Patient pathways: Solving the problem of institutional mortality in London during the later nineteenth century

Social History of Medicine

Volumn 12, Issue 2, 1999, Pages 227-269

  Mooney, Graham ^a   Luckin, Bill ^a,b   Tanner, Andrea ^a  

^a UNIVERSITY OF LONDON   (United Kingdom)

^b UNIVERSITY OF BOLTON   (United Kingdom)

Author keywords

Hospitals; London; Metropolitan Asylums Board; Mortality; Patients; Poor Law infirmaries

Indexed keywords

ARTICLE; HEALTH; HISTORY; HOSPITAL; HOSPITAL PATIENT; MORTALITY; UNITED KINGDOM;

GREAT BRITAIN; HISTORY, 19TH CENTURY; HOSPITAL MORTALITY; HOSPITALS; INPATIENTS; URBAN HEALTH;

EID: 0033176564     PISSN: 0951631X     EISSN: None     Source Type: Journal    
DOI: 10.1093/shm/12.2.227     Document Type: Article

References (185)

1. St Bartholomew's Hospital, MRS/12, 1866-71. The Census of Denmark Court, taken seven weeks before her admission (PRO RG10/417/52) has no reference to her, although a couple enumerated as Henry and Ann Sales and their child were resident there.
2. London Fever Hospital admission register, entry 978, 1871. The 1871 Census has no trace of Rachel or her family (PRO RG10/418/17-18). Her death certificate, signed by a hospital surgeon, also lists perforation of the bowels and peritonitis as secondary causes of death. It does not, however, give any information on her parents.
3. Brompton Hospital, No. 9,216, Register No. 15,972. The 1871 Census of Ireland Yard (PRO RG10/426/45) described Millican as a fancy salesman, so perhaps his illness made a change of occupation desirable. Doctors' Commons was a short walk from his home, which he shared with his widowed mother (a tailor) and three siblings.
4. London Metropolitan Archives [LMA], C.BG.334/3, City of London Union Admissions Registers; LMA, X20/34, Register of Deaths 1868-74, City of London Bow Workhouse. There was no trace of Morris or his wife at Widegate Street in the 1871 Census (PRO RG10/416/31-33).
5. The death certificates of these four patients show the registered district of death, while the original hospital records list their normal place of residence. Further discussion of these latter sources can be found in Section III of this paper.
6. E. Higgs, 'The Statistical Big Bang of 1911: Ideology, Technological Innovation, and the Production of Medical Statistics', Social History of Medicine, 10 (1996), pp. 423-4.
7. J. Eyler, 'Mortality Statistics and Victorian Health Policy: Program and Criticism', Bulletin of the History of Medicine, 50 (1976), 335-55; W. Luckin, 'Death and Survival in the City: Approaches to the History of Disease', Urban History Yearbook (1980), 53-61; A. Hardy, '"Death is the Cure of all Diseases": Using the General Register Office Causes of Death Statistics for 1837-1920', Social History of Medicine, 7 (1994), 473.
8. J. Eyler, 'Mortality Statistics and Victorian Health Policy: Program and Criticism', Bulletin of the History of Medicine, 50 (1976), 335-55; W. Luckin, 'Death and Survival in the City: Approaches to the History of Disease', Urban History Yearbook (1980), 53-61; A. Hardy, '"Death is the Cure of all Diseases": Using the General Register Office Causes of Death Statistics for 1837-1920', Social History of Medicine, 7 (1994), 473.
9. J. Eyler, 'Mortality Statistics and Victorian Health Policy: Program and Criticism', Bulletin of the History of Medicine, 50 (1976), 335-55; W. Luckin, 'Death and Survival in the City: Approaches to the History of Disease', Urban History Yearbook (1980), 53-61; A. Hardy, '"Death is the Cure of all Diseases": Using the General Register Office Causes of Death Statistics for 1837-1920', Social History of Medicine, 7 (1994), 473.
10. G. Mooney, 'Professionalization in Public Health and the Measurement of Sanitary Progress in Nineteenth-Century England and Wales', Social History of Medicine, 10 (1997), 58-9. For the original tables see the Decennial Supplements to the following: 25th Annual Report of the Registrar-General, 1862 (London, 1864), p. lx (henceforth ARRG); 35th ARRG, 1872 (London, 1875), p. cxc; and 45th ARRG, 1882 (London, 1885), p. lxvi. William Farr also performed a similar correction for the period 1838-44 in the Ninth ARRG, 1846 (London, 1848), pp. 161-6.
11. G. Mooney, 'Professionalization in Public Health and the Measurement of Sanitary Progress in Nineteenth-Century England and Wales', Social History of Medicine, 10 (1997), 58-9. For the original tables see the Decennial Supplements to the following: 25th Annual Report of the Registrar-General, 1862 (London, 1864), p. lx (henceforth ARRG); 35th ARRG, 1872 (London, 1875), p. cxc; and 45th ARRG, 1882 (London, 1885), p. lxvi. William Farr also performed a similar correction for the period 1838-44 in the Ninth ARRG, 1846 (London, 1848), pp. 161-6.
12. G. Mooney, 'Professionalization in Public Health and the Measurement of Sanitary Progress in Nineteenth-Century England and Wales', Social History of Medicine, 10 (1997), 58-9. For the original tables see the Decennial Supplements to the following: 25th Annual Report of the Registrar-General, 1862 (London, 1864), p. lx (henceforth ARRG); 35th ARRG, 1872 (London, 1875), p. cxc; and 45th ARRG, 1882 (London, 1885), p. lxvi. William Farr also performed a similar correction for the period 1838-44 in the Ninth ARRG, 1846 (London, 1848), pp. 161-6.
13. G. Mooney, 'Professionalization in Public Health and the Measurement of Sanitary Progress in Nineteenth-Century England and Wales', Social History of Medicine, 10 (1997), 58-9. For the original tables see the Decennial Supplements to the following: 25th Annual Report of the Registrar-General, 1862 (London, 1864), p. lx (henceforth ARRG); 35th ARRG, 1872 (London, 1875), p. cxc; and 45th ARRG, 1882 (London, 1885), p. lxvi. William Farr also performed a similar correction for the period 1838-44 in the Ninth ARRG, 1846 (London, 1848), pp. 161-6.
14. G. Mooney, 'Professionalization in Public Health and the Measurement of Sanitary Progress in Nineteenth-Century England and Wales', Social History of Medicine, 10 (1997), 58-9. For the original tables see the Decennial Supplements to the following: 25th Annual Report of the Registrar-General, 1862 (London, 1864), p. lx (henceforth ARRG); 35th ARRG, 1872 (London, 1875), p. cxc; and 45th ARRG, 1882 (London, 1885), p. lxvi. William Farr also performed a similar correction for the period 1838-44 in the Ninth ARRG, 1846 (London, 1848), pp. 161-6.
15. Brydges Henniker in the 47th ARRG, 1884 (London, 1886), p. xx, quoted in Higgs, 'The Statistical Big Bang', p. 423.
16. Brydges Henniker in the 47th ARRG, 1884 (London, 1886), p. xx, quoted in Higgs, 'The Statistical Big Bang', p. 423.
17. Given the obvious shortcomings of the GRO's own corrections outlined above, this assumption seems rather optimistic. Higgs, 'The Statistical Big Bang', p. 423. In fact, an occasional table of national institutional deaths did appear in the 24th ARRG, 1861 (London, 1863), p. 174. This table provided for the country what had in fact been available for London since 1851.
18. Given the obvious shortcomings of the GRO's own corrections outlined above, this assumption seems rather optimistic. Higgs, 'The Statistical Big Bang', p. 423. In fact, an occasional table of national institutional deaths did appear in the 24th ARRG, 1861 (London, 1863), p. 174. This table provided for the country what had in fact been available for London since 1851.
19. This formalized an independent system of redistribution developed earlier by MOHs with the sanction of the Local Government Board (LGB). It had been a response to the sometimes misleading manner in which institutionally inflated levels of mortality were used to question the apparent success of preventive medicine at a local level. The St Paneras MOH proposed returning institutional deaths back to the district of origin as early as 1857, although renewed efforts to persuade the Registrar-General to do this were not made until Thomas Orme Dudfield, Medical Officer for Health for Kensington, took up the cause in 1874. In their Annual Reports, he and a number of other Medical Officers of Health subtracted the' deaths of non-parishioners occurring in the institutions in their parishes, and added in deaths to residents who had died in institutions outside the parish. See Mooney, 'Professionalization in Public Health', p. 59, note 35.
20. W. Luckin and G. Mooney, 'Urban History and Historical Epidemiology: The Case of London, 1860-1920', Urban History, 24 (1997), 37-54.
21. For a consolidated statement of the original arguments, see T. R. McKeown, The Modem Rise of Population (London, 1976).
22. R. I. Woods and J. Woodward (eds), Urban Disease and Mortality in Nineteenth-Century England (London, 1984); S. R. S. Szreter, 'The Importance of Social Intervention in Britain's Mortality Decline r. 1850-1914: A Reinterpretation of the Role of Public Health', Social History of Medicine, 1 (1988), 1-37; G. Kearns, 'The Urban Penalty and the Population History of England', in A. Brändström and L.-G. Tedebrand (eds), Society and Health During the Demographic Transition (Stockholm, 1988), pp. 213-35; idem, 'Le Handicap Urbain et le Déclin de la Mortalité en Angleterre et au Pays du Galles, 1851-1900', Annales de Demographie Historique, (1993), 75-105; S. R. S. Szreter and G. Mooney, 'Urbanization, Mortality and the Standard of Living Debate: New Estimates of the Expectation of Life at Birth in Nineteenth-Century British Cities', Economic History Review, LI (1998), 84-112.
23. R. I. Woods and J. Woodward (eds), Urban Disease and Mortality in Nineteenth-Century England (London, 1984); S. R. S. Szreter, 'The Importance of Social Intervention in Britain's Mortality Decline r. 1850-1914: A Reinterpretation of the Role of Public Health', Social History of Medicine, 1 (1988), 1-37; G. Kearns, 'The Urban Penalty and the Population History of England', in A. Brändström and L.-G. Tedebrand (eds), Society and Health During the Demographic Transition (Stockholm, 1988), pp. 213-35; idem, 'Le Handicap Urbain et le Déclin de la Mortalité en Angleterre et au Pays du Galles, 1851-1900', Annales de Demographie Historique, (1993), 75-105; S. R. S. Szreter and G. Mooney, 'Urbanization, Mortality and the Standard of Living Debate: New Estimates of the Expectation of Life at Birth in Nineteenth-Century British Cities', Economic History Review, LI (1998), 84-112.
