7

Infection and Citizenship: (Not) Visiting in Mid-Victorian Britain

Graham Mooney

Local authority provision for the sequestration of infectious people mushroomed in Great Britain from the mid-1860s. By the First World War, more than 750 isolation hospitals contained almost 32,000 beds for infectious , most of whom were children. Trips to an isolation were problematic because visitors might contract there and spread it to the wider community. Various strategies sought to minimise this risk or eliminate it altogether. This chapter argues that the management of isolation hospital visitors was typical of Victorian ’s tendency to regulate people’s behaviour. By granting rights to, and conferring responsibilities on, the relatives of patients, visiting practices enshrined notions of citizenship that sought to govern ‘through’ the family.

The isolation of people with infectious disease has attracted an increasing amount of attention from historians. The fundamental rationales for the institutional exclusion of the infected – namely the protection of the wider population, the prevention or stamping out of an epidemic outbreak – are practically self-evident. Yet scrutiny in a variety of metropolitan and colonial contexts also reveals a set of practices that, over the course of the nineteenth century, seemingly were ever more laden with undertones of coercion, moral and physical rehabilitation and normalisation. The removal of biologically dangerous individuals from their community surroundings and into confinement has been characterised as a strategy of government power. In common, then, with penal incarceration and confinement of the mentally ill, isolation of the infected demonstrates a central contradiction of liberal governance: freedom was a means to govern because practices such as isolation created, in the words of Nikolas Rose, ‘the conditions in which subjects themselves would enact the responsibilities that composed their liberties’.1 Taking this cue, Bashford and Strange have noted that ‘isolation was not an aberration from liberal governance but central to its internal 147

Graham Mooney - 9789042026322 Downloaded from Brill.com09/26/2021 08:09:10PM via free access Graham Mooney logic’.2 Put simply, ensuring the liberty of the many necessarily meant restricting the freedom of the few. This chapter considers the isolation of patients with infectious disease in Victorian Britain. It begins with a very brief summary of scholarship on citizenship and public health in the Victorian period. Just how far isolation hospitals really were ‘isolated’ is explored next, by taking into account both physical location of hospitals and the movement of people in and out of them. This is followed by an attempt to enumerate those features of isolation hospitals that acted as obstacles to their acceptance in the local community. In the fourth section, the forced separation of children from their families is identified as a bone of contention between parents and the state. Finally, the state’s shaping of visiting regulations comes under scrutiny as an important aspect of this separation. Here, the spotlight is on the families and friends of patients who were visitors to isolation hospitals. Public health authorities took the opportunity visiting presented to inculcate behaviours in families that limited the possible transmission of infection outside the hospital. The argument is that isolation hospital visiting regulations were part-and-parcel with the liberal state’s desire to shape those activities in the domestic sphere that qualified people as being fit for citizenship. The consideration of visiting shifts the centre of attention away from diseased people – be they identified patients or carriers of disease as yet unidentified by a medical or state authority – towards those family members and friends who may be (or become) diseased, and spread disease, by the irresponsibility of their actions. In this way, the family – and not simply individuals with disease – comes into view as the locus of intervention. As one of the foremost authorities on the history of child welfare notes, one of the crucial questions for liberal democracies has been how the state relates to the private family in shaping ‘duties, responsibilities, rights and “needs”’.3 The ‘duties and responsibilities’ under investigation in this chapter are those imparted to family members who were visiting patients in isolation hospitals, while ‘rights and needs’ refer to the level of access that families were granted. The ‘costs to individual liberty and convenience’4 families underwent because of isolation were transformed by the state into an opportunity to underline the dangers of infection and encourage behaviours that would prevent its spread beyond the walls of the hospital. The critique presented in this chapter therefore tends towards an interpretation that the state increasingly sought to govern ‘through’ the family,5 an interpretation that sits comfortably alongside studies that, in the realm of health, have examined domestic visiting, the infant welfare movement, child protection and school welfare. To develop these lines of thought, three pivotal government inquiries are used, which were undertaken in the late 1870s and early 1880s. The first is 148

Graham Mooney - 9789042026322 Downloaded from Brill.com09/26/2021 08:09:10PM via free access Infection and Citizenship a survey of hospital isolation facilities written by Richard Thorne Thorne (hereafter his surname will be truncated to just Thorne), an inspector of the medical department of the Local Government Board (LGB). In addition to distributing a questionnaire to all English and Welsh sanitary authorities, Thorne personally visited a total of 82 authorities and 67 hospitals. The second is a report by another LGB inspector, William Power, on the influence of the Fulham Hospital as a focus of infection. The third is the Royal Commission on Smallpox and Fever Hospitals (RCSFH) which took evidence in 1881 and 1882 and was set up to consider the implications of Thorne’s and Power’s reports for the hospitals of the Metropolitan Asylums Board (MAB) in London. Interpretations of visiting that emerge from these central government documents are augmented by commentaries on the practices of local hospitals that can be found in Medical Officer of Health (MOH) reports, the archives of administrative bodies such as town council health committees, and accounts of isolation that occasionally surface in local newspapers written by the people who experienced it. Citizenship and public health The intersection of freedom, citizenship and health is proving to be fertile ground for historians of Great Britain. The production and maintenance of a healthy population in the twentieth century through primary health care, physical fitness, health education and army propaganda relates particularly well to the idea of ‘social’ citizenship put forward by T.H. Marshall in the mid-twentieth century.6 According to Peter Baldwin, the emphasis on individual responsibility and ‘internally accepted restrictions’ that was characteristic of some of the responses to the AIDS epidemic signified a ‘democratic public health’ in which the contract of health citizenship assumed that ‘individuals would curb harmful behaviour and develop healthy habits’.7 Isolation and exclusion are policies through which health and citizenship are seen to interact, notably in the and the sanatoria.8 In the latter, patients were rehabilitated, educated and inculcated into behaviours that were ‘appropriate’ to functioning and productive members of the citizenry.9 Rights are crucial in liberal democracies if individuals are to be free to pursue legitimate interests in the absence of interference from either other individuals or the state.10 Citizenship is an expression of the relationship between an individual in possession of rights, and the community, to which that individual has responsibilities, duties and obligations – and which, of course, grants those rights. Fluid and dynamic, citizenship is subject to constant redefinition as individuals find new ways of articulating their rights and obligations (in this case, as visitors) and as new institutions (in this case,

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Graham Mooney - 9789042026322 Downloaded from Brill.com09/26/2021 08:09:10PM via free access Graham Mooney isolation hospitals) are ‘constructed to give form to the changing needs and aspirations of the citizen and community’.11 No discussion of citizenship in Victorian Britain can avoid the issue of nationhood as a crucial component of state formation.12 National identity was the concept through which the ‘improvement’ of individuals and thus citizenship was articulated.13 Pamela Gilbert has recently elaborated on this theme in relation to public health between the 1830s and 1860s. Franchise reform in this period focused increasingly on the ‘fitness’ of the electorate to contribute to the social well-being of the nation as a whole. As qualification for the vote shifted from property ownership in 1832 to property rental in 1867, ‘fitness’ came to mean not simply the ability to pay taxes, but the capacity of working-class individuals to ‘procure’ and maintain a home and demonstrate a degree of prudent household economy that resonated with middle-class norms.14 At around about the same time, the rhetoric of sanitary reform was linking the physical degradation of urban places to the immorality of the inhabitants.15 While this seemingly ‘confirmed the vision of the poor as incapable of exercising citizenship’, Gilbert writes that ‘it also implied a remedy that might bring such creatures within the pale of those who could develop into citizens over time’.16 The ‘remedy’ was an environmentally based public health: cleaning up public space – the removal of sewage, the supply of water and so on – also secured the conditions under which individuals might achieve domestic propriety. As Mary Poovey points out, Edwin Chadwick’s sanitary report in the early years of Victoria’s reign concentrated on domestic as much as public space.17 Alongside the school, the home was the crucial site of liberal governance; the place where, through the agency of the family, moral character was built in order that individuals would behave rationally, as responsible citizens of a national community. Gilbert’s focus is on housing and the charitable efforts of Octavia Hill. In her book Bodily Matters, Nadja Durbach has revealed how citizenship was a crux of the debate over compulsory infant vaccination in England in the nineteenth century. Anti-vaccinationists argued for their rights as parents to withhold their children from vaccination; pro-vaccinationists saw vaccination as a way to ‘incorporate working people into the national community as citizens through participation in maintaining the public’s health’.18 Gilbert’s homes and Durbach’s infant bodies are both spaces of risk over which the role of family was contested.19 This chapter discusses yet another: isolation hospitals that were provided by local governments to sequestrate people with infectious disease.

