St Mark's Hospital was founded in 1835 by Frederick Salmon in a spirit of protest and independence against the closed world of the medical profession at the time.
Frederick Salmon – Rebel and Entrepreneur
Frederick Salmon was born in Bath in 1796, the sixth child of a practising attorney. He was apprenticed at the age of 15 to a surgeon-apothecary, a combination of both surgeon and physician, and at some time during this period, he came into contact with William White, one of the earliest surgeons in Britain to write on rectal disease and whom Frederick Salmon later credited with the direction his own medical specialisation took.
Salmon qualified for his licentiate of the Society of Apothecaries in 1817 and in October of that year entered St Bartholomew’s Hospital, Smithfield. He paid 6 guineas to ‘walk the wards’ as a pupil, together with 92 others.
Medical training at that time depended on money and influence – posts had to be paid for and were often earmarked for friends and relations of the surgeons and physicians. In 1818, Salmon was admitted as a member of the Royal College of Surgeons and he paid £8 15s 0d in order to become house surgeon at St Bartholomew’s Hospital. The traits of character that were to help him later must already have been well in evidence to secure him this post.
In 1827, at the age of 31, he became surgeon to the General Dispensary in Aldersgate Street. He resigned from the Dispensary in 1833, along with several others, in protest against an attempt by the hospital governors to revert to a system whereby posts were, in effect, bought. As The Lancet stated in October 1833, the practice was ‘one of money, of favour, of family interest’. The mass resignation from the Dispensary was a major medical scandal of the time and was widely reported in both the medical and the lay press.
The Fistula Infirmary
By this time, Frederick Salmon had published several books on rectal problems, one of which was already in its fourth edition, but despite his abilities, ambition and professional reputation, a suitable hospital appointment eluded him.
Unable to break into the closed medical world of the early nineteenth century, where contacts were more important than talent, Salmon decided to found his own institution in 1835. The ‘Infirmary for the Relief of the Poor Afflicted with Fistula and other Diseases of the Rectum’ was mainly an out-patient dispensary, with only seven beds, at 11 Aldersgate Street in the City of London. Salmon was assisted by a house surgeon and one nurse. In the first year of the new infirmary, they treated 131 patients for fistula, piles, rectal stricture or prolapse.
Charity hospitals at that time were for the poor. Many wealthy people became patrons and benefactors of their chosen institutions. Salmon’s Infirmary followed this pattern.
The ‘Fistula Infirmary’, as it soon became known, was inundated with work: the number of patients had trebled by 1838. To accommodate the increasing work-load Salmon moved to larger premises at 38 Charterhouse Square, where there was room for 14 beds and improved facilities for out-patients. The Square was on the edge of Smithfield Meat Market and one story passed down through Salmon’s descendants records that the operating table in the new hospital was a butcher’s table from the market. Salmon must have been a man of great charisma as well as determination.
The Workload Increases
This was a time of important changes in medical practice. London grew rapidly in the nineteenth century, with vast numbers moving in from the countryside, crowding into slums and living in insanitary conditions. Whereas formerly specialist practitioners such as ‘fistula doctors’ travelled from town to town to find patients, advertising on their way, there was now a sufficient concentration of potential patients in London to ensure success for hospitals specialising in particular ailments.
The formation of small specialised hospitals did not meet with the approval of those at the older and general hospitals, who felt that specialists undermined their position. However, bankers, lawyers and merchants of the City of London did not have any such misgivings and Salmon rapidly enlisted their help. Most important of all was that Salmon secured as the first President of the Hospital William Taylor Copeland. He was Lord Mayor of London in 1835 and Alderman of the Bishopsgate ward, in which the Hospital was situated.
He tried to place the new institution on an equal footing with the Aldersgate Street Dispensary and St Bartholomew’s, who also had call upon the Lord Mayor’s services. The Lord Mayor of London remained the Patron of the Hospital until the move from the City Road in 1995.
