Public health and medical services

PUBLIC HEALTH AND THE MEDICAL SERVICES

Leprosy, p. 318. Plague, p. 319. Smallpox, p. 321. Cholera, Sanitation, and Water, p. 324. Insanity and Mental Deficiency, p. 328. The School Health Service, p. 336. Hospitals, p. 340.

The early history of public health is largely a chronicle of epidemics. Principal among them were plague and smallpox, and many of the regulations of town councils and county justices reflect both the inefficacy of treatment and fear of infection of both these diseases. By the beginning of the 18th century, however, plague had disappeared, and the introduction of preventive inoculation provided the first hope of control of smallpox, made much more effective by the later practice of vaccination. The advance of medical and surgical skills allied with philanthropy to produce the new hospital foundations of the 18th century, of which the Salisbury General Infirmary is a worthy example. (fn. 1)

During the 19th century, cholera epidemics, traced to their source in defective sanitation, and theories of the miasmatic spread of infection, brought sanitary reform and uncontaminated water-supplies to most urban areas although the rural areas of the county lagged behind. About the same period growing humanitarianism, reinforced by legislation, led to stricter inspection of private lunatic asylums and the opening of the County Asylum for pauper lunatics.

Wiltshire has been particularly fortunate in the quality and extent of voluntary work devoted to the health services. Until the National Health Service took them over, both Salisbury General Infirmary and the cottage hospitals, which developed rapidly following the advent of anaesthesia and antisepsis, depended upon the loyal support of local committees and local workers. Early in the 20th century skilled nursing was extended to the home through the Wiltshire Nursing Association, an association of local committees for training and employing qualified nurses. Until long after the First World War improvements in midwifery, and in maternity and child welfare were largely due to the work of this association. Gradually central and local government authorities increased their responsibility for personal health services, either directly or by grant; a policy which culminated in the National Health Service Act (1946).

Leprosy

Segregation of sick persons through fear of infection preceded medical knowledge of the nature of many diseases. In Wiltshire, as elsewhere, special provision for the outcast lepers of the Middle Ages was made by the Church. Hospitals staffed by men and women, probably following a religious rule, and known to have harboured lepers at least for a time existed in Bradford-on-Avon, East Harnham (Salisbury), Malmesbury, Marlborough, Old Salisbury, and Southbroom (Devizes). (fn. 2) A number of 14th and 15th-century bequests to the hospital at East Harnham are recorded. (fn. 3) In 1620 £6 was paid to the governor or master of the hospital for a sick person admitted that year. (fn. 4) The constable of Calne is said to have given relief to a leper in 1676. (fn. 5)

Plague

Epidemics of plague occurred at intervals in Wiltshire for at least a century up to 1666. Such was the fear of the disease that drastic regulations were laid down by town councils and by quarter sessions in an attempt to prevent any spread of infection by contact with the sick, either personally or through goods and merchandise. Calne suffered attacks of plague in 1565 and 1569. (fn. 6) In 1579 as later in 1604, (fn. 7) the town council of Salisbury changed the place of the mayoral election 'because at the time of this election the plague or sickness is hot in or near the streets adjoining to St. Edmund's church' where the election was usually held. At the same time strangers and visitors avoided the infected town with consequent loss of trade. (fn. 8)

In 1603 when the king visited Salisbury and Wilton, and when plague was prevalent in London, the town council ordered that no carriages of any wares were to be received into Salisbury. (fn. 9) In January 1604 the Bishop of Salisbury, acting as justice of the peace, signed an order for the strict execution of the Act against rogues and vagabonds 'on account of the increase of the pestilence which was by daily experience found to grow by the wandering up and down the country of idle and loitering vagabonds'. (fn. 10) At the quarter sessions in the same month complaint was made of people who refused to remain in their houses although they had been in contact with the infection. For the future such persons were to be ordered to the house of correction for a month. (fn. 11)

About the same time a number of towns and villages were reported to be infected and many weavers of Salisbury, Devizes, Marlborough, and Fisherton Anger were losing work on this account. At the October quarter sessions the presence of plague in Westbury was reported, the inhabitants, mainly weavers and spinners, were seriously impoverished owing to their isolation. Arrangements were made whereby supplies of corn at market prices should be delivered in or near the markets of Warminster and Market Lavington to certain appointed persons from Westbury. (fn. 12)

John Noyes of Calne wrote to his wife from London in May 1607 giving her advice on avoiding the sickness which was then increasing in Calne. He particularly counselled her to avoid as much as possible the workers who came to the house. 'Let your spinners and weavers come in at the lower entrie, and so up into the wool lofte and let them come into no other part of your howse.' (fn. 13) Plague was also in Devizes in 1607, (fn. 14) and in Corsham in 1608. (fn. 15) In January 1610 Bradford petitioned at quarter sessions for relief, having been infected with plague for twenty weeks. (fn. 16) In the autumn of 1611 Chippenham suffered the infection. (fn. 17)

Salisbury organized most stringent day and night watch against strangers entering the town when plague raged in London in 1625, but failed to prevent an outbreak two years later which was the worst recorded in the city and comparable to the Great Plague of London in its effects. Many of the inhabitants fled, including, after a vain attempt to preserve their isolation, some of the occupants of the cathedral close. Three hundred and sixty-nine persons died of the disease and of the leading citizens only the mayor, John Ivie, stayed in the city to organize care for the sick, and to prevent complete lawlessness. (fn. 18)

When plague was widespread in 1636 stringent precautions were taken by the mayor and common council of Marlborough. Three men were appointed every day to patrol the town from sunrise to sunset and to forbid entry to all strangers who could not prove that they came from uninfected places. Each searcher was paid 6d. a day, raised by a tax on householders. (fn. 19)

Calne suffered another attack in 1637 when a London physician was engaged by Sir Edward Baynton and other Wiltshire gentlemen then in London. Samuel Smith, the physician, stayed two months in Calne for a fee of £20 and £6 13s. 10d. for medicines dispensed to the poor, and a fortnight's board. (fn. 20)

Devizes suffered a severe attack in June 1644. (fn. 21) Wootton Bassett was infected from 25 April 1645 for sixteen weeks, (fn. 22) and the tithings of Wick, Nursteed, Bedborough, and Roundway within the parish of Bishops Cannings suffered both from plague and from plundering about this time. (fn. 23) Maiden Bradley and Horningsham were also infected with 'the noysome and contagious disease' of the plague in 1646, (fn. 24) and a serious outbreak appears to have occurred at Wilton. (fn. 25)

When the disease was at its height in London in 1665, cases appeared at Donhead St. Mary and Salisbury. The usual orders were issued forbidding the receipt by tradesmen of goods from infected places, compelling suspected persons to remain shut up in their houses, and restraining the travelling of pedlars, tinkers, and fiddlers. (fn. 26) The following year, however, plague appeared at Marlborough, Mildenhall, and Wootton Bassett, and the Salisbury outbreak worsened. (fn. 27)

(a) Therapeutic measures

In the absence of any cure, most active measures were concentrated upon the isolation of the sick in their own homes or in public pest-houses. At Calne in 1636 the house of William Ingram in the Alders was taken for a pest-house; Ingram was provided with another house and paid £1 compensation for leaving and for certain goods left for the infected persons. (fn. 28) At the same time the materials from a pest-house in the Marsh of Calne were sold for £6. (fn. 29) There was a pest-house at Trowbridge in 1665, (fn. 30) and at Marlborough in 1666. (fn. 31) In May 1668 the town council of Salisbury ordered the pesthouse to be demolished or sold, (fn. 32) it was possibly the same house as a house for the poor and sick established at Bugmore in 1623. (fn. 33)

Other precautions included killing stray dogs and cats at Marlborough in 1666, or the pigs which had fed on the excrement of infected persons at Calne in 1636. (fn. 34) At Marlborough in 1666 particular supervision of children and servants was enjoined, and the streets were to be kept free from soil and dung. (fn. 35) No mention appears of the rat which acted as a reservoir of infection and carried the fleas which transmitted the disease.

(b) Reliefs

Rates were levied by town councils and by the justices to relieve distress caused by interruption of trade and by sickness. In 1604 the justices ordered weekly sums to be paid to unemployed weavers in infected areas. (fn. 36) A general contribution was levied in Salisbury where the disease was very prevalent, (fn. 37) and a special rate for the relief of the city was ordered in the quarter sessions on 4 October 1604. (fn. 38)

The town of Bradford petitioned for relief in January 1610, a tax imposed on places within five miles having proved insufficient. The justices ordered that the hundreds of Chippenham, Melksham, Whorwellsdown, and Bradford should be assessed to contribute. (fn. 39) In 1611 a rate levied within five miles of Chippenham proved insufficient for the relief of that town, and a rate of £40 weekly was levied on all places within ten miles, with the exception of Bradford and Westbury lately infected with the plague'. (fn. 40) The object of this relief was to prevent the inhabitants dispersing abroad and further spreading the disease.

The expenses of the 1636–7 epidemic submitted by the town and parish of Calne to the justices in 1638 were ordered to be paid by the parishioners. (fn. 41) Two years later a number of the parishioners of Calne petitioned the justices that £300 of the general rate levied for the plague relief and still in the hands of the collectors, should be paid over since trade was greatly impoverished and there were 2,000 poor and needy in the town. (fn. 42) Devizes on this occasion made a free gift of £6 to Calne for relief. (fn. 43) When Devizes itself suffered in 1644 inhabitants within 5 miles were charged with a weekly tax for three months, 'but by reason of great trouble and taxes laid upon this county by the King's party' the full rate could not be collected. In 1646 Melksham was also assessed to contribute but the full sum not being collected several of the constables were indicted at quarter sessions. (fn. 44) A relief was levied for Maiden Bradley and Horningsham in 1646. (fn. 45)

In January 1666 a tax was levied on several hundreds for the relief of Donhead St. Mary. (fn. 46) In July the whole county was rated at £100 a week for 20 weeks for the relief of Salisbury in response to a letter from the mayor stating that there were then 52 houses shut up with 196 inmates whose maintenance cost £22 15s. a week, and 23 families with 58 persons were in pest-houses costing £6 15s. 4d. a week; 553 families of 1,855 persons were in receipt of relief amounting to £108 4s. 2d.; and the total weekly sum spent on relief amounted to £154 7s. 6d. By January 1667 only £990 15s. 7d. had been received; the epidemic had ended but there were still 694 families of 2,192 persons on relief, and the town was £700 in debt. (fn. 47)

