The city of Cambridge: Public health

PUBLIC HEALTH

In tracing the history of health in Cambridge we are once more confronted by the two characteristic governing motifs: geography and the presence of the University. Harrison said in 1577 'Cambridge standeth very well, save that it is somewhat low and near to the Fens, whereby the wholesomeness of the air there is not a little corrupted', (fn. 1) and the very slight elevation above sea-level makes the disposal of refuse by water a serious problem. From the first coming of the clerks, the concern of the University for the health of its members (fn. 2) has acted as a stimulus to raise hygienic standards, and has led to much fruitful co-operation between the two communities.

From an early date town sanitation was associated with the town ditch. Though its origin is undoubtedly far earlier, (fn. 3) the first official reference to it is Henry III's order of 20 February 1268, 'That the town be cleansed from dirt and filth; that the watercourse should be opened and kept open as of old so that the filth may run off; and that the great ditch of the town be cleansed.' (fn. 4) Already in 1268, it would seem, 'What was meant for fortifying had become a great annoying.' The town records show that it was used as a receptacle for all kinds of refuse—entrails, dung, and garbage; privies, 'seges', or 'bocards' were built over it. (fn. 5) Six loads of manure were carted away from it in 1522 when a culvert was built at the point where Jesus Lane crossed it. (fn. 6) A survey of the ground levels explains its stagnancy. (fn. 7) There was a slight natural fall from Barnwell Gate in both directions which made through scouring impossible. The tradition that it was the holding of Parliament at Cambridge that produced the first Health Act in 1388 is supported by the terms of the statute referring to the casting of various 'corruptions' into ditches and rivers, and imposing on the Mayors and bailiffs the duty of cleaning up their towns on pain of answering for neglect in Chancery. (fn. 8) The machinery for enforcing these regulations was gradually built up, Mayor and Chancellor being stimulated by commands from Westminster. (fn. 9) By-laws were reinforced by the annual proclamation for the 'avoydance of muck' (fn. 10) and from 1459 both Vice-Chancellor and Mayor were empowered to inquire in their leets into such nuisances as wandering hogs, highway dunghills, the defilement of the town ditch and ill-paved roads. (fn. 11) The co-operation of the two was registered in the indenture of 1503, (fn. 12) which is in effect a local sanitary code, and was revised and renewed in 1575. (fn. 13) The primary responsibility rested with the town, but if the Mayor failed to take action upon a presentment within six weeks the Vice-Chancellor was to act. In 1544 an Act promoted by the Borough Members of Parliament (fn. 14) set up the machinery by which for the next 240 years Cambridge amenities were supposed to be guarded; the establishment of the paving leet held jointly by Mayor and Chancellor for enforcing the householder's statutory responsibility for paving the roadway in front of his house, for cleansing the streets, and for dealing with nuisances in general. (fn. 15)

Conditions favourable to the pollution of wells and the breeding of sewer rats were promoted by the overcrowding of the 16th and 17th centuries; (fn. 16) from 1584 onward the central government exhorted Mayor and Chancellor to check the practice of subdividing tenements to the overburdening of the town, 'a thing dangerous in time of infection'. (fn. 17) The pestilence of 1348–9 ushered in 300 years of similar recurrent visitations. (fn. 18) Between 1510 and 1550 there was an epidemic, on the average, every three years; between 1630 and 1645 there were nine. University activities were suspended 28 times, and even Sturbridge Fair was cancelled repeatedly. The death roll ranged from over 429 in 1610 to 797 in 1666. (fn. 19) Measures for dealing with it were gradually worked out, the justices of the peace assisting the corporation officials. Perfume, frankincense, charcoal and juniper, pitch and resin were used for 'ayringe and sweetninge' the Town Hall or churches where assemblies met. (fn. 20) Suspected victims were systematically 'searched'. Infected houses were closed. (fn. 21) Makeshift isolation hospitals were put up at the old clay pits, now Gonville Place, (fn. 22) on Midsummer Common, (fn. 23) Jesus Green, or Coldham's Common. (fn. 24) These finally gave place to permanent pest houses, completed, ironically enough, in 1666. (fn. 25) They were pulled down in 1703. (fn. 26) Vivid descriptions of plague conditions, mostly by members of the University, survive for 1625, 1630, 1636, and 1665. (fn. 27)