Sustaining an Infirmary with in-patients was far more expensive than running an out-patient facility. In 1838, total expenditure over the previous 16 months was £900, for items like the board and maintenance of patients, including washing, coal and candles (almost £150); the under-nurse was paid almost £20, the matron 25 guineas and the surgeons’ assistant 60 guineas. In 1840 one thousand pounds was received as the first of the large legacies, and several staff changes were made, including the employment of more servants.
One of Salmon’s private patients who became a Life Governor at this time was Charles Dickens. He was suffering from an anal fistula – in his own words ‘the consequence of too much sitting at my desk’. At his home in 1841, Dickens was operated upon by Salmon, without anaesthetic of course, ‘…last Friday Morning was obliged to submit to a cruel operation, and the cutting out root and branch of a disease caused by working overmuch which has been gathering it seems for years.’ In his diary he recorded: ‘I suffered agonies, as they related all to me, and did violence to myself in keeping to my seat. I could scarcely bear it.’ In gratitude for successful treatment, Dickens gave Salmon several autographed copies of his latest work, The Pickwick Papers, and contributed 10 guineas to the hospital.
The Founding of St Mark’s
The increasing demand from the poor of London for the services of the ‘Fistula Infirmary’, coupled with its success and recognition within the City, led to a search for larger premises in the 1840s. In 1851, a site in City Road, near the Angel in Islington, in the parish of St Mark’s Church, Myddelton Square, was acquired from the Worshipful Company of Dyers and a specially constructed hospital was begun.
The new Hospital was given a new name: St Mark’s. It was far easier to appeal for funds under a name like St Mark’s than as the ‘Fistula Infirmary’. Salmon was adamant that the specialised nature of the Hospital should be acknowledged in the title, so it became ‘St Mark’s Hospital for Fistula and other Diseases of the Rectum’. The title ‘St Mark’s Hospital for Fistula & c’ was carved in stone above the door. The official opening took place on St Mark’s Day, 25 April 1854.
The hospital was now faced with a substantial debt: it was necessary to raise a further £3,500 to complete the building and to supply equipment. Although it had been advertised that the Hospital would house 50 in-patients, it opened with only 24 beds and fluctuated between that and about 35 beds for many years. In spite of this, the opening represented a high point in the Infirmary’s history: ‘Beds always full; eager applicants waiting, often for weeks, for their turn of admission; sufferings such as it is difficult to realise, borne in secret and in silence through years of inconceivable and all but hopeless misery; – these are the hourly scenes with which the charity is familiar.’
Donations were received from many sources, including Prince Albert, Queen Victoria’s husband. In 1859 beds were increased to 33 and running costs were around £2,000 per annum. Finances continued to be a problem, made no easier when it emerged, in 1865, that the hospital secretary had defrauded the Hospital of more than £400. The money was never recovered and many changes were made to prevent such an occurrence happening again. The suppliers of meat and bread were changed and the Hospital’s business was contracted out to the lowest bidder. Many of those who worked in the Hospital, from the matron to the porter, were given provisions and fuel. They apparently ate fourteen ounces of meat each and eight and a half ounces of bread daily. However, it was decided that their alcohol consumption – three and, a quarter pints of beer a day each – was excessive. The matron blamed the porter, implying that he was selling it. To overcome this, payment in cash was gradually substituted for payment in kind.
The Work Continued
Salmon remained the only surgeon at the Hospital until his retirement in 1859, when he was succeeded by two surgeons carefully chosen to carry on his work. His most notable successors at St Mark’s in the Victorian era were William and Herbert Allingham, both of whom helped create the specialty of proctology and continued the successful development of the hospital.
In 1864 Salmon’s health began to fail and he retired to Worcestershire, where he died on 3 January 1868 at the age of 72. He is buried in Kensal Green Cemetery, in London.
The work continued to expand, but plans for an extension to the Hospital in the 1870s had to be delayed because of lack of funds. The new extension to the existing Hospital was eventually opened in 1896.