24. R. I. Woods and J. Woodward (eds), Urban Disease and Mortality in Nineteenth-Century England (London, 1984); S. R. S. Szreter, 'The Importance of Social Intervention in Britain's Mortality Decline r. 1850-1914: A Reinterpretation of the Role of Public Health', Social History of Medicine, 1 (1988), 1-37; G. Kearns, 'The Urban Penalty and the Population History of England', in A. Brändström and L.-G. Tedebrand (eds), Society and Health During the Demographic Transition (Stockholm, 1988), pp. 213-35; idem, 'Le Handicap Urbain et le Déclin de la Mortalité en Angleterre et au Pays du Galles, 1851-1900', Annales de Demographie Historique, (1993), 75-105; S. R. S. Szreter and G. Mooney, 'Urbanization, Mortality and the Standard of Living Debate: New Estimates of the Expectation of Life at Birth in Nineteenth-Century British Cities', Economic History Review, LI (1998), 84-112.
25. R. I. Woods and J. Woodward (eds), Urban Disease and Mortality in Nineteenth-Century England (London, 1984); S. R. S. Szreter, 'The Importance of Social Intervention in Britain's Mortality Decline r. 1850-1914: A Reinterpretation of the Role of Public Health', Social History of Medicine, 1 (1988), 1-37; G. Kearns, 'The Urban Penalty and the Population History of England', in A. Brändström and L.-G. Tedebrand (eds), Society and Health During the Demographic Transition (Stockholm, 1988), pp. 213-35; idem, 'Le Handicap Urbain et le Déclin de la Mortalité en Angleterre et au Pays du Galles, 1851-1900', Annales de Demographie Historique, (1993), 75-105; S. R. S. Szreter and G. Mooney, 'Urbanization, Mortality and the Standard of Living Debate: New Estimates of the Expectation of Life at Birth in Nineteenth-Century British Cities', Economic History Review, LI (1998), 84-112.
26. R. I. Woods and J. Woodward (eds), Urban Disease and Mortality in Nineteenth-Century England (London, 1984); S. R. S. Szreter, 'The Importance of Social Intervention in Britain's Mortality Decline r. 1850-1914: A Reinterpretation of the Role of Public Health', Social History of Medicine, 1 (1988), 1-37; G. Kearns, 'The Urban Penalty and the Population History of England', in A. Brändström and L.-G. Tedebrand (eds), Society and Health During the Demographic Transition (Stockholm, 1988), pp. 213-35; idem, 'Le Handicap Urbain et le Déclin de la Mortalité en Angleterre et au Pays du Galles, 1851-1900', Annales de Demographie Historique, (1993), 75-105; S. R. S. Szreter and G. Mooney, 'Urbanization, Mortality and the Standard of Living Debate: New Estimates of the Expectation of Life at Birth in Nineteenth-Century British Cities', Economic History Review, LI (1998), 84-112.
27. For geographical comparisons in this period, see R. I. Woods and N. Shelton, An Atlas of Victorian Mortality (Liverpool, 1997).
28. G. Mooney, 'Did London Pass the "Sanitary Test"? Seasonal Infant Mortality in London, 1870-1914', Journal of Historical Geography, 20 (1994), 158-74.
29. N. Williams and G. Mooney, 'Infant Mortality in an "Age of Great Cities": London and the Provincial Cities Compared, c. 1840-1910', Continuity and Change, 9 (1994), pp. 195-6.
30. W. Luckin, 'Evaluating the Sanitary Revolution: Typhus and Typhoid in London, 1851-1900', in Woods and Woodward, Urban Disease, pp. 102-19. Here, the reallocation of deaths to typhoid and typhus in the London Fever Hospital and Metropolian Asylums Board hospitals was undertaken.
31. 1860 marks the starting date of a project concerned with analysis of annual cause-specific mortality rates in London up until 1920. The GRO began publishing selective cause of death information for all the registration districts in England and Wales in 1856.
32. Between 1820 and 1860, over 40 specialist hospitals were established in London, in addition to several general ones. By the latter date, they were attracting over £155,000 a year in donations. D. Owen, English Philanthropy, 1660-1960 (Cambridge, MA, 1964), pp. 170-1; M. Powell, 'A Century of Hospital Planning in London: From the House of Lords' Enquiry to the Tomlinson Report', London Journal, 21 (1996), 164-80.
33. Between 1820 and 1860, over 40 specialist hospitals were established in London, in addition to several general ones. By the latter date, they were attracting over £155,000 a year in donations. D. Owen, English Philanthropy, 1660-1960 (Cambridge, MA, 1964), pp. 170-1; M. Powell, 'A Century of Hospital Planning in London: From the House of Lords' Enquiry to the Tomlinson Report', London Journal, 21 (1996), 164-80.
34. The potential list is almost endless, but examples include: F. Hart, The Roots of Service: A History of Charing Cross Hospital 1818-1874 (London, 1985); H. A. Ripman, Guy's Hospital 1725-1948 (London, 1951); A. T. Stanway, The Story of King's College Hospital (London, 1968); R. Sinclair, The London Hospital, Portrait of a Hospital in its Third Century (London, 1956); J. Longden-Davies, Westminster Hospital: Two Centuries of Voluntary Service 1719-1948 (London, 1952). Exemplary studies include L. Granshaw, 'St Thomas's Hospital, London, 1850-1980' (unpublished Ph.D. thesis, Bryn Mawr College, 1981); idem, St Mark's Hospital, London. A Social History of a Specialist Hospital (London, 1985); and W. F. Bynum, 'Hospital, Disease and Community: The London Fever Hospital 1801-1850', in C. E. Rosenberg (ed.), Healing and History. Essays for George Rosen (Folkestone, 1979), pp. 97-115. Useful overviews of research are provided in L. Granshaw, 'The Rise of the Modern Hospital in Britain', in A. Wear (ed.), Medicine in Society: Historical Essays (Cambridge, 1992), pp. 197-218; G. Rivett, 'Hospital Histories', Social History of Medicine, 6 (1993), 429-37; idem., The Development of the London Hospital System, 1832-1982 (London, 1986); and, for infectious disease hospitals, G. Ayers, England's First State Hospitals: The Metropolitan Asylums Board (London, 1971).
35. The potential list is almost endless, but examples include: F. Hart, The Roots of Service: A History of Charing Cross Hospital 1818-1874 (London, 1985); H. A. Ripman, Guy's Hospital 1725-1948 (London, 1951); A. T. Stanway, The Story of King's College Hospital (London, 1968); R. Sinclair, The London Hospital, Portrait of a Hospital in its Third Century (London, 1956); J. Longden-Davies, Westminster Hospital: Two Centuries of Voluntary Service 1719-1948 (London, 1952). Exemplary studies include L. Granshaw, 'St Thomas's Hospital, London, 1850-1980' (unpublished Ph.D. thesis, Bryn Mawr College, 1981); idem, St Mark's Hospital, London. A Social History of a Specialist Hospital (London, 1985); and W. F. Bynum, 'Hospital, Disease and Community: The London Fever Hospital 1801-1850', in C. E. Rosenberg (ed.), Healing and History. Essays for George Rosen (Folkestone, 1979), pp. 97-115. Useful overviews of research are provided in L. Granshaw, 'The Rise of the Modern Hospital in Britain', in A. Wear (ed.), Medicine in Society: Historical Essays (Cambridge, 1992), pp. 197-218; G. Rivett, 'Hospital Histories', Social History of Medicine, 6 (1993), 429-37; idem., The Development of the London Hospital System, 1832-1982 (London, 1986); and, for infectious disease hospitals, G. Ayers, England's First State Hospitals: The Metropolitan Asylums Board (London, 1971).
36. The potential list is almost endless, but examples include: F. Hart, The Roots of Service: A History of Charing Cross Hospital 1818-1874 (London, 1985); H. A. Ripman, Guy's Hospital 1725-1948 (London, 1951); A. T. Stanway, The Story of King's College Hospital (London, 1968); R. Sinclair, The London Hospital, Portrait of a Hospital in its Third Century (London, 1956); J. Longden-Davies, Westminster Hospital: Two Centuries of Voluntary Service 1719-1948 (London, 1952). Exemplary studies include L. Granshaw, 'St Thomas's Hospital, London, 1850-1980' (unpublished Ph.D. thesis, Bryn Mawr College, 1981); idem, St Mark's Hospital, London. A Social History of a Specialist Hospital (London, 1985); and W. F. Bynum, 'Hospital, Disease and Community: The London Fever Hospital 1801-1850', in C. E. Rosenberg (ed.), Healing and History. Essays for George Rosen (Folkestone, 1979), pp. 97-115. Useful overviews of research are provided in L. Granshaw, 'The Rise of the Modern Hospital in Britain', in A. Wear (ed.), Medicine in Society: Historical Essays (Cambridge, 1992), pp. 197-218; G. Rivett, 'Hospital Histories', Social History of Medicine, 6 (1993), 429-37; idem., The Development of the London Hospital System, 1832-1982 (London, 1986); and, for infectious disease hospitals, G. Ayers, England's First State Hospitals: The Metropolitan Asylums Board (London, 1971).
37. The potential list is almost endless, but examples include: F. Hart, The Roots of Service: A History of Charing Cross Hospital 1818-1874 (London, 1985); H. A. Ripman, Guy's Hospital 1725-1948 (London, 1951); A. T. Stanway, The Story of King's College Hospital (London, 1968); R. Sinclair, The London Hospital, Portrait of a Hospital in its Third Century (London, 1956); J. Longden-Davies, Westminster Hospital: Two Centuries of Voluntary Service 1719-1948 (London, 1952). Exemplary studies include L. Granshaw, 'St Thomas's Hospital, London, 1850-1980' (unpublished Ph.D. thesis, Bryn Mawr College, 1981); idem, St Mark's Hospital, London. A Social History of a Specialist Hospital (London, 1985); and W. F. Bynum, 'Hospital, Disease and Community: The London Fever Hospital 1801-1850', in C. E. Rosenberg (ed.), Healing and History. Essays for George Rosen (Folkestone, 1979), pp. 97-115. Useful overviews of research are provided in L. Granshaw, 'The Rise of the Modern Hospital in Britain', in A. Wear (ed.), Medicine in Society: Historical Essays (Cambridge, 1992), pp. 197-218; G. Rivett, 'Hospital Histories', Social History of Medicine, 6 (1993), 429-37; idem., The Development of the London Hospital System, 1832-1982 (London, 1986); and, for infectious disease hospitals, G. Ayers, England's First State Hospitals: The Metropolitan Asylums Board (London, 1971).
