■ ■ 
 
 .-■■■■- . . - 
 
 STORYof ENGLISH 
 PUBLIC HEALTH 
 
 Sir MALCOLM MORRIS 
 
Htxtt College of Agriculture 
 
 &t (Joructl Inuiersitij 
 
 3tljaca. JJ. Ij. 
 
 library 
 
_ . Cornell University Library 
 
 RA 487.M87 y 
 
 The story of English public health 
 
 3 1924 003 454 216 
 
The original of this book is in 
 the Cornell University Library. 
 
 There are no known copyright restrictions in 
 the United States on the use of the text. 
 
 http://www.archive.org/details/cu31924003454216 
 
ENGLISH PUBLIC HEALTH SERIES 
 
 THE STORY OF 
 ENGLISH PUBLIC HEALTH 
 
The Story of 
 
 English Public Health 
 
 BY 
 
 Sir MALCOLM MORRIS, K.C.V.O. 
 
 Member of the Royal Commission on Venereal Diseases, and of the 
 
 Executive Committee of the National Council for Combating Venereal 
 
 Diseases: President of the Institute of Hygiene; Fellow of the Royal 
 
 Sanitary Institute, etc. 
 
 GASSELL AND COMPANY, LTD 
 London, New York, Toronto and Melbourne 
 
First published 19x9 
 
 <S 1 6006 
 
PREFACE 
 
 With the creation of a Ministry of Health the 
 Public Health Service of England and Wales 
 enters upon a new era — an era, I doubt not, of 
 enhanced efficiency and fruitfulness. It seemed to 
 me that the occasion warranted an attempt to sketch 
 in outline the evolution of our Public Health system 
 from its small beginnings down to the present day, 
 when the seedling has grown into a mighty, many- 
 branched tree. Hence this little book. 
 
 I have not dealt separately with sanitary 
 legislation, but its great landmarks are noted in 
 connection with the growth and work of the 
 Authorities, central and local, which have been 
 charged with its administration. Incidentally, 
 brief accounts are given of some of the great 
 sanitarians and administrators by whom the 
 system has been built up. 
 
 In the early chapters I have made free use of 
 Sir John Simon's "English Sanitary Institutions," 
 which with fullness of detail and philosophic 
 insight records the history of English Public 
 Health down to the year 1890. For permission to 
 • v 
 
Preface 
 
 draw upon its treasures I tender warmest thanks 
 to Mr. John Murray, the publisher of the second 
 edition, which appeared in 1897, and is still on sale. 
 No one can claim to be well versed in this subject 
 who has not read and re-read that classic of Public 
 Health literature. 
 
 The present book is the introductory volume of 
 a series which is occupied with the discussion of 
 Public Health questions of special interest at the 
 present time. The books will, it is believed, appeal 
 to members of local authorities, district and other 
 nurses, school teachers, members of Voluntary Aid 
 Detachments, health visitors, and the great army 
 of voluntary workers in the various fields of 
 hygiene, and also,, it is hoped, to the general 
 reader. 
 
 M. M. 
 
 vi 
 
CONTENTS 
 
 CHAPTER I 
 The "New Humanity" 
 
 PAGtt 
 
 Rise of the "New Humanity "—The "Methodists"— 
 Prison Reform — Humane Treatment of the Insane — 
 Abolition of Slavery — Mitigation of the Penal Code 
 — Political Reform — Public Health and the Spirit of 
 Humanity — Child Labour in Factories — Robert Owen 
 and Lord Ashley — Freedom of Contract — Voluntary 
 Effort and Public Health — Edwin Chadwick — Florence 
 Nightingale — Governments and Vested Interests — 
 Inertia of Government Departments — Sir George New- 
 man on Voluntary Co-operation — Sir Arthur News- 
 holme on Public Opinion .... . i 
 
 CHAPTER II 
 
 Pioneers 
 
 Dr. Richard Mead and the Plague — Sir John Pringle and 
 Military Hygiene — Dr. Lind and Naval Hygiene — Sir 
 Gilbert Blane — Captain Cook — John Howard as a 
 Model Landlord — Prison Reform — Variolation — 
 Edward Jenner and Vaccination — Thackrah and 
 Industrial Diseases 14 
 
 CHAPTER III 
 
 The Nation's First Health Charter 
 
 Lack of Sanitation at the Beginning of the Victorian Era — 
 Edwin Chadwick and the " Sanitaiy Idea " — Secretary 
 
 vii 
 
Contents 
 
 to the Poor Law Commissioners — Their Reports on the 
 Sanitary Condition of the Metropolis — The Inquiry 
 Extended — Investigations of a Royal Commission — 
 The Public Health Act, 1848, and the General Board of 
 Health — The Nuisances Removal and Diseases Pre- 
 vention Act — Chadwick the Leading Spirit of the 
 Board — A Cholera Epidemic— Th£ Board's Work — 
 Opposition — Reconstitution — Chadwick Retired — His 
 Later Services to Hygiene — Sir Benjamin Hall — The 
 Board Abolished — Its Duties Divided between the 
 'Privy Council and the Home Office .... 24 
 
 CHAPTER IV 
 
 The Era of Inquiry and Education 
 
 John Simon's Work as Medical Officer of Health of the 
 City— Appointed Medical Officer of the Privy Council 
 — Public Health Functions of the Privy Council — 
 Study of Epidemics — Educative Value of Simon's 
 Annual Reports — The Sanitary Act of 1866 — Venereal 
 Diseases — Simon and Port Quarantine — Laboratory 
 Investigations — Report of the Royal Sanitary Com- 
 mission, 1843-5 — The Local Government Board Act, 
 1871 — Legislation Affecting Local Authorities — Con- 
 solidation of Sanitary Law, 1875 — Other Sequelae of the 
 Royal Commission's Report — Simon's influence . . 39 
 
 CHAPTER V 
 
 The Local Government Board 
 
 The Board Derived from the Poor Law Board — Mr. Stans- 
 feld the First President — The Poor Law Board's 
 Record — Early Mistakes of the New Board — Sub- 
 ordination of the Medical Department — Mr. Sclater- 
 Booth'9 Presidency — Simon's Disappointment and 
 Retirement — His Later Career — The Great Cholera 
 
 viii 
 
Contents 
 
 PAGE 
 
 Survey — Investigations by the Board's Medical In- 
 spectors and Others — Sir George Buchanan and Sir 
 Richard Thome- Thome — Sir William Power — Sir 
 Arthur Newsholme — Sir George Newman — The 
 Board's Constitution and Functions — Its Administra- 
 tion of the Poor Laws — Its Public Health Work . . 54 
 