Despite the fact that in 1900 there were just over 1,000 supporters of the Hospital, the increased financial burden almost brought disaster, and the Hospital was rescued by a charity matinee in 1902, organised by Lily Langtry at her theatre in Drury Lane. The souvenir programme related ‘The Story of St Mark’s’ , but no mention was made anywhere of the diseases which St Mark’s treated. The money raised was not enough. In 1903, each new out-patient was to be charged one shilling (5p) for the first attendance and sixpence (2 1/2p) thereafter. Each in-patient should, ‘according to his or her means, pay between 5 and 10 shillings a week for maintenance and treatment’. In addition, two rooms were to be set aside for private patients, who were to pay at least 4 guineas (£4 4s 0d) a week to cover nursing, food and medicine in addition to the surgeon’s fees.
St Mark’s and Cancer Research
Rectal cancer was becoming an important part of the work at St Mark’s, with surgeons developing new operations to treat the disease.
This work became so important that, in 1909, the Hospital’s title was changed to ‘St Mark’s Hospital for Cancer, Fistula and other Diseases of the Rectum’. In the period between the two world wars, 1918-1938, St Mark’s thrived and expanded while other hospitals faced major problems. The belief in progress, especially medical and scientific, was strong, and there was great confidence that with sufficient effort cancer could be overcome. With the energetic assistance of the surgeon Percy Lockhart-Mummery, who had joined the staff at the turn of the century, St Mark’s took its place in the crusade against cancer. Mr. Lockhart-Mummery also played a leading role in establishing the British Empire Cancer Campaign, later to become The Cancer Research Campaign in 1923.
This cancer charity, as well as the older-established Imperial Cancer Research Fund (ICRF), contributed a great deal to funding of work at the Hospital. In 1984, an ICRF Unit, to study colorectal cancer, was set up within St Mark’s, and remains to this day.
A pathologist was first appointed in 1908 and three years later the Pathology Department was formed. Cuthbert Dukes was the pathologist from 1922 to 1954. The Dukes classification of tumours remains the international standard. In 1921 the X-ray Department was established and in 1924 there was a major appeal, with a full page spread in the Telegraph, heralding St Mark’s as ‘fighting the nation’s battle against cancer’. As a result of this appeal the Hospital was able to build an extension and by 1927 there were 72 beds. A second appeal, launched at the Hospital’s centenary, allowed a Nurses’ Home to be built on to the side of the Hospital. It was completed in 1938 and opened by the Princess Royal.
Although cancer treatment was the primary means of raising funds, St Mark’s continued to treat inflammatory bowel disease and the other rectal problems which have always been a major part of its work.
During this period, the Hospital’s reputation in medical circles was high and increasing numbers of visitors came from all over the world. The operating theatre book for 1925 showed 190 visitors, who came from as far afield as the United States, Australia, New Zealand, Canada, South Africa and India.
The Second World War, with its air raids and economic stringencies, affected St Mark’s far more than World War I had done. All through the war years there were great staff shortages; by the autumn of 1943 there was a waiting-list of almost 250, rats were seen in the hospital, and there was such a shortage of maids that it was suggested that Matron ‘might approach Homes for the Feeble Minded, as it is possible they may carry out a maid’s duties’. On 29 December 1940 an incendiary device fell through the roof of the operating theatre and anaesthetic room, but damage was limited to a small fire. In June 1944 a bomb blast damaged the Nurses’ Home, but not extensively.
St Mark’s and the NHS
During this period, plans were being laid for the changes that would lead to the formation of the National Health Service and in 1945 St Mark’s realised that it would have to move shrewdly to avoid integration into another hospital. Aneurin Bevan, the new Minister of Health, had been treated as a private patient by a St Mark’s surgeon and had been quoted as saying that St Mark’s was to be a ‘jewel in the Health Service’. Only teaching hospitals were to be exempt from external administration and St Mark’s quickly boosted the teaching side of its activities by, amongst other things, appointing a Dean of Postgraduate Studies. As a result of these efforts, it was given postgraduate status, which it retains to this day.
