How did William Marsden Criticise London Hospitals, and how did he Approach Medical Care Differently? (As Seen in the Royal Free Minutes c.1828-1851)

Kenneth Hughes M.A. (April, 2015)

Surgeon William Marsden created the Royal Free Hospital in London at the start of the nineteenth century. It was at a time when most hospitals were charging patients and asking   for letters of recommendation before even letting them in...Marsden knew things had to change. Years after the Royal free he also founded the Marsden cancer hospital.

This paper focuses on William Marsden’s creation of the Royal Free Hospital, and his reasons for doing this. It looks at why Marsden wanted to do things differently by analysing his criticism of other hospitals and medical policy. This is relevant because Marsden’s team contributed to a rapidly emerging medical market, changing the way things were done. It is important to look at what Marsden did that went against culture and tradition and explain how it opposed the contested field of different ideas. This paper is relevant because it asks the question ‘what did Marsden criticise the medical establishment over?’ and ‘how did he try and fix it?’

Firstly, there is an extended look at the primary sources and analysis of their utility and limitations. The provenance of these sources are the hospital’s Board of Governors’ Minutes and the Committee of Management Minutes, both from 1828. Then the paper will look at Marsden’s hospital’s criticisms of how competitors operated and treated their patients, as discussed in those minutes. The criticisms explain that Marsden felt patients were not getting a good deal. Then a brief look at Marsden's  call to end fees and letters of recommendation is necessary, as well as his attitude to treating cholera and venereal disease, showing how Marsden operated differently during a time of conflicting ideologies.

This is not a biography of the hospital’s founder William Marsden, but his work in a wider medical and historical context. David Cannadine argues that biographers look at what makes their subjects unique and historians put them in context of their time.[1] Here, I will endeavour to do the latter and contextualise the events at the Royal Free. I will not examine his cancer treatments from 1851 or his training of female doctors. The hospital has had three names; but for simplicity, unless mentioned by name directly from a source, I will refer to it simply as The Royal Free or the hospital. The chosen dates, 1828-1851 have been selected because Marsden’s first hospital started in 1828 and his second in 1851, when his focus changed. I will, however, make reference to events outside those dates where relevant.

First it is important to analyse the primary sources and therefore Marsden’s criticisms of healthcare in London and beyond. Additionally, by including an account of treatment, which prove that Marsden practised what he preached. So when one part of the source states that he treats cholera victims, unlike many other hospitals (a criticism), another part then lists how many were actually taken in by Marsden. Therefore, the figures, charts, and statistics within the Management Committee Minutes show that Marsden and his team delivered what it called for; one book is more about policy (Governors’ Minutes), the other reports more the deliverance (Management Minutes), although there is much overlap. These leather bound hand written accounts date from 1828 are stored at the hospital’s archives in Hampstead, London, and are available to the public. [2]In contrast, records for The Royal Marsden (cancer hospital) are not readily available to the historian, and according to the archivist you need to know what you are looking for, so someone can retrieve it for you. [3]

Both the Governor and Management books are detailed accounts of the running of the hospital, about financial accounts, staffing, treatments and statistics. Additionally, there is an underlying attack on other hospitals and a political message when the Royal Free complains in its minutes of being overworked, underfunded and over stretched. It is saying that other hospitals are inadequate and all the work is being left to them. For example, in 1842, in the Management Committee Minutes state that it has to meet the ‘accumulating masses of poverty and wretchedness’. [4] This is also just as much an attack on the state as it is on the medical world.

The primary sources have some limitations. The hospital’s archivist says they are one-sided, and ‘almost corporate propaganda’. The Governors especially had to make the hospital look good to attract future subscribers and donations. In February 1832 an entry records 3,132 patients (of which 137 were cholera sufferers) over the previous year. It claims 2,119 were cured. Were they considered cured but went off, became sicker and died?[5]

We can identify another weakness in that they cover patient statistics but not the patients. In 1991, Roger French and Andrew Wear said that at this time ‘during increasing medical autonomy the patient’s narrative of illness was made utterly redundant and identified the emergence of the modernity of medicine and its link to State and science, and effect on doctor-patient relationships. By 2000 Kier Waddington was looking at philanthropy and the reasons behind it, links between charity to welfare state and the changing balance of power between doctors and governors; proof that Marsden was a threat to the establishment in the 1830s.[6]Marsden’s early work was when Edwin Chadwick was gathering evidence on public health. There was debate linking squalor to health and even the 1848 Public Health Act was not compulsory. This shows the uncertainty surrounding health issues when Marsden was pushing the boundaries. Miasma was still a popular theory.