Smallpox

Smallpox was endemic in the 18th century, becoming occasionally alarmingly epidemic, and ranking high among the causes of child mortality. Chippenham suffered heavily from smallpox in 1711, (fn. 48) and Salisbury in 1723, when 1,244 persons contracted the disease, of whom 165 died. (fn. 49) An epidemic in Calne lasted from July 1731 until October 1732 and caused 176 deaths. (fn. 50)

Inoculation, introduced from Turkey by Lady Mary Wortley Montagu in 1722, progressed slowly against medical advice and popular prejudice. The opposition was not unreasonable where due care was not taken to prevent inoculated persons becoming sources of infection, for they usually developed a mild attack of the disease. The principal inhabitants of Salisbury in November 1752, when the town was suffering an epidemic, requested the medical profession in the town not to inoculate any persons after 1 February 1753. Thirteen medical men acceded to the request but others refused. Notice was given 'that any inhabitant of Salisbury who took in any person inoculated or to be inoculated would be prosecuted to the utmost severity of the law'. (fn. 51) This inoculation campaign is referred to in a letter from Mr. Brown, an apothecary at Salisbury, to a fellow of the Royal Society in 1753. Brown wrote: 'Since the receipt of your letter, inoculating has been much practised here, and with great success; of which the account I now send may be looked upon as pretty authentic. From 13 August, to the beginning of February, have been inoculated in this city and neighbourhood, 422 persons. On five or six of these, to my knowledge it had no effect, though on one the experiment was tried a second time'. (fn. 52) In another effort to discourage inoculation Lord Folkestone gave £100 in December 1752 to be distributed for the benefit of the poor at 5s. for every inhabitant 'who hath had the smallpox in the natural way, since the 1st of September, or who shall have it hereafter'. (fn. 53) In the following January the grand inquest warned the general sessions of the peace that loss of trade, increase of taxes, and general detriment to the town would follow from allowing persons to come to Salisbury for inoculation, as they were doing both from places in Wiltshire and from neighbouring counties. (fn. 54) The town council voted 10 guineas to be paid to a surgeon and an apothecary for their services during the epidemic, and towards the end of 1753 declared the town free from infection. (fn. 55)

Wilton was anxious to proclaim its freedom from disease during the Salisbury epidemic, and in January 1753 the mayor, five aldermen, and other prominent men of Wilton signed a declaration that Wilton, and especially the Bell Inn, was free from infection despite a report to the contrary which 'has industriously been spread, by some malicious, ill-designing people'. (fn. 56)

In 1763 several gentlemen, tradesmen, and inhabitants of Salisbury opened a subscription list for a smallpox hospital. Viscount Folkestone then purchased a house and land in Bugmore which he vested in the corporation for use as a smallpox hospital and the money raised by subscription was spent on equipment. (fn. 57)

An epidemic in 1766 spread from neighbouring counties into Wiltshire, reaching Salisbury in June. (fn. 58) In the autumn of the same year Edward Spencer, surgeon, announced that Fonthill Lodge would again be opened for inoculating in September, (fn. 59) and Messrs. Wilks and Poore opened Pill Farm for the reception of patients in October. (fn. 60) Both these establishments boarded patients until they recovered from their attack of the disease.

About this time the new Sutton method of inoculation arrived in Wiltshire. The Salisbury Journal carried an advertisement for a book entitled 'Inoculation made easy; containing a full and true discovery of the method practised in the county of Essex', (fn. 61) and Henry Wyndham wrote of Sutton's methods 'he require no preparation nor care after the inoculation unless they are very ill, then he sweat them'. (fn. 62) The great advantage of this method was that by reducing the dangers of infection by inoculated persons, people could be inoculated in their own homes, or whole parishes could be inoculated at one time. The consequences are illustrated in an advertisement by Dr. Smith of Boscombe House, which he described as one of the best houses for the purpose of inoculation in the county there being '18 chambers, 4 parlours, a large Saloon and Hall, a Bowling Green with Gardens, and all other conveniences'. Finding, however, that many persons were now being inoculated in the City by the 'new operators', he informed the public that he had engaged a certain Mr. Forsyth, surgeon, at Salisbury, as an assistant in his true Suttonian method of inoculation who would wait up on families in their own homes if desired. (fn. 63)

Overseers of the poor in various parishes occasionally paid for inoculation of individual families (fn. 64) —but the advent of the Sutton method made possible more general action. At a vestry meeting in Chippenham in 1779 it was unanimously agreed to inoculate the poor of the parish; John Barry, surgeon, was engaged at a rate of 2s. 6d. per person including necessary medicines. On this occasion 426 persons were inoculated at a cost of £53 5s.; in 1785 the overseers paid for inoculation of 136 persons, and in March 1793 for 273 persons. As in other parishes the poor were eligible whether on relief or not. At times of epidemic in Chippenham a degree of isolation was obtained by sending patients to a cottage where they were attended and fed at the expense of the overseers. (fn. 65)

Although these campaigns for inoculation appear to have reduced epidemics in Chippenham, smallpox persisted in other areas. The smallpox hospital at Salisbury was full in 1790 when the governors of Salisbury Infirmary (opened in 1771) announced that they could not 'admit any patient that had not had the smallpox until further notice, as the distemper has been some months in the Infirmary, notwithstanding the utmost exertions to stop the infection'. (fn. 66)

During the following decade the great discovery of Jenner provided a safe means of immunization by use of the related virus of cowpox which is relatively innocuous to man. The Jennerian Institute opened in 1803 and on 18 June of that year the governors of Salisbury Infirmary requested the house apothecary 'to undertake the inoculation of persons upon the Jennerian system, and that such persons as choose to apply to the house apothecary under recommendation from subscribers, be inoculated gratis upon every Monday between 10 and 12 o'clock'. (fn. 67)

At Devizes in 1810 where smallpox was 'making great ravages' the corporation recommended to the medical profession of the town a general inoculation with the vaccine matter. People who refused vaccination but wished to be inoculated with smallpox were to be removed to a safe distance to avoid spreading the disease. (fn. 68) Inoculation was falling into disfavour, a handbill issued in Salisbury in 1825 informed the public that 'the medical gentlemen of this city at large are unanimous in recommending the cowpox as the best, and indeed the only method, of guarding children against the destructive effects of the smallpox'. (fn. 69) As vaccination became more widespread the smallpox death-rate began to fall. In Salisbury the death-rate from smallpox before 1803 was from 70 to 80 a year, in 1849 it was nineteen. (fn. 70)

Although a subject of controversy throughout the century, vaccination became compulsory in 1853. Boards of guardians were obliged to make arrangements for providing and advertising facilities for vaccination in each parish. (fn. 71) During 1863 and 1864 an inquiry into the working of the Act in certain districts of England and Wales was ordered by the medical officer of the Privy Council. Dr. Sanderson investigated seventeen Wiltshire unions, which were divided into 63 vaccination districts, identical except in Calne union with the areas for poor relief. (fn. 72) Contracts with vaccinators existed in all except Cricklade union, but the times and places originally appointed for vaccination were completely disregarded in 37 cases, only partially maintained in six, and fully observed in eleven. Efforts to enforce the Act varied; legal action had been taken in only one instance in the Cricklade union.

Official policy at this period favoured arm to arm vaccination, a method particularly difficult to carry out efficiently in rural areas where the uncertainties of agricultural demand and sparseness of population prevented regular attendance of a sufficient number of patients. Some of the best vaccinated districts in the county were, indeed, worked entirely on a domiciliary basis, as at Amesbury, Bishops Cannings, and Downton. Of the urban districts investigated, Bradford and Calne contracted with general practitioners; at Calne 'the guardians have contracted for the performance of vaccination with their medical officer, who is paid by salary, and required to devote the whole of his time to his public duties'; at Devizes also the medical officer employed by the guardians was public vaccinator. At Swindon the 'weekly vaccination of applicants is kept up with great regularity by the medical officer of the G.W.R. Company who acts as the deputy of the contractor'. (fn. 73)

Cholera, Sanitation, and Water

The advent of cholera, which reached England from the East in 1831, directed the attention of the country towards preventive measures. Under the General Board of Health of 1831–2 boards of health were established by Orders in Council. Letters instituting boards of health in Wiltshire in 1832 were sent to Melksham (26 July), Chippenham (30 July), Box (8 August), Warminster (11 August), Calne (25 August), Wilton (27 August), Corsham (28 August), Devizes (3 September), Trowbridge (3 September), Castle Combe (13 September), and Longbridge Deverill (15 September). (fn. 74) Some of these boards were very large and unwieldy bodies such as the Corsham board with 54 members. Among the nominated members were 4 medical practitioners at Calne, 2 surgeons at Wilton, a physician at Corsham, 5 surgeons and 4 physicians at Devizes, and 3 surgeons at Trowbridge. The board at Devizes soon made provision for a hospital for 'any poor persons attacked by the disease should it reach the town', and in September 1832, three members of the board attended a meeting of the improvement commissioners to inquire if the gas yard could be used as a cemetery for cholera victims. After a visit by the commissioners to the gas works it was resolved that 'the Gas Yard could not in any circumstances be used as a public cemetery'. (fn. 75) These local boards of health ceased to exist as the threat from cholera receded. Wiltshire suffered only slightly in this first epidemic of 1831–2. Salisbury made no return and may have escaped the infection, Chippenham recorded nine deaths, and Farley five. (fn. 76)

The highest cholera mortality in Wiltshire was in the 1849 epidemic with 320 deaths in the county, including 165 in Salisbury and 67 in Devizes. Before the next appearance of cholera various sanitary schemes had been carried out and the deaths in the county fell to 60 in 1854, and 11 in 1866, these years being the last two epidemic years of the century. (fn. 77)

Cholera produced a strong movement in favour of sanitary reform, which had already been advocated by Edwin Chadwick as secretary to the Poor Law Commissioners. Chadwick's emphasis on the association of poverty and disease as a constant drain upon the poor rates created support for reform, (fn. 78) and national vital statistics published by the General Register Office (1836) strengthened the arguments of the humanitarians. Public interest was aroused and informed by voluntary associations such as the health of towns association of which a branch existed in Marlborough in 1847. (fn. 79)

Salisbury in the decade 1841–50 was more densely populated than many large industrial areas such as Manchester or Bradford. Its mean annual death-rate during this decade was high at 28 per 1,000, (fn. 80) and house property had declined in value according to some observers because of the bad reputation of the town for ill health and lack of cleanliness. (fn. 81) While the principal streets were wide and airy, behind them were whole honeycombs of courts undrained, filthy, and crowded with inhabitants. In 1851 Thomas W. Rammell carried out an inspection of Salisbury for the General Board of Health. The main deficiency of Salisbury was in its drainage; most of the streets contained open water channels supplied from the Avon to which many of the house drains were connected. About twenty years before Rammell's visit, the open drains had been covered over to widen the streets and to improve the appearance of the town, but since the Visitation of cholera in 1849 they have been reopened, or are in course of reopening, as it was considered that they were unhealthy in their closed condition'. (fn. 82) Covered-in the drains had formed an ineffective method of drainage, being easily obstructed, but the open sewers which took their place were at certain times highly offensive. In addition there were large numbers of cesspits overflowing or seeping into the soil which was so waterlogged that most cellars were wet and walls damp. (fn. 83) Fisherton Anger was completely without sewers and drains and was consequently in a deplorable state. Rammell recommended the application of the Public Health Act 1848 to the town.