38. The potential list is almost endless, but examples include: F. Hart, The Roots of Service: A History of Charing Cross Hospital 1818-1874 (London, 1985); H. A. Ripman, Guy's Hospital 1725-1948 (London, 1951); A. T. Stanway, The Story of King's College Hospital (London, 1968); R. Sinclair, The London Hospital, Portrait of a Hospital in its Third Century (London, 1956); J. Longden-Davies, Westminster Hospital: Two Centuries of Voluntary Service 1719-1948 (London, 1952). Exemplary studies include L. Granshaw, 'St Thomas's Hospital, London, 1850-1980' (unpublished Ph.D. thesis, Bryn Mawr College, 1981); idem, St Mark's Hospital, London. A Social History of a Specialist Hospital (London, 1985); and W. F. Bynum, 'Hospital, Disease and Community: The London Fever Hospital 1801-1850', in C. E. Rosenberg (ed.), Healing and History. Essays for George Rosen (Folkestone, 1979), pp. 97-115. Useful overviews of research are provided in L. Granshaw, 'The Rise of the Modern Hospital in Britain', in A. Wear (ed.), Medicine in Society: Historical Essays (Cambridge, 1992), pp. 197-218; G. Rivett, 'Hospital Histories', Social History of Medicine, 6 (1993), 429-37; idem., The Development of the London Hospital System, 1832-1982 (London, 1986); and, for infectious disease hospitals, G. Ayers, England's First State Hospitals: The Metropolitan Asylums Board (London, 1971).
39. The potential list is almost endless, but examples include: F. Hart, The Roots of Service: A History of Charing Cross Hospital 1818-1874 (London, 1985); H. A. Ripman, Guy's Hospital 1725-1948 (London, 1951); A. T. Stanway, The Story of King's College Hospital (London, 1968); R. Sinclair, The London Hospital, Portrait of a Hospital in its Third Century (London, 1956); J. Longden-Davies, Westminster Hospital: Two Centuries of Voluntary Service 1719-1948 (London, 1952). Exemplary studies include L. Granshaw, 'St Thomas's Hospital, London, 1850-1980' (unpublished Ph.D. thesis, Bryn Mawr College, 1981); idem, St Mark's Hospital, London. A Social History of a Specialist Hospital (London, 1985); and W. F. Bynum, 'Hospital, Disease and Community: The London Fever Hospital 1801-1850', in C. E. Rosenberg (ed.), Healing and History. Essays for George Rosen (Folkestone, 1979), pp. 97-115. Useful overviews of research are provided in L. Granshaw, 'The Rise of the Modern Hospital in Britain', in A. Wear (ed.), Medicine in Society: Historical Essays (Cambridge, 1992), pp. 197-218; G. Rivett, 'Hospital Histories', Social History of Medicine, 6 (1993), 429-37; idem., The Development of the London Hospital System, 1832-1982 (London, 1986); and, for infectious disease hospitals, G. Ayers, England's First State Hospitals: The Metropolitan Asylums Board (London, 1971).
40. The potential list is almost endless, but examples include: F. Hart, The Roots of Service: A History of Charing Cross Hospital 1818-1874 (London, 1985); H. A. Ripman, Guy's Hospital 1725-1948 (London, 1951); A. T. Stanway, The Story of King's College Hospital (London, 1968); R. Sinclair, The London Hospital, Portrait of a Hospital in its Third Century (London, 1956); J. Longden-Davies, Westminster Hospital: Two Centuries of Voluntary Service 1719-1948 (London, 1952). Exemplary studies include L. Granshaw, 'St Thomas's Hospital, London, 1850-1980' (unpublished Ph.D. thesis, Bryn Mawr College, 1981); idem, St Mark's Hospital, London. A Social History of a Specialist Hospital (London, 1985); and W. F. Bynum, 'Hospital, Disease and Community: The London Fever Hospital 1801-1850', in C. E. Rosenberg (ed.), Healing and History. Essays for George Rosen (Folkestone, 1979), pp. 97-115. Useful overviews of research are provided in L. Granshaw, 'The Rise of the Modern Hospital in Britain', in A. Wear (ed.), Medicine in Society: Historical Essays (Cambridge, 1992), pp. 197-218; G. Rivett, 'Hospital Histories', Social History of Medicine, 6 (1993), 429-37; idem., The Development of the London Hospital System, 1832-1982 (London, 1986); and, for infectious disease hospitals, G. Ayers, England's First State Hospitals: The Metropolitan Asylums Board (London, 1971).
41. The potential list is almost endless, but examples include: F. Hart, The Roots of Service: A History of Charing Cross Hospital 1818-1874 (London, 1985); H. A. Ripman, Guy's Hospital 1725-1948 (London, 1951); A. T. Stanway, The Story of King's College Hospital (London, 1968); R. Sinclair, The London Hospital, Portrait of a Hospital in its Third Century (London, 1956); J. Longden-Davies, Westminster Hospital: Two Centuries of Voluntary Service 1719-1948 (London, 1952). Exemplary studies include L. Granshaw, 'St Thomas's Hospital, London, 1850-1980' (unpublished Ph.D. thesis, Bryn Mawr College, 1981); idem, St Mark's Hospital, London. A Social History of a Specialist Hospital (London, 1985); and W. F. Bynum, 'Hospital, Disease and Community: The London Fever Hospital 1801-1850', in C. E. Rosenberg (ed.), Healing and History. Essays for George Rosen (Folkestone, 1979), pp. 97-115. Useful overviews of research are provided in L. Granshaw, 'The Rise of the Modern Hospital in Britain', in A. Wear (ed.), Medicine in Society: Historical Essays (Cambridge, 1992), pp. 197-218; G. Rivett, 'Hospital Histories', Social History of Medicine, 6 (1993), 429-37; idem., The Development of the London Hospital System, 1832-1982 (London, 1986); and, for infectious disease hospitals, G. Ayers, England's First State Hospitals: The Metropolitan Asylums Board (London, 1971).
42. The potential list is almost endless, but examples include: F. Hart, The Roots of Service: A History of Charing Cross Hospital 1818-1874 (London, 1985); H. A. Ripman, Guy's Hospital 1725-1948 (London, 1951); A. T. Stanway, The Story of King's College Hospital (London, 1968); R. Sinclair, The London Hospital, Portrait of a Hospital in its Third Century (London, 1956); J. Longden-Davies, Westminster Hospital: Two Centuries of Voluntary Service 1719-1948 (London, 1952). Exemplary studies include L. Granshaw, 'St Thomas's Hospital, London, 1850-1980' (unpublished Ph.D. thesis, Bryn Mawr College, 1981); idem, St Mark's Hospital, London. A Social History of a Specialist Hospital (London, 1985); and W. F. Bynum, 'Hospital, Disease and Community: The London Fever Hospital 1801-1850', in C. E. Rosenberg (ed.), Healing and History. Essays for George Rosen (Folkestone, 1979), pp. 97-115. Useful overviews of research are provided in L. Granshaw, 'The Rise of the Modern Hospital in Britain', in A. Wear (ed.), Medicine in Society: Historical Essays (Cambridge, 1992), pp. 197-218; G. Rivett, 'Hospital Histories', Social History of Medicine, 6 (1993), 429-37; idem., The Development of the London Hospital System, 1832-1982 (London, 1986); and, for infectious disease hospitals, G. Ayers, England's First State Hospitals: The Metropolitan Asylums Board (London, 1971).
43. The potential list is almost endless, but examples include: F. Hart, The Roots of Service: A History of Charing Cross Hospital 1818-1874 (London, 1985); H. A. Ripman, Guy's Hospital 1725-1948 (London, 1951); A. T. Stanway, The Story of King's College Hospital (London, 1968); R. Sinclair, The London Hospital, Portrait of a Hospital in its Third Century (London, 1956); J. Longden-Davies, Westminster Hospital: Two Centuries of Voluntary Service 1719-1948 (London, 1952). Exemplary studies include L. Granshaw, 'St Thomas's Hospital, London, 1850-1980' (unpublished Ph.D. thesis, Bryn Mawr College, 1981); idem, St Mark's Hospital, London. A Social History of a Specialist Hospital (London, 1985); and W. F. Bynum, 'Hospital, Disease and Community: The London Fever Hospital 1801-1850', in C. E. Rosenberg (ed.), Healing and History. Essays for George Rosen (Folkestone, 1979), pp. 97-115. Useful overviews of research are provided in L. Granshaw, 'The Rise of the Modern Hospital in Britain', in A. Wear (ed.), Medicine in Society: Historical Essays (Cambridge, 1992), pp. 197-218; G. Rivett, 'Hospital Histories', Social History of Medicine, 6 (1993), 429-37; idem., The Development of the London Hospital System, 1832-1982 (London, 1986); and, for infectious disease hospitals, G. Ayers, England's First State Hospitals: The Metropolitan Asylums Board (London, 1971).
44. The potential list is almost endless, but examples include: F. Hart, The Roots of Service: A History of Charing Cross Hospital 1818-1874 (London, 1985); H. A. Ripman, Guy's Hospital 1725-1948 (London, 1951); A. T. Stanway, The Story of King's College Hospital (London, 1968); R. Sinclair, The London Hospital, Portrait of a Hospital in its Third Century (London, 1956); J. Longden-Davies, Westminster Hospital: Two Centuries of Voluntary Service 1719-1948 (London, 1952). Exemplary studies include L. Granshaw, 'St Thomas's Hospital, London, 1850-1980' (unpublished Ph.D. thesis, Bryn Mawr College, 1981); idem, St Mark's Hospital, London. A Social History of a Specialist Hospital (London, 1985); and W. F. Bynum, 'Hospital, Disease and Community: The London Fever Hospital 1801-1850', in C. E. Rosenberg (ed.), Healing and History. Essays for George Rosen (Folkestone, 1979), pp. 97-115. Useful overviews of research are provided in L. Granshaw, 'The Rise of the Modern Hospital in Britain', in A. Wear (ed.), Medicine in Society: Historical Essays (Cambridge, 1992), pp. 197-218; G. Rivett, 'Hospital Histories', Social History of Medicine, 6 (1993), 429-37; idem., The Development of the London Hospital System, 1832-1982 (London, 1986); and, for infectious disease hospitals, G. Ayers, England's First State Hospitals: The Metropolitan Asylums Board (London, 1971).
