In January of this year Dulwich lost an old friend with the death of Dr. David Mann. He was the last doctor of a medical family who had been in general practice in Dulwich for over sixty years. Many readers will have had fond memories of both him and his brother James and some also of his parents both of whom were doctors. When he left the practice at Paxton Green David wrote and left us an account of the medical world in which his parents lived and in which he and his brothers grew up and it is the basis of this article.
With the construction of the London South Coast railway in the 1860’s, new roads, the upgrade of the schools and not least the transfer of the Crystal Palace from Hyde Park to Sydenham, had an exponential rise in the population of Dulwich and Norwood over the second half of the nineteenth century. The area was favoured because of the (probably) correct impression that the air was cleaner than in central London. Into this increased population came the doctors, who put up their brass plates, perhaps attracted by the relatively wealthy element that had come to live here, for their patients were exclusively fee payers.
The poor were of course unable to afford medical fees unless supported by philanthropy but available to them were the services of a provident dispensary or sick club of which there were three in the vicinity. These required a weekly payment of about two and a half pence. Too often, if they were in real trouble, the poor had to resort to an infirmary linked workhouse. However the 1867 Metropolitan Poor Act required that infirmary accommodation be separate from workhouse buildings. The local Camberwell workhouse was situated on the borders of Peckham, while neighbouring Southwark’s was in overcrowded Newington near the Elephant and Castle. Following the Poor Act, the St Saviour’s Union, made up of three parishes in Southwark, (Southwark, Bermondsey and Newington) negotiated to build an Infirmary on the site which was to become Dulwich Hospital in later years. This was achieved in the teeth of opposition led by Sir Charles Barry and Sir Henry Bessemer who thought it would lower the tone of the area, but it was opened in 1887 with 723 beds.
Kings College Hospital had originally been a workhouse in Holborn, but had been established as a hospital in 1840 and did not move into its present site until 1913. It was then requisitioned as a military hospital by the War office for the duration of the First World War, dramatically described by Vera Brittain in her autobiographical book A Testament of Youth. Its reputation as a centre of excellence was to develop after the war, particularly after the discovery of Insulin as a treatment for Diabetes.
Alongside, and in many ways independent of the medical profession from the 1860’s, a district nursing service was developing. This was largely due to a philanthropist from Liverpool called William Rathbone who got the ear of Florence Nightingale and together they secured a grant of £70,000 from Queen Victoria in 1887 to establish the Queen’s Nursing Institute. From this emanated a national network of local nursing associations which established provident schemes to enable poor families to obtain a district nurse for around one shilling a year for individuals or two shillings and sixpence for families. The Metropolitan and National District Nursing Association was set up in London in 1875 which established training for district nurses and midwives enabling the poor to be looked after at home.
Dulwich gained its first Queen’s Nurse in the person of a Miss Moncrieff who was recorded in the parish of St Barnabas as having made 723 home visits during the first part of 1893, an unimaginable total, her attendances having been paid for by subscription administered by the chaplain at Christ’s Chapel.
Before the NHS, upwards of twenty five babies per thousand were stillborn or died soon after birth. Indeed prior to the First World War there was little if any ante-natal care, and significant numbers of mothers died in or just after childbirth, often from haemorrhage or overwhelming infections. The name midwife comes from the German “mit” i,e. with the wife and referred to traditional birth attendants, who could be anybody, and some of whom apparently were prostitutes with their services being paid in gin! The Nursing Associations started to provide training but the key moment came in 1902 with the Midwives Act that made it mandatory for midwives to be trained and registered. Right up to and even beyond the start of the NHS the majority of births were at home and the district midwife was a key member of the community, and as a result of the Midwife Act of 1936 the presence of a trained midwife at each birth became a statutory requirement.
The National Insurance Act introduced by David Lloyd George in 1911, heralded the first radical change to medical services by which working men were able to register with a doctor as so called Panel Patients, by dint of their insurance contributions. Because of the First World War this took a little time to take off but by the time Dr. James Mann senior came into Dulwich from his native Scotland in 1922 the Act was becoming fully implemented and the small brown medical records still known as ‘Lloyd George notes’, with which many will be familiar, were created.