 CHAPTER VI 
 Other Central Health Authorities 
 
 The Privy Council : Constitution and Discipline of the 
 Medical Profession — The General Medical Council — 
 The Pharmaceutical Society — What Medical Registra- 
 tion Means — Need for Further Legislation against 
 Unauthorised Treatment — The Midwifery Service — The 
 Central Midiwives Board. The General Register 
 Office : Its Foundation — Major George Graham — Dr. 
 William Farr— D.r. T. H. C. Stevenson. The Home 
 Office : The Prison Medical Service — Regulation of 
 Institutions for Mental Defectives — Difference between 
 a Factory and a Workshop — The Health and Morals 
 of Apprentices Act, 1802 — Other Acts for Regulating 
 Child Labour — Rapid Growth of Factory Legislation — 
 Control of Home Work — Dangerous Trades — Employ- 
 ment of Children Act, 1903 — The Health of Munition 
 Workers Committee — "Welfare Conditions" — Factory 
 Inspection . . . . . . 74 
 
 CHAPTER VII 
 
 Other Central Health Authorities {concluded) 
 
 The Board of Education : Edwin Chadwick's Prescience — 
 Establishment of a School Medical Service — Medical 
 Inspection and Treatment — School Clinics — Special 
 Schools — Medical Inspection of Secondary Schools — 
 Meals for Hungry Children — Physical Education — 
 Evening Play Centres — Schools for Mothers — Utilisa- 
 
 ix 
 
Contents 
 
 PAGE 
 
 tion of Voluntary Help — First Decennium of the School 
 Medical Service— The Future. The National Insur- 
 ance Commissions : Their Constitution — Work of the 
 Medical Research Committee — Benefits under the In- 
 surance Acts — Approved Societies and Insurance Com- 
 mittees—Institutional Treatment of Tuberculosis. 
 Central Health Authorities of Manor Importance . . 93 
 
 CHAPTER VIII 
 Local Health Authorities 
 
 Division of the Country into Urban and Rural Sanitary 
 Districts — Creation of County Councils, of Urban and 
 Rural District Councils and Parish Councils — Powers 
 and Duties of County Councils, of County Borough 
 and Municipal Borough Councils, of District Councils, 
 of Parish Councils — Boards of Guardians and Vaccina- 
 tion — Port Sanitary Authorities — The City Corporation 
 — The London County Council and Metropolitan 
 Borough Councils — The Metropolitan Water Board — 
 The Thames Conservancy Commission — The Metropoli- 
 tan Board of Works — Education Committees — Over- 
 lapping and Lacuna; in Local Health Administration . 107 
 
 CHAPTER IX 
 Bacteriology and Infection 
 
 Pasteur's Researches — Identification of Pathogenic Organ- 
 isms — Bacteria and Protozoa — Intermediate Hosts — 
 Methods of Infection — Undiscovered Germs — " Koch's 
 Postulates " — The Theory of Immunity — Vaccines and 
 Serums— Problems of Infection — Seed, Soil and En- 
 vironment — Evolutionary Variations of Germs — Evolu- 
 tion of Man against Infectious Diseases — Natural 
 Selection — Supreme Importance of a Healthy Environ- 
 ment — Prevention the Ultimate Aim of Sanitary Effort 118 
 
 X 
 
Contents 
 
 CHAPTER X 
 The Crusade Against Venereal Disease 
 
 PAGE 
 
 A Conspiracy of Silence — The Royal Commission on 
 Venereal Diseases — Telling the Nation the Truth — The 
 Royal Commission's Administrative Scheme adopted by 
 the Government — The National Council for Combating 
 Venereal Diseases and its Work — Recognition by the 
 Government — Prohibition of Unqualified Treatment — 
 What remains to be done 135 
 
 CHAPTER XI 
 The Ministry of Health 
 
 The English Public Health Service not a Failure — Its 
 Achievements — Outline of the Ministry of Health Act 
 — The Powers taken over by the New Ministry — The 
 Medical Research Committee — Administration of the 
 Factory and Workshop Acts — Provision for the De- 
 velopment of the Ministry of Health — Consultative 
 Councils — Wales and Ireland — How Local Health Ad- 
 ministration might be unified — Other Tasks for the 
 Ministry — Favourable Omens ... . . 144 
 
 Index . . . . ... 155 
 
 XI 
 
THE STORY OF 
 ENGLISH PUBLIC HEALTH 
 
 CHAPTER I 
 
 The "New Humanity" 
 
 The Public Health system of this country is a 
 creation of the last three-quarters of a century : it 
 may be dated from the year 1848, when the Public 
 Health Act which established the first Central 
 Health Authority was passed. But to seek the 
 origins of this great movement we must go much 
 farther back. We may regard it as originating in 
 two impulses. One, the scientific instinct, which 
 prompts men to inquire into the causes of avoid- 
 able disease and the means of counteracting them ; 
 of this some account will be given in the next 
 chapter. The other, the spirit which J. R. Green, 
 in the concluding Books of his "History of the 
 English People," variously calls the "new moral 
 enthusiasm," the "new philanthropy," and the 
 "new humanity." The last of these variants 
 appears to me to be the most sufficient and the 
 
 B 
 
The Story of Public Health 
 
 most richly suggestive, and I gladly borrow it as 
 the title of the present chapter. 
 
 The new humanity made its first manifestation 
 more than a century before the Public Health Act 
 of 1848 was added to the statute-book. In 1729 
 John and Charles Wesley founded that society to 
 promote religious study and conversation which, 
 soon called derisively "The Methodists," presently 
 effloresced into a pilgrimage of passion for the 
 spiritual uplifting of the degraded masses. The 
 religious revival began at Oxford, but the scene 
 of its activities was not the sequestered groves of 
 a university, but the "highways and hedges" of 
 the great world. And it was never known as the 
 "Oxford Movement," a title that was left available 
 for the Anglican movement of the next century, 
 which was one of its spiritual reactions. As the 
 historian of the English people shows, it not only 
 led to the creation of the great Methodist Societies 
 in this country and in America, and the spiritual 
 renascence of the Church of England, but was the 
 inspiration of an effort, which has never since 
 ceased, "to remedy the guilt, the ignorance, the 
 physical suffering, the social degradation of the 
 profligate and the poor." 
 