45. The potential list is almost endless, but examples include: F. Hart, The Roots of Service: A History of Charing Cross Hospital 1818-1874 (London, 1985); H. A. Ripman, Guy's Hospital 1725-1948 (London, 1951); A. T. Stanway, The Story of King's College Hospital (London, 1968); R. Sinclair, The London Hospital, Portrait of a Hospital in its Third Century (London, 1956); J. Longden-Davies, Westminster Hospital: Two Centuries of Voluntary Service 1719-1948 (London, 1952). Exemplary studies include L. Granshaw, 'St Thomas's Hospital, London, 1850-1980' (unpublished Ph.D. thesis, Bryn Mawr College, 1981); idem, St Mark's Hospital, London. A Social History of a Specialist Hospital (London, 1985); and W. F. Bynum, 'Hospital, Disease and Community: The London Fever Hospital 1801-1850', in C. E. Rosenberg (ed.), Healing and History. Essays for George Rosen (Folkestone, 1979), pp. 97-115. Useful overviews of research are provided in L. Granshaw, 'The Rise of the Modern Hospital in Britain', in A. Wear (ed.), Medicine in Society: Historical Essays (Cambridge, 1992), pp. 197-218; G. Rivett, 'Hospital Histories', Social History of Medicine, 6 (1993), 429-37; idem., The Development of the London Hospital System, 1832-1982 (London, 1986); and, for infectious disease hospitals, G. Ayers, England's First State Hospitals: The Metropolitan Asylums Board (London, 1971).
46. Free and direct access to hospitals and charities was supposedly available only in the case of accidents and emergencies, but see note 45 below. The proportion of accidents and emergency admissions could be considerable. Of the 1,949 in-patients treated at St Mary's Hospital, Paddington, only 490 were by letter: St Mary's Hospital Annual Report 1871, Appendix.
47. For family and neighbourhood networks of support for the sick, see E. Ross, 'Hungry Children: Housewives and London Charity 1870-1918', in P. Mandler (ed.), The Uses of Charity: The Poor on Relief in the Nineteenth Century Metropolis (Philadelphia, 1990), pp. 161-96. Dispensaries in London are detailed in S. Low, The Charities of London (London, 1861).
48. For family and neighbourhood networks of support for the sick, see E. Ross, 'Hungry Children: Housewives and London Charity 1870-1918', in P. Mandler (ed.), The Uses of Charity: The Poor on Relief in the Nineteenth Century Metropolis (Philadelphia, 1990), pp. 161-96. Dispensaries in London are detailed in S. Low, The Charities of London (London, 1861).
49. 4 & 5 Wm. IV. CAP 76, Poor Laws Amendment Act (14 August 1834).
50. Although it was supposedly inapplicable to those pauperized by sickness, the principle of less-eligibility undoubtedly served as a deterrent. The very act of accepting state medical relief also incurred the pauperization of the patient's dependants, and until 1885 carried with it the loss of privileges of citizenship, such as the right to vote. The exception to this rule was vaccination against smallpox. However, since the PLMO was often also the public vaccinator, and the procedure frequently took place in workhouse buildings, the stigma of association with the Poor Law remained strong: M. W. Flinn, 'The Medical Services Under the New Poor Law', in D. Fraser (ed.), The New Poor Law in the Nineteenth Century (London, 1976), pp. 45-66.
51. T. Dolan, evidence to the Lancet's Commission on Metropolitan Workhouse Infirmaries in 1866, quoted in L. Twining, A Letter on Some Matters of Poor Law Administration Addressed (by Permission) to the Right Honourable the President of the Local Covernment Board (London, 1887), p. 48.
52. H. B. Farnall, Report on the Infirmary Wards of Metropolitan Workhouses, PP 1866, LXI, p. 389; and E. Smith, Report on Metropolitan Workhouse Infirmaries and Sick Wards, PP 1866, LXI, p. 171.
53. H. B. Farnall, Report on the Infirmary Wards of Metropolitan Workhouses, PP 1866, LXI, p. 389; and E. Smith, Report on Metropolitan Workhouse Infirmaries and Sick Wards, PP 1866, LXI, p. 171.
54. 30 & 31 Vict. CAP 6, The Metropolitan Poor Act (29 March 1867). The Act established Sick Asylum Districts, whereby unions could band together to build an infirmary.
55. From the 1840s, PLMOs used outdoor relief as a means of keeping sick paupers out of the workhouse, giving annual relief 'rickets' - sometimes combined with referral to a local dispensary which enjoyed a grant from the guardians - to the elderly and chronic sick: Flinn, 'The Medical Services', p. 51. George Goschen, new President of the Poor Law Board in 1868 (and a member of the Charity Organisation Society), issued a minute in 1869 condemning the overabundance of outdoor relief in London. See 22nd Annual Report of the Poor Law Board, 1869-79, Appendix A, no. 4. The newly formed LGB issued a circular in 1871 aimed at abolishing outdoor relief altogether, First Annual Report of the Local Government Board, 1871-72, Appendix A, no. 20.
56. From the 1840s, PLMOs used outdoor relief as a means of keeping sick paupers out of the workhouse, giving annual relief 'rickets' - sometimes combined with referral to a local dispensary which enjoyed a grant from the guardians - to the elderly and chronic sick: Flinn, 'The Medical Services', p. 51. George Goschen, new President of the Poor Law Board in 1868 (and a member of the Charity Organisation Society), issued a minute in 1869 condemning the overabundance of outdoor relief in London. See 22nd Annual Report of the Poor Law Board, 1869-79, Appendix A, no. 4. The newly formed LGB issued a circular in 1871 aimed at abolishing outdoor relief altogether, First Annual Report of the Local Government Board, 1871-72, Appendix A, no. 20.
57. From the 1840s, PLMOs used outdoor relief as a means of keeping sick paupers out of the workhouse, giving annual relief 'rickets' - sometimes combined with referral to a local dispensary which enjoyed a grant from the guardians - to the elderly and chronic sick: Flinn, 'The Medical Services', p. 51. George Goschen, new President of the Poor Law Board in 1868 (and a member of the Charity Organisation Society), issued a minute in 1869 condemning the overabundance of outdoor relief in London. See 22nd Annual Report of the Poor Law Board, 1869-79, Appendix A, no. 4. The newly formed LGB issued a circular in 1871 aimed at abolishing outdoor relief altogether, First Annual Report of the Local Government Board, 1871-72, Appendix A, no. 20.
58. The metropolitan figures for the outdoor poor on New Year's day 1871 totalled 121,367, of whom 38,230 were incapacitated by old age or permanent disability and 41,822 by temporary sickness. See 'Statement of the Number of Paupers Relieved on 1st January 187', LGB Accounts and Papers, vol. 23,140 (B), PP 1871, LIX. Comparable figures for 1 July 1872 were much reduced, being 73,345, and 30,731, and 10,564 respectively, 'Statement of the Number of Paupers Relieved on 1st July 1872', LGB Accounts and Papers, vol. 16,140 (B1), PP 1872, LI.
59. The metropolitan figures for the outdoor poor on New Year's day 1871 totalled 121,367, of whom 38,230 were incapacitated by old age or permanent disability and 41,822 by temporary sickness. See 'Statement of the Number of Paupers Relieved on 1st January 187', LGB Accounts and Papers, vol. 23,140 (B), PP 1871, LIX. Comparable figures for 1 July 1872 were much reduced, being 73,345, and 30,731, and 10,564 respectively, 'Statement of the Number of Paupers Relieved on 1st July 1872', LGB Accounts and Papers, vol. 16,140 (B1), PP 1872, LI.
60. Select Committee of the House of Lords on Metropolitan Hospitals, First Report PP 1892, XIII, p. lxxii.
61. Bynum, 'Hospital, Disease and Community'.
62. In 1862, 2,458 of the 2,699 patients admitted to the London Fever Hospital were sent by parish order, A. Jacques, Fifty Years of the London Fever Hospital, 1848-1898, Royal Free Hospital Archives undated typescript, p. 57. St Paneras and Marylebone unions, which had two of the largest pre-1867 workhouses, kept some cases in separate wards within their infirmaries.
63. Kensington and St Paneras workhouses had their own isolation wards for such patients.
64. The general hospitals, which had a stated policy of excluding infectious cases, were reluctant to send patients who had never been on poor relief to the MAB hospitals, and several of them came to an agreement with the London Fever Hospital - which had lost its main source of income with the opening of the new MAB facilities and began to exclude paupers after 1871 - that contagious cases be sent there free of charge: Guy's Hospital Annual Report 1876, pp. 435-6. The Royal Free Hospital was so reluctant to pauperize its patients that it opened two temporary infectious wards in 1871, Royal Free Hospital Annual Report 1872, p. 5. Legislation of 1885 finally decreed that patients entering an MAB hospital were no longer subject to formal pauperization, 48 & 49 Vict. CAP 46, Medical Relief (Disqualification Removal) Act (6 August 1885).
65. The general hospitals, which had a stated policy of excluding infectious cases, were reluctant to send patients who had never been on poor relief to the MAB hospitals, and several of them came to an agreement with the London Fever Hospital - which had lost its main source of income with the opening of the new MAB facilities and began to exclude paupers after 1871 - that contagious cases be sent there free of charge: Guy's Hospital Annual Report 1876, pp. 435-6. The Royal Free Hospital was so reluctant to pauperize its patients that it opened two temporary infectious wards in 1871, Royal Free Hospital Annual Report 1872, p. 5. Legislation of 1885 finally decreed that patients entering an MAB hospital were no longer subject to formal pauperization, 48 & 49 Vict. CAP 46, Medical Relief (Disqualification Removal) Act (6 August 1885).
66. The general hospitals, which had a stated policy of excluding infectious cases, were reluctant to send patients who had never been on poor relief to the MAB hospitals, and several of them came to an agreement with the London Fever Hospital - which had lost its main source of income with the opening of the new MAB facilities and began to exclude paupers after 1871 - that contagious cases be sent there free of charge: Guy's Hospital Annual Report 1876, pp. 435-6. The Royal Free Hospital was so reluctant to pauperize its patients that it opened two temporary infectious wards in 1871, Royal Free Hospital Annual Report 1872, p. 5. Legislation of 1885 finally decreed that patients entering an MAB hospital were no longer subject to formal pauperization, 48 & 49 Vict. CAP 46, Medical Relief (Disqualification Removal) Act (6 August 1885).