The visitation of 1573 produced not only the reissue in 1575 of the street-cleaning indenture, but proposals for a new water-supply. In November 1574 the Vice-Chancellor, in a letter to Burghley admitting 'our synnes' as the principal cause of the plague, noted as a 'secondarie cause' the corruption of the King's Ditch, and suggested 'that the water that cometh from Shelford to Trumpington ford might be conveighed to the King's Ditch for the perpetual scouringe of the same, the which would be a singular benefite for the healthsomenes both of the Universite and of the Towne'. (fn. 28) He enclosed a map marked with the proposed course of the conduit, but the matter rested for 30 years. At last in 1606 a number of undertakers, including the University carrier Hobson, (fn. 29) subscribed towards the project. A commission of sewers was appointed in 1608, and after a hortatory letter from James I (fn. 30) and some compulsory purchases of land, an indenture was drawn up in 1610. By this deed, our chief evidence on the project, Thomas Chaplyn, the lord of the manor of Trumpington, granted to the town and University a 1,000-year lease of the land through which the recently-made watercourse was to convey a current of water from Nine Wells at White Hill near Shelford 'to scour and cleanse the common drain or sewer called the King's Ditch, as well as for the commodity of sundry drains and watercourses belonging to divers colleges'. (fn. 31) In the last clause lay the weakness of the scheme. The stream that can be seen today flowing down Trumpington Street in two small rivulets into the ditch under Mill Lane had six divergent branches. It supplied water not only to the fountain in the market-place, completed in 1614, with which Hobson's name was especially associated, but also to the 'Red Lion' in the Petty Cury, to a bath in Pembroke College, and to ponds in Emmanuel and Christ's College grounds. (fn. 32) The force of the flow was dissipated, the King's Ditch remained imperfectly scoured, (fn. 33) and the plague recurred with increasing violence. As a supply of drinking-water the 'new river' was a welcome addition to the medieval fountain that had given its name to Conduit (now Sidney) Street. The Franciscans, about 1327, had conveyed the water from Madingley Road to their house on the site of Sidney Sussex College. (fn. 34)

The trust was endowed by legacies of land and money from several persons, including Hobson himself and Stephen Perse. (fn. 35) Its income in 1950 was just under £300, and it still maintains the conduit though this is now only ornamental. (fn. 36) The fountain in Trinity Great Court, as well as the taps inside the hall and outside the Great Gate, are still supplied from the same source as the Franciscans used. The town pumps, drawing from shallow wells, often supplied polluted water; three at least adjoined overloaded churchyards. (fn. 37)

The King's Ditch gradually disappeared underground. By 1574 it was covered over in Mill Lane and part of Pembroke Street; in 1688 in Walls Lane (now Hobson Street). In 1798 Sidney ditch was covered in. In 1815 it was considered most unlikely that 'a very ancient sewer called the King's Ditch, and for the most part covered in' could have contributed to the epidemic of that year. (fn. 38) The remaining uncovered portions in Park Street, Tibbs Row, and the Botanical Garden on the site of the Austin Friars were built over in the 19th century; (fn. 39) the ditch can still be located under the science laboratories.

In 1815 it was supposed that the 'proper persons' would take steps to remove any obstruction in the ancient sewer that might cause trouble; (fn. 40) but those proper persons were no longer the Corporation. As in many other localities, (fn. 41) an authority had been constituted by Act of Parliament to see to the health and amenities for which the town government had in effect abandoned all responsibility. As the population increased and standards rose, conditions deteriorated, and the state of the roads was a public scandal. Gunning's description of Trumpington Street, with the channel of running water dividing the road into two unequal parts, has often been cited. (fn. 42) From 1769 onwards, when Tunwell's efforts met with violent opposition, (fn. 43) attempts were being made to establish a statutory authority. Finally in 1788 an Act was passed which superseded that of 1544. It created a body of Paving (later Improvement) Commissioners, who were empowered to pave, light, and cleanse the town, and to levy rates for those purposes. Seventeen were nominated in the Act; the remaining 52 were to be elected by the Corporation, the University, and the 14 parishes of Cambridge. (fn. 44) In 1794 18 more representatives of the University and 14 more of the parishes were added, bringing the number up to 99.

