17    Derived from contemporary accounts in the Lancet and the British Medical Journal.

18    Workhouse nursing. Medical Times and Gazette, 1865, i, p 386.

19    BM Add Mss 45787 f 54 & 61.

20    Young G M. Victorian England: portrait of an age. Oxford, Oxford University Press, 1953.

21    The Lancet sanitary commission on workhouses. Lancet, 1865, i, p 410.

22    The Lancet sanitary commission for investigating the state of the infirmaries of the workhouses in London. Lancet, 1865, ii, p 14.

23    Hospital doctors and workhouse patients. Medical Times and Gazette, 1866, i, p 176.

24    Lancet Sanitary Commission. see Lancet, 1865, ii, pp 14, 73, 131, 184, 240, 296, 355, 513, 575, 711; Lancet, 1866, i, pp 66, 104, 173, 376; and Lancet, 1866, ii, p 235.

25    BM Add Mss 45786 f 188, f 193, f 202, f 245.

26    Great Britain, Parliament, House of Commons. Accounts and papers 1866, Vol 23, No 521; and Correspondence between the Whitechapel Union and the Poor Law Board.

27    Hart E. The condition of our state hospitals. Fortnightly review, 1865, vol 3, pp 215—226. Reprinted 1866, Chapman and Hall.

28    Hart E. Metropolitan infirmaries for the pauper sick. Fortnightly Review, 1866, vol 4, no 12 p 459.

29    BM Add Mss 45786 f 188.

30    Poor Law Board. Annual report 1866—7. See also (12) and Obituary of Dr Joseph Rogers, British Medical Journal, 1889, i, p 864.

31    PRO/MH/32/24.

32    PRO/MH/32/67 and Lancet, 1868, i, pp 16, 133—4.

33    Smith E. Report on the metropolitan workhouse infirmaries etc to the Poor Law Board. House of Commons, 1866.

34    Parliamentary Debates (Hansard), House of Commons, series 3, 184, 1866, columns 2096—7; and Johnson N E. ed. The diary of Gathome Hardy. New York, Oxford University Press, 1981.

35    PRO/MH/32/13.

36    BM Add Mss 45763; 45764. (Nightingale Papers)

37    Poor Law Board. Report of the committee to consider the cubic space of metropolitan workhouses, London, HMSO, 1867; and British Medical Journal, 1867, i, p 202.

38    Corbett U and Markham W 0. Report to Mr Gathome Hardy on metropolitan workhouses. House of Commons, 1867.

39    The metropolitan poor bill. British MedicalJournal, 1867, i, p 85; Lancet, 1867, i, pp 338—9.

40    Parliamentary debates (Hansard), House of Commons, 21 February 1867, columns 746—80.

41    Florence Nightingale to Sir Harry Verney, February and 1 March 1867. Photocopy in Wellcome Institute for the History of Medicine.

42    PRO/MH/32/55.

43    The prospects of poor law reform. Lancet, 1869, i, p 17.

44    PRO/MH/12/7601; British Medical Journal, 1867, i, p 186; and Lancet, 1868, ii, p 282—3.

45    Report of the Poor Law Board 1867—8. London, HMSO.

46    Workhouse infirmary reform. Lancet, 1867, i, pp. 177—9, 282—3.

47    PRO/MH/17/2.

48    Saxon-Snell H. Charitable and parochial establishments. London, B J Batsford, 1881; and Mouat F and Saxon-Snell H. Hospital construction and management. London, J and A Churchill, 1883.

49    Saxon-Snell A. The Builder. 16 January 1904.

50    Gordon-Smith P. The planning of poor law buildings. London, Knight and Co, 1901.

51    The nursing at St Pancras Workhouse. Lancet, 1869, i, p 97.

52    Workhouse reform. British Medical Journal, 1870, i, p 415.

53    Mr Goschen on poor law and the guardians. Lancet, 1869, i, pp 165—6; and PRO/MH/17/2.

54    Lancet’s commission on workhouse infirmaries. Lancet, 1880, i, pp 954-6.

55    Metropolitan infirmaries. British Medical Journal, 1886, ii, p 1113.

Further reading

Hodgkinson R G. The origins of the National Health Service. London, Wellcome Historical Medical Library, 1967.

 
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