 One fruit of this "passionate impulse of sym- 
 pathy with the wronged and afflicted," to use 
 another of Green's phrases, was the prison reform 
 begun by John Howard. In the next chapter it 
 will be seen how direct is the connection between 
 
The "New Humanity" 
 
 this noble crusade and the Public Health move- 
 ment. Towards the end of the century the same 
 sympathy with the victims of an inhumane system 
 flamed out in the indignant protests of Burke and 
 Fox against the tyrannies and exactions of the 
 East India Company, and moved Burke to urge 
 with magnificent eloquence that India was no ex- 
 ception to the rule that political power established 
 over any set of men, being "a derogation from the 
 natural equality of mankind at large," must be 
 "exercised ultimately for their benefit." About the 
 same time William Tuke initiated the movement 
 for the humane treatment of the insane, a reform 
 which was continued in the next generation by 
 Dr. John Conolly; and Clarkson and Wilberforce 
 began their campaign against the grossest of all 
 forms of oppression, a campaign which led to the 
 passing of the Abolition Act of 1807, and finally, 
 in 1883, to the voting by Parliament of a sum of 
 twenty millions for the emancipation of the slaves 
 in our colonies. While this crusade was in pro- 
 gress a beginning was made with the mitigation 
 of our penal laws. _At the dawn of the nineteenth 
 century nearly three hundred offences were 
 punishable with death. The Legislature showed 
 no excessive eagerness to abate the brutality of its 
 atrocious penal code. In, 1808 Romilly was suc- 
 cessful in saving pickpockets from the scaffold; 
 but two years later it was still held to be in accord- 
 ance with the fitness of things that shoplifters who 
 
 3 
 
The Story of Public Health 
 
 had stolen five shillings' worth of goods should 
 suffer the extreme penalty of the law. Progress, 
 however, if halting, was sure, and of late years the 
 least observant cannot but have noticed that even 
 in murder, while the law itself makes no dis- 
 tinction between one case and another, it has been 
 administered in a' spirit of humanity which aims 
 at distinguishing between calculated homicide and 
 the taking of life under the spur of intolerable pro- 
 vocation or in a moment of frantic passion. 
 
 To the new humanity may also be traced the 
 political movements which have led to the removal 
 of one exclusive privilege after another, to the 
 abolition of religious tests, and to the gradual 
 extension of the franchise, until now it is shared 
 by virtually all those who toil and spin, women 
 as well as men. These reforms, and the social 
 ameliorations that have followed in their train, are 
 implicit in Jeremy Bentham's doctrine of "the 
 greatest happiness of the greatest number," a 
 formula which may be taken as the expression in 
 unemotional terms of utility of the passion of pity 
 for the common people which lay at the heart of 
 the religious revival. In these political movements 
 less lofty motives than compassion for the down- 
 trodden and dispossessed have also been at work ; 
 but men are actuated by mixed motives in other 
 spheres of activity than politics, and even in 
 politics, in the main and in the long run, it is the 
 higher motives that supply the driving power. 
 
 4 
 
The " New Humanity " 
 
 So it has been also with the Public Health 
 movement. Had it not been for a spirit of ^sym- 
 pathy with the multitude, who, herded together in 
 foul slums and toiling in crowded factories and 
 workshops or in the bowels of the earth, are the 
 chief sufferers from insanitation, how much more 
 difficult would have been the task of building up 
 our system of State Medicine ! True, at every step 
 it has been necessary to appeal to lower motives, 
 such as the fear of epidemics, and considerations 
 of economy. At first the stress laid upon the argu- 
 ment that in the long run sanitation spells economy 
 to the ratepayer and the taxpayer was extreme ; but 
 even in the present enlightened age we can hardly 
 afford to smile at the lack of hygienic enthusiasm 
 of an earlier generation, for the same argument 
 has to be diligently plied whenever any new de- 
 velopment of Public Health is advocated. The 
 man who is invited to tax himself for social pur- 
 poses is apt to gaze at the future with the telescope 
 reversed, and if no higher plea than economy had 
 been urged, who can doubt that the Public Health 
 system would have taken much more than three- 
 quarters of a century to reach its present stage of 
 evolution ? 
 
 A salient illustration of what State Medicine 
 owes to the spirit of humanity is to be found in 
 the history of the legislation to check the abuses 
 of industrialism, particularly in - connection with 
 the employment of child labour. This was essen- 
 
 5 
 
The Story of Public Health 
 
 tially a victory of philanthropy over a short- 
 sighted economy allied with a rigid and essentially 
 irrational theory of freedom of contract. The chief 
 pioneers of the reform were Robert Owen and Lord 
 Shaftesbury, the one inspired by the enthusiasm 
 of humanity, the other by the evangelical fervour 
 which had animated the leaders of the religious 
 revival. Robert Owen showed the better way not 
 only by argument but by his own example as a 
 cotton manufacturer in the days before he had 
 developed his Socialistic theories. At a time when 
 pauper children of tender years were swept into 
 factories wholesale he would employ no child 
 under the age of twelve, and instead of pressing 
 the children of his operatives into his factory he 
 established schools where they might be educated. 
 In 1819 he was able to induce the Government to 
 pass an Act regulating child labour in cotton 
 factories; but nothing had been done for factory 
 children in general when Lord Ashley (the future 
 Earl of Shaftesbury) took up the question about 
 the year 1830. The abuses to which the unre- 
 strained employment of children had led were 
 gross beyond description. Little mites who had 
 not long learned to walk had to toil for it might 
 be twelve or thirteen hours daily under the vilest 
 sanitary conditions for a penny a day. To meet 
 the demand for this cheap labour the Poor Law 
 authorities of London would collect children from 
 the metropolitan workhouses and send them in 
 
 6 
 
The "New Humanity" 
 
 droves to Lancashire, and that county only ceased 
 to import from the capital the children whom God 
 had forgotten when the operatives, to eke out their 
 miserable pittance of a shilling a day, offered their 
 own flesh and blood as the victims. Lord Ashley's 
 first Bill excited the gravest alarm among the 
 manufacturers, and was dealt with so drastically 
 that its introducer indignantly withdrew it. A 
 Royal Commission was appointed, and, Lord 
 Ashley's facts being inexpugnable, in 1833 the 
 Government carried through a Bill forbidding the 
 employment of children under nine and restrict- 
 ing the hours of those under sixteen, as will be 
 explained later. 
 
 The opposition offered to factory legislation in 
 the name of freedom of contract by M'Culloch and 
 Nassau Senior, Cobden and Bright, is a glaring 
 instance of the length to which humane men of 
 high character will go in support of an economic 
 theory. They were unable to comprehend, in Mr. 
 Sidney Webb's eloquent words, that "to set the 
 employer free to make exactly what arrangements 
 he chose for his work, and to conclude exactly 
 what bargains he chose with his individual opera- 
 tives, inevitably meant, because of his superiority 
 in economic strength, the reduction of wages. . . 
 to a point . . . which experience proved to be even 
 below what was physiologically necessary for sub- 
 sistence ; the exaction of hours of daily labour far 
 in excess of what was compatible with healthy 
 
 7 
 
The Story of Public Health 
 
 existence; the harnessing to the mill of the preg- 
 nant woman, of the nursing mother, of the im- 
 mature youth, even of the child; the subjection 
 of them all, in the attempt to reduce expenses 
 to a minimum, to brutalising and insanitary con- 
 ditions, and even to incessant risk of accident, for 
 lack of the necessary expensive precautions; and 
 actually, when it was found to facilitate the manu- 
 facture, to the deliberate use of deleterious sub- 
 stances and the deliberate vitiation of the atmo- 
 sphere by artificial heat and moisture to the ruin 
 of the operatives' health." * The fight was long and 
 strenuous, but the appeal to the humanity of the 
 nation won triumph after triumph; and as this 
 country was the first to frame factory laws, so it 
 still on the whole keeps the lead of the world in 
 this form of legislation. 
 
