Nineteenth century Nottingham

Nottingham in the nineteenth century saw rapid industrial change from the boom in cotton spinning, followed by the hosiery industry, to machine lace manufacturing; these fashion industries had been particularly vulnerable to cycles of boom and depression.^{Reference Bosworth3} In the mid-1850s, new major industries developed, including: Boots (pharmaceuticals and retail chemist shops), Raleigh (bicycles) and Players (tobacco), as well as the mining industry.^{Reference Chapman and Beckett12} Rapid population growth was also a feature, not only in Nottingham town (which became a city in 1897), but its surrounding industrial villages, expanding from 44 511 in 1811 to 239 743 in 1901.^{Reference Beckett and Beckett13} Public Health reported on the degree of general poverty in Nottingham in the mid-1800s, with its inadequate and overcrowded housing conditions, the lack of running water and the absence of sanitation, resulting in disease and pollution within the general public.^{Reference Amos14}

Establishment of specialist ENT services

The Nottingham specialist service provision for patients with diseases of the throat and ear was first advertised in the Nottingham Evening Post, 27th November 1886.¹⁵ This stated: ‘Hospital for Diseases of the Throat and Ear will be opened at 33 Peachy Terrace November 30th, for the necessitous poor, free of all charges. Medical Officer will attend at 3 pm. Days and hours in future notices’. A subsequent advertisement in May 1887 clarified that the ‘Medical officer attends on Tuesdays and Fridays’.¹⁶

The Nottingham Evening Post subsequently reported, on Thursday 21st July 1887, that a meeting had been held ‘this afternoon … for the purposes of considering the desirability of establishing in the town a small hospital and dispensary, for the special treatment of diseases of the throat and ear in order to facilitate the special investigation of these diseases and to benefit the indigent who suffer from them’.¹⁷ Those individuals recorded as being present included the mayor of Nottingham, the town clerk, three reverends, six doctors (three of which were current or future presidents of the Nottingham Medico-Chirurgical Society^{Reference Swift18}), and four gentlemen. Following discussion, it had been concluded that the resolution ‘expressing the advisability of establishing an institution as proposed was unanimously carried’.

First specialist in ENT diseases in Nottingham

Dr Donald Stewart (1843–1914), born in Glenbarr, in the parish of Killian, Cantre (Kintyre), Argyllshire, Scotland,¹⁹ was the seventh of eight children. He attended teacher training college and taught for several years before entering Glasgow Medical School (1870–1874). He graduated as a Bachelor of Medicine with honours, was awarded his Licentiate of the Royal College of Surgeons of Edinburgh in 1874, and was certified as a Doctor of Medicine at Glasgow University in 1876.

During one summer (1873), Dr Stewart worked as an assistant to Dr Thomas Burnie (Edinburgh graduate, and President of the Medico-Chirurgical Society in 1884 and 1903). On graduation, he worked temporarily for several Nottingham general practitioners. In 1874, he was appointed as the ENT house surgeon to the Blackburn and East Lancashire Infirmary (Figure 1). At some period, Dr Stewart studied in Edinburgh and Vienna, specialising in diseases of the throat and ear, and learnt to read and speak German (as indicated by Simon Moffett, the great-grandson of Donald Stewart, through his daughter Ada Mary Stewart). He befriended numerous influential Scottish doctors, notably Dr Walter Hunter, a medical school class-mate who was Medical Officer for Health in Nottingham and President of the Medico-Chirurgical Society in 1893, and Dr William Stafford, a graduate of Glasgow Medical School and a partner in general practice, who was also President of the Medico-Chirurgical Society in 1924.

Fig. 1. Dr Donald Stewart (1843–1914), Founder of the Nottingham and Nottinghamshire Hospital for Diseases of the Throat, Ear and Nose.

Hospital's early days

Searches of the Nottingham Directories conducted by the Nottinghamshire Archives show that the ‘Nottingham Throat, Nose & Ear Hospital’ was registered in 1886, and supported by voluntary donations, with ‘Dr Stewart Esq MD’ as the medical officer. After 1894, it was listed as the ‘Nottingham and Notts. (Nottinghamshire) Hospital for Diseases of the Throat, Ear & Nose’ (as revealed by a Nottingham Directories search performed by the Nottinghamshire Archives Research Service (Report PH/70/4/3/15 – R2805/Bradley), unpublished data).