Sanitary improvements began in Salisbury in 1853. Drainage by glazed pipes and brick sewers carried the sewage and water away from the town into the River Avon. No great concern was felt about river pollution and A. B. Middleton, one of the surgeons active in the sanitary reform campaign in Salisbury, wrote as late as 1864 that any 'act of the legislature... compelling the diversion of the sewage of Salisbury from the Avon, into which it is harmlessly flowing, would be a very unnecessary interference, and productive of great inconvenience and cost'. (fn. 84)

In 1851 the water-supplies came mostly from shallow wells easily contaminated. About two years earlier a project for establishing a water company had found no support. 'The idea was rather ridiculed of bringing more water into the town, when the great difficulty was in getting rid of what it contained already.' (fn. 85) Under the improvement scheme of 1853 water was pumped from a deep well into a covered reservoir for storage, and was then distributed through iron pipes at high pressure thus ensuring more constant and purer supplies.

The death-rate in Salisbury dropped rapidly in the years following these sanitary improvements, and between 1861 and 1870 was 20 per 1,000. Dr. Sanderson, reporting to the medical officer of the Privy Council in 1866 stated 'no other cause of any consequence can be suggested for the improvement in the public health of Salisbury than the sanitary measures which have been carried out in the city'. (fn. 86)

At Swindon the sanitary problem, complicated by the existence of two towns, centred in the early years on the New Town springing up round the G.W.R. works. Mr. Clark, who inspected Swindon for the General Board of Health in 1850 reported fairly favourably on the houses and streets, and general cleanliness of the town. Water-supplies were indifferent and drainage only by cesspits and gutters and the inspector recommended the application of the Public Health Act 1848 to the town, but neither the Old nor the New Town established a local board of health until 1864. (fn. 87) Between 1850 and 1864 the G.W.R. Medical Fund in New Swindon provided lime for cleansing and disinfecting houses and generally supervised the health and welfare of members. During the same years conditions deteriorated in Old Swindon and were not immediately remedied by the appointment of a board of health which employed an inefficient sanitary inspector. (fn. 88)

The Swindon Water Works Co. Ltd. formed in 1866, failed at first to provide a good service because its supply pipes from Wroughton reservoir were untested and leaky. The New Swindon urban district council made improvements when it took over the water-supplies in 1895, and a few years later in 1903 the corporation, formed by an amalgamation of the two towns, began the construction of new waterworks at Ogbourne St. George. (fn. 89)

As recorded elsewhere, ten local boards of health were established in the county under the Public Health Act (1848) and the Local Government Act (1858), carrying out their work with varying enthusiasm and success. (fn. 90) The Public Health Act (1872) created urban and rural sanitary authorities to cover the whole county. Interest still centred on sanitation and water although isolation of infectious disease and disinfection began to grow in importance. Each sanitary district, sometimes in association with a neighbouring authority, employed a medical officer of health and an inspector of nuisances. Frequently, adjacent districts with many common interests were kept apart by bitter local rivalries. The Local Government Board inspector in the north of the county in 1872 attempted to foster the formation of a large sanitary area without success. In December 1873 he wrote to Calne rural sanitary authority that both Chippenham and Melksham had appointed their medical officers of health for the year so that a combined district was no longer possible. His recommendation that Calne urban and Calne rural sanitary authorities should jointly appoint a medical officer was temporarily accepted. (fn. 91) These two districts later quarrelled for many years over sewage disposal involving the intervention of the Local Government Board and finally in 1891 the appointment of an impartial engineer to survey the problem. (fn. 92)

Improvement of sanitary conditions was in large measure due to the daily routine work of the inspector of nuisances. A typical weekly report from Calne rural sanitary authority's inspector illustrates his duties. On 4 October 1876 the inspector reported that during the previous week he had written to George Wild of Compton Bassett respecting vaults and privies. Nuisances at Quemerford and Compton Bassett had been removed, and vaults had been put to privies at Highway. The inspector had visited a case of typhoid fever at Highway, cautioned the inhabitants of the house against using the water from their well which was contaminated by sewage, and sent a supply of carbolic soap for disinfecting the linen. (fn. 93)

Many of the rural authorities were unable or reluctant to spend money on expensive waterworks. Sometimes villages were left to draw their supplies from the river, sometimes local landowners undertook the work at their own expense. Lord Lansdowne, for example, provided Foxham (Bremhill) with an excellent water-supply in 1887. (fn. 94) Lord Lansdowne also gave the land on which Calne urban and Calne rural sanitary authorities, after much argument, built their joint infectious diseases hospital which was ready in 1889. Such acts of local philanthropy commingle with the beginnings of government and county council grant. When Cricklade and Wootton Bassett purchased land for an infectious diseases hospital in 1893 the Isolation Hospitals Act, which had just reached the statute book, enabled the county council to make a contribution towards the cost and made possible the raising of a loan on easy terms. (fn. 95)

From the beginning of the present century the reports of the county medical officers of health provide a comprehensive picture of sanitary conditions. In the early years attention was focused on sewage disposal and river pollution. Many places like Malmesbury, Westbury and Wilton had only transferred crude sewage from houses and streets into rivers. Manufacturers' effluents increasingly caused problems of pollution. In 1902 Swindon and Warminster possessed working sewage disposal schemes, work was in progress on disposal schemes at Bradford-on-Avon, Marlborough and Salisbury, and plans had been drawn up for Trowbridge, Chippenham, Devizes, and Melksham. The enlargement of Salisbury borough in 1904 necessarily entailed new and extensive sewage works and took in some of the more crowded areas previously in the rural district.

In rural areas schemes were less advanced. The rivers of the north of the county being within the jurisdiction of the Thames Conservancy Board were carefully watched from Cricklade to Swindon. The Bristol Avon was not so well protected and in 1910 still received all the Malmesbury sewage, and also via its tributary the Marden, all the sewage and trade effluents from Melksham, and trade effluents at Trowbridge. The Salisbury Avon was cleaner receiving crude sewage only from Pewsey.

Despite persistent efforts Malmesbury remained the black spot of the county. In 1906 the medical officer of health reported that all schemes had been dropped for this town and added 'a very awkward precedent has been established and it only remains for any town or authority that does not wish to provide itself with proper Sewage Disposal Works, to get rid of the whole of its borrowing powers by purchasing Water Works, Markets, Town Halls, Gas Works, and other remunerative undertakings'. The county council brought an unsuccessful action against the town in 1920 on which occasion the county court judge stated that 'notwithstanding this pollution the Town of Malmesbury and District is a healthy one and has not suffered in any way in the past; neither does it suffer from the pollution at present, and I see no probability if the pollution continues that it will have any ill effects on the inhabitants of the Borough'. (fn. 96) In the decade 1920–9 some of the early sewage works began to fall into disrepair and new bacteriological disposal works were introduced. By extension and improvements in sewage schemes the rivers were gradually cleared of gross pollution before the Second World War.

The provision of pure water-supplies was naturally most rapid in towns. In 1900 private companies supplied water at Calne, Malmesbury, (fn. 97) and Trowbridge. Melksham was also supplied from Trowbridge waterworks, established in 1864. (fn. 98) A survey of water-supplies in the same year showed that supplies were very satisfactory at Chippenham, Bradford-on-Avon, Warminster, and Wilton, but that extra supplies were needed at Devizes, Swindon, and parts of Calne. At Marlborough there was some pollution, and at Salisbury the quality was variable. Some delay had occurred in building Westbury waterworks, and Trowbridge required means of storage. At Swindon for several months of the year the supply had to be augmented by water brought by railway from Kemble (Glos.) and pumped into the mains. The new corporation waterworks at Ogbourne St. George were begun in 1902 and were supplemented by further works at Latton (1933) and South Cerney (Glos.) (1944). (fn. 99)

In the rural areas at the beginning of the 20th century a great need existed for adequate water-supplies. Parish councils were frequently opposed on grounds of expense and many schemes were shelved or not carried out. A special incentive to provide pure water came from the large dairy interests in the county. In 1906 the medical officer of health reported 'farmers find an increasing difficulty with regard to the sale of their milk unless their water supply is above suspicion, those farmers who have a good pure water supply being able to send their milk to distant markets and obtain better prices'. This particularly applied to the London market for milk, so that to some extent London was responsible for improvements in Wiltshire.

In the main, however, villages still lacked adequate supplies when a survey was published in 1925. (fn. 100) The Local Government Act (1929) made new provisions for county council intervention in the matter of water-supplies. The Ministry of Health urged the county to undertake a survey of rural water-supplies and to make every effort at improvement. Many districts made applications for loans and in 1934 the county council decided not to give financial assistance unless the supply was by public standpipes, except where premises were efficiently drained or the means of supply was directly approved by the county medical officer.

The Rural Water Supplies and Sewerage Act (1944) made a piped water-supply obligatory. (fn. 101) In 1946 outline proposals were submitted and approved for 11 out of the 12 rural authorities. By 1950 the medical officer of health was able to report that many miles of pipes had been laid and a supply was nearer to many villages. Several schemes had already been completed and others were in progress.

Insanity and Mental Deficiency

The usual methods of dealing with lunatics until well into the 19th century were confinement and restraint, the law being more concerned with the property of lunatics than with their care and treatment. The first Act for regulating madhouses dates from 1774 and was continued by successive Acts until 1828. (fn. 102) In this year two Acts concerning lunatics were passed; the first gave permission to the justices to erect county asylums for pauper and criminal lunatics. The second Act (9 Geo. IV, c.41) 'to regulate the care and treatment of Insane Persons in England' declared that existing laws for licensing and regulating houses for the reception of insane persons were ineffectual and repealed all earlier legislation. This Act made it unlawful to keep a house for the reception of two or more insane persons without a licence. Licences were to be renewed annually at a cost based on the number of pauper and private patients, but at not less than £15, and plans of the buildings were to accompany applications for licence. Each house of reception with more than 100 patients was to have a resident medical man, and each house with less than 100 patients was to be visited by a physician, surgeon, or apothecary not less than twice a week.