 The student of the evolution of our system of 
 State Medicine will find ample evidence for a 
 conviction that has been brought home to me by 
 the share I have been called upon to take in certain 
 of its developments during my professional life — 
 the conviction that the movement owes more to 
 voluntary than to official effort. Before the Public 
 Health Act of 1848 was passed a Health of Towns 
 Association was actively at work disseminating 
 the knowledge which had been brought before Par- 
 liament as to the crying need for sanitary legisla- 
 tion, and all through the intervening years it has 
 * " Cairibridge Modern History," xii. 745. 
 8 
 
The "New Humanity" 
 
 been the pressure of such bands of voluntary 
 workers, animated mainly by the spirit of 
 humanity, that has impelled Governments to 
 action. Whole pages might be filled with a mere 
 list of health associations, but I will refer to two 
 only, with which I have been personally associated, 
 and these may be taken as typical instances. They 
 are the National Association for the Prevention of 
 Consumption, which, founded in 1898 to stir up 
 the medical profession and the public to adopt 
 effective measures against tuberculosis, is still 
 active in that cause, and the National Council for 
 Combating Venereal Diseases, which in 1916 pre- 
 vailed upon the Government then in office to adopt 
 the system recommended in the Report of the 
 Royal Commission issued in that year, and has 
 ever since been carrying on a vigorous and extra- 
 ordinarily successful propaganda, of which some- 
 thing more will be said later. 
 
 In the next chapter but one it will be shown 
 that the man who has the greatest right to be con- 
 sidered the founder of our State Medicine is Edwin 
 Chadwick, who had conceived an enthusiasm for 
 sanitation long before he became a Government 
 official, and was so ardent in the cause that he was 
 prematurely relegated to private life. Factory 
 legislation, as we have seen, was initiated by two 
 such extremely unofficial persons as Robert Owen 
 and Lord Shaftesbury, the latter of whom might 
 have attained to high office had he not preferred 
 
 9 
 
The Story of Public Health 
 
 to devote his considerable gifts to the service of 
 the poor, the defenceless and the outcast. And 
 the army sanitation which all but worked miracles 
 during the Great War received its great impetus 
 from the enthusiasm, the resolute will, the in- 
 satiable energy, and the organising genius of 
 Florence Nightingale. 
 
 That Public Health, so far as initiation is con- 
 cerned, should owe little to Governments is not 
 surprising. Their tendency has always been to 
 let sleeping dogs — that is, vested interests — lie. 
 Their business, as hitherto they have understood 
 it, is not to initiate reform, but reluctantly to 
 accept it when unofficial action has made it neces- 
 sary "to do something." Nor, so far as sanitary 
 reform is concerned, can it be ascribed to any en- 
 thusiasm among the people generally, but rather to 
 the irritating insistence of sanitarians, a small but 
 pertinacious minority of the community — consist- 
 ing partly of medical men, and partly of members 
 of local health authorities and others whose en- 
 lightened interest in public affairs has induced a 
 due sense of the importance of sanitation — who 
 make it their business to give publicity to the 
 facts, to demand official investigation, and by 
 persistent agitation to arouse the better instincts 
 of the public. The British people are certainly not 
 wanting in humanity; but they are not quick- 
 witted, they tend to an indolent, good-humoured 
 tolerance of abuses to which they have been long 
 
 10 
 
The "New Humanity" 
 
 accustomed, and much breath and ink have to be 
 expended before they come to see things as they 
 are. But at last the scales fall from their eyes, 
 conscience begins to prick, and the Government of 
 the day knows that the time has come to add a 
 plank to its platform. 
 
 What has been said about the attitude of 
 Governments to sanitary reform applies also to 
 Government Departments. Who that has had 
 anything to do with them does not know that 
 vis inertice is at least as powerful a force in Govern- 
 ment offices as in the physical universe? When 
 allowance is made for the number and lack of 
 co-ordination of the Central Health Authorities, 
 it must be allowed that they have done their 
 routine work with creditable efficiency, and that 
 in emergencies, as when unfamiliar diseases 
 appear in our midst, they have acted with 
 promptitude and vigour. But how often ^ have 
 they taken new departures except under the stimu- 
 lation of unofficial sanitarians? Factory legisla- 
 tion, it is true, owes a great deal to impulses from 
 the inspectorial staff of the Home Office, as we 
 shall see in a later chapter; and the Medical Ser- 
 vice of the Board of Education, under the vigorous 
 direction of Sir George Newman, has developed 
 so rapidly and in so many directions since it began 
 work, in 1908, as to form a notable exception to 
 the rule. But Sir George Newman would be the 
 last to underrate the importance of voluntary co- 
 
The Story of Public Health 
 
 operation. In his Annual Report for 1916 — and 
 he returns to the subject in the Report for 191 7 — 
 handsome acknowledgment is made of the success- 
 ful work done for School Hygiene by Voluntary 
 Children's Care Committees and similar organi- 
 sations, and the definite co-ordination of all such 
 bodies is held up as an ideal, to the end that for 
 the children in our elementary schools there may 
 be from birth to adolescence an unbroken chain of 
 medical supervision. 
 
 Sir Arthur Newsholme, again, while Mediral 
 Officer of the Local Government Board, pointed 
 out how necessary it is to have behind the Public 
 Health system a sympathetic and enlightened 
 public opinion. In his Annual Report for 1917-18 
 he insists that, whatever improvements might be 
 effected in administrative machinery by the crea- 
 tion of a Ministry of Health, in the last resort 
 everything will still depend upon public opinion. 
 That is undoubtedly true. Sanitarians up and 
 down the land, never so numerous as now, are 
 not so innocent as to suppose that a Health 
 Ministry may be left to go its own way, impelled 
 by nothing but its own sense of public duty. 
 Were that their view, I am persuaded that the 
 change, strenuously as I have advocated it, 
 would be a calamity. Enthusiasts for sanitation 
 are the chosen instruments of this phase of the 
 new humanity, and the time will never come when 
 it will cease to be necessary for them to press its 
 
 12 
 
The "New Humanity" 
 
 claims upon the official classes on the one hand 
 and upon the mass of the community on the other 
 hand. But, so far from being less energetic under 
 the new regime than before, they will have every 
 encouragement to redouble their efforts, for the 
 new Ministry will be able to give direction and 
 co-ordination to their activities, and thus the value 
 of their work will be immensely enhanced. 
 