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The isolation of isolation hospitals Although the early years of the nineteenth century witnessed the founding of a small number of private isolation (fever) hospitals in England, it was not until the second half of the century that such institutions began to proliferate nationally.20 Both the 1866 Sanitary Act and the 1875 Public Health Act gave local government the power to build an isolation hospital, and allowed them to borrow money for the purpose. By the end of the 1870s, the LGB estimated that 296 local authorities made some form of provision for the reception of patients suffering from an infectious disease, representing about one quarter of all provincial sanitary authorities.21 The Isolation Hospitals Act of 1893 enabled County Councils to build an isolation hospital and, if necessary, force local authorities under their jurisdiction to do so. Between this date and the eve of the First World War, more than 300 local authority isolation hospitals were constructed; as a result almost 32,000 beds were available nationally for infectious diseases, and isolation hospitals (755) outnumbered both Poor Law infirmaries (700) and general hospitals (594). Local authorities were not compelled to provide a permanent isolation hospital and this might explain why a significant minority of these facilities – about one-fifth – were buildings that had been converted from other uses, such as Poor Law institutions, private houses and even factories. Under such conditions, much of the local provision for epidemic outbreaks was rudimentary at best, and often of a temporary nature. The LGB, of course, was instrumental in imposing a greater degree of uniformity. It issued model hospital plans on a regular basis and it also withheld loans for proposed hospital buildings considered to be architecturally inferior.22 Isolation hospitals came to be an integral component of the panoply of public health measures that Peter Baldwin has dubbed ‘neo-quarantine’ and Michael Worboys has characterised as ‘exclusive’.23 Focusing on the transmission of disease between people, leading lights of public health considered the institutional isolation of infectious patients as vital to the successful control of epidemics when used in combination with infectious disease notification, disinfection and domestic quarantine.24 Noting the amount of human traffic coming out of and going into these institutions, however, Logie Barrow recently lamented ‘how prematurely historians label these institutions as “isolation” hospitals’.25 The immediate rationale for isolation lay with the state of knowledge about the communicability of diseases. In general, the diseases that accounted for the largest proportion of cases admitted to fever hospitals – and, increasingly from the late 1880s, diphtheria – were acknowledged to be contagious.26 Smallpox came to be exceptional because of the controversy about whether the disease 151

Graham Mooney - 9789042026322 Downloaded from Brill.com09/26/2021 08:09:10PM via free access Graham Mooney also could be carried in the air over long distances or not, a clear problem if the hospital was located amidst a populous district.27 This possibility sparked allegations that smallpox hospitals were foci for infection. Those for whom more proximate and intimate channels were required to pass on the disease rejected this. More crucial for them was the hospital’s endless traffic of people:

There are the milkman, the baker, the butcher, the greengrocer, and their assistants who call daily. To those who attend daily have to be added those who attend less frequently; contractors of various kinds, provision merchants, vendors of patents and disinfectants, the friends of the dead, inquirers after situations, the wine merchant, the brewer, the grocer, the cheesemonger, the oilman, the soap merchant, the crockery merchant, the brush man, &c., &c.28 Notwithstanding omission of the candlestick maker, this remains an extensive list. It does not even begin to enumerate the movements of the nursing and medical staff, ambulances and visitors to patients. Indeed, in one six-day period in January 1881, LGB inspector William Power recorded that 439 interactions of the sort mentioned above took place at the Fulham smallpox hospital.29 In accepting the case for long-distance smallpox transmission, the RCSFH also admitted that ‘personal communication’ between patients and individuals entering the hospital was a significant factor in raising the incidence of smallpox in the immediate neighbourhood.30 Following his extensive survey into isolation hospital provision, the Commission heard from Thorne that disease might, on occasion, have spread as the result of ‘illicit’ visits to patients or when patients were ‘so placed’ as to be able ‘to communicate with others outside the hospital’.31 The Commission clearly felt the weight of evidence was heavy enough to tighten the authorities’ grip on all possible routes of transmission between people and it made a series of recommendations intended to minimise the risks involved with these interactions. Tradespeople and contractors were to use a separate entrance; nurses’ and attendants’ leave should be less frequent, though of a longer duration; the ambulance service should be more closely managed and under the complete control of the hospital authority; and, significant in the context of this chapter, regulations for visitors to patients should be ‘strictly enforced’.32

The poor man’s spare bedroom? Both the popular perception and the reality of exclusion that surrounded isolation hospitals presented a tricky problem to public health officialdom,

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Graham Mooney - 9789042026322 Downloaded from Brill.com09/26/2021 08:09:10PM via free access Infection and Citizenship since it militated against the isolation of all cases that, ideally, was required to arrest an epidemic. Local authorities used hospitalisation rates as a rough- and-ready means of assessing community acceptance of, and satisfaction with, the isolation hospital. It is instructive that in 1891, Sheffield’s MOH regarded the city’s scarlet fever hospitalisation rate of twenty-nine per cent as a dismal figure.33 Although hospital accommodation in the city was ‘exceedingly well adapted to the requirements’, the MOH puzzled at parents’ reluctance to utilise the city’s hospital at Winter Street.34 By the late 1880s and early 1890s, some other local authorities were hospitalising as many as eighty per cent of all scarlet fever cases that were notified to them.35 This intensification of isolation hospital provision in the final quarter of the nineteenth century must have represented a real, sometimes troubling, shift in the community experience of institutionalisation.36 The overwhelming impression is that isolation hospitals tended to serve the working classes and poorest members of the community. For the most part, this is undoubtedly true, since legislation that sanctioned compulsory removal to hospital – the 1866 Sanitary Act – stipulated that it need only take place in instances where domestic isolation was not feasible – that is, in homes that were overcrowded. This was achieved by reformulating the definition of a nuisance to embrace ‘any house, or part of a house so overcrowded as to be dangerous or prejudicial’ to the residents. The link between the lack of domestic space and hospitalisation is significant in the context of the mid-century formulation of citizenship: the criteria of ‘fitness’ included a family’s ability to secure a dwelling that would promote moral and physical wellbeing;37 since ‘overcrowding’ itself evaded official technical definition until the 1890s, there was considerable leeway in the interpretation of this term.38 The opinions of public health officials, who tended to regard the working classes as either far too ignorant to understand the requirements of domestic isolation or unable to secure isolation of a in an overcrowded home, did much to foster the impression that isolation hospitals existed to serve primarily the needs of the poorer sections of society. The following quote from the Sheffield MOH indicates precisely why isolation hospitals came to be portrayed as the ‘poor man’s spare bedroom’:

It is quite impossible that proper isolation can be carried out in small houses where there are several members of a family, and where the room containing the patient is in close proximity to that used by others, or where the mother, no matter how careful in the use of disinfectants, has both to nurse the patient and superintend domestic arrangements. Efficient isolation consists in completely cutting off the sick room with all it contains, including the

