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The English Revolution in Social Medicine, 1889-1911

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The English Revolution in Social Medicine, 1889-1911 THE ENGLISH REVOLUTION IN SOCIAL MEDICINE, 1889-1911 UNIVERSITY OF LONDON PhD THESIS DOROTHY E. WATKINS 1984 To J.D.M.W. and E.C.W. 2 ABSTRACT The dissertation examines the development of preventive medicine between 1889-1911. It discusses the rise of expertise in prevention during this period and the consolidation of experts into a professional body. In this context the career histories of medical officers of health in London have been analysed to provide a basis for insight into the social structure of the profession. The prosopog- raphy of metropolitan officers demonstrated a broad spectrum of recruitment from the medical profession and the way in which patterns of recruitment changed over time. The level of specialisation in preventive medicine has been examined through a history of the development of the Diploma in Public Health. The courses and qualifying examinations undertaken by medical officers of health revealed the way in which training was linked to professionalisation through occupational monopoly. The association representing the interests of medical officers of health, their own Society, was Investigated through its recorded minutes of Council and Committees from the year it was first amalgamated into a national body, 1889, up to the date of the National Insur- ance Act in 1911. Here the aims and goals of the profession were set against their achievements and failures with regard to the new patterns of health care provision emerging during this period. This context of achievement and failure has been contrasted with an examination of the 'preventive ideal', as it was generated from within the community of preventive medical associations, of which the Society of Medical Officers of Health was one member. The interaction and exchange of ideas between these associations, including that with the Society, was traced through their journals and publications. Finally, the theoretical and practical knowledge which supported the development of technical expertise in preventive medicine is discussed through an analysis of hygiene text-books, available as instruction texts for diploma courses. Bearing in mind that It has been suggested by some historians that a revolution in social medicine took place in England during the 19th-Century, the thesis argues that this proposition needs to be re-examined historically. It suggests that an assumption that a revolution began and ended in the conventional realms of central and local politics would be unfounded. Alternatively, it suggests that the process of transition took place in the realm of the politics of expertise , linked to the rise of professionalism and changes in conceptual technology. It is hoped that this re-examination will allow the reader to re-address the question what is social medicine and when or if a revolution, even a typically English one, occurred. 3 ACKNOWLEDGEMENTS My first thanks are to my supervisor, Dr. William Bynum, without whose support the project would not have been completed. His challenging examination of my work encouraged me, always, to continue even when my own doubts were serious. I have received much assistance from the Libraries and staff of the Weilcome Institute London, the London School of Hygiene and Tropical Medicine and the Weilcome Unit for the History of Medicine at Oxford. I am especially grateful to Margaret Pelling, who catalogued the records of the Society of Medical Officers of Health, and was most helpful in making them easily available to me. Throughout the preparation of the dissertation I have been greatly strengthened and comforted by the advice and loyalty of my colleagues, friends and family, too numerous to mention individually, but to whom I give my thanks collectively. I would however like to thank Charlotte MacKenzie for helping to proof-read the text. Finally, I should like to thank Anne Darlington, simply, for being so 'speshal' 4 TABLE OF CONTENTS Prologue 5 1: Metropolitan Medical Officers of Health, 1856-1900. 32 2: Licensed to Practise: The Diploma of Public Health, 1868-1911. 105 3: The Society of Medical Officers of Health and the Professionalisation of Preventive Practice. 160 4: The Preventive Ideal. 276 5: Hygiene: The Technology of Prevention. 334 Conclusion. 439 Bibliography. 445 PROLOGUE. 