The medical scene was very different to that we see today. Most if not all the doctors were effectively single handed, even if nominally in partnership, usually practising from downstairs rooms of their homes. There were no receptionists except on the occasions when the doctor was assisted by his wife. The wealthier patients were seen in the doctor’s home but the poorer were often seen at the back of a shop premises, usually a pharmacy, such as the chemist that was to become Mills & Smith (now the Paxton Pharmacy).
Practices had to be bought and sold and when Dr. James Mann appeared with his wife Dr. Olwen Mann he had to buy a share of an existing practice in what was to become a partnership, but he and his wife were taken on with the expectation that they would look after the poorer patients. A new surgery, located in former shop premises in 231 Gipsy Road was acquired, to conform with the aforementioned insurance act, to split doctors from chemists, so that doctors could no longer see their patients at the back of their shops. David Mann described the 231 Gipsy Road premises originally as a grim site with the bottom half of the windows painted dark green for privacy, a couple of awful pictures in the waiting area and a bench along which the queue of patients shuffled when the doctor cried “Next”.
Patients were offered a consultation and a “bottle” for one shilling and nine pence. The bottle’s contents had an awful taste and dramatic names such as “Mist. Pot. Iod. and Stramon.” or “Mist. Pot. Brom. and Nux Vomica.” The commonest was “Mist. Tuss. Nig.” which really meant the black cough mixture. These were of course the placebos for minor illnesses and the worse they tasted the more good they were thought to do.
However there were much more serious problems to be dealt with. Severe bacterial infections often led to early death and the Streptococcus was a major culprit causing scarlet fever, rheumatic fever, heart disease or nephritis. When it got into the uterus after a birth, the dreaded childbirth fever was a frequent cause for new mothers to die. And the Pneumococcus was a frequent cause of lobar pneumonia which could strike and kill at any age.
Measles, Mumps and Whooping cough were a ritual that every child had to go through and the major dread of every family was Poliomyelitis that could kill or leave a child permanently paralysed. Tuberculosis, historically known as Consumption or Psthisis was still widespread and from time to time in spite of the availability of vaccination outbreaks of Smallpox would crop up. Diphtheria was perhaps the most deadly disease for which often the only remedy was tracheotomy i.e. surgery to make an opening into the windpipe. Dr. Mann senior had in fact caught this himself from a patient while working in a fever hospital before he came to Dulwich, and from which he was lucky to survive. Remedies for many of these infections were limited so that the doctors had to rely on antisepsis and hygiene, or as in the case of diphtheria and tuberculosis radical surgery with the use of sanatoria or isolation hospitals, hoping that their patients’ immune systems would effect cure.
With time, the practice clientele of the senior Manns expanded, as they had proved to be skilled and approachable, but with the Second World War Dulwich, including their own home, was extensively bombed. Many residents were evacuated causing a fall in the local population and a temporary diminution in their practice and until the end of the war only limited improvements were possible. Then 1948 brought the start of the NHS with freedom of access to medical care at the point of delivery and this coincided with the discovery of the effectiveness of Penicillin. The discovery of Streptomycin at the same time was the first of a long series of anti-tuberculous agents. The Streptococcus and the Pneumococcus were both sensitive to Penicillin and have indeed, in spite of other antibiotic resistant bacteria remained so. It is hard now to realize how much these two factors revolutionized the spectrum of disease that was encountered and along with both universal childhood immunization and the improvement in public health why the generation in which I grew up regarded the NHS as a gift.
David Mann, who along with his elder brother James, succeeded his parents was largely responsible for negotiating the building of the Paxton Green Health Centre. The movement of the practice from Gipsy Road to purpose built premises pioneered a change in the delivery of medical care in Dulwich and Norwood that would have been beyond the wildest dreams of the pre war doctors’ days. 231 Gipsy Road is now a veterinary surgery and looks a great deal better than ever it did when the patients were members of the human race, although to be fair very considerable improvements had been made in the post war years.