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nurse, from the rest of the house and family, and, except in special cases, this is quite impossible in private houses.39 The need to hospitalise all but the wealthiest patients created barriers to acceptance, particularly over the thorny issue of pauperisation. In London, where the MAB was a constituted authority of the Poor Law, those unable to secure domestic isolation and submitting to hospital admission were immediately pauperised – and thus disenfranchised.40 Though MAB hospitals could in fact admit any person without a relieving officer’s certificate if they were deemed to present a danger to the public, the legal status of pauperism was not removed until the Diseases Prevention (Metropolis) Act of 1883.41 The spectre of pauperisation might have prejudiced the domestically overcrowded working classes against isolation hospitals in London; everywhere else, the spectre of paupers prejudiced the well-to-do. In the provinces around this time, some isolation hospitals contracted with the local guardians to admit paupers with an infectious disease, especially where separate accommodation did not exist in the workhouse infirmary. In the late 1870s, four per cent of Salford’s isolation hospital patients were drawn from the middle and upper classes (tradespeople, clerks, professionals) and fifty-four per cent from the ‘wage-earning classes’. The remainder – a little over forty per cent – were paupers, a figure similar to that in neighbouring Manchester’s Monsall Hospital in 1880. A minority of hospitals reported that no troubles were encountered with the admission of out-door paupers, particularly if their ragged or dirty clothing was replaced with hospital-issue uniform, as was the case in Salford.42 In Oldham, where the hospital outfits came in a variety of patterns ‘so as to avoid the appearance of a uniform’, newly arrived patients were also issued a numbered bag containing a clean brush and comb. Bathing, the cutting of hair and the sorting and disinfection of clothing became routine for patients everywhere.43 While these rituals of standardisation certainly can be interpreted as the inculcation of desirable hygienic behaviours, within the hospital itself they also aimed at dissolving the separation of the pauper ‘anti-citizen’ from the respectable working class.44 Despite this, securing the isolation of patients unwilling to co-habit wards with paupers was a recurring problem in places such as Blackpool, Carlisle, Manchester, Newcastle and Nottingham. Some local authorities administering isolation hospitals refused to admit paupers altogether.45 Most hospitals had private rooms that the better-off families living in detached houses might pay for. This saved their children from having to commingle with the hoi polloi, a state of affairs wealthier parents quite ‘naturally refuse to allow’.46 Birkenhead’s MOH encouraged the provision of such rooms by tantalising his council with the prospect of 154

Graham Mooney - 9789042026322 Downloaded from Brill.com09/26/2021 08:09:10PM via free access Infection and Citizenship recovering at least some of their costs through charging wealthier patients ‘double or three times the ordinary’ rate.47 Elsewhere, such patients were further induced into the hospital by being allowed, again at their own cost, to call in their own general practitioner.48 Isolating children Pamela Gilbert’s recent contribution on citizenship and public health recognises that children ‘are of particular interest within liberalism because they represent the limit case of individual freedom and responsibility’.49 Children’s status as dependents and their future potential to act as autonomous citizens legitimated the provision of free education by the state on the one hand and interference in the domestic sphere on the other. Isolation hospitals are important in this respect because infectious diseases most afflict immunologically unprotected young members of the family. There are two points to consider here. First, the separation of children from their domestic environment raises the question of where responsibility for children’s health lies: is it with the government or with the family? This echoes the vehement anti-vaccination debates in which infants’ bodies were fought over by parents and the state. Second, removal of a diseased family member to hospital placed the regulation of home life firmly into the social realm.50 Through the body of the infected child, parental competence in domestic hygiene was being put on display in the isolation hospital.51 In London in the 1870s, every tenth death of a child aged between 5 and 9 years old was caused by scarlet fever – for every age above twenty years it was less than one in a hundred. Data for morbidity is harder to come by, though evidence from Nottingham around the turn of the century indicates that around ninety per cent of all scarlet fever cases occurred in children under 14 years old.52 As Thorne discovered, isolation hospital admissions rapidly came to reflect this age-specific incidence and he seemed genuinely impressed and pleased that parents were so willing to relinquish their children to the care of the hospital authorities (Table 7.1 overleaf).53 Thorne’s report gave official credence to the idea that isolation hospitals were gaining in popularity, though instances of local resentment and resistance suggest this was a partial view. Hostile feelings were expressed more or less covertly, and not without the occasional connivance of the family physician. Leicester’s Sanitary Inspector, Sergeant Braley, reported on one couple who were in the habit of sending their sick children to their grandmother, and had initially refused to allow their child to be taken to hospital after the family practitioner had advised them that it would be treated equally well at home.54 It was also in Leicester around this time that one newspaper letter-writer with the pseudonym ‘An Englishman’ observed:

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Table 7.1

Isolation Hospital Admissions by Age, Sanitary Authorities in England and Wales, c.1881

All Patients Patients <=10 yrs % Alcester 220 179 81 Bradford 812 485 59 Grantham 66 49 74 Huddersfield 452 303 67 Isle of Thanet 138 83 60 Leeds 523 183 35 Leicester 346 251 72 Maidstone 48 24 50 Manchester 500 166 33 Oldham 200 118 59 Salford 1,263 710 56 Warrington 190 122 69

Source: R. Thorne Thorne, ‘On the Use and Influence of Hospitals for Infectious Diseases’, Tenth Annual Report of the Local Government Board 1880–81. Supplement containing Reports and Papers submitted by the Board’s Medical Officer on the Use and Influence of Hospitals for Infectious Disease (Cd 3290, London, 1882), 27.

[W]ho amongst us would think of running to the Sanitary Inspector and saying, ‘Please, sir, my child has the ; come and fetch it from its mother, and take it to the ; it will be quite safe under Dr Johnston [Leicester’s Medical Officer of Health], for they say he can cure all diseases.’55 It was believed by some that the concealment of disease to avoid hospital admission was as likely amongst the wealthy as it was among the poorer classes.56 Some agitation took place on a scale that might be noticed by a local authority. The 16,000 signatories to Nottingham’s ‘Rights and Liberties Defence League’ petition reacted in this way to the Council’s resolution to adopt the 1890 Infectious Diseases (Prevention) Act:

We the undersigned inhabitants and ratepayers of the town of Nottingham, pray that your honourable Council will take such steps as may be necessary to rescind the resolution recently passed by the Council, which converts our hospital into a prison and deprives us of our right to nurse our sick and claim

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our dead. We consider that the power conferred upon certain officials under this resolution are greatly in excess of any that ought to be granted, that they are absolutely uncalled for, certain to be abused, and calculated to create a spirit of prejudice against an institution which has cost the ratepayers very dear.57 This issue brought a great deal of raw emotion to the surface and re-opened old sores for at least one parent. ‘As a ratepayer of Nottingham I am diametrically opposed to any further compulsory powers being granted to our town officials’, wrote C.J. Welton, recounting his own child’s death but ten hours after hospital admission:

What would the world be without sentiment? What can be better than kindness and happy endearing surroundings for a person who is suffering from some foul disease? Your cold, callous doctrine of isolation and separation from all friends, even if directed against all adults, is unbearable when applied to children, who are to be dragged away from their parents, perhaps never to see them alive again… I would suffer imprisonment sooner than I would allow another child to be cruelly dragged from its parents to die in a hospital.58 Similar examples of protest and resistance are gradually being recovered in public health histories.59 That isolation procedures could be coercive is difficult to deny, though not all public health authorities were unsympathetic. In Leicester, one family doctor demanded to know why the Sanitary Inspector – a Mr Buxton on this occasion – had refused to remove a child immediately to the isolation hospital one evening in May 1880.60 He met with this reply from the Health Committee, relayed by the city’s town clerk:

I am directed to inform you that the Sanitary Office closes at 6 o’clock: I am directed however to say that it is the wish of the committee that the inspectors should give every facility for and assistance in the removal of cases to the hospital after their usual business hours. With regard to this particular case it appears that the delay was caused by the difficulty Buxton felt in removing an infant of such tender age into the hospital and therefore separating it from the mother, especially as he was informed that it was in a very critical condition. Not being able to consult Dr Johnston [the MOH], Buxton went to the chairman [of the Health Committee] for advice and on the following morning the child was removed into the hospital. I understand the child died the next day after it was received into the hospital.61 Returning to Nottingham, we might contrast Mr Welton’s experience with that of local surgeon, Thomas Burnie: 157

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Without any compulsion, I was glad to avail myself of the opportunity of sending to the Bagthorpe Hospital one of my boys who, some three months ago, began with scarlet fever. He has recently come home in good health and excellent condition, and no other member of the family has taken the disease. During his stay in the hospital he was treated with the utmost care and kindness by everyone connected with the institution, and everything that could conduce to his recovery or well-being was provided for him without stint… I am fully conscious of the grave objections there must always be to a parent parting with his or her child, especially when the child is seriously ill, but I am able, from my own experience, to assure my fellow townsmen that if they do send their children when ill to one of these institutions they will be tenderly and gently cared for, and will have provided for them everything necessary to their comfort and welfare.62 As a surgeon and member of the local medical élite, we might treat Burnie’s account with a larger pinch of salt than if he were, say, one of the city’s lace-makers. But personal accounts such as this probably did have a positive impact on the regard in which isolation hospitals were held. Thorne himself believed that admission rates were aided by ‘the steady diffusion of the reports made by previous patients as to the comforts and excellence of nursing obtained with the several hospitals.’63 In advocating the extension of its isolation hospital, Birmingham’s Health Committee used patient evidence to show the hospital was ‘becoming increasingly popular’. The committee told the City Council in 1884 that the hospital had ‘received letters from discharged patients, thanking them for their kindness and attention’, arguing they had little difficulty ‘inducing the relatives of the sufferers to send them to hospital’.64 Mostly, it seems, medical officers and hospitals relied on word-of-mouth to increase the popularity of isolation hospitals and they were confident that any unwillingness would dissipate once parents realised that by sending their child to the hospital they would be free to go to work or to keep their businesses running.65 Some hospitals were more proactive and practiced what would now be termed ‘outreach’. Four cottages served as the isolation facilities in the Kent town of Maidstone. The medical superintendent there adopted the practice of sending out a nurse from the hospital not only ‘to assist in washing linen and to superintend any measures of disinfection’, but also to ‘use her personal influence to secure the removal of patients’. The nurse encouraged mothers to consult with neighbours as to the ‘comforts which other children enjoyed when in hospital’.66 This section of the chapter has sought to illustrate some of the issues at stake in the isolation of children. The official creed was that popular opposition to isolation hospitals was on the wane and that parents gradually 158

Graham Mooney - 9789042026322 Downloaded from Brill.com09/26/2021 08:09:10PM via free access Infection and Citizenship acquiesced to the state’s requirement that they act out their duty towards community well-being by giving up their children for removal. The apparent success of gentle moral persuasion and self-enlightenment – that is, individuals realising for themselves the benefits of isolation – carries a whiff of delusion, since local authorities had recourse to legal powers in the face of a recalcitrant patient. While instances to the contrary were not infrequent, the sparing use of compulsory removal orders was cited by contemporaries as evidence that the working class were readily submitting to the increasingly clear benefits of isolation hospitals.67 But the underlying threat of coercion is of equal importance to its legislative enforcement. Thorne pointed to numerous occasions when simply initiating the process of obtaining a magistrate’s order for removal was enough to induce admission; the order itself rarely required enacting. Parents were faced with relatively little choice than perhaps to protest at the state’s interference with traditional modes and spaces of familial care-giving, yet ultimately submit to it. Below is considered how hospital authorities circumscribed parents’ rights to visit their children whilst in hospital, and the discipline they attempted to inculcate in familial behaviours. Regulating visitors The regulation of visiting in many institutional contexts was about preserving the moral and hygienic order of the hospital.68 While this was also an issue for the administrators of isolation hospitals,69 the connection with public health meant that of equal, if not greater, concern was that visitors might unwittingly contract a disease in hospital and contaminate the outside world by taking it with them into the local community. Isolation hospitals were spaces laden with infectious risk. Visitors were dangerous not because, like patients, they had contracted a disease with visible signs; nor even because they harboured a disease asymptomatically. Rather, visitors constituted a danger because they were susceptible to the biological threat of the isolation environment. Consequently, visitors were expected to submit to rules and regulations that acted as strategies to underline the exclusionary nature of infectious disease isolation both to them and the patient. In his report, Thorne could point to no examples where ward visiting by family and friends was freely allowed in isolation hospitals. As we shall see, visiting did take place in most isolation hospitals under tightly controlled conditions, conditions that probably became more stringent in the aftermath of the Royal Commission.70 Nowhere, at least in the official rhetoric, was it possible for a parent to turn up, walk onto a smallpox, scarlet fever or diphtheria ward and take a seat next to their sick son or daughter. If daily, weekly or even monthly ward visiting times were ever posted, they never made their way into Thorne’s report. In fact, Thorne only came across two 159

Graham Mooney - 9789042026322 Downloaded from Brill.com09/26/2021 08:09:10PM via free access Graham Mooney provincial locations where the visiting rules were committed to paper (Alcester and Bradford; the MAB also published visiting regulations). Perhaps this in itself reflects a reluctance to entertain the idea of visitors: there was no need to produce a set of rules for a constituency that was not supposed to exist in the first place.71 Typically, given the feminised character of the social body, mothers were portrayed as problematic. The author has already alluded to the ways in which mothers became the hospital authorities’ focus of outreach activities. The need for tactful handling of parental feelings extended to allowing mothers to accompany children in the ambulance and make sure that they were settled in bed. Thorne’s review of his evidence indicated that it was ‘general policy’ to admit a mother along with her child ‘if isolation could not be secured domestically’.72 Except in cases where the mother was breastfeeding, the length of stay ranged between a few hours and three days. The picture was more complicated than Thorne’s summary of his own survey would have us believe. To begin with, in at least one hospital (Aberdare, south Wales), mothers were expressly forbidden from accompanying their children. This policy was also adopted in 1881 at the MAB Homerton Smallpox Hospital, much to the apparent regret of William Gayton, a medical superintendent there.73 In Aberdare’s case, Thorne was prepared to admit that this practice probably caused resentment among the local population and contributed to the perceived failure of the hospital. At the other extreme, parents in Sunderland were admitted with their children if they so desired and if their occupation was ‘of such a nature as to facilitate the spread of infection from their homes or shops’.74 Alternatives were adopted elsewhere. One was the introduction of a financial charge that served to reclassify accompanying parents not as visitors but as inmates. In Blackpool, mothers were billed at the same daily rate, 3s 6d, as paying patients. In Carlisle, it was the ‘custom’ to admit a parent, relative or nurse along with the patient and a weekly payment of 10s 6d.75 These costs were clearly prohibitive for the average working family, particularly when lengths of confinement for scarlet fever were between six and nine weeks.76 Not surprisingly in Carlisle – where the 10s 6d payment also procured a private room – only the better-off could afford these fees, so the ‘arrangement is thus not applicable to the lower classes’: no money, no mother.77 In addition to these financial disincentives, hospital officials were confident that the rituals of isolation were enough to discourage parents from wanting to stay in hospital for any length of time. In Oldham, parents were permitted to go in with their children, but ‘the restrictions to which such parents are necessarily subjected when in the hospital soon induce them to leave their children, and there are but few who have not within a few days 160