 »3 
 
CHAPTER II 
 
 Pioneers 
 
 The eighteenth and the early years of the nine- 
 teenth century witnessed pioneering work which, 
 though it did not go beyond the beggarly elements 
 of Public Health, was none the less of permanent 
 value. The earliest of the Fathers of -Preventive 
 Medicine, as Sir John Simon calls them in his 
 "English Sanitary Institutions," was Richard 
 Mead .(1673-1754), Physician to St. Thomas's 
 Hospital, and the undisputed leader of the medical 
 profession in this country. Mead was a classical 
 scholar, and a friend of most of the learned men of 
 the day, and Dr. Johnson said of him that he "lived 
 more in the broad sunlight of life than almost 
 any man " — a tribute that it is not over-fanciful, 
 perhaps, to regard as a preliminary version of 
 Landor's saying concerning himself, that he had 
 "warmed both hands at the fire of life." 
 
 In the second decade of the eighteenth century 
 England was threatened with another visitation 
 of the Plague which some fifty years before had 
 reduced the population of the country By, it is 
 believed, ninety thousand. The Government 
 
 J 4 
 
Pioneers 
 
 therefore begged Dr. Mead to advise precau- 
 tionary measures, and in 1720 he published his 
 "Short Discourse concerning Pestilential Con- 
 tagion/' which in its first year went through seven 
 editions. In prescribing strict quarantine against 
 infected countries, and the isolation of any town 
 in which the pestilence might appear, he was only 
 the exponent of the common usage of those times ; 
 but in dealing with the management of infected 
 dwellings he broke new ground. The practice 
 had been to shut up an infected house, with all its 
 inmates, the sound as well as the sick, for at least 
 a month after all the family had died or recovered. 
 This he condemned as both futile and cruel. He 
 pointed out that it savoured of "punishment rather 
 than of a compassionate care," and that it offered 
 householders every inducement to practise con- 
 cealment. In place of these inhumane and mis- 
 directed measures he counselled that when the 
 disease appeared in a town a Council of Health 
 should be formed, charged with the duty of re- 
 moving the sick some three or four miles outside 
 the boundaries and of cleansing and removing 
 those who had been in contact with them, all this 
 to be done, be it noted, at the public expense. 
 Here in rough outline we may see the rudiments of 
 our system of providing, out of the public funds, 
 isolation hospitals, and places of refuge for what 
 are now called "contacts." 
 
 Dr. Mead also insisted, by no means super- 
 x 5 
 
The Story of Public Health 
 
 fluously, upon the necessity for keeping streets 
 and houses clean, "for as nastiness is a great 
 source of infection, so cleanliness is the greatest 
 preservative." In the disinfecting efficacy of 
 fumigations he had a very limited belief, but he 
 made a partial reservation in favour of "the smoke 
 of sulphur," because it "abounds with an acid 
 spirit which is found by experience to be very 
 penetrating." Sulphur is still used for the dis- ' 
 infection of rooms; but some authorities on sani- 
 tation think little more of such fumigations than 
 did Dr. Mead. In some American cities they have 
 been abandoned, and Whitelegge and Newman, in 
 their well-known manual,* do not claim more for 
 them than that they are preliminaries to more 
 thorough measures of disinfection. One further 
 recommendation of Dr. Mead's may be cited — 
 that when epidemics were raging "all unnecessary 
 assemblies" should be avoided — a precaution 
 which was urged by responsible authorities during 
 the influenza epidemic of 1918-19. 
 
 In the next generation Sir John Pringle (1707- 
 82), as Physician-General to the British Forces, 
 and physician to military hospitals, had oppor- 
 tunities, which his scientific acquirements enabled 
 him to turn to good account, of laying the founda- 
 tions of our system of military hygiene. In 1752 
 he published his classical work on "Diseases of the 
 Army," in which he brought into relief the part 
 * " Hygiene and Public Health," 13th Edit. 1917. 
 16 
 
Pioneers 
 
 played by filth and foul air in the propagation 
 of such diseases as dysentery, gangrene, and 
 typhus fever in camps and hospitals. This re- 
 mained the standard work on military hygiene for 
 many years, holding in the eighteenth century the 
 same position of authority as in the next century 
 was occupied by the "Practical Hygiene" of Dr. 
 Edmund Parkes, first published in 1864.* 
 
 1° 1753. the year after Pringle's work on mili- 
 tary medicine was published, there appeared a 
 Treatise on Scurvy from the pen of Dr. James 
 Lind (1716-94), Physician to Haslar Hospital, 
 which may be regarded as the foundation-stone of 
 naval hygiene. It was the first work on the sub- 
 ject written by a medical man who had had 
 experience of a disease that had been one of the 
 historic plagues of armies and was still ravaging 
 our seamen. In the last naval war before the book 
 saw the light more men perished from scurvy than 
 were slain in engagements with the French and 
 Spanish ships. This work was followed by others 
 dealing with typhus and enteric fever and other 
 diseases prevalent among sailors. Following in 
 Pringle's steps, Lind taught that hospital fever 
 and jail fever and ship fever were only so many 
 different names for what is now always called 
 typhus, and the means he recommended for check- 
 
 * Dr. Parkes, in his day the greatest authority on civil as 
 well as military hygiene, is commemorated by the Parkes 
 Museum, now incorporated with the Royal Sanitary Institute. 
 
 C 17 
 
The Story of Public Health 
 
 ing its dissemination in ships and hospitals are 
 virtually the same as those that have speeded its 
 disappearance from the general community. As 
 to scurvy, it had been believed more or less for 
 a couple of hundred years that lime juice was a pro- 
 phylactic and corrective, but it was Lind who first 
 proclaimed the fact with an authority derived from 
 medical experience. His advice was that sailors 
 should be plentifully supplied with oranges, 
 lemons, onions, etc., and, when these could not be 
 got, with lime juice. It was not, however, until 
 more than forty years afterwards, in 1795, that the 
 Admiralty, under the prompting of another Father 
 of naval hygiene, Sir Gilbert Blane (1749-1834), 
 ordered that the Navy should, be provided with 
 lime juice, a deliberate way of doing things which 
 is noted by Herbert Spencer, in his "Sociology," 
 as an illustration of administrative torpor. Another 
 service rendered by Lind to those who go down 
 to the sea in ships was his discovery that fresh 
 water can be distilled from salt water, and - the 
 indication of a simple means of thus rendering 
 ships independent of the shore for their water 
 supply. 
 
