Meanwhile, however, the substitution of indoor for outdoor relief in the case of the sick[674] was being supported on grounds, not of Poor Law principle, but of medical efficiency. The transformation of the workhouses into what the Poor Law inspectors themselves began to call "State hospitals" made more striking than ever the contrast between the light, clean, and airy newly-built infirmary ward, with trained nurses, a resident doctor, complete equipment, and a scientifically determined dietary, on the one hand; and the insanitary and overcrowded hovel or slum tenement, on the other, in which the sick pauper had no other food than was provided by the pittance of outdoor relief, no further nursing than his family could supply, and no better medical attendance than the grudgingly accorded order on the district medical officer could command. Quite irrespective of "Poor Law principles," the case for institutional rather than domiciliary treatment of nearly every sick case became, to the medical experts who now advised the Central Authority, simply overwhelming. "The treatment which in sickness the poor receive in workhouses constitutes," said the Central Authority in 1878, "one of the most valuable forms of medical relief. _With a considerable portion of the population, indeed, it is the only mode in which, when overtaken by sickness, their medical needs can be adequately met._"[675] This policy led not only to an incessant pressure on boards of guardians to provide the "State hospitals" which had, from 1865 onwards, been expected from the guardians of all populous unions,[676] but also to a positive encouragement of sick persons, whether or not actually destitute in the technical sense of the term, to take advantage of them. We see this first with regard to infectious diseases. The hospitals of the Metropolitan Asylums Board, maintained out of the Poor Rate exclusively for paupers, and technically only workhouses like any others, soon came to be used, free of charge, by small-pox and fever patients who were not paupers.[677] It became the official policy, well understood by the Central Authority, to get removed to these Poor Law institutions every patient, whether destitute or not, who could not be adequately isolated at home.[678] Already in 1875 the Central Authority expressly authorised the medical superintendent to admit without an order any small-pox or fever patient presenting himself, if refusal to admit might involve danger,[679] and in 1887 it expressly permitted even non-urgent cases to be admitted on the certificate of any medical practitioner.[680] Nevertheless, in 1877 the Central Authority was still taking the line that "the hospitals ... of ... the Metropolitan Asylums Board are essentially intended to meet the requirements of the destitute class, and that the admission ... of persons not in need of poor relief is altogether exceptional."[681] Two years later, however, by a statute