Graham Mooney - 9789042026322 Downloaded from Brill.com09/26/2021 08:09:10PM via free access Infection and Citizenship returned to their own homes’. Being required to take a bath and have their clothes disinfected may have proved deterrent enough for many parents wanting to remain with their child – the author will return to these rituals below.78 While the presence on the ward of parents and close relatives was not necessarily an unusual occurrence, it was a portentous one. In nearly all the instances where visiting rules and practices are known, visitors were only permitted when a patient was deemed to be so ‘dangerously ill’ as to be close to death.79 For Mancunian patients, the chance of this final comfort was slight, since ‘visitors have only in one or two very special cases been admitted even when fatal results were anticipated’.80 According to the oral testimony of one nurse who worked at the London Fever Hospital, as late as the 1930s, there was no visiting at all except for patients in the private wards.81 In Alcester, dangerously ill patients were allowed to see only one of their ‘nearest relatives or intimate friends’ for no more than fifteen minutes, although in very urgent cases two visitors were allowed and the time was extended.82 A one-time 4½-year-old patient at a Kent isolation hospital during the First World War, later recalled that when one girl died ‘the gardener had to walk to her house to inform her parents’.83 The terms of hospital rules were open to interpretation and ultimate authority lay at the top of the hospital hierarchy. The medically qualified staff deemed when a patient was dangerously ill or not. Evidence also suggests that it was not lodge-keepers or junior nurses who decided whether visitors met the blood- line or intimacy criteria. At the Queen’s Memorial Infectious Diseases Hospital, Australia, this gate-keeping power extended to the matron.84 In , no visitor entered the City Hospital’s wards without a pass issued by the Medical Superintendent himself, and this was the case at the MAB’s smallpox hospital in Fulham. Also at Fulham, the name of each visitor was recorded, presumably to prevent multiple visits by the same person on the same day.85 One piece of evidence presented to the RCSFH, in 1882, provided a thumbnail sketch of visiting to three of the MAB’s hospitals, from January 1878 to the end of 1881 (Table 7.2 overleaf). Taking all three hospitals together, the vast majority (eighty-seven per cent) of the dangerously ill patients in both the smallpox and fever hospitals were, in fact, visited. On average, those dangerously ill patients who were visited received two visitors and each visitor came to the hospital about three times. The number of visitors was not insignificant, especially in the one fever hospital represented here. It seems fairly clear that the fever hospital tended to be more receptive to visitors than the two smallpox hospitals – perhaps reflecting popular fears of infectiousness and subsequent fatality – but there are nonetheless intriguing variations between the Stockwell and Fulham smallpox hospitals. 161

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Table 7.2

Admissions, Deaths and Visitors to Dangerously Ill Patients, London MAB Hospitals, 1878–81

Stockwell Stockwell Fulham Fever Smallpox Smallpox Total Admissions 3,833 2,283 3,368 9,984 Deaths 587 205 530 1,322 Dangerously Ill 1,474 825 710 3,009 Dangerously Ill Visited 1,407 721 479 2,607 Number of Visitors 3,911 1,103 683 5,697 Number of Visits 11,553 3,947 1,391 16,891 Visitors Subsequently 0 1 14 15 Admitted

Source: Royal Commission on Smallpox and Fever Hospitals (Cd. 3314, London, 1882) 91; deaths and admissions from MAB statistical reports.

For whatever reason, patients in the latter were far less likely to be visited than those in the former. This may have been due to a localised prejudice against the Fulham smallpox hospital, which was the subject of Power’s inquiry in 1881.86 But one should not discount that differences between any hospitals might have been due simply to differences in the opinions of medical superintendents about the propriety of allowing visitors. Once admitted, the behaviour of visitors was highly circumscribed. In almost all the hospitals where details of visiting are known, relatives and friends were required to wear some form of special clothing, typically described as a ‘wrapper’, an ‘overall’, a mackintosh or some other ‘impervious covering’.87 Such rituals existed well into the twentieth century.88 Visitors were allowed to sit at the bedside, but at ‘some little distance from the patient’ in order ‘to avoid touching the patient, or exposing themselves to the breath or to the emanations from the skin’.89 Contact with bedding was also forbidden. Unless every visitor was closely monitored by the staff, it beggars belief how these strictures on non-bodily contact could be enforced in all cases, especially when hospital wards teemed during an epidemic outbreak. One witness to the RCSFH cited a flagrant breach of the rules at the MAB’s Deptford Hospital, where a wife in borrowed items of clothing spent the afternoon with her infected husband’s head on her breast.90 According to the rules, in the absence of infection-proofing garments, visitors were required to remove their clothing for fumigation once the visit was over and, 162

Graham Mooney - 9789042026322 Downloaded from Brill.com09/26/2021 08:09:10PM via free access Infection and Citizenship regardless of attire, all visitors were requested to wash hands, face and head with a disinfecting agent, usually carbolic soap.91 In Huddersfield, this cleansing stage extended to a full bath.92 The epidemiological rationale behind these procedures was obvious. The most pressing need was to minimise the possibility of visitors acquiring infection – though the otherwise unacknowledged point was made by Alexander Collie, medical superintendent at the MAB’s Homerton Hospital, that it would be highly unlikely that the most common visitors, mothers and wives, would not already have been exposed to the disease in the domestic environment.93 This explains the wrappers and the prohibition of contact with the patient. Nonetheless, the chance of infection remained, and the cleansing of garments and bodies provided an additional hurdle in the way of infection’s escape from the hospital. However, these regulations were also employed as a management tool to deter visiting in the first place. Huddersfield’s respondent to Thorne’s survey observed that the tiresome rituals associated with visiting had served practically to do away with any demand to enter the wards.94 Thorne himself admitted that the wearing of distinctive garments, the disinfection of clothing and the washing procedures had ‘the unquestionable advantage of indicating to the public the views which are entertained by the hospital authorities as to the danger likely to result from needless visits.’95 The pointed use of ‘needless’ betrays Thorne’s attitude; the ordeal of entering the ward should take place only when the patient was perilously close to death. It is also striking that in the few instances where visiting regulations were formalised, various attempts were made to condition the behaviour of the visitors well beyond the boundary of the hospital, both before and after their encounter with isolation. Entry as a patient visitor into the MAB smallpox hospitals required physical evidence of successful vaccination.96 With the warning that ‘they run a great risk when entering the hospital’ still ringing in their ears, visitors to both metropolitan and provincial isolation facilities were advised not to enter the wards if they were ‘in a weak state of health, or in an exhausted condition’. This stipulation certainly can be understood in relation to a visitor’s potential susceptibility to infection when in a compromised physical state, but for reasons the author is unable to fathom, eating food before entering the hospital was also frowned upon.97 A further exhortation not to use a train or any other form of public transport ‘immediately after leaving the hospital’ is, at first glance, wise advice. However, given the state of knowledge regarding incubation periods of infectious disease, allied to the relative inaccessibility of many isolation hospitals by any means other than public transport, the dispensation of such advice was practically pointless. Once again, the laying down of these rules served more than just an epidemiological purpose. Since the hospital was 163

Graham Mooney - 9789042026322 Downloaded from Brill.com09/26/2021 08:09:10PM via free access Graham Mooney doing all in its power to reduce the possibility of infection being exported, and since families were openly warned of the risks of entering such a contaminated environment, responsibility for an epidemic outbreak subsequent to a visit could be legitimately directed at the visitors themselves. As such, a variety of alternative management strategies evolved that allowed relatives and friends to see patients but further served to underline the exclusionary nature of isolation. One concession was the operation of what can be termed ‘window appointments’. Here, relatives and friends were allowed to view the patient through the ward windows for brief periods, at set times, on specified days of the week. Alcester hospital set aside one hour for this activity on Tuesday and Friday afternoons.98 One hour per week was the norm at Broadstairs.99 It is not clear whether the windows were open or closed during such visits. On one occasion in Broadstairs, a window appointment was thought to have caused scarlet fever to spread in the district, so it might be guessed that the windows were open that time. In Aberdeen, the stated practice was to keep the windows shut.100 Systems of window appointments endured until after the First World War. Quoted in Margaret Currie’s book on fever nursing, this is Jean Bell’s list of the worst aspects of her job at West Lane Fever Hospital, Middlesborough in the late 1950s:

Deaths in young and small children; looking after septic abortions, and VD. Seeing a dead foetus. Doing loads of sluicing and emptying mugs from TB patients. Seeing children upset when relations could just look through the window at them when visiting.101 During the war itself, visitors were unable to see much inside one hospital because sandbags were piled up to protect the windows!102 Many authorities successfully kept potential visitors at arms’ length simply by providing daily updates on the welfare of each patient. In Nottingham, Leicester and London, parents and relatives were told that information could be had at the hospital lodge. At the Fulham smallpox hospital, a daily list of dangerously ill patients was kept by the gate porter and appearance on the list qualified patients to receive visitors.103 For most working-class parents and relatives in places where isolation hospitals were located on the outskirts of the communities they served, such information was quite literally beyond their reach.104 As James Gray has described, a system of daily newspaper bulletins was developed in Edinburgh within four years of the city isolation hospital opening. This involved ascribing a number to each patient on admission. The number was known to the family of the patient but otherwise preserved anonymity. Each patient’s number was then

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Graham Mooney - 9789042026322 Downloaded from Brill.com09/26/2021 08:09:10PM via free access Infection and Citizenship classified into one of four categories, according to his or her condition, as follows:

Dangerously ill, friends requested to come out Seriously ill, no immediate danger Ill, making satisfactory progress Not quite so well, no cause for anxiety The list then was published in the daily newspapers.105 As well as providing an indication of the well-being of all patients, the list acted as a signal to relatives of dangerously ill patients to come and visit. Accessibility to patient information was solved in some places by the introduction of new technology. At Monsall Hospital, Manchester, where ward visiting was practically unheard of, the isolation hospital’s telephone connection with the more centrally located Royal Infirmary acted as a line of communication to the outside world and saved some inquirers a journey of several miles. Thorne witnessed this system in operation and was highly impressed:

Whilst at the hospital I could not fail to note that the answers sent to inquirers, instead of being merely formal or limited to monosyllables, afforded some detailed information as to the progress of the patients in question, and to this is probably due to the fact that the arrangement has to a very great extent done away with the difficulties which might otherwise have attended the rule which prohibits visiting.106 Thorne’s official rubber stamp of approval can be read alongside John Burdon Sanderson’s recommendation to the RCSFH that telephones should link the ‘interior and exterior of each ward’ to ‘render the visits to patients of their friends as seldom as possible’.107 All these channels of information provision were designed to prevent visiting and conferred privilege on those in possession of the means of transport and communication.

Conclusion Isolation in a variety of penal and health-related settings has been described as a technique by which states came to know the populations they sought to govern.108 Strange and Bashford remark that:

The ‘dangerous’ became those who did not deserve, or those who could not be trusted with, the freedoms that responsible and healthy citizens enjoyed. In both liberal and totalitarian regimes, experts and government bureaucrats stretched the definition of ‘dangerousness’ to capture individuals who had not yet committed offences.109

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This point of view is both complemented and complicated by forefronting visitors. To be sure, the interpretation offered here is sympathetic to Strange and Bashford’s observation in the sense that the net of dangerousness also captured the potentially diseased. But visitors to isolation hospitals also blurred the line that unequivocally marks the non-diseased and non-isolated as ‘responsible and healthy citizens’. Visitors, it seems, were cast in a somewhat ambiguous role, one that might be best described as that of compromised citizens. Flirting with infection in and around the isolation hospital, visitors teetered on the precipice of disease. As such, their health was vulnerable to risk in ways that for ‘free’ citizens it was not. What is more, the sub-standard domestic hygiene practised by parents was expressed through the infected status of their children and brought the adults’ fitness as citizens into question. The sequestration of children ran against traditional ways of treating sickness in the home and drew families into unavoidable contact with a state that, not untypically, infantilised them. Visiting was an opportunity that public health grasped to mould ‘self- managing citizens capable of conducting themselves in freedom… according to norms of civility’.110 Once inside the hospital, parents, other relatives and close friends were pressed on their responsibility to engage in behaviours that would not facilitate the spread of disease. This advice was not restricted simply to how visitors should act inside the hospital, but also to what they should or should not do before and after crossing the hospital boundary. Acknowledgements I am grateful to the Wellcome Trust for financial support. Additional research was facilitated in 2003 by a Visiting Fellowship to the University of Nottingham’s Institute for the Study of Genetics, Bio-risks and Society. Earlier versions of this chapter were presented to the 2004 Social Science History Conference in Chicago, the 2006 conference of the American Association for the History of Medicine in Halifax, Canada and a colloquium in the Johns Hopkins Program in the History of Science, Medicine and Technology. I am thankful to these audiences and to Harry Marks, Matthew Newsom Kerr and Jonathan Reinarz for their perceptive comments.

Notes 1. N. Rose, Powers of Freedom: Reframing Political Thought (Cambridge: Cambridge University Press, 1999), 72. See also P. Joyce, The Rule of Freedom: Liberalism and the Modern City (London: Verso, 2003); U.C. Mehta, ‘Liberal Strategies of Exclusion’, Politics and Society, 18 (1990), 427–54. These studies, of course, flow from the writings of Michel Foucault: M. Foucault, Discipline and Punish: The Birth of the Prison (London: Allen 166

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Lane, 1977); J.D. Faubion (ed.), Michel Foucault: Power (New York: The New Press, 1994). 2. A. Bashford and C. Strange, ‘Isolation and Exclusion in the Modern World: An Introductory Essay’, in C. Strange and A. Bashford (eds), Isolation: Places and Practices of Exclusion (London: Routledge, 2003), 1–19: 3. 3. H. Hendrick, Child Welfare: England, 1872–1989 (London: Routledge, 1994). Child welfare is further explored by L. Murdoch, Imagined Orphans: Poor Families, Child Welfare, and Contested Citizenship in London (New Brunswick: Rutgers University Press, 2006). Chapter 4 is most relevant to the question of visiting. 4. Royal Commission to Inquire Respecting Smallpox and Fever Hospitals in Metropolis. Report, Minutes of Evidence, Appendix (Cd. 3314, London, 1882) (henceforth RCSFH), x. 5. J. Donzelot, The Policing of Families (New York: Pantheon Books, 1979). 6. A. Beach, ‘Potential for Participation: Health Centres and the Idea of Citizenship c. 1920–1940’, in C. Lawrence and A.K. Mayer (eds), Regenerating England (Amsterdam: Rodopi, 2000), 203–30; B. Harris, ‘Educational Reform, Citizenship and the Origins of the School Medical Service’, in M. Gijswijt-Hofstra and H. Marland (eds), Cultures of Child Health in Britain and the Netherlands in the Twentieth Century (Amsterdam: Rodopi, 2003), 85–101; J. Welshman, ‘Child Health, National Fitness, and Physical Education in Britain, 1900–1940’, in Gijswijt-Hofstra and Marland, idem, 61–84; M. Harrison, ‘Sex and the Citizen Soldier: Health, Morals and Discipline in the British Army during the Second World War’, in R. Cooter, M. Harrison and S. Sturdy (eds), Medicine and Modern Warfare (Amsterdam: Rodopi, 1999), 225–49; P. Gruffudd, ‘“Science and the Stuff of Life”: Modernist Health Centres in 1930s London’, Journal of Historical Geography, 27 (2001), 395–416. 7. P. Baldwin, Disease and Democracy: The Industrialized World Faces AIDS (Berkeley: University of California Press, 2005). 8. A. Bashford and M. Nugent, ‘Leprosy and the Management of Race, Sexuality and Nation in Tropical Australia’, in A. Bashford and C. Hooker (eds), Contagion: Historical and Cultural Studies (London: Routledge, 2001), 106–28; W. Anderson, ‘Leprosy and Citizenship’, Positions, 6 (1998), 707–38. 9. A. Bashford, ‘Cultures of Confinement: Tuberculosis, Isolation and the Sanatorium’, in Strange and Bashford, op. cit. (note 2), 133–50; S. Craddock, ‘Engendered/Endangered: Women, Tuberculosis, and the Project of Citizenship’, Journal of Historical Geography, 27 (2001), 338–54. 10. For an accessible summary of citizenship theory, see K. Faulks, Citizenship (London: Routledge, 2000). 11. Ibid., 5–6. 167

