The rapid increase in death and disease, in London in particular, was linked with the mid- 19th century revolution in the way industry worked. Recognition of the importance of protection of public health and safety to ensure the working population remained productive led to the development of the first public health laws aimed at improving the sanitary conditions of the working classes.209 There was recognition that ambulance services were necessary and important but there were no laws that authorised the establishment of a charitable, coordinated, city-wide ambulance service.210 In lieu of this, public cabs commenced operating as a proxy ambulance service. However, in 1832 the city was hit by a cholera outbreak and from this grew a recognition that a public cab was an inappropriate means by which to transfer sick and contagious people to hospital. Fire
207 John Haller, ‘The Beginnings of Urban Ambulance Service in the United States and England’ (1990) 8
Journal of Emergency Medicine 743. The Middlesex Hospital Board provided a horse-drawn wheeled sedan chair to transport injured persons around 1777, and in 1796 the Manchester Board of Health also provided a sedan chair to transport fevered patients to the newly established quarantine hospital. By 1852, the
Chelmsford Board of Health in Essex had also commenced using a modified cart to convey cholera patients to hospital.
208 Roger Cooter and Bill Luckin (eds), Accidents in History: Injuries, Fatalities and Social Relations
(Editions Redopi, 1997) 116.
209 Edwin Chadwick, A Report on the Sanitary Conditions of the Labouring Population (Publisher, 1842).
210 The Poor Law Amendment Act 1834, 14 Geo 4,created 30 autonomous boards to oversee London’s
charitable services. See Ryan Corbett Bell, The Ambulance: A History (McFarland and Co, 2009) 24;
Matthew L Newsom Kerr, ‘“Perambulating Fever Nests of our London Streets”: Cabs, Omnibuses,
Ambulances, and Other “Pest-Vehicles”’ in the Victorian Metropolis’ (2010) 49 Journal of British Studies
services were considered an alternative because they could place a stretcher on their fire wagon but it was recognised this was also not ideal because the infected person would be exposed to the community, thus risking further spread of disease.211 City officials realised the unique role and vital purpose that ambulance services could play in the protection of public health and began establishing a dedicated ambulance service fit for purpose.212 Growth in the sector was rapid over the next 15 years as the recognition of the benefits and the importance of the service as a public health tool grew. Along with this recognition came the first elements of ambulance authority—the culmination of an acknowledgement of the significant nature of ambulance work and the need to have that work performed in a particular way. This growing authority was most obviously demonstrated in the inclusion of ambulance services in the law.
3.2.1Ambulances and the Law
By 1856 the medical journal The Lancet was publicly advocating the benefits of and need for each workhouse to have its own ambulance.213 Continuing outbreaks of infectious diseases including smallpox and a shortage of suitable conveyances for the diseased led to the passing of the Sanitary Act 1866 (UK). The law was responsible for the development of the ambulance into a legitimate, unique and vital public health service by requiring local communities to ‘construct suitable ambulances for contagious cases’.214 Although the term ‘ambulance’ is not used in this piece of law nor the Public Health Act 1875 (‘the PHA’) that followed it, section 123 of the PHA does encourage local sanitary authorities to provide a ‘conveyance for infected persons’.215
At this time ambulances often resembled cabs and so the local metropolitan authorities were invited to mark ambulances with the word ‘AMBULANCE’ in ‘conspicuous letters’
211 Sally Wilde, From Driver to Paramedic: A History of the Training of Ambulance Officers in Victoria
(Ambulance Officers Training Centre, 1999).
212 Manchester officials realised the importance of this justified the use of public funds to purchase a special
van to carry victims. Unfortunately, the van resembled a hearse and so scared patients that they were afraid
to call for it. See Ken Smith, ‘The Ambulance Service Past, Present and Future’ (1988) 232Practitioner
879, 882; Ryan Corbett Bell, The Ambulance: A History (McFarland and Co, 2009) 25.
213 ‘The Lancet: London: Saturday, 12 April 1856: “Street Cabs and Contagious Diseases”’ (1856) 67
Lancet 389, 409.