 Maritime hygiene owes much also to a contem- 
 porary of Lind's who was a great navigator by 
 vocation and incidentally a very successful sani- 
 tarian. Taught by bitter experience as commander 
 of the Endeavour in the three years' expedition to 
 the Pacific to observe the transit of Venus, when 
 
 18 
 
Pioneers 
 
 he lost thirty men out of a complement of eighty- 
 five from scurvy and other diseases, Captain Cook 
 (1728-79), in his second expedition, when he sailed 
 round the globe, adopted such effectual sanitary 
 measures that during three years only one man 
 died out of 118. In 1776 he communicated to the 
 Royal Society a paper describing the nature of 
 his precautions, which included insistence upon 
 the strictest cleanliness, the avoidance of unneces- 
 sary exposure and of too protracted watches, 
 ventilation of the ship, laying in supplies of 
 fresh meat and vegetables wherever possible, and 
 supplementing these with a sufficient stock of 
 oranges and lemons, sugar, etc. Later in the same 
 year the Society's Copley medal was awarded to 
 him, though not in person, for by this time he had 
 sailed on the voyage from which he was never to 
 return. 
 
 With Captain Cook as a pioneer of naval 
 hygiene may be bracketed his contemporary, John 
 Howard (1726-90), as the pioneer of prison 
 hygiene. With one of his aims, the abolition of 
 the vicious system by which jailers, instead of 
 being salaried officials, lived by the fees exacted 
 from their prisoners, we have no concern in these 
 pages. His other aim", the reform of prisons in a 
 sanitary sense, is very much to our present pur- 
 pose. It is not necessary to recall in detail the 
 dismal story of what prisons were like in those 
 days; enough to say that they were so many 
 
 '9 
 
The Story of Public Health 
 
 seminaries of loathsome disease. In them typhus 
 -fever and other diseases encouraged by filth and 
 overcrowding and lack of ventilation were, so to 
 speak, endemic, and from them fatal infections 
 were constantly overflowing into courts of justice, 
 barracks, fleets and hospitals. 
 
 Howard was one with whom reform began at 
 home. Before constituting himself the unpaid in- 
 spector of prisons, first of this nation, then in turn 
 of wellnigh all the nations of the Continent, he 
 pulled down and rebuilt every cottage on his Bed- 
 fordshire estate, and, in the words of Dr. Thomas 
 Guy, gradually transformed the whole village 
 "from damp squalor to bright, wholesome cheerful- 
 ness, from sickliness to healthiness." When Dr. 
 Guy wrote, in 1882, the cottages were as sound and 
 strong as when they were built, more than a cen- 
 tury before. Howard travelled more than fifty 
 thousand miles in fulfilment of his self-imposed 
 mission. He first gave evidence as to the con- 
 dition of English prisons in X774.J, before the 
 House of Commons, and the House awarded him 
 its thanks, and — what he no doubt appreciated 
 much more — at once passed Acts to remove the 
 abuses he had exposed. So began a movement 
 which was continued until our prisons became, in 
 a sanitary if not in a reformatory sense, model 
 institutions. 
 
 Towards the end of the eighteenth century a 
 new departure in Preventive Medicine was taken 
 
 20 
 
Pioneers 
 
 in connection with smallpox. In the second decade 
 of that century the practice of variolation, long in 
 vogue in the Orient, began to find favour in this 
 country as the result of a letter written from Con- 
 stantinople by Lady Mary Wortley Montagu. So 
 rife was smallpox, arid so great the dread of it, 
 that people preferred to have it voluntarily in a 
 mitigated form by inoculation, from a mild case 
 rather than run the risk of contracting it involun- 
 tarily in a more severe form. Arm-to-arm inocula- 
 tion was the usual mode, and in the great majority 
 of cases only a local reaction followed, or if an 
 attack of a general character developed it was in- 
 significant. 
 
 As all the world knows, the credit of replacing 
 variolation with vaccination belongs mainly to 
 Edward Jenner, a medical man who, without any 
 remarkable scientific aptitudes, had an observant 
 and inquiring mind, great pertinacity in following 
 up a- clue and pressing his views upon the com- 
 munity, and a due sense of his own merits. Before 
 coming to London, where he studied under the 
 great John Hunter, he was struck with the remark 
 of a young countrywoman that she could not take 
 smallpox because she had had cowpox — a pustular 
 disease of the udders of cows, known medically as 
 vaccinia, which sometimes infects the hands of 
 milkers. He kept the subject in mind, and in due 
 time found enough evidence to justify him in 
 making an experiment on a human subject. 
 
 21 
 
The Story of Public Health 
 
 Having, in 1796, inoculated a boy with cow- 
 pox, a few weeks later he inoculated him with the 
 virus of smallpox, as others had done, and found 
 that a condition of immunity to the more serious 
 disease had been set up. He observed also that 
 such 4 of his patients as were suffering or had 
 suffered from cowpox did not contract smallpox 
 when specially exposed to the contagion by nursing 
 or even sleeping with patients. The conclusion 
 seemed to be irresistible that cowpox protected 
 against smallpox, and he began an agitation to 
 substitute vaccination for variolation. He pub- 
 lished his results in 1798, and vaccination won its 
 way so swiftly that in 1802 he received from Par- 
 liament a grant of j£io,ooo. In the following year 
 he came to London and took a house in Hertford 
 Street, Mayfair — now marked by a commemorative 
 tablet — on a ten years' lease at a high rent in the 
 expectation of establishing a lucrative practice. 
 His hopes disappointed, he went back to his 
 countryside patfents in Gloucestershire, and in 
 1806 Parliament awarded him a further grant of 
 ,£20,000. Jenner certainly was not without honour 
 in his own generation, nor did he go without due 
 pecuniary reward. 
 
 One other name miist be cited among the 
 pioneers of Preventive Medicine. In 1831 a work 
 was published embodying the results of a study 
 of industrial diseases prosecuted By a Leeds 
 surgeon, C. Turner Thackrah. It was an exten- 
 
 22 
 
Pioneers 
 
 sive and a diligent research, covering as many as 
 250 branches of industry, and it is noteworthy as 
 the first systematic attempt made in this country 
 to draw out the connection between work and 
 disease, and to suggest that it behoved the State 
 to take preventive measures against avoidable 
 industrial diseases. 
 
 23 
 
CHAPTER III 
 
 The Nation's First Health Charter 
 
 When Queen Victoria ascended the throne, in 
 1837, the country was without even the rudiments 
 of any system of Public Health by which such 
 sanitary knowledge as had been acquired could 
 be translated into action. There was on the 
 statute-book an Act establishing an ineffectual 
 system of quarantine, and a sum of ,£2,000 was 
 annually voted for the purposes of a National 
 Vaccine Board to combat smallpox ; but with those 
 exceptions the law and the Government had no 
 concern with the nation's health. There, were, 
 it is true, local Commissions of Sewers- — an in- 
 stitution of great antiquity ; but their business was 
 to make provision against floods; they had no 
 responsibility for the removal of filth, and the 
 town sewers often allowed more liquid sewage to 
 escape by leakage than they conveyed to the out- 
 fall, so that, as Simon says, they were "among the 
 worst nuisances to the neighbourhoods which they 
 pretended to relieve." And those nuisances were 
 multitudinous and widespread and formidable. 
 The 'householder may have enjoyed far less 
 
 24 
 
First Health Charter 
 
 political liberty than he held himself entitled to, 
 but in the creation of nuisances his rights were 
 virtually absolute. Almost every house rejoiced in 
 its cesspool, and in towns it was, as a rule, snugly 
 ensconced in the basement, where its noisome ex- 
 halations were least exposed to adulteration with 
 the pure air of heaven. 
 