Specialities within Specialities
In recent years there have been major developments in the treatment of colorectal diseases, many of them influenced by the work at St Mark’s. These have included stoma-saving operations in cancer, colitis and polyposis and medical treatments for colitis and Crohn’s disease. St Mark’s has also pioneered improved diagnostic procedures in colonoscopy, pathology and radiology. In 1986 the Imperial Cancer Research Fund established two units at St Mark’s, the Colorectal Cancer Unit and Nuclear Medicine Unit. The Hospital is at the forefront of research into the genetics of cancer and bowel diseases via the Polyposis Registry and the Family Cancer Clinic. Other major contributions include the development of nutritional aid to those who cannot absorb food in the usual way, improvements in the surgical and physiological treatment of injuries sustained during childbirth and the development of specialist nursing.
St Mark’s is exceptional in the way the resources of each department are combined to provide an umbrella of treatment and multidisciplinary care for the patient.
St Mark’s on the Move
By 1989, it was clear that the old building was no longer able to house St Mark’s if it was to continue and expand its work as a national centre for intestinal diseases. Discussions were held with Northwick Park Hospital in Harrow and in 1994 the Northwick Park and St Mark’s NHS Trust was created. On Saturday 15 July 1995 the Hospital moved into specially adapted premises previously occupied by the Medical Research Council on the Northwick Park site in Harrow. With the co-operation and support of the staff, the move was made with the minimum of fuss and disruption. The Hospital remained operational and after a closure of only one week admissions and out-patients’ clinics were resumed.
Since the Move
The relocation from inner to outer London has been a success. St Mark’s has maintained its referral practice and has developed its services, research and teaching. It has benefited professionally in establishing collaboration with the doctors and nurses of Northwick Park Hospital and has developed close links with Imperial College School of Medicine. Academic appointments are being made, postgraduate education has increased and undergraduate teaching has been introduced. Research is expanding, helped by some government funding and the vital support of the St Mark’s Research Foundation, the Marksman Appeal and the Imperial Cancer Research Fund.
In 1999 the Northwick Park and St Mark’s NHS Trust and Central Middlesex Hospital NHS Trust merged to form the North West London Hospitals Trust.
The Hospital founded in 1835 by Frederick Salmon continues to uphold his ideals. It is well equipped to go ahead successfully into the twenty-first century.
The unique atmosphere at St Mark’s Hospital inspires great loyalty from both patients and staff. Staff tend to come and stay, with the record being held by Dr. Dick Bussey, who arrived in 1924, aged 17, as an assistant in the Pathology Department and stayed more than 60 years. Those who do not stay have carried the work of St Mark’s throughout the world and their students continue to come and learn, to research and, sometimes, to stay themselves.
Perhaps the meaning of St Mark’s is best summed up by the patients, one of whom wrote:
‘I have been a patient (at St Mark’s) in and out, for over 17 years and the hospital has consistently met my needs. To put it simply – being a patient at St Mark’s has transformed my life. When I arrived here all those years ago, I felt frightened, angry and confused by what had befallen me. But at St Mark’s I found understanding, acceptance and a calm, positive attitude towards coping with my illness. Perhaps most important of all, what disease had taken from me – my status and dignity as a human being – was restored. I was treated like a person, not a disease on legs…
‘For a St Mark’s patient, a specialist is only a phone call away. If we are worried about any aspect of our condition, we can phone and speak to a doctor, nurse, social worker, pharmacist, dietitian, psychotherapist, physiotherapist and many others, all specialising in the care of patients with gut problems.
‘I do have the expertise (who better than a patient?) to talk about quality, and that is what I have experienced at St Mark’s… I am convinced that if those who are empowered will it, then St Mark’s…can remain for me, for thousands of others like me and ultimately for us all, a ray of hope.’