Wiltshire was served at this time by asylums at Laverstock House, Salisbury; Fiddington House, Market Lavington; Fisherton House, Fisherton Anger; Kingsdown House, Box; Belle Vue, Devizes; and a house at Fonthill Gifford. In addition the justices licensed a small house at Calne in 1833.

Committees of visitors, each of which included a medical man, were appointed at Michaelmas quarter sessions to inquire into the provision of religious services, opportunities for intellectual improvement, amusement, and recreation. (fn. 103) Answers which satisfied the visitors appear somewhat vague and evasive. At Fonthill Gifford divine service was not performed but 'such as require Bibles, Prayer Books, or other unsophisticated good works are supplied with the same'. At the same house amusements consisted of a hand organ and cards, 'as well as canary and other singing birds for the gratification of those who are attached to such domesticated living objects'. (fn. 104) In almost every case visitors gave favourable reports which contrast strangely with the condemnations launched at many of the Wiltshire houses by the Lunacy Commissioners after 1845. (fn. 105)

Laverstock House, set in 12 acres of land about a mile from Salisbury, had been an asylum since the 1760's and was originally licensed to the father of Dr. William Finch, the licensee for the reception of lunatic patients in 1829. (fn. 106) The visitors reported in 1829 that the house was particularly clean and well ventilated, that there had been no case of unjustified restraint, and that divine service was performed every Sunday in a chapel in the grounds. (fn. 107) There were 96 patients in 1829, 141 in 1830, and 125 in 1846. Of 115 patients in 1849, 33 were paupers. Laverstock was licensed for pauper as well as for private patients until 1852 when, following the opening of the county asylum at Devizes, the pauper licence was not renewed. (fn. 108) About 1847 Mrs. Finch and others received the licence and in subsequent years the house changed hands several times until in 1862 the licence was granted to Dr. J. J. Bushnan for 41 private patients of each sex. By this time the old pauper buildings had been mostly pulled down and a large part of the existing asylum rebuilt to provide 'fair accommodation for patients of the middle classes'. A resident medical officer had also been appointed but the Lunacy Commissioners reported want of neatness and personal cleanliness in some cases and too great use of restraint. (fn. 109) Three years later the house was in much worse condition, it had fallen into the hands of a 'non-medical proprietor who regards it as a money speculation only'. The justices co-operated in bringing pressure to bear upon the house by renewing the licence for three months only during which time many improvements were made. (fn. 110) J. Haynes and Dr. S. L. Haynes received the licence in 1867, a resident medical officer was appointed in 1872, and ten years later the commissioners reported the accommodation and care to be very good.

Fiddington House at Market Lavington was originally intended for pauper patients. (fn. 111) In 1829 the justices licensed Robert Willett, a non-medical man, for the reception of about 72 patients; the medical attendant visited the house twice a week. The visitors reported the house to be clean and comfortable and that restraint when used was of 'the mildest and most simple nature'. At a later date the Lunacy Commissioners reported that the use of restraint was habitual. The original asylum consisted of detached buildings mostly of one story, some with stone floors and without ceilings. Considerable overcrowding occurred around 1846 when about 200 patients were received although the premises were only licensed for 175 patients. Charles Hitchcock received the licence in 1850 and soon after the opening of the county asylum the pauper patients were transferred. The number of private patients for which Fiddington was licensed in 1862 was 24 male and 26 female. (fn. 112) Reports on the house became more favourable and in 1882 the accommodation was described as plain but comfortable at an average cost of £100 a year.

The asylum at Fisherton Anger, which in 1829 belonged to Charles Finch, became very large and important during the period between 1850 and 1880 when it was licensed to receive large numbers of pauper patients, and also criminal lunatics under Home Office licence. This was the only Wiltshire house in 1829 to provide any occupation for patients, several of the pauper patients being employed in gardening which the visitors reported 'appears to have been very beneficial and therefore seems to merit more general adoption'. (fn. 113) Extensions and improvements came rapidly after 1846, and although adverse reports of dirt and overcrowding marked the years from 1850 to 1853, for the most part favourable reports were received. The premises originally consisted of a large dwelling-house and a number of converted outbuildings with rather small and gloomy rooms, by 1862 the buildings covered a large extent of ground and included a detached chapel, recreation, reading, and billiard-rooms. These amenities followed the abandonment of seclusion as a method of treatment in 1854 and great reduction in the use of restraint, made possible by increases in staff. (fn. 114) In 1862 the house contained 245 criminal lunatics, 75 paupers, and 84 private patients. Some criminal lunatics left on the opening of Broadmoor in 1863 and the rest were transferred before 1872. Pauper patients from Wiltshire were transferred to the county asylum at Devizes but their places were filled by pauper patients from other authorities such as Portsmouth until 1880, and the Middlesex unions, many of whose patients were at Fisherton in 1888. (fn. 115) The Finch family continued as proprietors; Dr. W. C. Finch succeeded Charles Finch, and in his turn was followed by W. C. Finch, junior, and Dr. Lush.

Kingsdown House at Box was an old establishment reputed to date back 300 years. Although the visitors of 1829 found the 'Institution conducted very much to their liking', the commissioners found on their early inspections after 1845 mechanical restraint, including strait waistcoats, iron frames, hand locks, leg locks, and chains, used to an excessive degree, an inadequate staff, and the utmost uproar and excitement among the patients. (fn. 116) The house passed in 1849 from Dr. C. C. Langworthy to Dr. R. A. Langworthy, then to his widow, was later leased to Dr. Nash, and in turn was taken over by Dr. Nash's son in 1856. From this time many improvements were undertaken. (fn. 117) Almost all the pauper patients had left before the opening of the county asylum after which the house became purely private. Abandoning constraint and seclusion, the owner converted Kingsdown House into a healthy, well-run middle-class asylum for 20–30 patients at moderate charges around £80 a year. (fn. 118)

The second largest asylum in the county in 1846 was Belle Vue at Devizes with 182 patients, the majority of whom were paupers. The commissioners expressed constant dissatisfaction with the state of this house and in 1850 complained of want of proper drainage, insufficient bedding and clothes, lack of furniture, poor diet, uncleanliness, and absence of books and amusements. The commissioners considered these faults to be mainly caused by the proprietor, T. Phillips, 'having failed to expend a fair and sufficient sum in return for payments made by parishes'. (fn. 119) The state of the asylum forced the commissioners to draw the attention of the justices to the desirability of withdrawing the licence. The justices took no action but certain improvements were made at the asylum. Severe cases of distress and ill treatment were again reported at Belle Vue in 1851, and the commissioners and the Board of Lunacy again recommended to the justices in March 1853 that the pauper licence should not be renewed. In October 1853, however, the justices renewed the licence in the same form for pauper and private patients. (fn. 120) The provision of accommodation at the county asylum enabled the justices in the following year to withdraw the licence for 180 paupers and 20 private patients and substitute a licence for 30 private patients only. By 1862 a great portion of the old buildings had been demolished and the house provided suitable treatment for private patients of small means. (fn. 121)

A smaller house at Fonthill Gifford owned by Joseph Frowd Spencer, surgeon, accommodated 23 patients in 1828. Numbers gradually declined to four in May 1844 and the house appears to have closed before the Act of 1845. (fn. 122)

At Calne George Shadforth Ogilvie, surgeon and apothecary, opened a small house in 1833. From one female patient the numbers increased only slowly and never rose above seven. At this house the visitors appointed by the justices registered in 1844 one of their infrequent complaints about 'boarders' resident in the house although not regularly certified patients. (fn. 123) This house closed before the first report of the commissioners in lunacy in 1846. Dr. James Pownall opened Northfield House at Calne for the reception of five patients in 1854. This was a short-lived venture which closed in 1855. (fn. 124)

During 1852 the county asylum opened at Devizes for pauper patients from the county. (fn. 125) With 335 beds in 1858, 451 in 1872, and 626 in 1884 this institution altered the position of private asylums in Wiltshire all of which except Fisherton House lost their licences for pauper patients. Conditions for both pauper and private patients improved as a result; the reports on the county asylum were constantly good with only minor recommendations from the visiting commissioners. (fn. 126)

The problem of mental deficiency in the county was tackled vigorously after the First World War following the Mental Deficiency Act (1913). In 1920 the county appointed an inspector to the staff of the medical officer of health to carry out the administrative work, and an energetic and progressive mental deficiency committee faced the problem left by migration from rural areas. 'The residuum of the population particularly in the more remote villages, is largely leavened by cases of feeblemindedness in varying degree.' (fn. 127) In 1921 a careful classification of all mental defectives in the county was undertaken: previously no records existed of those under 7 years or over 16 years of age, nor of those referred to the mental deficiency committee by the general education committee. (fn. 128)

Throughout the 19th century mental defectives crowded many poor law institutions. Under the 1913 Mental Deficiency Act mental defectives were received at Devizes, Trowbridge and Melksham, Wilton, and Pewsey poor law institutions. The Local Government Act (1929) made possible conversion of these buildings for different uses and therefore more complete segregation of different classes of defective. The first institution to be divorced from the poor law was Pewsey which was taken over by the mental deficiency committee as the nucleus of an industrial colony. (fn. 129) After alterations and additions, and tended with much care and attention, the Pewsey colony expanded to 500 beds in 1938 mainly for adolescents and younger males, and high and medium-grade females. Before the Second World War the committee largely fulfilled its intention 'to centralize as far as possible the treatment of those cases of mental deficiency in the County which call for institutional accommodation and the benefits of training in a Colony'. (fn. 130)

A certain number of mental defectives remained at Devizes, Semington, Wilton, and Purton public assistance institutions. The mental deficiency committee appropriated Purton and Wilton in 1936 with the intention of closing Wilton as soon as other accommodation was available. (fn. 131)

The Wiltshire voluntary association for mental welfare ably assisted the work of the county council with which it co-operated closely. The association ascertained the numbers of mental defectives and visited those under supervision making half-yearly reports to the mental deficiency committee. From 1936 an annual grant towards this work was made by the county council.

The association also pioneered juvenile occupation centres in Chippenham, Salisbury, Trowbridge, and Swindon. The first part-time centre opened in Salisbury in 1923 and for the following twelve years was staffed for five half-days each week. From 1936 an extra half-day was added, and the centre became full-time in 1947. After several years work the Chippenham centre closed in 1934 and was not reopened until 1947; it became full-time in 1950. Trowbridge extended its work to become the first full-time centre in the county in 1935 but it could not maintain this programme, and from 1937 until 1950, when it became full-time again, it was open three days each week. At Trowbridge in 1934 and 1935 the Association also experimented with an adult occupation centre open one evening each week. The Swindon centre continued successfully to extend its activity from two days in 1929 until it became full-time in 1949. All the centres, when placed under the county council by the National Health Service Act, were therefore expanded to full activity.