Historians would not expect to see accounts of opposition in minutes that were designed to make the hospital look good. Marsden had much support, including royalty. There are clues to the opposition in Marsden’s obituary in the British Medical Journal in 1867, which comments on the opposition from respected names in medicine, and how his second hospital was hated by doctors because it drew patients away from them, which had been seen as bodies to practice on. [7]

What is difficult to extract from the primary sources is evidence of opposition and prejudice towards Marsden. This is something mentioned many times in the secondary literature. The historiography of William Marsden is limited, but they include: An Illustrated History of the Royal Free Hospital by Lynne A. Amidon, 1996. This is a detailed linear narrative, rich in timelines, primary source images, illustrations and tables. Its weakness is that it is published by the hospital and ironically has the same corporate propaganda elements as the minutes. It mentions the opposition repeatedly.Meanwhile, Surgeon Compassionate, is Marsden’s 1960 biography written by his great-granddaughter Frieda Sandwith.Although historically true the narrative is flowery and descriptive. It is difficult to establish what is fact and what is fictional padding.

Meanwhile, opposition is mentioned in many chapters. Eve Wiltshaw’s A History of The Royal Marsden, is about his later life, post 1851, which is a limitation, but this 1998 book also mentions opposition from 1828. Again, there is no detail. In 2004, Willcocks’s Cordwainers goes as far as saying that the medical establishment obstructed him. In 2005, secondary literature around Marsden has failed to move on, as G Barry and L Carruthers, A History of Britain’s Hospitals, has a narrative of Marsden’s work, mentions the opposition, but again no detail. This, as with the others, is limited by the fact it is not written by historians. Marsden was all about doing things first, so the factsheet called Royal Free Firsts is a useful research tool. It has a limited scope, as it is a short, factual list produced in-house by archivists, for historians. [8]  The historiography surrounding opposition has not developed since 1960.

Having assessed the usefulness and limitations of the primary sources, let us examine how they answer the question about how Marsden’s team criticised other hospitals. In 1832, a statement recorded in the Management Committee Minutes details their attack. It says it is distressing to see so many ‘wretched objects’ infected and wandering around, infecting others. The statement questions the amount of human suffering in a Christian and benevolent society. It becomes a political statement when it says it is a disgrace that many other continental towns have free hospitals. [9] It remarks it is astonishing that the key to ‘diminishing this load of human suffering’ is free and immediate care just as in Paris and other continental towns. [10]

The primary sources show how the Royal Free called other London hospitals ‘incompetent’ and questioned delays at getting seen, stating that sick people were being turned away. The report says ‘instant relief and constant attention are of the utmost importance’. It criticises the on-going policies with restriction and regulations on admissions. Many hospitals only saw their out-patients once a week. Marsden said that this was inadequate and that his organisation aimed to see patients twice a day.[11] The primary sources show a direct attack on government and the emerging medical profession, with accusations of inadequacy in numbers and incompetency in hospitals. [12] Marsden’s team made another political statement in relation to supporting a free hospital, stating ‘if benevolence and religion did not recommend an institution, let us do it for selfish reasons, to keep alive industrious, valuable members of society’.[13] Furthermore, he criticised industries poor effect on medical services, going beyond the traditional attack on other hospitals. They criticised employers for casting out sick workers and not helping them in their search for treatment. However, this 1832 public outburst and criticism was to create attention, as well as political, financial and medical unrest. The Royal Free was about to expand and was trying to attract more money.

In addition to this, Marsden’s first annual report in 1829, he attacked the quacks and said many had ‘fallen into the hands of ignorant and needy empirics who drug them with pugnacious medicines so long as their money will hold out and then discard them, often in a worse state then at the start’.[14] This was complemented in the Governors’ minutes when is scorned physicians for using the wrong treatments, for example, for rheumatism ‘occasioned by the improper use of mercury’.[15] In Eve Wiltshaw’s account of the history of his later hospital, The Royal Marsden, she says Marsden saw the quacks as exploiting the sick.[16] Despite Marsden’s attacks of the quacks, there were two within his ranks, which caused a scandal. His apothecary and one of his surgeons were selling Franks Specific Solutions, a quack remedy for VD. Both employees were dismissed as seen in both primary sources.