67. Ayers, England's First State Hospitals, p. 727. Each hospital eventually adopted the name of the region within the metropolis in which it was situated and which it purportedly served. For example, the Stockwell Smallpox and Fever Hospitals became the South Western District Smallpox and Fever Hospitals in 1882. The original hospital name will be referred to here.
68. Further space was created when the mentally ill were removed from the workhouses of London to new district asylums in the countryside. Ibid., ch. 4.
69. The 1865 Medical Directory details over 400 bodies retaining the services of medical practitioners.
70. A letter of admission was no guarantee of treatment, as most hospitals gave preference to urgent cases. See evidence of Robert Bass, receiver of St Thomas's Hospital, to Select Committee of the House of Lords on Metropolitan Hospitals, Second Report, PP 1890-91, XIII, p. 827.
71. Tickets for treatment were intended to allow the recipients to attend evening out-patient clinics at the hospital, and the Fund only gave grants to hospitals governed by a committee elected by subscribers, thereby ensuring its influence over hospital policies. Evidence of Reginald Acland, chairman of the Hospital Saturday Fund, House of Lords Select Committee Second Report, pp. 300 and 595-601.
72. The London medical institutions were largely philanthropic in character, dependent on annual subscriptions for their daily running costs of £1,800. St Thomas's Hospital was the first to introduce payments in metropolitan general hospitals in 1881. By 1890 such fees made up 5% of the income of London hospitals. House of Lords Select Committee First Report PP 1890, VXI, pp. 5 and 149.
73. For a full consideration of what benefactors gained from charitable giving, see S-Cavallo, 'The Motivation of Benefactors: An Overview of Approaches to the Study of Charity', in J. Barry and C. Jones (eds.), Medicine and Charity Before the Welfare State (London, 1991), pp. 46-62.
74. Evidence of Dr James Bury of the Royal Free Hospital and Dr Arthur Barker of University College Hospital. The latter hospital at that date treated pauper patients for 1s 6d per day, and also those recommended by private practitioners, House of Lords Select Committee Second Report, pp. 272-4 and 301-3.
75. Select Committee Second Report, p. 727.
76. From 1868, admission to St George's Hospital out-patient department was free of charge, enabling its staff 'to exercise much more control over the admission of patients than when they brought governors' letters, when it was difficult under such circumstances to refuse any', St George's Hospital Annual Report, 1875, p. 4. Between 1840 and 1855, King's College Hospital admitted to its wards 6,107 people in possession of a subscriber's letter, a total that was dwarfed by the 13,069 admitted without one: King's College Hospital, Report for 1856, p. 19.
77. From 1868, admission to St George's Hospital out-patient department was free of charge, enabling its staff 'to exercise much more control over the admission of patients than when they brought governors' letters, when it was difficult under such circumstances to refuse any', St George's Hospital Annual Report, 1875, p. 4. Between 1840 and 1855, King's College Hospital admitted to its wards 6,107 people in possession of a subscriber's letter, a total that was dwarfed by the 13,069 admitted without one: King's College Hospital, Report for 1856, p. 19.
78. In addition, numerous new medical charities were founded, ranging from traditional dispensaries to agencies for the free distribution of trusses. In the 1860s, total London charity receipts exceeded £2,500,000, far more than the income of the Metropolitan Poor Law: D. Fraser, The Evolution of the British Welfare State (Basingstoke, 1984), p. 125.
79. By a variety of measures, including the number of hospitals and hospital beds, the period of most rapid growth in London during modern times was the 1860s and 1870s. See P. Cowan, 'Some Observations Concerning the Increase of Hospital Provision in London Between 1850 and 1960', Medical History, 14 (1970), 42-52.
80. The background to the enquiry (apart from the incessant complaints from general practitioners that the hospitals' out-patients departments were depriving them of income) was that financial shortfalls in the London hospitals had closed 2,000 beds and put those hospitals with medical schools almost £100,000 in debt by 1889. See B. Abel-Smith (with the assistance of R. Pinker), The Hospitals, 1800-1948: A Study in Social Administration in England and Wales (London, 1964), p. 163. The Poor Law infirmaries contained nearly 8,000 beds at that time.
81. A central London location was considered essential in order to attract distinguished doctors, without whom it would be impossible to establish an active committee of management.
82. Dr Frederick Alderson claimed that, 'every medical man knows positively that people go to the hospitals and dispensaries who can well afford to pay a private medical practitioner', House of Lards Select Committee Second Report, p. 304.
83. Association Medical Journal, 15 (15 April 1853), 315-16. Several of the general hospitals, led by King's College Hospital, began to make enquiries as to the financial circumstances of patients from the early 1870s. See Abel-Smith, The Hospitals, pp. 107-17. According to the 1868 annual report of St George's Hospital, located in west London, 480 of the 1,754 admissions (27%) were domestic servants, R. Thompson, 'Annual Report of Medical Cases During the year 1868', in St George's Hospital Annual Report, 1869, pp. 285-300.
84. Association Medical Journal, 15 (15 April 1853), 315-16. Several of the general hospitals, led by King's College Hospital, began to make enquiries as to the financial circumstances of patients from the early 1870s. See Abel-Smith, The Hospitals, pp. 107-17. According to the 1868 annual report of St George's Hospital, located in west London, 480 of the 1,754 admissions (27%) were domestic servants, R. Thompson, 'Annual Report of Medical Cases During the year 1868', in St George's Hospital Annual Report, 1869, pp. 285-300.
85. Association Medical Journal, 15 (15 April 1853), 315-16. Several of the general hospitals, led by King's College Hospital, began to make enquiries as to the financial circumstances of patients from the early 1870s. See Abel-Smith, The Hospitals, pp. 107-17. According to the 1868 annual report of St George's Hospital, located in west London, 480 of the 1,754 admissions (27%) were domestic servants, R. Thompson, 'Annual Report of Medical Cases During the year 1868', in St George's Hospital Annual Report, 1869, pp. 285-300.
86. See K. Waddington, 'Unsuitable Cases: The Debate over Outpatient Admissions, the Medical Profession and late-Victorian London Hospitals', Medical History, 42 (1998), 26-46.
87. The House of Lords Select Committee heard from the Dean of Westminster Medical School that the out-patient officer had sole responsibility for selecting patients for admission, who may have included infectious cases. But the St Bartholomew's Hospital witness claimed that all cases of infectious disease or chronic illness were forwarded to the parish infirmary, House of Lords Select Committee Second Report, pp. 241 and 732.
88. As the location of the capital's institutional provision expanded outwards, some of those counties encircling London approached, but did not exceed, this figure of 30%. In 1901, Surrey had an institutional mortality of 21%, Kent 20% and Middlesex and Essex each 16%. All of these percentages were greater than those recorded by some of the northern English industrialized counties, such as Lancashire with 15% and the West Riding of Yorkshire with 11%. As with some places in London, however, individual urbanized districts within these counties could register very high levels of institu-tional mortality, as in Liverpool with 40% in 1901. Calculated from the 64th ARRG, 1901 (London, 1903).
89. The Registrar-General's practice of listing deaths in prisons was discontinued in 1869, probably because they very rarely accounted for more that 0.1% of London's total annual mortality.
90. The figures concerning the number of deaths in hospitals differs marginally from the London county totals published in the tables of institutional deaths in the ARRGs. We include the deaths in a number of smaller, private hospitals which appear only as footnotes to the Registrar-General's main table. For example, 43 deaths occurred in Nazareth House, Fulham, in 1901 which are not included in the ARRG county total.
91. Some geographical comparisons emphasize this to a greater degree. Lancashire claimed 16% both of the national total deaths and institutional deaths in 1881, the corresponding figures for the West Riding being nine and six per cent respectively.
92. 1871 was selected as the censal mid-point of the period under study, 1860-84. As we shall see, this particular year also offers an opportunity to demonstrate some of the problems encountered with the redistribution of epidemic deaths.
93. The crude death rate is measured as the total number of deaths per 1,000 living population. Its popular and professional significance as an overall indicator of health is dealt with in Mooney, 'Professionalization in Public Health'.
94. Ayers, England's First State Hospitals, p. 52.
95. The data in the Annual Summaries were provided for local sanitary areas (that is, parishes and combinations of parishes termed 'district boards', which were the employing authorities of London's MOHs) and not registration districts, as was the case with the ARRGs. By combining some sanitary areas, it is a relatively simple task to make them coterminous with registration districts, the boundaries of which were based upon Poor Law union boundaries, which in turn were modelled on parish boundaries. For a list of the sanitary areas with their corresponding registration district, see the Decennial Supplement to the 55th ARRG, 1892 (London, 1895), pp. xl-xli.
96. The hospitals and workhouses included in Farr's calculations can be derived from the table appearing in the 24th ARRG, 1861, p. 174. The 24 hospitals included a number of infectious disease hospitals as well as general voluntary hospitals.
97. Some of the urban percentages were considerably higher. The 24 London hospitals registered 90.84%, the Northern Hospital in Liverpool 128.71% and the Manchester Royal Infirmary 130.69%. Although a footnote to the original tables concedes the source of error in the calculations, it argues that, 'the aggregate result . . . furnishes a sufficiently correct indication of the prevailing mortality'. See 24th ARRG, 1861, p. 205 and pp. 229-31.
98. Quoted in Rivett, The Development, pp. 41-3.
99. F. Nightingale, Notes on Hospitals (3rd edn, London, 1863); J. Woodward, To Do the Sick No Harm: A Study of the British Voluntary Hospital System to 1875 (London, 1974), pp. 124-6; see also E. M. Sigsworth, 'Gateways to Death? Medicine, Hospitals and Mortality, 1700-1850', in P. Mathias (ed.), Science and Society, 1600-1900 (London, 1972), p. 102.
100. F. Nightingale, Notes on Hospitals (3rd edn, London, 1863); J. Woodward, To Do the Sick No Harm: A Study of the British Voluntary Hospital System to 1875 (London, 1974), pp. 124-6; see also E. M. Sigsworth, 'Gateways to Death? Medicine, Hospitals and Mortality, 1700-1850', in P. Mathias (ed.), Science and Society, 1600-1900 (London, 1972), p. 102.