In 1937 the Wiltshire voluntary association for mental welfare introduced a home training scheme in the Trowbridge area. Three years later Swindon and Salisbury were included in the provision. Towards the cost of these and the occupation centres the county council from 1938 made a substantial annual grant but in the early days the main burden of the work was borne voluntarily. (fn. 132) From 1947 the home training was undertaken by two social visitors, and after 1948 by deputy mental health officers appointed by the county council in accordance with its obligations under the 1946 Act. These officers in addition are concerned with preventive visiting and are duly authorized officers in lunacy, responsible for the work previously carried out under the public assistance committee. Through these officers a sub-committee of the public health committee appointed to administer the mental health service was able to integrate much of the work for which the county was responsible under the Mental Deficiency, Lunacy, and Mental Treatment Acts. By the new provisions the work of the voluntary association became redundant and it was disbanded on 5 July 1948, the day on which the Act came into force. (fn. 133)

Under the National Health Service Act the Regional Hospital Boards took over the county lunatic asylum at Devizes, later called Roundway Hospital, and the mental home at Pewsey, each of which was placed under its own management committee.

Maternity and Child Welfare

The first step in reducing maternal and infant mortality was the registration and certification of midwives. Responsibility for carrying out inspection of midwives under the Midwives Act (1902) was placed on the county council. The medical officer of health reported in 1906 that there were 225 midwives on the register who had given notice of their intention to practise in Wiltshire. Many of these were living in most inaccessible parts of the county and inspection of their books, instruments, and appliances and of their method of work entailed considerable time and labour. A very large proportion of the women were altogether illiterate, or so illiterate that it was extremely difficult for them to keep the necessary registers, and constant personal supervision was required. After four years, however, the medical officer of health was able to report considerable improvement in the way the midwives carried out their duties, and in co-operation between the health department and the midwives in the efforts to lessen the great mortality among infants.

Of first importance in this field was the Wiltshire nursing association founded by Lady Radnor and Mrs. Charles Hobhouse in 1904. During 1906 Miss K. J. Stephenson undertook the various secretarial duties of the association and during the next 42 years it was largely due to her efforts and enthusiasm that the association carried out so much successful work. The object of the association was 'to encourage and develop all District Nursing throughout the County, and to meet the requirements of the Midwives' Registration Act as far as possible by the means of certificated midwives'. (fn. 134) Local associations were free to appoint their nurse, and to decide their own rules, subscriptions, and fees. By affiliation to the county association they gained help and advice, opportunities for training candidates, and assistance in obtaining nurses and candidates for training. The county association planned to raise a central fund for 'the training of suitable women as Nurses or Midwives and to obtain such training wherever efficiency can be ensured within the County'. (fn. 135) To this end the county training home at Swindon was established in 1904 and maintained until it was handed over to the town council in 1928. The association always emphasized its desire to train candidates from the county, in the county, and for the county. (fn. 136)

In 1909 the Wiltshire nursing association applied to the county council for a grant in aid of midwifery training, and for co-operation in the work of providing and inspecting midwives in urban and rural districts. A weakness in the organization at this time was that different local associations adopted different regulations. In one district the midwife was not allowed to undertake cases when household wages exceeded 15s. a week unless a medical man was engaged, and other districts refused the services of the midwife for illegitimate births. A local authority grant could only be given if there was an assurance that every woman was entitled to assistance at her confinement. (fn. 137)

The Midwives Act was fully implemented in April 1910 after which time only bonafide and certificated midwives were to assist at births. In sparsely populated rural areas where such assistance was regarded as a neighbourly act this rule was difficult to enforce and for a long time the 'handy woman' who attended with the doctor remained. (fn. 138)

The county adopted in May 1915 the Notification of Births Act, an important contribution to the improvement of infant care, for which exchequer grants were made available in 1915. Three full-time health visitors were appointed who were to act also as inspectors of midwives. The county council sought the help of the Wiltshire nursing association in the provision of part-time health visitors for maternity and child welfare on the following basis: 'all nurse-midwives to keep in touch with their maternity cases for 12 months after the confinement and report to the medical officer of health, also to visit and report on any special cases when so directed by the medical officer.... The county council to make a grant of £2 per 1,000 population of the area served by the nurse.' This scheme was accepted by the majority of nursing associations and in 1916 was reported to be working satisfactorily with good results. (fn. 139)

The co-operation of voluntary effort with local authority grant continued in the administration of the Maternity and Child Welfare Act (1918). The main objects of this Act were to extend health visiting and child welfare centres to cover the 1 to 5 year-old children, and to provide hospital accommodation for abnormal and difficult maternity cases. From April 1915 the Wiltshire nursing association had received a Local Government Board grant for distribution to associations which covered rural areas. In 1919 the county council took over the responsibility of maintaining the midwifery service throughout the county by contributing necessary financial aid. Grants were conditional upon the employment of a competent midwife who would undertake school and health visiting and be available for all women who should need her services. (fn. 140) Until the appointment of a supervisor of midwives in 1944 the health visitor continued to inspect the work of the midwives.

The gradual increase in the activities of health visitors throughout the county was of paramount importance in introducing the work of the public health department into the home. From three full-time health visitors in 1915 the staff gradually increased to ten, supplemented from the beginning by the part-time employment of district nurses. (fn. 141) The original staff was only sufficient to visit infants under one year old, a scheme which left children from one year until school age outside the purview of the public health authority. The Ministry of Health urged the county to extend the service to cover this age group, but not until 1929 was this achieved. In the same year provision for under fives was made at the school clinics for eyes, ears, nose, and throat inspection. Having supervised the child in the home for five years the health visitor frequently followed its progress as school nurse and a natural division developed between this work with schoolchildren and the midwifery and district nursing services. Under the National Health Service Act (1946) the work of the health visitors was no longer confined to maternity and child welfare and the county is developing the co-operation between health visitor and general practitioner in preventive and follow-up work.

In the provision of maternity beds the county council relied from the first on cooperation with voluntary bodies. In 1919 there were only two maternity homes in the county, at Swindon and at Corsham. Two maternity beds, for Swindon cases only, were available at the Swindon nurses training home, the town council being responsible for their maintenance and the Corsham nursing association providing the staff. (fn. 142) The home at Corsham, one of the earliest rural maternity homes in the country, sprang from the initiative of Miss D. P. Chappell, secretary of the local nursing association, by which it was administered and staffed. In 1919 one of the three beds at Corsham was reserved for county council cases and in the following year the county took over another bed and brought forward a scheme to equip and maintain six beds at the home. (fn. 143) When the county scheme was completed in 1921, maternity beds were available at Corsham, Malmesbury cottage hospital maternity ward, Swindon maternity home, and the maternity ward of Salisbury General Infirmary.

As the Ministry of Health pointed out when sending the grant for 1924–5, many rural parishes at that date still lacked any nursing or midwifery service. (fn. 144) The motorcar and motor-cycle, however, soon extended the range of each midwife and travel allowances and loans for the purchase of vehicles were made available. (fn. 145) In 1931 the nursing association also agreed to make a grant towards the installation of the telephone in a nurse's home. The Midwives Act (1936) laid upon the county council the obligation to provide a complete domiciliary service for the whole area. So successful had been the close co-operation with the county nursing association that only minor alterations were made. County council midwives were appointed in Salisbury, Trowbridge, and Devizes, and the county took over responsibility for emergency services. The basis of grant was also changed, the county paying 30 to 50 per cent, of the inclusive salary of district nurse midwives. (fn. 146)

Arrangements for maternity beds altered only slightly during the period. Swindon town council took over the Swindon home in 1928 and built a new maternity hospital, opened in 1931. The new Trowbridge and district hospital, opened in 1929, also provided extra accommodation for county maternity cases. Maternity accommodation materially increased during the Second World War when under the government evacuation scheme maternity units were established at Berryfield House, Bradford-on-Avon, and at the old cottage hospital, Melksham. In 1944 this unit provided twenty beds for the county and in the same year the county council assumed responsibility for the Corsham home at the request of the local committee. After the war the county took over Berryfield House and purchased Greenways at Chippenham for conversion to a maternity home.

Ante-natal and post-natal care has also contributed to the decrease in maternal mortality and morbidity. Many infant-welfare clinics undertook this work, and consultant clinics were established at Trowbridge, Swindon, and Salisbury. In 1937 a scheme for ante-natal care by general practitioners was initiated in the Corsham area. (fn. 147) A graph would show the striking decline in infant mortality in the county during this century from a peak of 116 per 1,000 live births in 1899 to 23 per 1,000 in 1950. The Wiltshire figures run constantly below the national figures but reflect the same downward trend. This steady improvement was very largely due to the care and educative work of midwives and health visitors, and to the growth of infant-welfare centres. Swindon and Salisbury had infant-welfare centres in 1919, and the first two in the county were at Malmesbury cottage hospital under the care of the matron, and at Downton under a voluntary committee.

The first county council clinic opened in Trowbridge in November 1922. During the following decade clinics opened at Ashton Keynes (1923), Corsham (1924), Chippenham, Marlborough, Melksham (1925), Devizes, Pewsey, Warminster (1926), Bradfordon-Avon (1927), West Lavington (1928), Tisbury (1930), East Knoyle (1931). All these centres were run by voluntary committees, in many cases by the district nursing associations, (fn. 148) and by 1930 all except Ashton Keynes and Tisbury were recognized for grant by the Ministry. The Pewsey centre was taken over by the county in 1928. Progress was maintained in this field and the numbers of clinics and health-visitor's centres increased rapidly in the early war years to meet the needs of evacuees. By 1946 the number of infant-welfare centres had increased to 29 and health-visitor's centres to 33. Only two years later these numbers had increased to 41 and 55 respectively and the M.O.H. reported that 'much keenness in voluntary effort is shown in the organisation of new Centres and maintenance of many of those which have for years been examples of the good work accomplished by voluntary committees'. Until 1948 Swindon and Salisbury were separate midwifery and child-welfare authorities. Since the National Health Service Act an area sub-committee of the public-health committee has been established to administer the maternity and child-welfare services for Swindon. The medical officer of health for the borough acts in these services as deputy to the county medical officer.

The School Health Service

The Education (Administrative Provisions) Act of 1907 laid upon local education authorities the duty of providing for the medical inspection of schoolchildren on entry into public elementary schools and on any other occasion that should be directed by the Board of Education. The Act also empowered local authorities to make, subject to the approval of the Board, arrangements for the treatment of children whose condition required medical attention. In 1918 this power became a duty and secondary schools were included in the school health services.