To deal with Marsden’s opposition to letters of recommendation and fees, we should start by looking at an announcement in the Morning Post in London, in Dec 1831, by the London General Institution (The name The Royal Free was first known as), that links in with Marsden’s other criticisms of hospitals made in the minutes. During an appeal for funds it mentioned that it had been founded under royal patronage to take in all the poor, sick people that the other hospitals had refused to take, boasting that no letter of recommendation ‘or other dilatory form is required from the patient’. It stated that ‘no obstacle intervenes between their necessity and their instant relief’.[17] It proved it was driven by the needs of its patients.

In 1832 the Royal Free reiterated its policy on referrals by stating ‘no ticket or recommendation from a subscriber is necessary to be provided …poverty and disease alone are the wretched qualifications’.[18] At this time, many hospitals were still insisting on letters of recommendation. Marsden’s biographer Freida Sandwith claims many were suspicious of the free services without referrals, thinking it might be a workhouse. [19]  Historians should read between the lines of the hospital minutes, and Marsden’s actions, as his policies were a criticism of the establishment. F.B. Smith tells us that pregnant women usually needed a letter of recommendation well into the 1880s. The Royal Free was overseeing infant deliveries almost a quarter of a century before that, without referrals.[20] 

In the wider historiography, the 1974 classic John Woodward’s To Do The Sick No Harm, outlined the difficulty of getting free healthcare at this time. His social policy analysis explains who was and was not allowed treatment. Woodward calls it a ‘formidable list of exclusions’. [21] This shows why Marsden identified the need to offer treatment to all, without recommendation or fees. However, he deals more with regulation and social policy than the patient. Twenty-eight years on and Anne Digby’s Making a Medical Living: Doctors and Patients in the English Market, is less policy and more patient focussed, but also looking at how doctors made money, exploring the socio-economic history of medical practice. She includes a cartoon of a doctor taking payment for a house call. Digby’s explanation of the laissez-faire ethos of the medical culture explains why Marsden’s carefully managed strategies were not met with cheer by doctors. In 1996, Steven Cherry’s Medical Services and the Hospitals in Britain: 1860-1939, debates why it was a problem to get free healthcare when the medical profession was being re-organised. He says medical progress was about better knowledge and techniques, both in their infancy when Marsden started out. [22]

Let us now take two diseases, cholera and venereal disease, to show how Marsden and his team treated those who needed help the most, as it stated in the primary sources, and his attack on those who did not. During the 1832 epidemic most hospitals were closing their doors to victims, but the Royal Free was welcoming them. There was a public debate about keeping sufferers separate, but the Royal Free was putting them together, with cholera wards by 1846. The primary sources show the growing number of cholera patients admitted. The Management Committee Minutes details the numbers of cholera patients each quarter.

There was friction between Marsden and other hospitals about whether cholera patients should be admitted and kept together. It was a field of contested ideas over contagion. There were great epidemiological and pathological debates, and advances, throughout the first half of the nineteenth century. The 1832 epidemic was before Chadwick’s report and the final plans for sanitary reform. It was before an aetiological approach to cholera, seventeen years before Jon Snow’s water theory in Soho (accepted after 1866) and almost fifty years before Robert Koch’s identification of the etiological microbe that caused cholera. The uncertainty is evident in the fact that more than sixty years after Marsden opened his doors to cholera patients, the Royal College of Physicians was still not advising people to boil their water.[23]  The uncertainty over contagion or non-contagion is not covered in the primary sources, just records of thousands of cholera patients being admitted. The uncertainty in the medical world about whether this was right was understandable. The 1832 epidemic was way before the emergence of the germ theory and at the time Marsden was admitting cholera patients, the miasma theory was often favoured.