From 1788 to 1889 the Improvement Commissioners were responsible for the lighting, paving, and drainage of Cambridge. A new lighting system was installed in 1788, the central gutter in Trumpington Street was replaced by two roadside runnels, and the repaving of the town was completed by 1793. (fn. 45)

The 'Cambridge fever' of January to April 1815, probably typhoid, called attention to health conditions. (fn. 46) The population had been increasingly rapidly, and though the Inclosure Acts of 1801, 1802, and 1807 had relieved the congestion, and Cambridge was said to be 'famed for its salubrity', housing conditions were very bad and sanitation non-existent in the older parishes inside the ditch. In 1848, at the request of the ratepayers, Cambridge was constituted a district under the Public Health Act of that year, and the Improvement Commissioners were recognized as the Local Board of Health. (fn. 47) The report, published in May 1849, of the General Board's Inspector into the sewerage, drainage, water-supply, and health of the town gives a terrible picture of the overcrowding and filth in the small courts. Some of these were only 2½ feet across, (fn. 48) sun and air were excluded, and the only recent advance in sanitation that could be recorded was that the scavengers' carts came thrice instead of twice a week to collect the 'night soil'. 'The conditions are so wretched as to be a disgrace to civilization; it is next to impossible for the inhabitants to be healthy, cleanly, moral, decent or modest.' Some had to go a quarter of a mile to obtain clean water; others paid a farthing a gallon for it. 'There are no public baths; the inhabitants have no resource but the sluggish and polluted Cam.' (fn. 49) Six hundred and twenty-five thousand gallons of water a day were needed for the town. Slaughterhouse offal in what is now Corn Exchange Street and a horrible dump of old bones in East Street 'in the midst of dwelling houses' are also described. On the other hand, Cambridge was commended for its new burial grounds (Histon Road, 1842; Mill Road, 1848) and for its open spaces, especially Parker's Piece. (fn. 50)

The census of 1851 reported the demolition of old tenements as well as the clearance due to the fire of 1849 in the Market Place, (fn. 51) but the opening up of the old yards and courts is best followed in the maps of the town. A fresh-water supply was obtained from Cherry Hinton in 1855, later supplemented from wells at Fulbourn and from Shardelowes near the Fleam Dyke. (fn. 52) Its exceptionally pure water-supply has never been known to fail, even in the driest summer. The foundation at this time of the Cambridge University and Town Water Company was one of the most important events in the sanitary history of the town. It now serves a very wide area, including much more than the City. (fn. 53) From 1864 onwards the question of a main drainage system was under hot discussion, schemes being propounded in 1864, 1866, 1870, 1871, and 1886. (fn. 54) The Rivers Pollution Act of 1876 made it more difficult, as the growth of the town made more unpleasant the use of the Cam for sewer outfalls. The Bursar of Trinity in 1884, one of the Improvement Commissioners since 1869, could say that 'a sweet pellucid stream was from a sanitary point of view more a luxury than a necessity'. (fn. 55) It had been felt for some time that the health authority was out of date. (fn. 56) As remodelled after the Local Government Act of 1835, it consisted of 88 members, 9 ex officio, 36 elected by the University and 43 by the Corporation and the 14 vestries; the quorum was seven. Under the provisions of the Public Health Act of 1875 the Improvement Commissioners eventually ceased to exist. Their powers were handed over to the Town Council on 9 November 1889, (fn. 57) and it was a new health authority that carried through the main drainage system in 1895. This solved the problem of the levels by a system of deep sewers and a pumping station two miles from the centre of the town.

The responsibility once incumbent on the Mayor and the Vice-Chancellor and later on the Improvement Commissioners, with the additional functions necessitated by modern demands, are today discharged by the various sub-committees of the City Council, whilst the Conservators of the Cam, appointed by City, University, and county, are still responsible for wider ranging drainage. As in the field of education and juvenile employment, the municipal authorities have profited by the work and the experience of earlier voluntary welfare agencies, (fn. 58) sometimes taking over their functions and sometimes, as in the field of housing, (fn. 59) working alongside. Amongst these, special reference should be made to the results accomplished for the health of the mothers and children of Cambridge. The survey of social conditions in Cambridge published in 1908 reports that in 1904, 107 infants under twelve months died in Cambridge—roughly one in eight; (fn. 60) in 1949, with a considerably increased population, the number was 35, or one in 38. (fn. 61) For this the Voluntary Association for Maternity and Child Welfare was very largely responsible. It originated in the appointment, in 1906, of two health visitors to mothers in their homes, by a society formed to combat tuberculosis. In 1910 a milk depot was set up in Newmarket Road, to which babies were brought to be weighed, and by 1912 there were four infant welfare centres. In 1915 the association was formally constituted. From 1917 an annual grant was made to it by the Borough, and in 1919 the Borough Council requested the Voluntary Association to organize all the work, now very extensive, with the financial backing of the town. In 1937 the association, at its own request, surrendered the responsibility to the Maternity and Child Welfare Committee, with which it had been linked since 1919, but it continued to organize voluntary help at the centres till the end of the war, and only wound itself up in 1946. (fn. 62) Cambridge was, in 1909, the first town in the British Isles to give dental treatment for school children. Here also the pioneer work had been on a voluntary basis. (fn. 63)