The first year of the new service in Wiltshire was not without its administrative difficulties. Some conflict arose between the county council, anxious to retain direction of its own policy, and the Board of Education's desire for uniformity. The general education committee of the county council recommended in February 1908 that the supervision of the medical inspection of schoolchildren should be entrusted to the county medical officer of health, with the assistance throughout the county of the local medical officers as inspectors, and providing for the employment where necessary of general practitioners on a per capita payment. (fn. 149) The appointment of the county medical officer was in line with the official policy of the Board of Education which accordingly sanctioned the Wiltshire proposals in August, 1908. (fn. 150)

The cost of employing part-time inspectors, the irregularity of the inspections, and the difficulty of obtaining uniform standards of report were considered in October 1908 by the education committee which recommended the suspension of the existing scheme and the employment of two full-time officers to carry out the work for the whole county. (fn. 151) The county council, which viewed with 'extreme disfavour any avoidable addition to the number of salaried officials', rejected the plan. (fn. 152) As an economy measure lower fees were offered to the part-time inspectors but understandably refused and the council therefore confined itself to requesting the inspectors to be more particular with eyesight tests and to consider the need for uniformity of inspection. (fn. 153)

The chief medical officer of the Board of Education, George Newman, continued to press for improvement and for the employment of full-time officers; in January 1909 he visited Wiltshire to explain to the general education committee the views of the Board. (fn. 154) The council eventually agreed in March to adopt the recommendations made earlier by appointing a school medical officer and medical assistant, the clerical work to be carried out by the staff of the director of education. This destroyed the co-ordination through the county medical officer whom the Board of Education urged the council to include. The council refused to modify its scheme further and in June 1909 appointed Dr. R. H. Bremridge school medical officer. (fn. 155)

Administration of the service was at first financially restricted, for example, it was only under pressure from the Board that the committee eventually agreed to purchase weighing machines and measuring standards in February 1909. (fn. 156) No attempt was made to provide treatment centres, medical care being left to private practitioners or to poor relief. Under the Children Act (1908) local authorities were empowered to prosecute parents who neglected to provide medical treatment if their children were in obvious need of attention. Necessitous cases could be referred to the boards of guardians, but this was obviously an unsatisfactory way of dealing with the problem. After much discussion about the appointment of a school nurse the committee finally decided in 1911 to appoint a sub-committee as a central children's care committee and to encourage the formation of local care committees connected with each school in the county. (fn. 157) The report of the school medical officer was forwarded to the committees who were to follow up cases by visiting the homes and advising parents to ensure 'that no child shall be prevented by indifference, ignorance, or poverty from receiving the help it needs'. (fn. 158) By 1912 238 local care committees had been constituted and by December 1913 255 representing 334 schools, but unlike many other voluntary bodies in the area the movement was not outstandingly successful. The work was partly taken over by the school nurses after 1915, and their activities, together with the lapse in medical inspections during the war reduced the number of care committees to seven at the end of 1919. Attempts to revive the system produced only temporary improvements. (fn. 159)

An urgent problem revealed by the early inspections was the need to improve the cleanliness of the children. Of more than 12,000 girls examined in 1910 one-third were verminous including one-seventh who were very verminous. By 1919 only 9 per cent, were verminous with 1 per cent, very verminous. Maintenance of this improvement was largely due to the constant vigilance of school nurses and teachers and the exclusion of the dirtiest children until their condition improved.

In 1911 the committee made its first direct contribution towards treatment when it authorized the school medical officer to prescribe and supply spectacles at the expense of the parents. (fn. 160) The medical officer was permitted to use a school room for these consultations and if necessary make it a centre for the neighbourhood. The first county vision clinic was held in the school clinic of the Swindon education authority; towards the end of 1914 an eye clinic opened in Trowbridge. (fn. 161)

Inspectors found only about 30 per cent, of the children with no obvious signs of dental decay. (fn. 162) Reference of necessitous cases to the guardians scarcely touched the problem and the appointment of a dental officer was urged by the school medical officer and the care committees. The education committee tried to avoid a further official appointment by making grants for dental treatment to local care committees but failed to obtain the sanction of the Board of Education which strongly advocated the appointment of a county dental officer. (fn. 163) At last in September 1913 F. R. Wallis became the first county dentist. A full-time dental nurse was appointed to assist him in 1914.

These appointments heralded a complete reorganization of the school health service in the county. In June 1912 the board had expressed dissatisfaction with the examination of school-leavers, and in his report for the year Dr. Bremridge referred to the very small amount of money spent on medical inspection in Wiltshire compared with such neighbouring counties as Hampshire, Gloucestershire, and Somersetshire. (fn. 164) From April 1914 the county medical officer of health became also school medical officer with Dr. R. H. Bremridge as deputy medical officer of health, chief school medical inspector, and school oculist. (fn. 165) A most important agreement was reached with the county nursing association for the services of nurses in school medical work both to assist at examinations and to undertake the treatment of minor illnesses in the home. Of the 340 elementary schools in the county, 290 were furnished with nurses from the local associations. (fn. 166) One nurse in the Trowbridge area was wholly engaged in school work although still employed by the nursing association. The committee also arranged to pay travelling expenses for children attending dental centres or for those visiting hospitals for the treatment of tonsils and adenoids.

During 1916 the county appointed eight full-time nurses to the staff of the public health department. One was solely concerned with school work, but the three health visitors, three tuberculosis nurses, and the dental nurse also took part in the school work. With the opening of a school clinic at Bythesea Road, Trowbridge, early in 1915 and with the appointment of a second dental officer and nurse in 1917 the service began to assume a more efficient and effective role.

The impetus of post-war reform and the obligations under the 1918 Act brought increases of staff by the appointment in 1919 of an ophthalmic surgeon and a third dental officer. Arrangements with local hospitals made operative treatment of tonsils and adenoids available for children. In 1920 the number of health visitors was increased to eight.

Dr. C. E. Tangye, who succeeded Dr. J. Tubb-Thomas as medical officer of health for the county in 1920, was keenly interested in crippling deformities found either at medical inspection or reported to his department. He urged the council to adopt an orthopaedic scheme during 1921 and 1922, and in 1923 succeeded in persuading the education committee to adopt a plan which was sanctioned by the Board of Education. In 1924 the trustees of a charitable fund in Devizes decided to devote the income to the maintenance of an orthopaedic clinic. The clinic worked in close association with the Bath and Wessex Children's Orthopaedic Hospital and two of the surgeons from that institution gave their voluntary services at Devizes. (fn. 167) Other clinics followed at Corsham, Salisbury, Swindon, and Trowbridge. Each clinic was run by a voluntary committee with financial aid from the county council.

By 1930 ear, nose, and throat clinics were established at Trowbridge, Swindon, Salisbury, Savernake, and Malmesbury; and heart clinics opened in 1931 at Chippenham, Malmesbury, Salisbury, Savernake, Swindon, and Trowbridge. (fn. 168) The county council purchased the old premises of the Trowbridge cottage hospital in 1928 to house the various clinics and school health activities in the area, and to replace the semi-detached house in Bythesea Road which had hitherto served for the purpose. With a further increase in the staff of health visitors and the improved opportunities for treatment, the school medical officer reported in 1929 'medical work among schoolchildren, including all the usual forms of investigation and treatment, together with some facilities unusual in country areas, has now become mainly a matter of routine requiring only careful administration to secure efficiency'. (fn. 169)

Five per cent. of the children examined in 1911 were considered to be undernourished and 3¼ per cent, suffered from deformities mostly due to rickets. Although rickets was already recognized as a deficiency disease no action was taken to implement the School Meals Act or to provide any supplement to the diet of undernourished children until after the First World War. In 1924 the committee supplied cod liver oil to most undernourished children, except in a few special cases where milk was considered more desirable. The scheme devised in connexion with the Milk Marketing Board for the daily supply of one-third of a pint of milk at a subsidized price of ½d. was introduced in the autumn of 1934. (fn. 170) Free milk was provided for all children whose parents could not afford to pay. (fn. 171) Not until the introduction in 1946 of free milk for all children irrespective of parental income was every county school receiving a daily supply of fresh milk. (fn. 172)

In 1921 some equipment for the preparation of school meals was purchased although not brought into use, but during the following years arrangements were more generally made for children who stayed at school all day to eat their own food under supervision and in a more suitable environment. In 1930 experimental schemes for school dinners began at Calne, Durrington, Pewsey, Devizes, and Downton. These experiments continued for some years until in 1938 a special investigation of the problem of school dinners was undertaken by the education committee. The investigating committee recommended that school meals should be provided in certain schools, and that free meals should be given to necessitous and undernourished children. (fn. 173) Suitable and extended arrangements had already been made by the education committee, when the war-time plans for canteen feeding, and the influx of evacuees into the county, completely altered the picture. During the war school canteens rapidly increased and by December 1946 199 schools possessed canteens and provided meals for 11,522 children each week. (fn. 174) For the seriously undernourished child the county found accommodation at the Marlborough children's convalescent home developed from the old poor law institution after 1929. This establishment proved a most useful auxiliary to the school health service and in 1939 was about to obtain recognition as an open-air school when it had to be taken over as a hostel for evacuees. Only in 1946 was the home released for its allotted part in the Wiltshire educational scheme. (fn. 175)

An important development of the war years was the diphtheria immunization campaign launched in 1940. By the end of 1943 60 per cent, of under five year olds and 96.5 per cent. of schoolchildren had been immunized. (fn. 176)

After the war the education committee extended the school health service in a new direction. In 1947 arrangements were made for speech therapy clinics at Chippenham and Salisbury and for some cases to be referred to clinics at Swindon and Bath. The appointment to the staff of a full-time speech therapist enabled the committee to open regular sessions at Trowbridge, Devizes, Marlborough, Pewsey, Malmesbury, and Mere, in addition to the two already established. From 1946 children in need of psychiatric treatment were sent by arrangement to the Bath clinic. The growing need for such work within the county was met in September 1949 by two clinics—at Corsham and Amesbury (later moved to Salisbury). A psychiatrist was employed at each clinic, and an educational psychologist and a psychiatric social worker were appointed to the county staff. (fn. 177) Another extension of facilities for children was made by the provision in 1948 of chiropody treatment.