101. F. Nightingale, Notes on Hospitals (3rd edn, London, 1863); J. Woodward, To Do the Sick No Harm: A Study of the British Voluntary Hospital System to 1875 (London, 1974), pp. 124-6; see also E. M. Sigsworth, 'Gateways to Death? Medicine, Hospitals and Mortality, 1700-1850', in P. Mathias (ed.), Science and Society, 1600-1900 (London, 1972), p. 102.
102. This was despite the inclusion of the London Fever Hospital's 117 deaths in Fair's table. The assertions contained in hospital annual reports and published rules that general hospitals never admitted fever patients are questioned and tested in Woodward, To Do the Sick No Harm, pp. 61-74. There, and in Sigsworth, 'Gateways to Death', serious doubt is cast over the idea that hospitals raised local mortality rates by bringing infected patients together with non-infected ones. This theory had been given sustained credence by T. McKeown and R. G. Brown, 'Medical Evidence Related to English Population Changes in the Eighteenth Century', Population Studies, 9 (1955), 119-41.
103. This was despite the inclusion of the London Fever Hospital's 117 deaths in Fair's table. The assertions contained in hospital annual reports and published rules that general hospitals never admitted fever patients are questioned and tested in Woodward, To Do the Sick No Harm, pp. 61-74. There, and in Sigsworth, 'Gateways to Death', serious doubt is cast over the idea that hospitals raised local mortality rates by bringing infected patients together with non-infected ones. This theory had been given sustained credence by T. McKeown and R. G. Brown, 'Medical Evidence Related to English Population Changes in the Eighteenth Century', Population Studies, 9 (1955), 119-41.
104. This was despite the inclusion of the London Fever Hospital's 117 deaths in Fair's table. The assertions contained in hospital annual reports and published rules that general hospitals never admitted fever patients are questioned and tested in Woodward, To Do the Sick No Harm, pp. 61-74. There, and in Sigsworth, 'Gateways to Death', serious doubt is cast over the idea that hospitals raised local mortality rates by bringing infected patients together with non-infected ones. This theory had been given sustained credence by T. McKeown and R. G. Brown, 'Medical Evidence Related to English Population Changes in the Eighteenth Century', Population Studies, 9 (1955), 119-41.
105. Bristowe and Holmes note that in 1861 St Thomas's admitted 92 phthisis cases with 68 deaths. In 1862 Guy's admitted 181 phthisis patients, 63 of whom died, while the corresponding figures for St Bartholomew's were 140 and 76 respectively: J. S. Bristowe and T. Holmes, 'The Hospitals of the United Kingdom', Sixth Annual Report of the Medical Officer of the Privy Council PP 1864, XXVII, p. 520.
106. It was undoubtedly the case that some of the chronic degenerative diseases - such as cancer, heart disease, and stroke - escaped the diagnoses of medical practitioners and were placed in the 'Old age' category. This point is made by P. Weindling, 'From Infectious to Chronic Diseases: Changing Patterns of Sickness in the Nineteenth and Twentieth Centuries', in Wear (ed.), Medicine in Society, p. 306.
107. 24th ARRG, pp. 206-7.
108. Expedient hospital staff often turned a blind eye to the rules and regulations. The house-surgeon acted as a barrier between the public and the staff of the hospital, selecting cases for admission from among the new out-patients. The house-surgeon's key role in determining the character of those patients that were admitted is given emphasis by the fact that in 1892 only one in six adults and one in four children applying for treatment made it on to the wards. See A. Egmont Hake, Suffering London (London, 1892), p. 133.
109. G. B. Risse and J. H. Warner, 'Reconstructing Clinical Activities: Patient Records in Medical History', Social History of Medicine, 5 (1992), 183-206; M. W. Dupree, 'Family Care and Hospital Care: the Sick Poor in Nineteenth-Century Glasgow', Social History of Medicine, 6 (1993), 195-212, links a sample of fever hospital patient records with census material. Historians of mental illness have long used patient registers and doctors' casebooks to examine changing perceptions of insanity. See C. Mackenzie, 'Social Factors in the Admission, Discharge and Continuing Stay of Patients at the Ticehurst Asylum, 1845-1917', in W. F. Bynum, R. Porter, and M. Shepherd (eds.), The Anatomy of Madness: Essays in the History of Psychiatry, vol. II (London and New York, 1985), pp. 147-74.
110. G. B. Risse and J. H. Warner, 'Reconstructing Clinical Activities: Patient Records in Medical History', Social History of Medicine, 5 (1992), 183-206; M. W. Dupree, 'Family Care and Hospital Care: the Sick Poor in Nineteenth-Century Glasgow', Social History of Medicine, 6 (1993), 195-212, links a sample of fever hospital patient records with census material. Historians of mental illness have long used patient registers and doctors' casebooks to examine changing perceptions of insanity. See C. Mackenzie, 'Social Factors in the Admission, Discharge and Continuing Stay of Patients at the Ticehurst Asylum, 1845-1917', in W. F. Bynum, R. Porter, and M. Shepherd (eds.), The Anatomy of Madness: Essays in the History of Psychiatry, vol. II (London and New York, 1985), pp. 147-74.
111. G. B. Risse and J. H. Warner, 'Reconstructing Clinical Activities: Patient Records in Medical History', Social History of Medicine, 5 (1992), 183-206; M. W. Dupree, 'Family Care and Hospital Care: the Sick Poor in Nineteenth-Century Glasgow', Social History of Medicine, 6 (1993), 195-212, links a sample of fever hospital patient records with census material. Historians of mental illness have long used patient registers and doctors' casebooks to examine changing perceptions of insanity. See C. Mackenzie, 'Social Factors in the Admission, Discharge and Continuing Stay of Patients at the Ticehurst Asylum, 1845-1917', in W. F. Bynum, R. Porter, and M. Shepherd (eds.), The Anatomy of Madness: Essays in the History of Psychiatry, Vol. II (London and New York, 1985), pp. 147-74.
112. H. Marland, Medicine and Society in Wakefield and Huddersfield, 1780-1870 (Cambridge, 1987), pp. 147 and 149.
113. While it is true that subscribers to the voluntary hospitals did indeed come from all over the country, the patients themselves - most of whom, as we have already noted, were out-patients - would necessarily have been resident within travelling distance of the hospital, at least for the duration of the treatment. Institutions dependent on annual subscriptions were under constant threat of financial crises and ward closures meant that not all patients were admitted. See F. Prochaska, 'Philanthropy', in F. M. L. Thompson (ed.), Cambridge Social History of Britain, 1750-1950, vol. III (Cambridge, 1990), pp. 371-5.
114. This was despite the fact that the authors would have had access to the full set of current hospital records including admission and discharge registers, consultant files, postmortem ledgers and outpatient registers. Reports were generally much stronger on admission policies, patient, bed and operation numbers, hours of out-patient attendance and the average length of patient residence. In 1856, almost 60% of in-patients admitted to King's College Hospital, Strand came from districts in central London. See King's College Hospital, Report for 1856, p. 18. Geoffrey Rivett reproduces an analysis of 2,473 medical and surgical admissions to St Thomas's Hospital, collected by the resident medical officer, R. G. Whitfield, in 1861. About 18% of the patients came from the immediate area of the hospital, 27% from southwest London and 40% from southeast, with the remainder coming from the rest of the southern Home Counties. See Rivett, The Development, p. 98.
115. This was despite the fact that the authors would have had access to the full set of current hospital records including admission and discharge registers, consultant files, postmortem ledgers and outpatient registers. Reports were generally much stronger on admission policies, patient, bed and operation numbers, hours of out-patient attendance and the average length of patient residence. In 1856, almost 60% of in-patients admitted to King's College Hospital, Strand came from districts in central London. See King's College Hospital, Report for 1856, p. 18. Geoffrey Rivett reproduces an analysis of 2,473 medical and surgical admissions to St Thomas's Hospital, collected by the resident medical officer, R. G. Whitfield, in 1861. About 18% of the patients came from the immediate area of the hospital, 27% from southwest London and 40% from southeast, with the remainder coming from the rest of the southern Home Counties. See Rivett, The Development, p. 98.
116. If not a full address with a house number and street, then at least a commonly recognizable entity such as a parish name or another administrative unit was normally given. Higgs notes that the frequent ambiguity of addresses given on death certificates often provided an excuse for MOHs not to accept an institutional death as a resident of their district: Higgs, 'The Statistical Big Bang', pp. 424-5.
117. Where the address given related to a street traversing more than one registration district, then the death was allocated to the district having most house numbers of that street according to the census enumerators' schedules.
118. The catchment areas for the individual hospitals shown in Table 4 can be found in G. Mooney, 'The Epidemiological Implications of Reconstructing Hospital Catchment Areas in Victorian London', History and Computing (forthcoming).
119. These groups of registration districts were often used by the Registrar-General for rudimentary demographic and epidemiological analysis in the capital. In 1860 they consisted of: west London (Kensington - later split into Kensington, Paddington and Fulham; Chelsea; St George Hanover Square; Westminster-incorporated into St George Hanover Square in 1870; St. Martin in the Fields - later incorporated into Strand registration district; and St James Westminster - renamed Westminster in 1870); north London (Marylebone; Hampstead; Paneras; Islington; and Hackney); central London (St Giles; Strand; Holbom; Clerkenwell; St Luke; and London City registration district - which absorbed East London and West London registration districts in 1868); east London (Shoreditch; Bethnal Green; Whitechapel; St George in the East; Stepney - later split into Stepney and Mile End Old Town; and Poplar); and south London (St Saviour Southwark - which later absorbed St George Southwark and Newington; St Olave Southwark - later to incorporate Bermondsey and Rotherhithe; Lambeth; Wandsworth; Camberwell; Greenwich - later split into Greenwich and Woolwich; and Lewisham).
120. Brompton Hospital is an exceptional case, as the greatest percentage of deaths occurred among non-Londoners. Out-patients too weak to make the journey home were generally admitted and many subsequently died: Henry Dobbin, House of Lords Select Committee Second Report, p. 339.
121. The London Hospital in Whitechapel only has registers surviving from 1883, so the district of origin of dead patients in that year was used for all the other years between 1860 and 1884.