 The true begetter of the nation's first Health 
 Charter, the Public Health Act of 1848, was Edwin 
 Chadwick. For him I have claimed the distinction 
 v of being the founder of our Public Health organi- 
 sation. Born in Manchester in 1800, he acquired 
 in early life a reputation as an able publicist, and 
 became one of Jeremy Bentham's intimate friends. 
 ^He conceived what he termed the "sanitary idea" 
 in 1828, in preparing an article on Life Assurance 
 for the Westminster Review, and his enthusiasm 
 for sanitation remained with him to the end of his 
 long and fruitful life. In his mind the "sanitary 
 idea," if I may condense it into a single phrase, 
 connoted a wholesome environment, and so firm 
 was his faith in it that he thought the medical 
 profession "not very likely to last"; he looked 
 forward to the time when, as Sir William Collins 
 wittily says, "doctors would be unable to live, yet 
 perhaps unable to die."* In 1832 he was ap- 
 pointed an Assistant-Commissioner, and in 1833 
 a Commissioner of Inquiry into the working of the 
 
 * " The Chadwick School of Thought," Journal oj the Royal 
 Sanitary Institute, xxxiv. 318. 
 
 25 
 
The Story of Public Health 
 
 Poor Laws. In the latter year, too, he served on 
 a Royal Commission to investigate the treatment 
 of children in factories, and in that capacity had 
 the daring to propose that employers should be 
 held liable for accidents to their workmen — a prin- 
 ciple that had to wait until the year 1898 for its 
 full acceptance. The Report of the Poor Law 
 Inquiry Commission led to the passing of the Poor 
 Law Amendment Act of 1834, ani ^ ne was made 
 Secretary to the new Poor Law Commission, 
 formed to carry out that Act. 
 
 With such a Secretary the new Commissioners 
 ran little risk of adopting a policy of masterly in- 
 activity. In 1838 they addressed a letter to Lord 
 John Russell, the Home Secretary, indicting pre- 
 ventable disease as a fertile cause of destitution 
 and death, and urging immediate legislation to 
 obviate it. They had already, no doubt at Chad- 
 wick's suggestion, instructed three medical men to 
 conduct investigations into the fever prevalent in 
 London, and they submitted to the Home Secre- 
 tary two Reports setting out the results. One was 
 by Dr. Neil Arnott and Dr. Phillips Kay (after- 
 wards Sir J. P. Kay-Shu ttleworth), the other by 
 Dr. Southwood Smith, who had been for fourteen 
 years Physician to the London Fever Hospital.* 
 
 • Like Chadwick, Dr. Southwood Smith was a disciple of 
 Jeremy Bentham's, and it was he who carried out that philo- 
 sopher's direction that his body should be dissected in the 
 interests of Science, and who delivered a funeral address over 
 
 the remains. 
 
 26 
 
First Health Charter 
 
 These documents painted in vivid colours the in- 
 sanitary conditions prevalent in the poorer regions 
 of the metropolis. In a supplementary statement, 
 issued a little later, Dr. Southwood Smith showed 
 that while street and sanitary improvements had 
 been carried out in The districts inhabited by the 
 wealthier classes, nothing whatever had been done 
 for the poorer quarters. "Such is the filthy, close, 
 and' crowded state of the houses," he proceeded, 
 "and the poisonous condition of the localities . . . 
 from the total want of drainage, and the masses 
 of putrefying matters of all sorts which are allowed 
 to remain and accumulate indefinitely, that during 
 the last year, in several of the parishes, both 
 relieving officers and medical men lost their lives." 
 He added that out of 77,000 indoor and outdoor 
 paupers, 14,000 had been attacked with fever, and 
 nearly 1,300 had died. 
 
 The Reports were discussed in both Houses 
 of Parliament, and in 1839 the House of Lords, 
 on the motion of the Bishop of London, Dr. 
 Blomfield, who was inspired by Chadwick, voted 
 an Address praying that the Poor Law Commis- 
 sioners might be ' instructed to collect similar 
 information with regard to other parts of England 
 and Wales. The Cammissioners at once entered 
 upon the investigation, which was extended so 
 as to include Scotland. Their Reports, issued in 
 1842, included a "General Report on the Sanitary 
 Condition of the Labouring Population of Great 
 
 27 
 
The Story of Public Health 
 
 Britain," avowedly written by Chadwick himself. 
 It was an elaborate and a powerful description of 
 the shockingly insanitary conditions — atmospheric 
 impurities produced by decomposing animal and 
 vegetable substances, damp and filth, close and 
 overcrowded dwellings — under which the masses 
 of the people were living in every part of the 
 kingdom — in rural villages, in small towns, and 
 in larger towns. It pointed out that the formation 
 of habits of cleanliness was obstructed by defec- 
 tive supplies of water; that the annual loss of life 
 from diseases induced by filth and bad ventilation 
 was greater than that in any wars in which the 
 country had engaged in modern times; that the 
 physique of the younger population suffered from 
 the noxious physical conditions under which they 
 were bred ; that the effect upon the adult population 
 was to make them "short-lived, improvident, reck- 
 less, and intemperate " ; and that the defective 
 town cleansing fostered habits of "the most abject 
 degradation." As to the remedies, the Report 
 instanced drainage, the .removal of all refuse of 
 habitations, streets, and roads, and the improve- 
 ment of water supplies, as the primary necessities, 
 and recommended that refuse should be removed by 
 running water instead of in the solid form by hand 
 labour and cartage, and that the permanent charges 
 should be spread over "periods coincident with the 
 benefits," and should not fall entirely upon those 
 who "had only short interests in the benefits." 
 