5 In his famous essay of 1947, George Rosen asserted that, historically, the appearance of the concept of social medicine had occurred in response to problems of disease created by industrialism) He cited the origin of the concept in the mind of Rudolf Virchow (1821-1902) who, when faced with an epidemic of typhus in Upper Silesia during 1847, reported that the outbreak of the disease was due to complex social and economic factors Virchow believed that the disease in Silesia was not the abdominal typhus which was endemic in Berlin and Paris but was a British variety, a form associated with famine and war. 3 His epidemiological analysis of the outbreak went further than simply pointing to malnutrition as the cause. In his essay on the treatment of the epidemic Virchow outlined, for the first time, his sociological model of epidem- iology. Here he argued that full democracy, education, liberty, national autonomy, communal self-government, new roads, improvements in agriculture, Iustry,co-oper- atives etc. would prevent the circumstances under which unfavourable climatic conditions were able to stimulate the epidemic. A free, educated, prosperous population would not, he believed, be so easily overwhelmed by the disease.4 6 Virchow's concept of public health was socio- political rather than technical and a feature of his politics of medical reform. 5 He believed that as politics became more involved with social change then medicine would only progress by being part of this transition. The right of every individual citizen to a healthful existence could only be achieved, he thought, through the intervention of the state. Virchow's suspicion of bureaucracy, however, encouraged him to always stress that community intervention should be as decentralized as possible. Public health was, he believed, concerned with the housing of the individual, work for the unenip- loyed, treatment for the indigent, insurance against invalidity, health of migrants, unhealthy barracks, large drainage works and school hygiene. 6 It included, also, prison reform and the replacement of the penitent- iary system with psychiatric education of criminals.7 George Rosen has suggested that this socio-economic model of prophylaxis constituted an ideal which subs- equent systems of health care throughout Europe only partially realised during the 19th-century. 8 Rosen also admits, however, that the emergence of social med- icine in revolutionary Germany in 1848 was only one moment in the history of disease control amon gst coxnm- unities which began with the development of systems of medical police. Johann Peter Frank (1745-1821) defined this system in 1779, which coincided with the rise of cameralism in Germany and the need for the mercantile 7 state to be provided with a sufficient strength of physical subjects to defend it in war. 9 By comparison, the growth of the medical police concept in England was slow. Roy Macleod has accounted for this with the lack of 'state-craft' in England which delayed consideration of the issue until two centuries after William Petty had established his political arithmetic.'0 It was not until Andrew Duncan (1744-1828), Professor of the Institute of Medicine in Edinburgh, reflected upon J.P. Frank's work in his lectures on jurisprudence in 1795 that consideration of the relationship between the state and health began in earnest. 11 The question of health care provision by the state, however, soon became absorbed into the Bentharnite movement of social reform which linked sickness and poverty as reciprocally determined.' 2 The rise of infant mortality from 1815 led William Farr(l807-1883) to conclude that it was beyond doubt coterminous with an increase in density. 13 The rise in mortality together with the recurring epidemics of yellow fever, typhoid and typhus stimulated a generation of English sanitarians into attacking the issue of controlling the environment of 14 disease propagation. A generation which, as Margaret Pelling has pointed out, used the invasion of cholera as a major tool of propaganda to gain statutory regulation of the underlying problem which the 'official orthodoxy' believed was the correlation of fever with filth)5 8 The issue of sanitation was however, R.H. Shryock reminds us, only .ne feature of a protest for general social and economic change throughout Europe. 16 Chadwick, Southwood-Smith and their associates led a great social reform in creating a sanitary programme. For example: Men did not demand sanitary reform simply in order to improve factories- rather did they urge factory legislation as part of a far wider comprehensive programme of health reform. 17 Sanitary science was simply an effective application of statistically-based hygiene to achieve that end which, in the view of some, was the closest English equivalent 18 to the Virchow model of social medicine. The dominance of medicine in public health began with the appointment of John Simon (1816-1904) to the General Board of Health in 1854 and the medical depart- ment of the Privy Council created during 1858.19 A "New Era" in state medicine was subsequently ushered in, according to Simon's biographer,Royston Lambert°This era was most ideally represented in the Essays on State Medicine, written by Henry Rumsey U809-1876) in 1856. Rumsey's six essays outlined a theoretical system of state medicine and health police which was far more 21 comprehensive than any that existed at that time. His sanitary code included the regulation of location and construction of towns, complete systems of water supply, drainage and sewage removal, sale of food and drugs, trades and factory pollution, safety of locomotion and the burial of the dead .
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