122. In 1863 Bristowe and Holmes lamented the poor or non-existent modes of record-keeping in some of these hospitals. The Middlesex, in particular, was singled out as a place where 'the records of the hospital unfortunately seem very imperfectly kept, and hence the experience of the institution, for those at least who are not of it, is in great measure lost': Bristowe and Holmes, 'The Hospitals', p. 589.
123. This approach is perhaps over-simplistic, since a district adjacent, but not belonging, to one sector might plausibly contribute a great number of deaths to a hospital within that sector. However, the use of sectors in this way appeared to be the most straightforward method by which the hospitals with missing registers could be treated with equanimity. Admissions data relating to one of the missing hospitals, King's College in Strand, show that almost 60% of in-patients in 1856 lived in central London (King's College Hospital, Report for 1856, p. 18). Reassuringly close to this proportion, in 1861 the seven hospitals in Table 4 drew 56% of their deaths from the sectors in which they were situated.
124. See the discussion below relating to the London Fever Hospital registers.
125. With a hospital standardized mortality ratio of 115 once the deaths of the Consumption Hospital are subtracted (see Table 3 and accompanying text), the close correspondence between the level of phthisis mortality in the hospitals and that in the metropolitan population as a whole means that the annual hospital phthisis deaths are calculated according to the annual percentage of deaths to this disease in the capital. Following the GRO's adoption of a revised nosology in 1881, disease categorization includes not only phthisis, but also other respiratory diseases, diseases of the circulatory, urinary, and digestive systems, violence, and Other' causes.
126. Very few of the deaths in the Consumption Hospital were to causes other than phthisis. In 1877, for example, the local MOH reported that only eleven of that year's 130 deaths were not due to consumption: T. Orme Dudfield, Annual Report on the Sanitary Condition of the Parish of St Mary Abbots, Kensington, 1877, p. 40. The authorities of Great Ormond Street did admit cases of fever. In a single year, 1862, typhoid, scarlet fever, measles and diphtheria together represented 17% of all the hospital admissions. (Calculated from E. Lomax, 'The Control of Contagious Disease in Nineteenth-Century British Paediatric Hospitals', Social History of Medicine, 7 (1994), Table 6, p. 306.) In 1866 the same causes accounted for 36% of all deaths occurring in the hospital. However, the small annual number of fever deaths involved - only 24 in 1866 for example - renders the cause-specific redistribution of the Great Ormond Street deaths unnecessary for our purposes. Further, the division of the deaths between the range of fevers listed above and the annual variability in epidemic prevalence of these diseases makes it an extremely hazardous exercise.
127. Very few of the deaths in the Consumption Hospital were to causes other than phthisis. In 1877, for example, the local MOH reported that only eleven of that year's 130 deaths were not due to consumption: T. Orme Dudfield, Annual Report on the Sanitary Condition of the Parish of St Mary Abbots, Kensington, 1877, p. 40. The authorities of Great Ormond Street did admit cases of fever. In a single year, 1862, typhoid, scarlet fever, measles and diphtheria together represented 17% of all the hospital admissions. (Calculated from E. Lomax, 'The Control of Contagious Disease in Nineteenth-Century British Paediatric Hospitals', Social History of Medicine, 7 (1994), Table 6, p. 306.) In 1866 the same causes accounted for 36% of all deaths occurring in the hospital. However, the small annual number of fever deaths involved - only 24 in 1866 for example - renders the cause-specific redistribution of the Great Ormond Street deaths unnecessary for our purposes. Further, the division of the deaths between the range of fevers listed above and the annual variability in epidemic prevalence of these diseases makes it an extremely hazardous exercise.
128. One evident problem is the 1866 cholera epidemic, when a number of general hospitals, but especially the London Hospital in Whitechapel, received cholera patients. In his famous Report, William Farr performed a prescient redistribution exercise which returned the majority of the 5,596 London cholera deaths to their rightful place of origin. W. Farr, 'Report of Epidemic Cholera in England in 1866', Supplement to 29th ARRG, 1866 (London, 1868). We have adopted these figures as correct. See also W. Luckin, 'The Final Catastrophe: Cholera in London, 1866', Medical History, 21 (1977), 33.
129. One evident problem is the 1866 cholera epidemic, when a number of general hospitals, but especially the London Hospital in Whitechapel, received cholera patients. In his famous Report, William Farr performed a prescient redistribution exercise which returned the majority of the 5,596 London cholera deaths to their rightful place of origin. W. Farr, 'Report of Epidemic Cholera in England in 1866', Supplement to 29th ARRG, 1866 (London, 1868). We have adopted these figures as correct. See also W. Luckin, 'The Final Catastrophe: Cholera in London, 1866', Medical History, 21 (1977), 33.
130. These figures are calculated from data provided by Bristowe and Holmes, 'The Hospitals', pp. 512, 580 and 584.
131. In St Mary's Hospital, Paddington the percentage of in-patients admitted as accidents and emergencies rose from 56% in 1861, to 75% ten years later and even further to 78% by 1881. (Calculated from St Mary's Hospital Annual Reports.) These broad distinctions were undoubtedly made in order to emphasize the declining importance of the ticket system.
132. 24th ARRG, 1861, pp. 208-10. Of the 3,828 deaths occurring in 24 hospitals, 590 were due to violent causes.
133. For example, the Royal Hospital for Diseases of the Chest in Holborn registered only nine deaths in 1871, 34th ARRG, 1871 (London, 1873), pp. 102-3.
134. Bynum, 'Hospital, Disease and Community', p. 106; A. Hardy, The Epidemic Streets: Infectious Disease and the Rise of Preventive Medicine, 1856-1900 (Oxford, 1993), p. 201.
135. Bynum, 'Hospital, Disease and Community', p. 106; A. Hardy, The Epidemic Streets: Infectious Disease and the Rise of Preventive Medicine, 1856-1900 (Oxford, 1993), p. 201.
136. The working of this policy in relation to the vestry of St George the Martyr, Southwark is summarized in W. Rendle, London Vestries and Their Sanitary Work (London, 1865).
137. Annual total admissions to the London Fever Hospital appear in C. Murchison, The Continued Fevers of Great Britain (3rd edn, London, 1884), pp. 52-3.
138. We may be reasonably confident about the accuracy of these registers. Columns categorize admissions into typhus, typhoid, scarlatina, relapsing fever, and febricula cases and the outcome of each case as cured, uncured, or died was later recorded. A further column was also available for the insertion of additional information on each case wherever necessary. When a patient succumbed to an ailment other than one of the previously defined diseases listed above, then the cause was noted in this column.
139. 1866 was a major exception: in that year the hospital admitted cholera cases and 54 deaths were registered to that cause. In all, 154 separate causes of death were recorded during the period in which the patient registers were scrutinized, and although it is not evident from Figure 2, each of these causes has been placed into the relevant category according to the Registrar-General's classification.
140. Hardy, The Epidemic Streets, p. 202.
141. Case-fatality rates have been calculated by dividing the number of deaths at district level by the number of admissions recorded in the hospital's Annual Reports.
142. Until their first hospital was opened, the MAB erected temporary iron buildings in the grounds of the London Fever Hospital: Jacques, Fifty Years, p. 58.
143. Hardy, The Epidemic Streets, p. 295.
144. On the public campaigns to prevent the opening of smallpox hospitals, see ibid., pp. 137-42.
145. The Fulham Hospital was retitled the Western Hospital, Hampstead the North Western, Homerton the Eastern, Stockwell the South Western and Deptford the South Eastern Hospital. A map of the location of these institutions can be found in Ayers, England's First State Hospitals (no page).
146. Ibid., Appendix II. Ayers tabulates detailed information on annual admissions, deaths and case fatality rates broken down by disease, age and sex taken from the MAB's Annual Reports.
147. According to the hospital authorities there were no deaths resulting from any of the relapsing and simple continued fever admissions. Additionally, although measles was purportedly excluded from the hospitals by MAB order in 1872, a total of 25 deaths from 90 admissions were recorded in the Homerton Reports of 1882 and 1883. Admissions and deaths in the other hospitals, if they occurred, would probably have been placed in the 'other causes' category. Unfortunately, the diseases which come under this heading are rarely elaborated upon in the Reports.
148. Admissions data by district are not available for the Homerton Hospital for 1876, so the 1875 pattern of admissions is imposed upon it, since the two years both witnessed a scarlet fever epidemic in the capital.
149. E. Seaton, 'Report on the Late Epidemic of Smallpox in the United Kingdom in its Relation to Vaccination and the Vaccination Laws', in Annual Report of the Medical Officer of the Privy Council and the Local Government Board, 1874, New Series IV, PP 1875 XL, p. 79.
150. For example: from 1873 for Stockwell Hospital; from 1878 for Fulham and Deptford Hospitals; 1879 for Homerton Hospital; and from 1884 for Hampstead Hospital, the Darenth Camp and the Hospital Ships.
151. Homerton Hospital was opened in 1871 but not used for smallpox until 1873. Information for neither deaths nor admissions by district can be located for the Hampstead Hospital.
152. G. Mooney, '"A Tissue of the Most Flagrant Anomalies": Smallpox Vaccination and the Centralization of Sanitary Administration in Nineteenth-Century London', Medical History, 41 (1997), 261-90.
153. Further modifications to the case-fatality rate approach for smallpox were dictated by the availability of the data in three hospitals. Global admissions and deaths only were provided for the Homerton in 1871. Thus, the percentage distribution of admissions by district was calculated for the combined years of 1873 and 1874 and the total deaths for 1871 were allocated to districts according to these percentages (Homerton Hospital apparently did not take smallpox cases in 1872 or 1875, so the two years nearest to 1871 were used). The only information given on each district's contribution to the Hampstead Hospital's admissions is combined into a 1876-78 total. No geographical breakdown of deaths is given. The Hospital's overall smallpox case-fatality rate can be calculated for 1876, 1877, and 1878 separately. The 1876-78 geographical distribution of admissions was assumed to apply to the total admissions for the individual years, and the annual hospital case-fatality rate was then applied to the estimated geographical distribution of admissions for each year. The first Annual Report of the Deptford Hospital's Medical Officer covered the period from April 1878 to the end of 1879. Admissions were provided by district for 1878 and 1879 separately, but the deaths were broken down by district for the two years combined. Therefore, the total deaths for each district in 1878-79 were apportioned between the two years according to the percentage distribution of the admissions in the respective year.