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12. P. Corrigan and D. Sayer, The Great Arch: English State Formation as Cultural Revolution (Oxford: Blackwell, 1985), Ch. 6. 13. M. Poovey, Making a Social Body: British Cultural Formation, 1830–1864 (Chicago: University of Chicago Press, 1995), Ch. 3. 14. P. Gilbert, The Citizen’s Body: Desire, Health and the Social in Victorian England (Columbus: Ohio State University Press, 2007), 55; See also C. Hall, K. McClelland and J. Rendall, Defining the Victorian Nation: Class, Race, Gender and the Reform Act of 1867 (Cambridge: Cambridge University Press, 2000); K. McClelland and S. Rose, ‘Citizenship and Empire, 1867–1928’, in C. Hall and S. Rose (eds), At Home with the Empire: Metropolitan Culture and the Imperial World (Cambridge: Cambridge University Press, 2006), 275–97. 15. Poovey, op. cit. (note 13), Ch. 2; C. Hamlin, Public Health and Social Justice in the Age of Chadwick: Britain, 1800–1854 (Cambridge: Cambridge University Press, 1998). 16. Gilbert, op. cit. (note 14), 18–24; Corrigan and Sayer, op. cit. (note 12), 150–1. 17. Poovey, op. cit. (note 13), Ch. 6. 18. N. Durbach, Bodily Matters: The Anti-Vaccination Movement in England, 1853–1907 (Durham: Duke University Press, 2005). 19. On sites of risk, see D.N. Livingstone, Putting Science in its Place: Geographies of Scientific Knowledge (Chicago: University of Chicago Press, 2003), Ch. 2. 20. H. Richardson, English Hospitals 1660–1948: A Survey of their Architecture and Design (Swindon: Royal Commission on the Historical Monuments of England, 1998). There were, of course, fever wards in Poor Law institutions. M.R. Currie, Fever Hospitals and Fever Nurses – A British Social History of Fever Nursing: A National Service (London: Routledge, 2005), 13, notes fever hospitals were founded in Liverpool, London, Manchester and Newcastle- upon-Tyne between 1800 and 1804. In this chapter I use the term ‘isolation hospital’, which came to replace ‘fever hospital’, a notable shift in title that receives some attention in Currie’s work, but perhaps would repay closer scrutiny. 21. R. Thorne Thorne, ‘On the Use and Influence of Hospitals for Infectious Diseases’, Tenth Annual Report of the Local Government Board 1880–81: Supplement Containing Reports and Papers Submitted by the Board’s Medical Officer on the Use and Influence of Hospitals for Infectious Disease (Cd 3290, London, 1882). 22. Richardson, op. cit. (note 20), 139, although bed provision in the Poor Law Infirmaries (94,001 beds) outstripped all other types of institution combined. See S. Sheard, ‘Reluctant Providers? The Politics and Ideology of Finance 1870–1914’, in M. Gorsky and S. Sheard (eds), 168

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Financing Medicine: The British Experience Since 1750 (Abingdon: Routledge, 2006), 112–29. 23. P. Baldwin, Contagion and the State in Europe, 1830–1930 (Cambridge: Cambridge University Press, 1999); M. Worboys, Spreading Germs: Disease Theories and Medical Practice in Britain, 1865–1900 (Cambridge: Cambridge University Press, 2000). See also M. Pelling, , Fever and English Medicine, 1825–1865 (Oxford: Oxford University Press, 1978), Ch. 6. Some aspects of isolation and hospitals are dealt with in the following: P. Weindling, ‘From Isolation to Therapy: Children’s Hospitals and Diphtheria in Fin De Siècle Paris, London and Berlin’, in R. Cooter (ed.), In the Name of the Child: Health and Welfare, 1880–1940 (London: Routledge, 1992), 124–45; J.M. Eyler, ‘Scarlet Fever and Confinement: The Edwardian Debate Over Isolation Hospitals’, Bulletin of the History of Medicine, 61 (1987), 1–24. 24. J.M. Eyler, Sir Arthur Newsholme and State Medicine, 1885–1935 (Cambridge: Cambridge University Press, 1997). 25. L. Barrow, ‘Victorian “Pest-Houses” Amid London’s March of Bricks and Mortar’, Recherches Anglaises et Américaines, 36 (2003), 127–37: 134. Barrow does not directly name the historians he has in mind. ‘Isolation hospital’ was of course, a commonly used term by the late-nineteenth century. 26. For qualifications to this generalization, see Worboys, op. cit. (note 23). Diphtheria occupied a dual position as both a filth disease (sewer gas continued to be identified as a culprit) and a disease that was infective. Isolation of enteric (typhoid) fever cases was advocated to ensure that patients’ excreta could be dealt with safely. RCSFH, op. cit. (note 4), question 2,485. 27. Barrow, op. cit. (note 25). 28. RCSFH, op. cit. (note 4), question 4,494. 29. W.H. Power, ‘Influence of the Fulham Smallpox Hospital on the Neighbourhood Surrounding it’, Tenth Annual Report, op. cit. (note 21). See M.L. Newsom Kerr, Fevered Metropolis: Epidemic Disease and Isolation in Victorian London (Unpublished PhD: University of Southern California, 2007), Ch. 12. 30. RCSFH, op. cit. (note 4), xxv–xxvii. 31. Ibid., question 1,037. 32. Ibid. In addition, all letters were to be disinfected and the exposure of bedding and clothing was to be minimised as far as possible. Although the commission was concerned with the situation in London, and in particular the duplication of authority between the Poor Law and the MAB, the majority of these recommendations were, of course, applicable to other places.