The Education Act of 1944 placed upon education authorities full responsibility for providing free medical treatment, other than domiciliary care, for pupils attending their schools. This made agreements necessary with the local hospitals for general medical and surgical treatment for all children sent up by the local committee. The National Health Service Act caused some dislocation of the school health service during 1948. All responsibility for in-patient treatment was transferred to the regional hospital boards, who were also to provide the services of consultants for both out-patient and school clinics. The services which remained the direct responsibility of the education committee were medical inspection, ascertainment of and provision for handicapped children, treatment of minor ailments at school clinics, speech therapy, child guidance, and dental inspection and treatment.

Hospitals

The hospitals of the county represent three main movements for care of the sick. Salisbury General Infirmary is a monument to 18th-century philanthropy, to which London and the provinces owe many of their greatest medical centres. Towards the end of the 19th century a new demand for hospitals was created by the reduction in hospital mortality which followed the introduction of antisepsis, and improvement in surgery by the advent of anaesthetics. The cottage hospital movement met this need especially well in rural areas where economic resources and transport difficulties made the large general hospital impracticable. The public health authorities provided isolation hospitals for the county in the early years of this century and after the Local Government Act (1929), converted many public-assistance institutions to special uses.

(a) Salisbury General Infirmary

The will of Lord Feversham, who died in 1763, stimulated local effort by a bequest of £500 'to the first Infirmary that should be established in the County of Wilts. within five years of his decease'. (fn. 178) Salisbury town council, the bishop and clergy, and local landlords, all supported the hospital scheme. On 24 September 1766 subscribers and benefactors at their first general meeting resolved 'that a society be instituted, and distinguished by the name of the Governors of the General Infirmary at Salisbury, for the Relief of the Sick and Lame Poor, from whatsoever county recommended'. Land was purchased in Fisherton and a row of houses converted for temporary accommodation for patients while the hospital was being built. The new Infirmary opened for patients in 1771.

The original rules of the hospital emphasized the intention to provide only for the sick and lame poor to avoid both exploitation of charitable provision and 'disadvantage to the faculty, particularly of the surgeons who attend gratis'. To forestall any accusations of encouraging beggars the Infirmary was ready to make an allowance of 1s. towards the weekly lodging of out-patients from a distance greater than 7 miles, 'provided that the officers of their respective parishes will allow them 2s., or 2s. 6d., during their time of abode in Salisbury as out-patients.' (fn. 179)

Hospitals at this period suffered high death-rates. Surgery, limited in the main to amputations, was often fatal because of wound infections. Hospital gangrene was constantly feared and often broke out, as in Pembroke Ward of Salisbury Infirmary in 1818–19 when, during the post-war depression, the hospital was overcrowded, many patients sleeping two in a bed. Water-supplies in the hospital were inadequate, and until the substitution of iron bars for sacking on the beds in 1829, lice and their associated diseases were a menace to the healthiness of the institution. In 1833 a serious outbreak of erysipelas caused the authorities to draw up regulations for cleansing the hospital and the bedding. No patients were for the future to use bedding previously used by another. Most important, however, was the rule that all sponges and poultice cloths should be destroyed after use for these were potent vectors of infection. Another outbreak in 1853 was considered to be due to defective ventilation and to cesspools close to the house. This was the year in which the town began its drainage scheme and the hospital deferred taking measures until the Local Board of Health had finished its works. (fn. 180)

The death-rate of Salisbury Infirmary was not, however, unduly high. Dr. Bristowe, who reported on the state of the hospital in 1863, (fn. 181) stated that of the patients admitted in the year ending 2 August 1862, 2.3 per cent. died. For the 95 years 1767–1862 the figure was 2.9 per cent. He attributed the low mortality of the hospital to the rules of admission: 'The majority of patients are admitted by letter, but accidents and urgent cases come in without. The following cases are excluded: women big with child, children under seven (except in special cases), persons disordered in their senses or epileptic, persons suffering from infectious diseases, and all such as are manifestly dying or incurable. The greater number of patients come from the country districts around Salisbury, and consist in large proportion of agricultural labourers, and of servants.' As a result the great majority of both medical and surgical cases were chronic rather than acute. Dr. Bristowe summed up his account thus: 'The hospital is a purely country hospital, and, though far from being a model hospital, is clean, fairly ventilated, and well adapted to its purpose.'

All 18th-century and early 19th-century hospitals were training grounds for the apprentices and pupils of the honorary medical staff. At the Infirmary, as at most hospitals, the admission of pupils was regulated by the governors. Each surgeon was allowed to introduce two pupils and one apprentice who, to safeguard the patients, were to carry out their work only under the direction of one of the surgeons. The house apothecary was permitted one pupil and the fees for his instruction, together with £10 a year 'for instructing the surgeon's pupil in the knowledge of drugs, during the time of the pupil's apprenticeship'. (fn. 182)

Contemporary prejudice against anatomical investigation voiced itself in Salisbury in the last decade of the 18th century. An entry in the Infirmary minutes stated: 'The committee having carefully examined the grounds and causes of a complaint charging the surgeons of the charity with inhumanity and indecency in the conduct of the recent dissection of a malefactor, order an advertisement "that neither the governors, surgeons, nor pupils have any knowledge of the matter and have resolved that no dissection of a condemned criminal shall in future take place in the Infirmary".' (fn. 183)

In order to pass qualifying examinations required by the Society of Apothecaries after the Apothecaries' Act, 1815, pupils had to supplement practical education by formal lecture courses. In 1816 the committee granted the use of a room in the Infirmary to Dr. Smith and Mr. Henry Coates, one of the honorary surgeons, for occasional lectures in the several branches of medicine and surgery. For a long period at the beginning of the 19th century the hospital was served by Dr. Fowler on the medical side and Mr. Henry Coates on the surgical. Dr. Richard Fowler acted as honorary physician for the 45 years between 1796 and 1841 and continued to give advice and guidance for many years after his retirement. Born in 1765, he studied medicine in Edinburgh and in Paris before the Revolution. He graduated M.D. in Edinburgh in 1793, and was admitted a licentiate of the College of Physicians of London in March 1796, the year in which he took up his appointment in Salisbury. Interested in science, he was elected F.R.S. in 1802, and later became a most active member of the British Association. (fn. 184) For a similar period 1804–47 Henry Coates was honorary surgeon; he was succeeded in 1847 by William Martin Coates, who had entered the hospital as Dr. Fowler's pupil in 1830. (fn. 185)

At Salisbury as elsewhere, nursing was for long an unskilled and unsought occupation. In a recruitment campaign of 1803 the governors ordered notices to be sent to all the villages pointing out the 'advantages to young, strong, respectable women, who would be taught how to look after sick people'. At this time some of the nurses were said to be past work and very deaf. Twenty-five years later the governors recommended 'that there shall be 5 permanent nurses and such other day and night nurses as the honorary staff shall order, these occasional nurses to be provided by the matron'. In 1848 Florence Nightingale, whose family were friends of Dr. Fowler, tried to persuade her parents to allow her to go to Salisbury Infirmary to learn nursing. (fn. 186) Doubtless the Infirmary's close association with Sidney Herbert, who became president in 1842, speeded nursing reform. The impact of the Crimean War soon produced results. In 1857 the governors applied to Mrs. Fry's Nursing Institution in Devonshire Square for a superintendent nurse to regulate the nursing for a limited time. Advice from Florence Nightingale was forwarded by Sidney Herbert. The Infirmary increased the resident staff, improved wages and living conditions, and provided uniforms. Mrs. Fowler initiated a superannuation fund for nurses in 1863. A few years later, trainees from a nursing institution in Salisbury, and probationers, were admitted. The opening of a nurses home in 1901 completed efforts for improving the standards and conditions of nursing in the 19th century.

Better conditions for patients, advances in surgery and medical knowledge, and the introduction of more complicated apparatus into methods of treatment increased the demand and the need for hospital services. To meet the expansion, new ways of raising money for the Infirmary were devised. The Infirmary League, founded to raise funds in every parish, after the First World War developed its contributory scheme to secure the support of the working-classes by weekly contributions. Treatment was in this way made available not only to the 'sick and lame poor' but also to a class of patient who could afford to pay something towards its cost.

(b) Other Voluntary Hospitals

Salisbury Infirmary was difficult of access to patients in the north and west of the county, where the demand for hospital treatment was met by the cottage hospital. General practitioners provided the medical care at these institutions, at many of which some graduated payment by patients was required. Consultant services in Wiltshire were provided from Bath, Bristol, Oxford and London as well as Salisbury, an arrangement foreshadowing the division of the county under the regional hospital boards.

The first of these smaller hospitals was the Savernake Hospital at Marlborough founded in 1866. Built on a site given by the Marquess of Ailesbury the new hospital opened for 25 patients in 1872. Sir Henry Burdett wrote of this institution it 'has enabled some of the medical practitioners in the district to acquire a skill in the treat ment of surgical cases which is equal to that of the leading surgeons of the day'. (fn. 187) The hospital has frequently been extended and was equipped in 1931 with a new nurses' home and in 1935 with a new operating theatre. There were 80 beds in 1931, and 90 in 1951. According to the original rules admission was by governor's letter. During the inter-war period in line with other institutions the Savernake Hospital League devised a local contributory scheme. (fn. 188)

Melksham cottage hospital, founded in 1868, provided 7 beds by 1895. Patients were admitted on payment of not less than 5s. a week, but emergencies were accepted. In 1938 the hospital moved into new buildings, the gift of a local benefactress. (fn. 189) In 1948 there were 44 beds served by 5 general practitioners with 4 consultants from Bath on call. (fn. 190) Devizes cottage hospital, established in 1870, was enlarged in 1887 to 16 beds. Associated with the in-patient department was a dispensary catering for a large number of out-patients. Admission to the hospital was by payment of from 3s. 6d. to 7s. a week. Towards the end of the century a private nursing department with a matron and one nurse was founded. Further extensions brought the number of beds up to 46 in 1948, and 60 in 1951. As at other hospitals, the medical staff consisted of general practitioners and visiting consultants from Bath and Bristol. (fn. 191) A cottage hospital was established at Trowbridge in 1870 and was supported by voluntary contributions. In 1886 the committee proposed to build a new hospital. Money for building was provided by Jesse Gouldsmith, who also leased to the hospital the site in the Halve at a peppercorn rent. (fn. 192) In 1895 the hospital had 10 beds. Admission was by the subscriber's letter or payment of from 3s. to 10s. a week. Patients had to bring a change of linen and arrange for their own laundry. The hospital moved to an entirely new site in 1929 having outgrown the old buildings in the Halve which were taken over for county council clinics. (fn. 193) Hospitals at Warminster (1875), Malmesbury (1889), Chippenham (1896), and Westbury and district (1897) were all founded on similar lines. These hospitals, situated in less populous areas, remained small. (fn. 194)