154. There were, for example, 290 deaths registered in the Hospital in 1863 and 190 in 1871. By 1872, however, the MAB hospitals were taking the majority of cases, and only 49 deaths were registered in this, the second year of the epidemic. See 26th ARRG, 1863 (London, 1865), p. 84, 34th ARRG, 1871, p. 102, and 35th ARRG, 1872 (London, 1874), p. 102.
155. There were, for example, 290 deaths registered in the Hospital in 1863 and 190 in 1871. By 1872, however, the MAB hospitals were taking the majority of cases, and only 49 deaths were registered in this, the second year of the epidemic. See 26th ARRG, 1863 (London, 1865), p. 84, 34th ARRG, 1871, p. 102, and 35th ARRG, 1872 (London, 1874), p. 102.
156. There were, for example, 290 deaths registered in the Hospital in 1863 and 190 in 1871. By 1872, however, the MAB hospitals were taking the majority of cases, and only 49 deaths were registered in this, the second year of the epidemic. See 26th ARRG, 1863 (London, 1865), p. 84, 34th ARRG, 1871, p. 102, and 35th ARRG, 1872 (London, 1874), p. 102.
157. Mooney, '"A Tissue of the Most Flagrant Anomalies"', p. 277, note 71.
158. LMA, H.NW.1/SP/4. The London Smallpox Hospital death registers survive only after 1878. This presents no problem for the period 1873-77, over which there were only two deaths recorded in the Hospital, according to the tables in the ARRGs. The origin of deaths by district in other years before 1879 must be estimated. The percentage of deaths recorded in each district in 1871-72 given in the Privy Council Report were applied to the annual total of deaths occurring in the Hospital in each year 1860-70. The Hospital register for 1878, when 59 deaths were recorded, is also missing, so the average pattern for the years 1879-84, taken from the Hospital registers, was used for this year.
159. Hardy, 'Smallpox in London: Factors in the Decline of the Disease in the Nineteenth Century', Medical History, 27 (1983), 121.
160. After the 1867 Metropolitan Poor Act, London was divided into 'Sick Asylum Districts'. The parishes governed hitherto by local acts were brought fully into the system, and adequate institutional provision for the sick indoor poor was required by law throughout the capital. Some unions built new workhouse infirmaries, divorced from the workhouse proper, but financial constraints meant that the majority adapted an existing building as a hospital, poverty preventing the large union of Bethnal Green from building an infirmary by the last decade of the century.
161. Luckin and Mooney, 'Urban History and Historical Epidemiology', Table 6.
162. Fifth ARRG, 1842 (London, 1843), Appendix, p. 229; and Decennial Supplement to 35th ARRG, 1872, p. cxc. Under the Settlement Act of 1862 (13 & 14 Car. II. CAP 12) destitute individuals were deemed the responsibility of their parish of birth. Adults applying for relief elsewhere were liable to be removed to their birthplace. Apprenticeship automatically transferred settlement to the parish where training was given; marriage gave a woman her husband's settlement; and dependent children took their father's place of settlement. The 1834 legislation created unions of parishes as the place of settlement. Changes in the terms of settlement thereafter meant that, by 1867, one year's residence in a union was enough to gain settlement there.
163. Fifth ARRG, 1842 (London, 1843), Appendix, p. 229; and Decennial Supplement to 35th ARRG, 1872, p. cxc. Under the Settlement Act of 1862 (13 & 14 Car. II. CAP 12) destitute individuals were deemed the responsibility of their parish of birth. Adults applying for relief elsewhere were liable to be removed to their birthplace. Apprenticeship automatically transferred settlement to the parish where training was given; marriage gave a woman her husband's settlement; and dependent children took their father's place of settlement. The 1834 legislation created unions of parishes as the place of settlement. Changes in the terms of settlement thereafter meant that, by 1867, one year's residence in a union was enough to gain settlement there.
164. Fifth ARRG, 1842 (London, 1843), Appendix, p. 229; and Decennial Supplement to 35th ARRG, 1872, p. cxc. Under the Settlement Act of 1862 (13 & 14 Car. II. CAP 12) destitute individuals were deemed the responsibility of their parish of birth. Adults applying for relief elsewhere were liable to be removed to their birthplace. Apprenticeship automatically transferred settlement to the parish where training was given; marriage gave a woman her husband's settlement; and dependent children took their father's place of settlement. The 1834 legislation created unions of parishes as the place of settlement. Changes in the terms of settlement thereafter meant that, by 1867, one year's residence in a union was enough to gain settlement there.
165. 'Tramps were generally viewed as prime spreaders of infectious disease in common lodging houses and in the casual wards of the workhouses: Annual Reports of the Kensington Medical Officer of Health, 1880-1890. The centrally located City of London union claimed that a very high percentage of stranger admissions were attracted to the huge charitable resources of the Square Mile. See A. I. Tanner, 'The City of London Poor Law Union, 1837-1869' (unpublished Ph.D. thesis, University of London, 1995). Conversely, districts with a free dispensary, night refuge or a high number of charities might have relatively few sick indoor paupers.
166. 'Tramps were generally viewed as prime spreaders of infectious disease in common lodging houses and in the casual wards of the workhouses: Annual Reports of the Kensington Medical Officer of Health, 1880-1890. The centrally located City of London union claimed that a very high percentage of stranger admissions were attracted to the huge charitable resources of the Square Mile. See A. I. Tanner, 'The City of London Poor Law Union, 1837-1869' (unpublished Ph.D. thesis, University of London, 1995). Conversely, districts with a free dispensary, night refuge or a high number of charities might have relatively few sick indoor paupers.
167. When temporary inmates such as accident victims died in the workhouse or its infirmary, the death was automatically attributed to the registration district in which the workhouse was located, with no regard to the deceased's previous residence.
168. Paupers who were registered as non-able-bodied could not be physically removed to their place of settlement, but the unions who cared for them were entitled to claim the cost of their support. The existence of details regarding such financial transactions between unions might allow the estimation of the number of paupers treated beyond the boundaries of their own parish.
169. H. Famall and E. Smith, Return of the Number of Sick Cases on the Books of District Poor Law Medical Officers in the Metropolis, PP 1866, LXI, p. 13. Covering accommodation, medical supplies, medical attendance, and provision for nursing, this return directly led to the Metropolitan Poor Act of the following year.
170. There is no hard evidence of collusion on the part of Poor Law officials and paupers regarding place of settlement. The very cost of poor relief was probably enough to dissuade the admission of non-residents on a large scale. The possibility cannot be discounted fully, however, since the cost of transporting the applicant back to his or her place of settlement had to be borne by the union from which the person had sought relief.
171. The remainder were attributed to the neighbouring parish of Stoke Newington, which, for the purposes of the registration of births and deaths in our period, was in any case part of Hackney, LMA Ha.BG.211/1. For Bermondsey, see LMA, B.BG.576/4 and X20/5; Camberwell, LMA, Ca.BG.175/6-10, X20/404; Hampstead, LMA, Hp.BG.103/1-4, X20/54; Greenwich, LMA, X20/47.
172. As in the case of 'stranger' deaths, the centrally produced data of the PLB and LGB reveal little about cause of death. The only published returns which give information on name of deceased, address, occupation, and age are for those registered as dying from starvation, produced annually from 1868 to 1900. One further return from workhouses in January 1876 regarding disease and death throughout England and Wales is arranged by union, although the detailed tables are given only for venereal disease: Returns of General Diseases and of Venereal Diseases from the Workhouses of each Union in England and Wales, During the First Week in January 1876, PP 1877, LXXI, p. 373.
173. These workhouse data were supplied to the Medical Officer of Health, Thomas Orme Dudfield, by the Medical Superintendents of the workhouse. In 1882 phthisis deaths were placed in the respiratory diseases category: T. Orme Dudfield, Annual Report on the Sanitary Condition of the Parish of St Mary Abbots, Kensington, 1882.
174. Unfortunately, the age breakdown of the Registrar-General's published data does not allow exact comparison with those in the Kensington workhouse, but in the decade 1871-80 the proportion of all deaths occurring in the whole of London to persons over 55 years of age was 25%. This figure probably would be reduced by about 5% if the proportion for those over 60 years could be calculated.
175. Of course, the 62 deaths allocated to 'old age' in the workhouse may well belong to any of the other disease categories under discussion.
176. Luckin, 'Death and Survival'; Hardy, '"Death is the Cure of all Diseases"'; and Higgs, 'The Statistical Big Bang'.
177. Luckin, 'Death and Survival'; Hardy, '"Death is the Cure of all Diseases"'; and Higgs, 'The Statistical Big Bang'.
178. Luckin, 'Death and Survival'; Hardy, '"Death is the Cure of all Diseases"'; and Higgs, 'The Statistical Big Bang'.
179. The death rates in Figures 4-8 use an estimated intercensal population at risk calculated by assuming that each district had a constant annual rate of population growth. See G. Mooney, 'The Geography of Mortality Decline in Victorian London' (unpublished Ph.D. thesis, University of Liverpool, 1994), p. 91. The 'uncorrected' deaths in the figures are taken from the Registrar-General's Annual Reports; the 'corrected' deaths between 1860 and 1884 are estimated using the redistribution methods described in this paper, and the 'corrected' deaths 1885-90 are taken from the Registrar-General's Annual Summaries. The latter have been included to demonstrate the close correspondence between our redistribution and that appearing in the Annual Summaries.
180. These were places which sent a great number of sufferers northwards to the Hospital.
181. See Hardy, The Epidemic Streets, ch. 3.
182. It should be remembered here that the mortality data published in the Annual Summaries did not give phthisis deaths separately until 1894. The correction factor that was applied to the 'uncorrected' phthisis deaths for each of the nine years 1885-93 was calculated as the arithmetic progression between the percentage difference of the average 'corrected' and 'uncorrected' values for 1882-84 and 1894-96.
183. Comparison with Figure 8.2b in Anne Hardy's The Epidemic Streets (p. 216) demonstrates that the reductions to Whitechapel's respiratory tuberculosis mortality rate shown in our Figure 6 would place that district's levels roughly equal to those of its east London counterparts, Shoreditch and Bethnal Green.
184. For example, Hackney's corrected average annual scarlet fever mortality rate of 353 per million for the decade 1881-90 sets it alongside Whitechapel (332), Greenwich (342) and, of course, Lambeth (303), but well below Shoreditch (511) and Bethnal Green (666).
185. This point should be qualified by noting, of course, that admission and discharge registers for institutions in other cities might not survive. Even where they do, the required information detailing usual address or district of residence may not be provided.