Cross infection worries often gave hospitals a negative reputation. Guenter B. Risse, in Mending Bodies, Saving Souls, said the ‘gateway to death’ image put many people off from going to hospital.[24]  William Marsden was ahead of his time, like Hawthorne, Margaret Pelling explains the scientific uncertainty over diseases such as the fever and cholera in the early nineteenth century. Physicians experimented with bleeding or opium. Others tried homeopathic methods or various regimes including a change of diet or hygiene. Pelling states that Southwood Smith’s articles in the Review on sanitary reform were great at influencing the general public, but medical opinion was mostly with contagion [25] Pelling documents the change is beliefs surrounding contagion, the germ theory and epidemics, and the on-going debate. This 1978 book is more science and statistics based and great men and their influences, but by 2000 Joan Lane is looking more at primary sources and the social history of medicine to examine patients’ experiences. Some of these descriptions agree with commentary in Marsden’s minutes. The medical profession did not need someone as forthright as Marsden, telling them they were all doing it wrong, when none of them knew for sure how they should be doing it at all. Pelling links the sanitary ideas and public health concerns to epidemiology. Smith takes a wider look at the battle between sanitary improvements and medical/scientific research and the myriad of treatments.[26] 

Let us now see how Marsden criticised others for their treatment of venereal disease. In 1837, the hospital was reporting on its fundraising ideas with the Lord Mayor, in the Morning Post, stating that after years of treating cholera patients, it was broke.  Here, the hospital was attacking the establishment by reminding readers it had been the first to disregard referral letters, and had treated more than 700 female VD sufferers, or as it called them, ‘females of a certain class…restored to industry and virtue’. [27]  In 1843, the Royal Free treated 2,739 VD cases.[28]

The minutes show us that Marsden’s team heavily criticised the way other hospitals (the few that agreed to see women with venereal diseases), treated their female patients. He called their examinations unladylike, sad that they lost any ‘remaining sense of decency’ and that they are treated cruelly. [29] As his biographer Frieda Sandwith pointed out in her book Surgeon Compassionate, at the 1829 first anniversary dinner with guests, governors and supporters, Marsden announced more help would be given to VD sufferers. He denied that helping them would encourage them and promote bad behaviour.  Marsden declared that ‘wretched females who frequent the streets have always been welcome…the more wretched they are, and the more diseased, the greater is their claim on this charity’. It was an attack on the other hospitals that morally judged these women. The Royal Free said ‘these poor girls enticed from their country homes, seduced, diseased, abandoned…have no shelter or refuge left to them save within the walls of institutions similar to the Royal Free’. This policy is clearly stated in the minutes, is an attack on society as a whole. Each year the minutes show how many venereal disease cases were treated. By 1843, the Board of Governors’ Minutes were recording 2,739 venereal disease patients (men and women) for the whole year; almost a third of its workload. [30]

The wider historiography explains how prostitutes were perceived and the link to venereal disease. Fessler reported on a House of Commons discussion about a government visit to a workhouse and how a young diseased working girl was chained to a wall to stop her escaping and infecting others’.[31] Fessler also quotes Chadwick’s 1833 report that criticises a workhouse for allowing prostitutes to mix with women, and that the prostitutes were ‘the worst character’.[32] Lesley hall questions VD statistics, stating many were too ashamed to get help. [33]

However, A VD scandal recorded in the minutes engulfed the Royal Free. [34] In 1845 two women were refused despite having TB because the only beds left were for VD sufferers. So despite poverty and sickness being the only passports to treatment, according to the Management and Governors’ minute, this was not true when the girls were turned away. One of them was found dead the next morning. There was a public inquiry and bad press in the Times and Morning Chronicle newspapers over the following weeks. Marsden was accused of letting all the ‘strumpets off the streets’, in preference to respectable women. [35]

In Conclusion, Marsden was ahead of his time, but his free, instant health care for all was really needed. His policy of treating who needed it was vital. Guenter B. Risse said in Mending Bodies, Saving Souls, that ‘hospitals were usually launched in response to perceived needs in their surrounding  populations…prompted by local needs and epidemics’ [36]and this is exactly what happened when Marsden set up his first free hospital in London. Whilst Southwood Smith, Chadwick and Farr were looking at sanitary conditions and the city’s health issues, Marsden was making it easy for people to seek help. However, his determination to treat cholera and VD attracted more supporters than critics (including royalty).  F.B. Smith shows just how ahead of his time Marsden was on cholera, for example, and at logger-heads with the Royal College of Physicians. The primary sources tells us of cases where Marsden has some success using saline solution for cholera. Pelling tells us this too. Forty years after Snow’s water theory and nine years after Koch’s discovery of micro-organisms, was still not advising people to boil water, Marsden had already worked out cholera was passed person to person. [37] The two main primary sources, despite their bias and lack of patient-as-people approach, remain very useful tools in understanding the story and its significance. Marsden’s desire for free treatment was years ahead of the start of the National Health Service in 1948. Marsden’s early days are framed by social changes and attitudes, and an emerging medical market with little control until the 1858 Medical Act. There was little understanding of the danger of germs and bacteria. By criticising hospitals for not taking in cholera patients or VD patients during a period of scientific, epidemiological andpathological changes, Marsden was showing his disapproval of the medical establishment as seen in his 1832 statement in the Royal Free minutes. Pages and pages of patients with cholera, fever, VD and other afflictions, in the sources, show Marsden tried to moved treatment forward. He was treated thousands of these patients years before the 1863 Contagious Deiseases Act.