The first annual general meeting was held in late February 1888, under the title of ‘The Nottingham and Notts. Hospital for Diseases of the Throat, Ear and Nose’.²⁰ Dr Stewart reported that during the first 13 months of the charity, 515 patients had applied for relief; these necessitated 2567 attendances. The number of patients suffering from ear disease was 362 (70 per cent), and the number suffering from throat and nose diseases was 153 (30 per cent).

The fourth annual general meeting, in 1891, reported increasing attendances, and commented that it was no longer possible for a single person to cope with the demand.²¹ Mr Robert Warren Herrick, Doctor of Medicine graduate of Trinity College Dublin, was appointed Honorary Assistant Surgeon (aged 25 years), and Mr James Johnstone, awarded his Licentiate in Dental Surgery of Edinburgh, was appointed as Honorary Dental Surgeon (he died in 1915 following a motor cycle accident). Dr Stewart highlighted that the ‘amount of work done was lessened in usefulness by the want of one or two beds. The hospital could not be considered complete, nor could it deal efficiently with the graver cases until it had beds in which to receive patients who were too ill to attend out-patients’. There was discussion regarding the fall in donation numbers and amounts (from patients and families), and the need for an increase in subscriptions, all of which were required for the stability and efficient running of the hospital.

At the ninth annual general meeting, in 1896, Dr Stewart tendered his resignation because of ill health (a back injury was incurred while conducting a home visit).²² Dr Herrick became Senior Honorary Surgeon, and Dr J Power-Gray, Fellow of the Royal College of Surgeons of England, was appointed as Honorary Assistant Surgeon. In 1898, the practice moved to 88 Upper Parliament Street (near the town centre),²³ and was the out-patient station until 1921. The activity recorded during 1899 showed that the clinic was open 153 days, saw 1237 new patients, with a total attendance of 4706 (each patient was seen on average 3.8 times) and with daily attendances of more than 30.²⁴

New location, with in-patient services

By 1905, premises were leased at 94 Shakespeare Street, with six beds, allowing for in-patient treatments.²⁵ This location was active until 1925 (determined by a Nottingham Directories search performed by the Nottinghamshire Archives Research Service (Report PH/70/4/3/16 – R797/Bradley), unpublished data). Fortuitously, the next-door property (number 92) became vacant, and was rented from 1921–1925, allowing relocation of the out-patient clinic. During 1906, 256 in-patient treatments were performed.²⁶ By 1907, this number had risen to 281,²⁷ but concern was expressed that there were ‘large numbers’ of patients waiting for admission.

Nottingham was overwhelmed by the Great Influenza Pandemic of 1918–19, which caused serious disruption to public services. Dr Philip Bobbyer, the Medical Officer for Health, helped to set up an emergency influenza hospital (in what had been a war-time crèche), as well as setting aside 36 beds for influenza patients in Bagthorpe Isolation Hospital where he was medical superintendent. There was a great shortage of beds in Nottingham, which meant that most patients were cared for at home, with input from their general practitioner and advice from the Nottingham Dispensary.²⁸

At the 37th annual general meeting, held in 1924, it was noted that Dr Herrick had retired during the previous year (in 1923) (and had been appointed Honorary Consultant Anaesthetist at the Nottingham General Hospital).²⁹ Dr FW Wesley was appointed surgeon to maintain the service, which continued to grow; however, there remained an urgent need for additional in-patient accommodation. The managers were directed by the governors to proceed with negotiations and to seek new premises.³⁰ Mr GH Mansfield was appointed as the third surgeon, in 1926.

During the annual general meeting of 1927, it was reported that ‘the surgical procedures had increased to 607 while the additional number performed under local anaesthetic was “considerable”’.³¹ A deficit of £1,500 was declared, most likely related to the purchase of the Goldsmith Street premises.^31,32

Purchase of hospital premises

The purchase of 63 Goldsmith Street (in 1925) necessitated the refurbishment of the original house (for use by in-patients) and the building of a single-story out-patient department. The new building was built and opened in 1928.³² The house refurbishment allowed for 5 extra beds (11 in total). Moreover, it was reported in 1929 that the number of operations had increased to 718, with ‘a large number under local anaesthetic’. The admissions waiting list was reported to have more than 250 patients. Efforts to reduce the hospital debit proved difficult, because of the need for renovating, decorating and painting the hospital. During 1929, the governors introduced ‘a ward’ for paying patients.³³