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33. H. Littlejohn, Annual Report on the Health of the Borough of Sheffield for the Year 1892, 53. 34. H. Littlejohn, Annual Report on the Health of the Borough of Sheffield for the Year 1891, 34. 35. Publication of hospital admissions was uneven. Scarlet fever hospitalisation rates can be calculated from MOH reports in all the following cities from 1892. In that year, Birmingham hospitalised 80% of cases notified, Edinburgh 46%, Leicester 55%, and Nottingham 88%. On infectious disease notification, see G. Mooney, ‘Public Health Versus Private Practice: The Contested Development of Compulsory Notification of Infectious Disease in Late-Nineteenth-Century Britain’, Bulletin of the History of Medicine, 73 (1999), 238–67. 36. Not dealt with here are the mass invasions by a curious public of newly- constructed isolation hospitals that took place before they began admitting patients. On Edinburgh, see J.A. Gray, The Edinburgh City Hospital (East Lothian: Tuckwell Press, 1999), 135; on Oldham see Thorne, op. cit. (note 21), 217; and on Nottingham, see Nottingham City Archives (henceforth NCA), CA.CM/Health/14, Borough of Nottingham, Health Committee Minute Books, 8 May 1891, 44. 37. Gilbert, op. cit. (note 14), Ch. 3. 38. J. Burnett, A Social History of Housing, 1815–1985, 2nd edn (London: Methuen, 1986), 144–5. 39. Littlejohn, op. cit. (note 33), 53. See also F.M. Hardy, ‘The Infectious Diseases Question’, Nottingham Daily Express, 11 April 1891, 6. 40. RCSFH, op. cit. (note 4), questions 2,853–4. 41. G. Ayers, England’s First State Hospitals: The Metropolitan Asylums Board (London: Wellcome, 1971), 81–2. 42. Ibid., 230. 43. Thorne, op. cit. (note 21), 174–8, 218 and 230. 44. Gilbert adopts the term ‘anti-citizen’ to describe paupers, reflecting their lack of both political rights and domestic attachment. Gilbert, op. cit. (note 14), 46. 45. Thorne, op. cit. (note 21), 30. 46. Littlejohn, op. cit. (note 34), 34. 47. F. Vacher, Report on the Sanitary Condition of Birkenhead and Claughton-cum- Grange for the Year 1874, 28. 48. Thorne, op. cit. (note 21), 49. See also NCA, CA.CM/Health/6, Borough of Nottingham, Health Committee Minute Books, 16 April 1875, 154. 49. Gilbert, op. cit. (note 14), 18, note 1. Gilbert does not pursue this theme in any great detail. 50. Here, I take ‘social’ to mean that which mediates between the private and the public spheres. Ibid., Ch. 4 and Poovey, op. cit. (note 13). 170

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51. For the recreation of middle-class domesticity in an isolation setting (the London Fever Hospital), see Newsom Kerr, op. cit. (note 29), Ch. 6. 52. Calculated from P. Boobyer, Nottingham Annual Health Reports for 1899–1901. 53. Thorne, op. cit. (note 21), 27. 54. Leicester City Archives (henceforth LCA), CM32/8, Borough of Leicester, Minute Book of the Sanitary Committee, 7 March 1879, 377–86. 55. An Englishman, ‘The Proposed Compulsory Registration of Infectious Diseases’, The Leicester Chronicle and Leicestershire Mercury (18 January 1879), 6. It was not usual for local authorities to hospitalise whooping cough and I have come across no evidence that it ever was in Leicester. 56. RCSFH, op. cit. (note 4), questions 500 and 1,191. 57. Nottingham Daily Express, 3 March 1891, 6. 58. C.J. Welton, ‘The Infectious Diseases Question’, Nottingham Daily Express, 16 April 1891, 6. 59. M. Sigsworth and M. Worboys, ‘The Public’s View of Public Health in Mid- Victorian Britain’, Urban History, 21 (1994), 237–50; Durbach, op. cit. (note 18); Barrow, op. cit. (note 25). 60. LCA, CM32/9, Borough of Leicester, Minute Book of the Sanitary Committee, 4 June 1880, 314. 61. LCA, 22D57/74, Borough of Leicester, Town Clerk Correspondence (Out), 10 May 1880. 62. T. Burnie, ‘The Nottingham Hospital for Infectious Disease’, Nottingham Daily Express, 6 April 1891, 6. Burnie’s profession is listed in Wright’s Directory of Nottingham, 1894–95. 63. Thorne, op. cit. (note 21), 27. 64. Birmingham City Archives, Borough of Birmingham, Birmingham Health Committee Minute Book, 26 March 1884, 76. 65. Littlejohn, op. cit. (note 34), 34. 66. Thorne, op. cit. (note 21), 168. 67. J. Tatham, Seventeenth Annual Report on the Health of Salford for the Year 1885, 61; Thorne, op. cit. (note 21), 28, who stated that in the course of his inquiry he came across no more than three dozen cases where patients were removed to hospital by force. 68. C.E. Rosenberg, The Care of Strangers: The Rise of America’s Hospital System (Baltimore: Johns Hopkins University Press, 1987), 35, 286–7. 69. Gray, op. cit. (note 36), 158. 70. Newsom Kerr, op. cit. (note 29), Ch. 10. 71. In 1881, Sheffield’s Health Committee proposed appointing a non-resident medical officer to its newly opened hospital. Of course, this was cheaper than having a resident medical officer, but also was seen as necessary since the Committee assumed that otherwise it would be ‘impossible for friends, 171

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visitors or charitable persons to visit the patients’. Sheffield Local Studies Library (henceforth SLSL), 352.042.SQ, City Council of Sheffield, Minutes of the Council, 7 June 1882, 344. 72. Thorne, op. cit. (note 21), 27. See also NCA, CA.CM/Health/7, Borough of Nottingham, Health Committee Minute Books, 4 April 1878, 332. 73. RCSFH, op. cit. (note 4), evidence of William Gayton, questions 2,680–1. 74. Thorne, op. cit. (note 21), 257, citing a case of mother who worked in a pawnbrokers being admitted with her children. 75. Ibid., 83 and 92. 76. Eyler, op. cit. (note 24), 111. 77. Thorne, op. cit. (note 21), 92. 78. Ibid., 150, 217. 79. RCSFH, op. cit. (note 4), question 1,260. 80. Thorne, op. cit. (note 21), 176. 81. See Currie, op. cit. (note 20), 81, testimony of Sarah England (Hicks). 82. Thorne, op. cit. (note 21), 51. 83. See Currie, op. cit. (note 20), 63. 84. W.K. Anderson, Fever Hospital: A History of Fairfield Infectious Disease Hospital (Melbourne: Melbourne University Press, 2002), 33. 85. Gray, op. cit. (note 36), 158. RCSFH, op. cit. (note 4), question 1,260. 86. Power, op. cit. (note 29). At the time of the Royal Commission, the Fulham smallpox hospital was closed to all cases except those occurring within a mile of it. 87. Thorne, op. cit. (note 21), 27 and 52; Gray, op. cit. (note 36), 158; I.A. Porter and M.J. Williams, Epidemic Diseases in Aberdeen and the History of the City Hospital, No. 2 (Aberdeen: Aberdeen History of Medicine Publications, 2001), 48. 88. See Currie, op. cit. (note 20), 81, testimony of Sarah England (Hicks). 89. Exceptions commonly were made in the case of erysipelas and enteric fever wards. 90. Barrow, op. cit. (note 25), 134. 91. Thorne, op. cit. (note 21), 294. Porter and Williams, op. cit. (note 87), 48. 92. Thorne, op. cit. (note 21), 134. 93. RCSFH, op. cit. (note 4) question 2,057. 94. Thorne, op. cit. (note 21), 134. 95. Ibid., 27. 96. Ibid., 294. 97. Ibid., 51 and 294. 98. Ibid., 51. 99. Ibid., 89. 100. Porter and Williams, op. cit. (note 87), 48 101. Currie, op. cit. (note 20), 86, testimony of Jean Bell (Hall). 172

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102. Ibid., 99, testimony of Olive Dodd (Cowley), Dunstable and District Joint Isolation Hospital, 1942–4. 103. Thorne, op. cit. (note 21), 150, 209 and 294. RCSFH, op. cit. (note 4), evidence of John Ashton Bostock, question 1,260. 104. Thorne, op. cit. (note 21), 8. 105. Gray, op. cit. (note 36), 149. 106. Thorne, op. cit. (note 21), 176. The health committee in Sheffield also argued that a telephone would reduce the time and inconvenience that the MOH incurred when seeking out cases to induce them to come to the hospital. See, City Council of Sheffield, op. cit. (note 71), 344. 107. J. Burden Sanderson, ‘Memorandum on the Administration of Urban Hospitals for Smallpox’, RCSFH, op. cit. (note 4), 315. 108. M. Dean, ‘Liberal Government and Authoritarianism’, Economy and Society, 21 (2002), 37–61. 109. Bashford and Strange, op. cit. (note 2), 3–4. 110. Rose, op. cit. (note 1), 242.

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