Historians like Pelling, Lane, Cherry and Digby create a framework to show what Marsden was up against at the time. They contextualise his work in an emerging and developing medical market which they explain from different approaches. One even draw upon writers like Charles Rosenberg who identifies the importance of medical innovations (like Marsden's) as ‘a major driver of change in the history of Hospitals’.[38] Meanwhile, Roy Porter examines medicine within a wider political, philosophical and religious framework, in The Greatest Benefit to Mankind, and sources like these help us understand what Marsden had to deal with at that time, and what was happening in the social background. We can therefore better understand what Marsden criticised hospitals for, and how he followed this up by doing it, his way.  I would go as far as to argue that Marsden’s criticisms of other hospitals and his new way of working helped shape the health service as we know it today.

[1] D. Cannadine, Aspects of Aristocracy, p.3

[2] Handwritten Royal Free Archives 1828-1880s, plus later editions typed

[3] (Interview with Royal Marsden’s archivist) LMA holds some original records, some are held privately by the Marsden family, others are held in the hospital’s safe on Fulham Road, London, only inspected by management if you state exactly what you are looking for – unless you use the Freedom of Information Act – requests in writing months in advance

[4]Management Committee Minutes, 1842

[5]Ibid, Management Minutes, 1832

[6] K. Waddington, Charity and the London Hospitals 1850-1898, p.12

[7]British Medical Journal, vol.1 no. 317, p.96/7

[8]  Royal Free Firsts Fact-Sheet, 2011

[9]  Management Committee Minutes, 1832

[10] Ibid, Management Minutes, 1832

[11] Ibid, Management Minutes, 1832

[12] Ibid, Management Minutes, 1832

[13] Ibid, Management Minutes, 1832

[14]Ibid, Management Minutes, 1829

[15]Board of Governors’ Minutes, 1829

[16] E. Wiltshaw, A History of the Royal Marsden, p.5

[17]The Morning Post, 26/12/1831, issue 19046, via 19th Century British Library Newspapers online

[18]Board of Governors’ Minutes, 1832

[19] F. Sandwith, Surgeon Compassionate, p.73

[20] F. B. Smith, The People’s Health 1830-1910, p.29

[21] J. Woodward, To Do The Sick No Harm, p.45

[22] S. Cherry, Medical Services and the Hospitals in Britain: 1860-1939, p.2

[23] F.B. Smith, The People’s Health 1830-1910, p.233

[24] G.B. Risse, Mending Bodies, Saving Souls, p.5

[25] M. Pelling, Cholera, p.29

[26] Smith, The People’s Health, p.236/7

[27]Morning Post, 23/11/1837, accessed via nineteenth century newspapers online

[28]Management Committee Minutes, 1843

[29]Board of Governors’ Minutes, 1846

[30] Ibid, Governors’ Minutes, 1843

[31]A. Fessler, VD in the reports of the Poor Law Commissioners 1834-1850, in British Journal of Venereal   Diseases, Sept. 1951, 27 (3), p.154/5

[32] Fessler, VD in the reports of the Poor Law Commissioners

[33] L. Hall, The Cinderella of Medicine: Sexually Transmitted Diseases in Britain in the Nineteenth and Twentieth Centuries, in the British Medical Journal, 1993, p.314

[34] Management Committee Minutes, 1845

[35] G. Barry and L. Carruthers, A History of Britain’s Hospitals, p.106

[36] G.B. Risse, Mending Bodies, Saving Souls, p.6

[37] F.B.Smith, The People’s Health 1830-1910, p.233

[38] C. Rosenberg, Medical Innovations, in Health and History Journal, p.168