Part 28

Edwin Chadwick (1800-90), who was not a medical man, introduced to public notice what he called the ‘sanitary idea’, a conception that colored the whole of his extraordinarily active life. He sat on Government Commissions on Poor Law, on Police, and on the investigation of the condition of factory children. One of his Reports (1833), issued while he and the century were both in the early thirties, recommended a system of inspection with a view to limiting children’s hours of work. The current system of pensions and of trade instruction to soldiers and sailors is the descendant of a scheme of Chadwick’s devising. An item in the evidence attached to one of his Reports is the public provision of open spaces for recreation, a topic of current interest at the moment of writing.

At the time of the accession of Queen Victoria in 1837 Chadwick was agitating for the appointment of a Sanitary Commission. Two years later, as a result of a grave epidemical outbreak in London, the Commission was appointed. Its reports, which drew wide attention at the time, have had a large share in determining the general course of health legislation in the ninety years that have since elapsed. The scientific basis of health legislation can only be determined if proper vital statistics be available. The Registration Act of 1838, under a developed form of which we still live and die, was in essence his work. If we search into the history of any department of the scientific treatment of the Public Health, we shall always ultimately work back either to Southwood Smith or to Chadwick and through them to Bentham.

Among the most important documents for which Chadwick was responsible was the Parliamentary General Report on the Sanitary Condition of the Labouring Population of Great Britain (1842). It came to fruit in 1848 with the Public Health Act, which established a new governmental department, the ‘General Board of Health’ (p. 196). The same year saw the passage of the Nuisances Removal and Diseases Prevention Act, by which summary action in such matters was rendered possible on the complaint of specially authorized local authorities. Just as the Board came into action there was an outbreak of Cholera in England, of which 54,000 persons died. The statistics available under the new system made possible the deduction that the infection is conveyed by drinking-water and led to suitable precautions. This is one of the many instances in which the practice of prevention of a germ-borne disease preceded any knowledge of its organic cause, or indeed any direct knowledge of disease germs at all.

The first town in England to appoint a Medical Officer of Health was Liverpool. The City of London followed in 1848, when Simon took office. After Southwood Smith and Chadwick, Sir John Simon (1816-1904) was the foremost figure in the history of the Public Health of this country. He later became medical officer to the ‘General Board of Health’. The work of this Board--together with its medical officer--was taken over, for political and administrative reasons, by the Privy Council. The medical department of the Privy Council became in 1871 part of the Local Government Board, the medical functions of which were absorbed by the new Ministry of Health in 1917.

To Simon are due the abolition of urban cesspits and improvement of the system of sewers, and the institution of sanitary inspectors and legislation concerning housing and overcrowding. One important result of these measures was that it became possible to abandon the cruel and wasteful system of quarantine that had been of value in the eighteenth century. Simon’s plan, which was gradually adopted, was to trust to the same preventive methods for foreign as for native infections. This was, of course, only possible with an efficient sanitary service such as he succeeded in instituting. Such measures were aided by laboratory investigations, begun by a small staff. At first largely occupied with examinations in connection with actual outbreaks, its scientific functions rapidly grew. Working on a wider basis, these functions have been performed for the nation since 1911 under the direction of the Medical Research Council.

It will be seen that the curve begins definitely to take a downward trend about 1870. It has been falling ever since. It is now less than half of what it was sixty years ago. This fall is largely, though not entirely, due to decrease in infant mortality. Some of the more important epidemics are indicated. Typhus disappears as an important cause of death in the forties and Cholera and Small-pox in the sixties. Since then the death-rate has been considerably influenced by Influenza outbreaks.

(b) Preventive Medicine in the United States.

In the United States the history of the national Public Health Service has been very different from that of the English system. The same philosophical tendencies have been at the basis of the American as of the English system. In the United States, however, the National Service has been linked with the Army and Navy in a manner quite foreign to British traditions. The Federal health system had its origin in the old Marine Hospital Service, first authorized by Congress in 1798. This enabled the President to appoint medical officers at ports and elsewhere for the purpose of giving medical treatment to disabled merchant seamen. The funds were obtained by a tax on those employed on American vessels.