Continued need for additional accommodation

During the 1930s, two building projects were undertaken: an extension of the in-patient block (the house) to accommodate a kitchen and scullery (in 1933) (as revealed by the Nottingham Directories search (Report PH/70/4/3/16 – R797/Bradley)), and an extension over the existing single-story wing to increase the out-patient accommodation (in 1934). While recognising that this project would incur additional debt, it was ‘hoped that with the generosity of the subscribers, could be maintained if not increase the numbers so that the debt could be cleared’. Over the following years, the subscribers, donations, patient fees and public collection money (on flag days) continued to flow in. The proposed extension and refurbishment of the ground floor was delayed because of the need for building repairs and so on,³⁴ but was finally built and opened in 1935.³⁵

In 1936, six cottages in Auburn Terrace were purchased,³⁶ located at the rear of the hospital premises. It was hoped that demolition of the cottages would allow access for the building of a new hospital wing. This new building proposal was submitted and approved by the General Works and Highways Committee of Nottingham City in 1937 (as revealed by the Nottingham Directories search (Report PH/70/4/3/16 – R797/Bradley)). This building development was deferred because of the existing debt and later by war-time building restrictions. Fortuitously, the additional income obtained from renting the cottages considerably boosted the annual budget.

During 1936, the deaths of Dr Gray and Dr Wesley were reported, followed by that of Dr Herrick in 1937. These deaths necessitated the appointment of three surgeons: Dr HB Lieberman, Mr EJ Gilroy Glass and Mr RA Marshall.^37,38 Lieutenant Colonel EJ Gilroy Glass was seconded to the HM Forces in 1939, and was demobbed in 1945.

In 1940, the Nottingham and Nottinghamshire Hospital for Diseases of the Throat, Ear and Nose was for the first time the recipient of money from a local contributory scheme called the ‘Nottingham and Nottinghamshire Hospital Saturday Fund’.³⁹ This Fund, founded in 1873, collected money at the workplace from the workers, on fixed Saturdays during the year, for the local voluntary hospitals.^{Reference Bosworth3} This funding, initially a voluntary contribution, became a weekly collection deducted from source by employers.^{Reference Cherry40} Most of the Fund money went to the Nottingham General Hospital, with the remaining money allocated to the smaller hospitals.^{Reference Bosworth3} By 1943, more than half of the hospital's income was from the ‘Saturday Fund’ (£1208, 7 shillings and 6 pence).³⁹ The clinical activity continued despite local hardships, staff and bed shortages, and surgical scheduling; ‘the question of further expansion of the accommodation continued, but the timing was considered inopportune for any building scheme, the moneys would be transferred to a building fund and be used when trade conditions become more normal’.^39,41 However, during the war years (1939–1945), the clinical and surgical service continued to increase, despite the many difficulties.

During 1944, the White Paper A National Health Service was published, which detailed the government's vision of a comprehensive, free and unified healthcare system.⁴² While the possible consequence of the proposed government-funded healthcare system was debated, activity and planning at the hospital continued. By 1945, the President, Mr Thomas Cecil Howitt (1887–1968) (previously Governor, Vice-President and City Architect) reported that ‘there was £6,000 in the building fund, finances were satisfactory, but the volume of work continued to increase, the workforce suffered from understaffing, with the surgeons being overworked’.⁴³ He reported in 1946 that ‘while the Government's plans regarding the hospital services were not known, an option had been taken on a site on Mapperley Road for a new building, at a cost about £60,000’.⁴⁴ The Treasurer reported that the subscription and box collection amount during that year was £278.00 out of a total income of £2128.00, with a total expenditure of £1996.00, and the building and equipment fund stood at £6739.00. In February 1947, it was reported by the Honorary Treasurer, Mr RA Page, ‘that that scheme to provide a hospital on Mapperley Road …had fallen through. Some cottages… it was hoped to build a new wing’.⁴⁵ These cottages, bought in 1936, had been approved for demolition and a new building in 1937 (as revealed by the Nottingham Directories search (Report PH/70/4/3/16 – R797/Bradley)).