214 Ryan Corbett Bell, The Ambulance: A History (McFarland and Co, 2009).
to differentiate them.216 Although ambulance services did not have a complete monopoly on the conveyance of the sick and injured to hospital, the PHA did provide legitimacy to the term and notion of a particular vehicle being associated with the transportation of particular types of people—namely the diseased.217 Although cabs could still be used for the conveyance of the sick and injured, it became an indictable offence for any cab to transport a non-infectious person unless the cab had been adequately disinfected.218 This provision raised concern by the medical establishment that such a law would ‘[convert] the cabman into a pathologist’;219 perhaps in so doing, it inadvertently identified the need for such a person. If such a role were to be developed, then further education of those staff would be required. This was the first time the law was used to provide ambulance services with a monopoly or at least an authority to provide a service for a particular purpose in a particular way, and disallowed others from doing so. This is further evidence of the progression towards the professionalisation of paramedicine as it is consistent with the Freidson criterion that identifies that having special knowledge and skills to adequately and arguably safely apply a unique and significant public service is a trait common to professions.
3.2.2The Need for Further Education
In 1878 the London Standard reported that the Order of St John would not only provide relief for the sick and wounded of the British Army; it would also commence instructing individuals ‘not belonging to the Medical Profession’ in ways of ‘tending and relieving persons injured by accident in a time of peace’.220 The organisation relied on the principles of care delivered on the battle field: the preservation of life, prevention of further harm and promotion of recovery. The type of care provided was largely adopted from the St John Ambulance Association training manual First Aid to the Injured, which was first published
216 Matthew L Newsom Kerr, ‘“Perambulating Fever Nests of our London Streets”: Cabs, Omnibuses,
Ambulances, and Other “Pest-Vehicles”’ in the Victorian Metropolis’ (2010) 49 Journal of British Studies
283.
217 Ibid.
218 Ryan Corbett Bell, The Ambulance: A History (McFarland and Co, 2009) 27.
219 ‘Conveyance of Fever Patients in Public Vehicles’, (1853) XXVII Medical Times and Gazette 651, 652
cited in Matthew L Newsom Kerr ‘“Perambulating Fever Nests of our London Streets”: Cabs, Omnibuses,
Ambulances, and Other “Pest-Vehicles” in the Victorian Metropolis’ (2010) 49 Journal of British Studies
283, 295.
220The London Standard (2 January 1878) cited in Murdoch Wales and John Pearn, First in First Aid: The
in 1879. Shepherd wrote the first text on first aid. He had been a surgeon-major in the British Army and had quickly transposed the essential elements of first aid utilised in battle to the text. This event marked the beginning of the recognition of the need for an organised, trained and progressive civilian ambulance service.
By 1879 the Metropolitan Asylums Board had centralised the metropolitan ambulance operations. It sought to deliver a swift response via a sophisticated communication system that involved a call being placed to the ambulance station where a uniformed crew of drivers and a special nurse would be dispatched to the patient.221 It established principles of service including ‘efficiency, safety and discipline’ to promote confidence in the service.222 It also introduced purpose-built technology to ambulances, which further set them apart from other modes of transportation. For example, specially constructed ventilation shafts treated with ‘germicide solution’ were built into the ‘patent safety fever van’.223 However, there was still a lack of suitably qualified staff and vehicles available to meet demand. In 1881 a letter written by a doctor about his ill son and his efforts to find an appropriate conveyance to remove him to hospital and published in the British Medical Journal highlighted this gap:
the whole square was deeply shocked at the sight of the conveyance. I can only describe it as a cross between a hearse and a dirty linen cart, painted black and with funereal side glass; a black horse … and a driver of the most woeful aspect, also in deep black … surely the metropolis will not long delay this much needed proper ambulance provision.224
This case demonstrates that although paramedic professionalisation was incidentally benefiting from advances in technology arising from industrialisation and the associated increase in trauma and disease; in terms of a recognition of the importance of their role as a public health service, there was still some concern over the level of knowledge and skill they possessed to provide an ‘efficient, safe and disciplined’ workforce. There appeared to
221 Matthew L Newsom Kerr, ‘“Perambulating Fever Nests of our London Streets”: Cabs, Omnibuses,
Ambulances, and Other “Pest-Vehicles”’ in the Victorian Metropolis’ (2010) 49 Journal of British Studies
283.
222 Ibid.
223 “Safety Fever Ambulance,” Lancet, 23 August 1884, 330; “Safety Fever Ambulance Vans,” Camden
and Kentish Towns Gazette, 23 August 1884, 3.
be some suggestion that to acquire a moral authority over their work, ambulance attendants had to improve their standards of professionalism.