The first marine hospital under the Act was at Norfolk, Va., in 1800. In 1802 a marine hospital was built for the port of Boston, and from time to time hospitals were built at other important seaports. To provide for the relief of seamen on inland waters Congress passed in 1837 an Act for the appointment of a board of advisory medical officers of the Army. A number of hospitals were established on its advice.

The evolution of public health functions from this service was along natural lines. The medical officers, in providing care for the American merchant marine, were often the first physicians to diagnose such diseases as Cholera, Yellow Fever, Small-pox and the like, which were being imported into the United States. In the epidemics of Cholera which occurred in certain ports of the United States the marine hospitals and their medical officers were utilized for the relief of those suffering from the disease. During the Civil War the marine hospitals, together with the medical officers, were used by the military authorities, both North and South, for the care of the military forces.

Not until 1878 did Congress authorize any extensive use of the Marine Hospital Service as a Federal Health Service. An Act of 1878 gave broad powers to the Service to co-operate with State and local health authorities in the control of disease, especially of Yellow Fever. In 1890 Congress decided to utilize the Marine Hospital Service as the Federal Health agency for the prevention of inter-State spread of Cholera, Yellow Fever, Small-pox and Plague. In 1893 the powers of the Marine Hospital Service in this regard were extended to cover all infectious and contagious diseases, in co-operation with State and local health agencies.

The efficiency of the Marine Hospital Corps in the control of epidemic diseases became widely recognized. In 1889 Congress passed an Act which made possible the further organization of the Marine Hospital Corps, and provided that the officers be commissioned in grades similar to those of the medical department of the United States Army. An Act of 1875 had already provided that the Surgeon-General (supervising surgeon) should be appointed by the President, with the consent of the Senate.

In 1893 the Marine Hospital Service was organized into the Federal Health Service. Congress continued to impose additional health functions upon the Service, and in 1902 changed its name to the ‘Public Health and Marine Hospital Service’ and made it a health service in name as well as function. The larger part of its duties, up to this time, had been the combating of epidemics, especially those of Yellow Fever, which from time to time swept the country. With the threat of Bubonic Plague in 1900 at San Francisco, the Marine Hospital Service was placed in charge of control methods and succeeded in preventing any extensive spread of the disease.

In addition to the quarantine and hospital functions, the activities of the Service soon came to include research and educational work. In 1902 Congress authorized the establishment of the Hygienic Laboratory for investigating Cholera, Yellow Fever, and other conditions. The Laboratory grew rapidly and is now a very important research institution, equipped for carrying on pathological, zoological, pharmacological, bacteriological, chemical, and physiological work.

From the control of epidemics, the Public Health and Marine Hospital Service began to develop control measures for the more common contagious and infectious diseases, such as Typhoid Fever, Diphtheria, and Scarlet Fever. The history of the wonderful control of Typhoid Fever which has taken place in the United States within the past twenty years is a part of the history of the Public Health Service in co-operation with State and local health agencies. Typhoid fever, which formerly took a toll of more than 50,000 lives annually, is responsible for the death of a mere fraction of this number at the present day.

The development of health functions of the Public Health and Marine Hospital Service continued until Congress in 1912 changed the name to its present one, the ‘United States Public Health Service’, and at the same time gave it broad powers to investigate the diseases of man and the pollution of navigable streams and lakes.

During the courses of Federal development the separate States of the Union were not devoid of protagonists of State intervention in matters of public health. Among these was Lemuel Shattuck (1793-1859), who, like Chadwick, was no medical man, but a student of social problems. Under the influence of Chadwick he drafted in 1850 the Report of the Massachusetts Sanitary Commission. This publication set forth a complete scheme of Public Health organization. The formation of the first State Board of Health in Massachusetts was, however, delayed till 1869. In this matter Massachusetts was, in fact, anticipated by Louisiana, which obtained a State Board of Health in 1855, and by New York City, which obtained a Board of Health in 1866. Most of the States followed in the seventies. The seventies and eighties were the decades in which the general principles suggested by the work of Pasteur and Koch were put into effect. The working hypothesis of sanitarians of the time was that filth and ill-drainage were direct factors in the production of epidemic disease. The view is now untenable, but there was unquestionably an immense improvement in health conditions resulting both directly and indirectly from the improved drainage, water-supply, housing, and the like that the agitation had stimulated.