National survey of hospitals

A national survey of hospitals had been conducted in 1938 to consider the provision for casualties in the event of war. During World War II, the Ministry of Health and the Nuffield Provincial Hospitals Trust undertook a survey (1942–1944) of the 10 regions in England and Wales.^{Reference Godber46} The survey of Sheffield and East Midlands was one of the first such reports, published in 1945.⁴⁷ Three surveyors visited every institution that ‘might’ be called a hospital. They reported that the ‘Nottingham Throat, Nose and Ear Hospital’ ‘was grossly overcrowded. It is housed in buildings unsuitable for hospital use; the work undertaken is mostly of a minor character; e.g. tonsillectomies and nasal operations. Rebuilding has been planned on the same site’.⁴⁷

The hospital's demise

In the Nottingham Evening Post of Wednesday 22nd October 1947, it was announced that a meeting had been called, to be held on Friday 29th October, to consider the resolution that ‘the Hospital be amalgamated with the ENT Wing of the Nottingham General Hospital’.⁴⁸ The Annual Report of Nottingham General Hospital for 1948 reported that the amalgamation had been approved by the Ministry of Health and the Charity Commission.⁴⁹ Mr Howitt commented ‘that during the War period the country's building programme on housing was curtailed and the hospital was not able to expand the accommodation nor able to purchase any equipment, resulting that it was unable to cope with the ever increasing demand’.⁵⁰ The President of the Nottingham General Hospital, Lieutenant Colonel N Jervis Pearson, reported that ‘they had accommodation and facilities to increase the numbers of beds for in-patients, and would be able to deal more rapidly with the waiting list’.⁵⁰

The ‘old’ hospital building was occupied by the Ministry of Health for Pathological Services of Nottingham. Approximately £14 000 was used to upgrade the operating theatres and sterilising room, and to add 2 single wards, increasing the ENT department bed complement to 49. The last of the money received from the sale of the Nottingham and Nottinghamshire Hospital for Diseases of the Throat, Ear and Nose premises was used in 1973 to upgrade the out-patient department and provide teaching facilities for medical students. The medical school was established in 1964, and admitted the first students in 1970. Nottingham Medical School was the first new medical school created in the UK in the twentieth century.

The ENT Department of Nottingham General Hospital exists today, having relocated to Nottingham University Hospitals, Queen's Medical Campus, Nottingham, in 1983.

Commentary

Dr Donald Stewart, a Scottish doctor, identified the need for a specialist ENT disease service for the sick poor of Nottingham, in 1886. The identification of the need for such a service in the local Nottingham and Nottinghamshire population could be construed as ‘tardy’ compared with what was available in other English provincial cities and towns. A survey in 1913 reported that there were clinics (hospitals, infirmaries and dispensaries) offering ENT disease services to patients at 41 locations in London and 44 in the English provinces, in addition to 14 clinics that combined ENT with ophthalmology (eye and ear clinics).^{Reference McKenzie51}

The specialty of otolaryngology underwent many dramatic developments during the mid-nineteenth century and into the twentieth century; the use of anaesthesia (local and general, and intubation; 1850–1900), the discovery of antibiotics (e.g. penicillin, in 1928), the commercialisation of sulphonamides (since 1938), and the development in optics with microscopes and endoscopes, have changed our discipline from a semblance of ‘quackery’ to a ‘physician-surgical’ discipline with science.^{Reference Harrison8}

The debate as to ‘best housing’ of our discipline, between ‘specialist hospitals’ versus ‘specialist departments’ within a larger establishment (secondary or tertiary hospital), has been discussed widely in many European countries. Advocates for a ‘specialist hospital’ system, and there are not many, cite emotional arguments advocating a ‘cosy’, ‘friendly’ and ‘protectionist’ ambition for our working environment. However, the ‘specialist department’ allows: more integration, co-operation, camaraderie and belonging; enhanced sharing and teaching; easier access to facilities, laboratories and imaging; and improvements in diagnostics and emergency work.^{Reference Russell-Wells52}

The relationship between the community and the voluntary hospitals changed over time, as the working-class payments increased as a proportion of the hospitals’ income, and it was recognised that the financial costs should be more broadly shared across the social classes.^{Reference Hayes53} Healthcare has become more expensive, and the financial burden for inventions and developments needs to be shared across the community and ultimately across the nation.