The rapid growth of Swindon made it the natural centre for medical services for the north of the county. New Swindon, however, was so much the creation of one industry with its own medical provision that general services in the town at first failed to develop as rapidly as the neighbourhood required. The Swindon and North Wiltshire Victoria Hospital, a memorial of Queen Victoria's Golden Jubilee, opened in 1888 with 6 beds increased to 12 by 1892 and 24 by 1897. To commemorate the Diamond Jubilee the urban district councils of Old and New Swindon started an endowment fund for the hospital. By 1930 there were 80 beds, and in 1948 there were 104 beds. From the first admission was free, medical attention being provided by general practitioners. The hospital was later recognized as a nurses' training school. (fn. 195)

Particularly interesting in the medical history of Swindon was the Great Western Medical Fund Society. The principles of thrift and self-help so much commended in the latter half of the 19th century, were supplemented by local philanthropy in most cottage hospitals. In New Swindon the employees of the new G.W.R. locomotive works had to rely mainly on their own efforts. Distress and unemployment in 1847 led Daniel Gooch, locomotive superintendent at Paddington, to ask the railway directors for their support. He wrote: 'those men who are to be retained in the Company's service have very generously offered to assist the unfortunate men in any way in their power, and one of the plans is to arrange with Mr. Rae, Surgeon, to attend the whole for a small weekly payment by each man. This arrangement I have no doubt I will be able to bring about if I can get some assistance from the Directors. What I would beg of them to do is to allow Mr. Rae to live in the cottages house-free in consideration of his attending all the accidents that occur in the Works for nothing.' The directors agreed to this request and the medical fund was founded. (fn. 196) According to the first rules 'the object of the Medical Fund is to provide Medicine and Attendance to the men employed in the Works of the Great Western Railway at Swindon and their wives and families; and in order to carry out the regulations of the Company that all men employed at this establishment shall subscribe a rateable portion of their wages towards a General Fund, the following Rules for giving effect to this regulation have been determined upon'. (fn. 197)

In its earliest years sanitation occupied a good deal of the attention of the Society and representations were made at various times to the guardians and the local board of health. Washing-, turkish-, swimming-, and shower-baths were built in the sixties. In March 1871 the committee resolved to establish a cottage hospital for the treatment of their own members' accident cases. The next year the hospital opened with four beds, an operating room, a bathroom, surgery, mortuary, and nurses house. With its out-patient department the hospital became in effect the first-aid station for the company.

Membership was entirely restricted to G.W.R. employees and their dependents. In 1873 the society was registered as a Friendly Society. Expansion continued with a dental clinic in 1887, and new consulting rooms, waiting halls, dispensary, and swimming-baths in 1892. The hospital extension of 1927 increased the bed capacity to 42, and added an X-ray department, and blood-donor service. During the following years the ophthalmic and chiropody departments, and the skin, the psychological, and the paediatric clinics were opened. So indispensable had the society become to the community which it served that some replacement had to be found when its existence came to an end in 1948. The medical officer of health for Wiltshire wrote in his annual report for 1950, 'The passing of the National Health Service Act in 1946 abolished the prime reason for the existence of the Medical Fund Society, but it at once became clear that the medical service it had built up and which was used by almost 40,000 Swindon persons—families of the railway workers being included—must be carried on.' The county council, therefore, purchased part of the buildings for the only health centre in the county. The rest of the organization has been split up between the Swindon and district hospital management committee and the Swindon corporation. (fn. 198)

In Salisbury a large proportion of the population provided for their medical services, on a less comprehensive scale than the railway employees, by joining the Salisbury and South Wilts. provident dispensary. In 1909 it was estimated that the dispensary covered 9,190 members or 1 in 2 of the population. (fn. 199)

Two smaller voluntary hospitals must be mentioned. Near Malmesbury the Charlton cottage home was founded in 1870. Under Lady Victoria Howard as lady manager the hospital provided 11 beds for 'ricketty and weakly children of 10 years of age and under'. (fn. 200) Patients were later selected by the Invalid Children's Aid Society. At Westbury the Prideaux voluntary hospital was opened in 1928 with Miss Prideaux as medical officer. The hospital provided from 8 to 10 beds with consultants from Bath and Bristol called when necessary. (fn. 201)

(c) Local Authority Hospitals

Provision of isolation hospitals by local authorities began in the last decade of the 19th century. At the beginning of this century the Swindon borough hospital was an efficient unit frequently used, but other areas were less fortunate. Some hospitals, like those at Warminster and Tisbury, were converted cottages. At Malmesbury a wooden building contained 6 beds in 2 wards which opened into each other, there was no cooking apparatus, bath-house or bath, and an old baker's cart was used as an ambulance. (fn. 202) The public health committee of the county council exercised some pressure on the responsible authorities in the following years. In 1904 the medical officer of health stated that the isolation hospital must be regarded as the poor man's spare room. An additional incentive in Wiltshire came from its large dairy interests, for many milk producers, as a result of precautions in the towns, were under contractual obligations to declare to the purchaser the existence of any infection.

After the First World War, when there were ten isolation hospitals in the county, a policy of fewer but larger hospitals was adopted. In 1920 the medical officer of health wrote: 'Motor ambulances for infectious diseases have so modified the problem, that the further provision, and in some cases the continued use of small isolation hospitals, can no longer be financially justified in view of the economy and efficiency of the larger hospital with the larger area of service.' Despite some reluctance on the part of local committees the consolidation of districts gradually advanced. Cricklade and Wootton Bassett agreed to close on 31 March 1930. Calne held out until a Ministry order for amalgamation of 1 April 1934 merged this district in Chippenham and Malmesbury. In the same year Trowbridge took over the Warminster area. Chippenham and Devizes were extended in line with the policy for larger units. (fn. 203)

Transference to the county council of workhouse accommodation by the Local Government Act 1929 made possible increased provision for the sick and the classification of selected institutions for specific purposes. The workhouse infirmary at Stratton St. Margaret was allocated for development on modern hospital lines to serve the northern part of the country. In 1933 a resident medical officer together with a consulting surgeon from Swindon were appointed to the staff. An operating theatre and two small surgical wards were built and equipped for use by 1935. Appropriated under the public health committee from 1 February 1936 the institution was used for public health and for public assistance patients, and by 1938 St. Margaret's could accommodate 188 in the house and 148 in the infirmary. Incorporated in the emergency medical services scheme during the war, St. Margaret's benefited by the addition of five ward huts which were retained when peace returned. Tower House, Salisbury was also developed for general hospital services with special emphasis on difficult male cases attended by male nurses. In 1932 34 beds were available for male cases, and double the number in the following year. By 1938 Tower House had 140 beds in the house and 164 in the infirmary. Except for 3 wards the hospital was incorporated in the emergency medical services scheme and 5 ward huts were built. Marlborough institution was converted for use as a children's convalescent home and was appropriated by the public health committee in 1934. Chippenham infirmary developed on hospital lines especially for difficult female cases. At Devizes the infirmary wards were modernized. Amesbury became mainly an epileptic colony. Semington provided for 22 male and 36 female mental defectives with infirmary accommodation for 68 sick persons. Warminster was improved and provided infirmary accommodation for 49 in 1938. Some institutions were unsuitable for conversion and closed as soon as other arrangements could be made for the occupants. Of these Calne closed in 1932, Malmesbury and Westbury in 1933, and Tisbury in 1936. (fn. 204)

The county council has carried on the fight against tuberculosis throughout this century and the county contains two sanatoria. Harnwood sanatorium, Salisbury, opened in 1919 with 30 beds, was managed by the county council. By 1946 there were 50 beds. At Winsley sanatorium, near Bradford-on-Avon, which was built in 1903 (fn. 205) and placed under a joint committee of Bristol, Bath, and Wiltshire authorities, 36 beds were available for Wiltshire cases. During the Second World War beds at Salisbury and Devizes isolation hospitals were used for tuberculosis patients.

Under the National Health Service Act the hospitals of the county were divided between three regional hospital boards: Salisbury and the south-east of the county came into the south-west metropolitan area, Swindon and the north into the Oxford area, and the west of the county into the south-western area.

To detail all the work of the health authorities would be to chronicle the sanitary and medical legislation of the last 50 years. Throughout this period the district councils have retained responsibility for the environmental health services—dealing with nuisances and sanitation through their sanitary inspectors, administering the food and drugs acts, supervising housing conditions and building new houses. In almost every case close co-operation has been maintained between county and district by the appointment of district medical officers as assistant county medical officers.

Clinics and treatment centres for different specialties have greatly increased. Voluntary notification of tuberculosis was adopted in some districts as early as 1900. (fn. 206) Further responsibility for compulsory notification of the disease was laid upon the county in 1913, a full-time tuberculosis officer was appointed and three clinics opened at Salisbury, Swindon, and Trowbridge. From 1920 part-time assistant tuberculosis officers, usually assistant county medical officers, were appointed. Further clinics opened at Savernake (1936), Devizes (1943), Corsham (1947), and Chippenham (1952). After-care work was carried out by a sub-committee of the health committee with assistance from the British Red Cross Society and the National Assistance Board.

Venereal disease clinics were established during the First World War and continued at Salisbury, Swindon, and Trowbridge. In 1932 necessitous cancer patients came under the care of the public health department and in 1933 an out-patient clinic for follow-up was established at Salisbury. Further clinics for cancer opened at Trowbridge (1935), and Swindon (1937). By 1938 clinics for rheumatoid arthritis and birth control were open in Salisbury. In preparing a scheme for domiciliary assistance for blind persons in 1935, and in maintaining a register of blind persons in the county, the public health department worked closely with the voluntary association for the care of the blind. The department in 1937 compiled a register of the deaf and dumb in the county.

Responsibility for the administration of different sections of the National Health Service Act was divided between regional hospital boards, local executive councils, and the local health authorities. One of the biggest changes for the county was the transfer to the public health department of all the district nurse midwives previously employed by the nursing associations. At the same time the three regional hospital boards took over complete responsibility for all hospitals in their areas and for the provision of consultant services in hospitals and clinics. The Wiltshire executive council regulates matters of registration and payment in general practice.

The Swindon health centre provides a good illustration of some of the administrative problems which arise; the premises were purchased by the county council, medical and dental members of the staff came under the Wiltshire executive council, other staff were county council employees, and the Oxford regional hospital board assumed responsibility for specialist clinics. (fn. 207) Many difficulties which derived from these complicated administrative arrangements have been solved by the overlap of the same persons acting on different bodies. By bridging unforeseen gaps in the scheme they have prevented any interruption of the main provisions of the public health and medical services which have developed so rapidly during the last hundred years.