As the bacteriological discoveries of the time became generally accepted, they were widely applied on American soil to the administrative control of disease, notably by the New York Department of Health under Hermann M. Biggs. That body, in 1892, instituted a bacteriological laboratory, the scope of which has steadily increased. Its work in connection with Diphtheria is elsewhere discussed (pp. 265-6).

To follow into our own time the development of factory legislation, vital statistics, school medical service, local health authorities, municipal laboratories and clinics, methods of food inspection, would be to write a text-book of Public Health Administration. In all these developments we see working the rational spirit in the peculiarly English field of Preventive Medicine. The spirit of Rational Medicine cannot function, however, without material upon which to work. The basis, the elementary matter, as it were, of that material, is the conception we form of the nature of the bodily processes. Such a conception it is the function of Physiology to provide and to Physiology we therefore now turn.

A ‘Seamen’s Hospital Society’ was founded in England in 1817. Its first hospital was the Grampus, an old 50 gun ship moored off Greenwich. This was succeeded in 1830 by the Dreadnought, 104 guns, and this in 1857 by the Caledonia, 120 guns, renamed Dreadnought. In 1870 this last wooden Dreadnought was broken up and the patients were transferred to a building on shore close by. The darkness, damp, ill-ventilation, noisiness and septic character of a wooden ship made it thoroughly unsuitable for hospital purposes.

In 1899 the ‘Seamen’s Hospital Society’ established a special Hospital and School for Tropical Diseases such as are peculiarly common among seamen. ]

§ 3. The Transition to a Physiological Synthesis.

Modern developments in physiological knowledge introduce an important period in the History of Medicine, for the study of the functions of the body is a natural portal of entry to the study of the perversions and suspensions of those functions that we call disease. The general character of physiological thought during the modern period may perhaps be described as the ‘synthetic study of the animal body’. The study has become synthetic because organs have not been studied so much in and for themselves as in relation to other organs. There has been, in fact, during the period, an increasing consciousness of the integration of the organs into one organic whole, the entire process being under the control of the nervous system, the various parts of which are themselves integrated (p. 308). This movement has, to some extent, mitigated the ever growing evils of scientific specialization.

(a) Anatomy and Embryology in the Earlier Nineteenth Century.

Let us first glance at the state of anatomical knowledge in the early and middle nineteenth century. The general structure of the animal body was well known. Descriptive Anatomy was not far from where it now is. Comparative Anatomy, which had made good progress, was given a fresh impetus by the researches and by the authority of a brilliant group of French investigators, headed by Baron Georges Cuvier (1769-1832), whose influence spread to England, Germany, and America, where the leading exponents were Richard Owen (1804-92), Karl Gegenbaur (1826-1903), and E. D. Cope (1840-97). Cuvier was a biological dictator whose opinion did much to encourage investigation, and something to discourage some important investigators. His services to Comparative Anatomy can hardly be overrated. There was, however, still no effective knowledge of the anatomical differences between the races of man, while the species of man and of allied forms, whose skeletons palaeontologists have since described, were quite unknown.

As regards knowledge of the process of Development of the animal body, the broad lines of Embryology were being put on a firm basis by Karl Ernst von Baer (1792-1876), whose work was finished in 1837, though he lived another forty years. The subject was to be given a new meaning by the evolutionary school, which applied to new details and to particular instances the work of Charles Darwin (1809-82). Foremost of this school was Francis Maitland Balfour (1851-82).

(b) Chemical Physiology in the Earlier Nineteenth Century.

The analysis of the functions and workings of the body had advanced far less than the knowledge of its structure. The study of Respiration was perhaps in the best position. The elementary conception of Respiration attained by Lavoisier at the end of the eighteenth century (p. 155) was hardly extended till E. F. W. Pflüger of Bonn (1829-1910), in the sixties and seventies of the nineteenth century, showed that the essential chemical changes of respiration do not occur in the blood or in the lungs, but in the tissues.