In 1815 it was claimed that 'patients in the last stage of a decline have recovered on coming to reside here', (fn. 64) and it may be that the open spaces even then counteracted the sunless and noisome yards. In 1949 it was as true as it had been in 1925 to say that 'Cambridge is among the healthiest of the larger towns in England'. (fn. 65)

Of the medieval hospitals, St. John's was for the poor rather than the sick. Sturbridge leper hospital ceased for lack of patients and that of St. Anthony and St. Eloy (Eligius) became an almshouse, as has been told elsewhere. (fn. 66) They were both outside the town ditch and the second, commemorated today in St. Anthony Street and St. Eligius Street, gave to the suburb outside Trumpington Gate the name of the Spittle End. It is a remarkable fact that a site so near by should have been chosen in the 18th century for Addenbrooke's Hospital.

Addenbrooke's Hospital

John Addenbrooke, (fn. 67) a fellow of St. Catharine's College and a Cambridge M.D., practised medicine in London for a short time after leaving Cambridge in 1711 and died at Buntingford in 1719. He left his books and his medicine chest to St. Catharine's, and bequeathed the reversion of the small fortune he had inherited from his mother's brother 'to hire, fit up or purchase or erect a building fit for a small physical hospital in the town of Cambridge for poor people, to be open to every sick poor person of any county, if room and revenue permitted'. (fn. 68)

Mrs. Addenbrooke died in 1720, but financial and legal difficulties impeded action until in 1759 Chancery appointed eleven new trustees, of whom ten were heads of Cambridge colleges. These purchased in 1763 the present site in Trumpington Street, then almost at the southern extremity of the town, and building began. By 1766 £4,000 had been spent and only £200 remained to build a kitchen and provide for staff and upkeep. (fn. 69) On 30 April 1766 a meeting of the gentlemen of the University, the county, and the Borough was held, (fn. 70) and a scheme was approved for a hospital based on the joint-stock principle prevalent in 18th-century philanthropy. Immediate subscriptions enabled the hospital to open on 13 October 1766, (fn. 71) and an Act of Parliament of 1767 empowered Addenbrooke's trustees to make over their funds and responsibilities to a corporation consisting of (i) ex-officio officers representing the University, the county, and the Borough, (ii) life-governors who had made a donation of 20 guineas upwards, and (iii) annual subscribers of 2 guineas upwards. (fn. 72) A private infirmary was thus constituted a 'general hospital'. The Lord Lieutenant was the ex-officio president, and there are frequent references to the running of the hospital in the seventies and eighties in the letters of Dr. Ewin, the first treasurer, and Dr. Plumptre to Lord Hardwicke. (fn. 73)

Though Addenbrooke had set no geographical limits, the rules drawn up for the hospital secured that normally only poor Cambridgeshire patients should be received. (fn. 74) Three Cambridge parishes appear on the first subscription list, and three county parishes in 1768; (fn. 75) by 1803 all the Borough parishes and 52 country parishes were subscribers, of which six were in adjoining counties. (fn. 76) In the first year 106 in-patients and 157 out-patients were treated; the average annual number of in-patients rose from 282, 1770–9 to 379, 1780–9, but fell to 333 in the next decade. The average number of out-patients rose in the same period from 324 to 376. (fn. 77) Infectious and incurable patients were not received and patients were normally discharged after two months. (fn. 78) The subscribers' governing rights were exercised by a quorum of nine in quarterly general courts at which appointments were made, accounts passed, contracts approved and rules revised, whilst a weekly board, with a quorum of five, regulated the admission of patients and dealt with current business. (fn. 79) Town, county, and University co-operated in steady support, and two prominent members of the anti-Mortlock faction in the Corporation served the hospital long and faithfully, Alderman Newling as treasurer from 1770 to 1815 and Alderman Bond as a visiting surgeon from 1775 to 1803.

In addition to subscriptions, donations, and legacies, the hospital funds were augmented by collections taken at the annual sermon at Commencement and the proceeds of benefit concerts then held, (fn. 80) but these were uncertain sources, and it was reported in 1802 that for the last seven years expenses had exceeded receipts by about £150. The weekly meetings had been poorly attended, and the leading members of the medical and administrative staff had held their posts for 25 years or more. (fn. 81) Reforms were obviously needed, and eighteen select governors (fn. 82) were appointed who undertook to attend the weekly boards in rotation. These persons served in effect as executive and finance committee until 1898, though any governor was still free to attend the meetings. (fn. 83) A financial drive increased the subscribers from 526 to 728, and brought in some 1,200 new donations, whilst the institution of 'Hospital Sunday' in some 119 parish churches provided a fresh source of revenue. (fn. 84)

The expansion of the hospital proceeded rapidly. By the middle of the 19th century the average number of in-patients per annum had reached 690, by 1880, 880, by 1900, 1,320. (fn. 85) The number of beds, about 100 in 1866, (fn. 86) was 153 in 1889. In the latter year the hospital contained three surgical and three medical wards, two eye wards, two children's wards, an accident ward, and three special wards. (fn. 87) By 1915 the number of beds had reached 192 and in 1951, 357. (fn. 88)

In 1822 two wings and a colonnade were added, (fn. 89) masking but not replacing the original building which remains today embedded in the modern structure. The extension had been made possible by the legacy of £7,000 from John Bowtell, the antiquary and a native of Cambridge, in 1813. (fn. 90) The hospital was greatly enlarged in 1864–5, a third story being added. (fn. 91) New wards were built in 1878, a dormitory in 1883, an outpatients department and a nurses' building in 1895–6, a clinical laboratory in 1913, new wards in 1915, 1929, and 1932, and an additional home for the nursing staff in 1924, and new accommodation for the orthopaedic department and the medical staff in 1934. (fn. 92)

After the reforms of 1802 no change of importance was made in the government of the hospital until 1898, though the rules were revised in 1812 and 1833. By 1898 the need of change was felt both on administrative and financial grounds. The quarterly courts were out of date, especially in relation to appointments, and rival schemes were hotly discussed by the governors. (fn. 93) A committee of twelve, representing University, town, and county, was appointed to consider the situation. The proposal to delegate the government of the hospital to an advisory council of fifteen governors was rejected in favour of a more elaborate scheme which was examined and approved by the Charity Commissioners, and incorporated in the Addenbrooke's Hospital Scheme Confirmation Act of 1903. (fn. 94)

On 12 March 1910 a meeting of representative working men was held at the hospital, at which it was decided to establish a system of regular contributions to a fund for maintaining the hospital. This scheme functioned as the Cambridge and District Workers' Hospital Fund until 1931. It then became the Contributory Scheme under which the various county parishes, like those of the Borough, secured for their inhabitants rights to be received in sickness in return for a standing subscription, a system which continued until the passing of the National Health Act of 1948. (fn. 95)

In 1767 the resident medical staff consisted of one apothecary, who was expected to be permanently on the premises. His salary rose from £25 with a bonus of £5 in 1770 to £50 without a bonus in 1800. In 1846 it was £86. He then had a dispenser to assist him and an apprentice whose premium augmented his income. The matron's salary was £15 in 1770 and had risen to £50 by 1833, but her responsibility was merely that of a housekeeper and cook, with some disciplinary duties added. In 1800 she had four assistant nurses whose combined salaries came to £38. There were three visiting surgeons and three visiting physicians in 1770. The number had risen to five of each class by 1802, but was reduced once more to three of each in the reforms of that year. They included Sir Isaac Pennington, Regius Professor of Physic, Sir Busick Harwood, Professor of Anatomy, and T. V. Okes, whose pamphlet on the Cambridge epidemic of 1815 has been quoted above. (fn. 96) By the end of the 19th century the visiting staff had risen to eleven, and the resident staff to four. The matron, besides a domestic staff of 21, had some 40 nurses and probationers working under her, (fn. 97) for in 1877 a training school for nurses had been established by Alice Fisher, the matron. (fn. 98)

Adden brooke's had been serving as a medical school ever since 1841 when the governors had made regulations for the admission of students. The report for 1889 describes it as a large and important medical school, recognized both by the University and the examining bodies as a place of training, and arrangements were being made with the University for lectures to be given there by persons who were not members of the hospital staff. (fn. 99) In 1900, by an arrangement with the University, the Regius Professor of Physic and the Professor of Surgery were elected as additional members of the medical staff. New arrangements had to be made for the teaching of students from October 1936 owing to changes in the curriculum. Addenbrooke's is recognized by the University as a place of clinical study. (fn. 100)

Since 1948 the whole organization of the hospital has become part of the National Health Service, and Addenbrooke's forms one of the group of United Cambridge Hospitals which supply the principal hospital service for the eastern counties. The other members of the group are the Chesterton Hospital in Union Lane, Brookfield Hospital in Mabel Lane, and the Cambridge Maternity Hospital in Mill Road, formerly the poor law infirmary. The joint medical staff in 1950 numbered 46. (fn. 101)