 28 
 
First Health Charter 
 
 This rousing work was widely circulated, and 
 made a profound impression upon Sir Robert 
 Peel's Government. But there were no precedents 
 for such measures as those To which it pointed, 
 and many a long year was to pass before it was 
 clearly seen that it is the business of statesmen to 
 create, and not merely to follow, precedents. So 
 a Royal Commission was appointed to explore the 
 whole question, with the Duke of Buccleuch as 
 Chairman, and with Richard Owen and Lyon 
 Playfair — names still familiar "to our ears — as two 
 of its members. It was energetically shepherded 
 by Chadwick, who afterwards told Simon that he 
 was the habitual assistant of the Chairman and 
 the Secretary, that he "precognised " all the wit- 
 nesses, and that he drafted the first Report, issued 
 in 1844, and the recommendations of the second 
 Report, which followed in the next year. It was by 
 no means a delaving or a shelving Commission. 
 Its Reports provided the amplest confirmation of 
 the findings of the Poor Law Commissioners as to 
 the gross defects in drainage, water supply, paving 
 and cleansing, ventilation, etc., and advised that 
 the Crown should have control of all general 
 measures of sanitation, that all such matters should 
 be placed under one administrative body, that the 
 local authorities should be armed with additional 
 powers but that their operations should be subject 
 to central control, while the Crown should have 
 power to compel them to action in case of default. 
 
 29 
 
The Story of Public Health 
 
 The attempt made to give effect to these far- 
 reaching recommendations was not immediately 
 successful, but in 1848 was passed the Public 
 Health Act, establishing a new Government De- 
 partment, the General Board of Health, as the 
 "one administrative body " contemplated by the 
 Buccleuch Commission, invested with power to 
 form local sanitary districts under Local Boards of 
 Health, the power to be exercised compulsorily 
 where the death-rate of a district was as high as 
 23 per thousand, in other cases on petition from 
 the ratepayers. From the operation of the Act the 
 metropolis was excluded, but a Bill was passed 
 during the Session providing for the appointment 
 of a Metropolitan Commission of Sewers to replace 
 the separate Sewers Commissions then existing, 
 and immediately afterwards the City Sewers Act 
 was passed in the interests of "the City," the "one 
 square mile " over which the Lord Mayor has 
 jurisdiction. 
 
 The year 1848 also witnessed the passing of a 
 measure complementary to the Public Health Act, 
 the Nuisances Removal and Diseases Prevention 
 Act, giving powers for the summary abatement of 
 nuisances injurious to health. This was a measure 
 of great importance. By the common law the 
 only remedy for any act or omission endangering 
 health was an action for damages or an indict- 
 ment for nuisance, proceedings which' were not 
 precisely summary. Now, justices of the peace, on 
 
 30 
 
 / 
 
First Health Charter 
 
 complaint of local authorities specially authorised 
 for the purpose, were empowered promptly to 
 suppress such nuisances as were at that time 
 recognised. 
 
 At first the General Board of Health consisted 
 of an ex-oFBcio member, the First Commissioner of 
 Works, and two members appointed by the Crown, 
 one paid, the other unpaid. Neither of the three 
 was a medical man. The time had not quite come 
 to recognise the medical profession as entitled to 
 any direct voice in health administration. With- 
 in two years, however, a permanent medical 
 member, in the person of Dr. Southwood Smith, 
 was added to the Board under a Burials Act then 
 passed, the Metropolitan Interments Act, 1850. 
 Coming in such a way, this concession naturally 
 provoked ironical comment. "Who would have 
 thought," asked Dr. Rumsey, in the Preface to his 
 " Essays in State Medicine," published a few years 
 later, "that in. the last decade of advancing civili- 
 sation ... the whimsical experiment should have 
 been actually tried of appointing three non-medical 
 authorities — two Lords and a Barrister — to preserve 
 the health of the living; and then, after a year or 
 two of doubtful success, calling in a Physician to 
 bury the dead?" 
 
 The two lords were Lord Morpeth "(afterwards 
 Earl of Carlisle), who had carried the Public 
 Health Bill through the House of Commons, and 
 the future Lord Shaftesbury; the barrister was 
 
 31 
 
The Story of Public Health 
 
 Edwin Chadwick, who was the paid member, while 
 Lord Morpeth sat by virtue of his office as First 
 Commissioner of Works. The functions of the 
 Board were to sanction the schemes promoted by 
 V local authorities under the Public Health Act of 
 1848, and to regulate any measures which might 
 be necessary, during the prevalence of epidemics, 
 under the Nuisances Removal and Diseases Pre- 
 vention Act of the same year. 
 
 The beginning of its career synchronised with 
 the second visitation of cholera which this country 
 experienced. The first cholera epidemic had 
 taken place in 1831-33, when some 31,000 deaths 
 had occurred in certain parts of Great Britain, and 
 21,000 in Ireland. The King in Council had 
 ordered a Form of Prayer against the disease, 
 and a consultative board had been appointed 
 to promulgate certain temporary Rules and 
 Regulations which did little more than enjoin 
 cleanliness and ventilation. The epidemic was 
 of some service in drawing attention to the danger 
 arising out of the neglect of public and domestic 
 sanitation, but nothing more definite came of it. 
 The second epidemic (1848-497, in which 54,000 
 persons perished in England alone, provided much 
 occupation for the new Board, and yielded to Dr. 
 John Snow the important deduction that the disease 
 was propagated by means of intestinal discharges, 
 a theory for which he found substantial confirma- 
 tion in a third visitation that occurred in 1853-54. 
 
 32 
 
First Health Charter 
 
 By the end of 1853 the Board had applied the 
 Public Health Act to 182 places having an aggre- 
 gate population of more than two millions, had 
 framed by-laws regulating the health activities of 
 local authorities, and had issued a valuable series 
 of Instructional Minutes for the guidance of such 
 authorities, besides the action it had taken with 
 a view to the control of cholera. Further, in 1850 
 and 185 1 it had issued Reports dealing with the 
 urgent question of burials in towns. It recom- 
 mended that what are loosely called intramural 
 interments — that is interments in cities and towns 
 — should be prohibited. It also had the boldness 
 to propound a highly centralised system for the 
 disposal of the dead. The Government was to be 
 the nation's Burial Authority, was to have power 
 to contract for the carrying out of funerals, to 
 provide mortuaries and appoint medical officers 
 of health in connection with them, and to regulate 
 undertakers' and all other funeral charges. In 
 London the work was to be done presumably by 
 the Board itself ; in country towns by local bodies 
 acting under the Board's supervision. The Gov- 
 ernment, of course, declined the invitation to take 
 up so vast and so socialistic a scheme ; still, some- 
 thing came of the Board's grapple with the question, 
 for in 1852 intramural interments were prohibited 
 in London by an Act which in the following year 
 was extended to the provinces, and was afterwards 
 further extended to Scotland and Ireland. 
 
 D , 33 
 
The Story of Public Health 
 
 The Board also investigated another big ques- 
 tion, that of the water supply of London. It 
 roundly condemned the supply on the grounds of 
 insufficiency, impurity, intermittency, and cost- 
 liness, and, making another daring excursion into 
 the sphere of centralisation, advised that the water 
 companies should be superseded by a Public 
 Authority which should also be charged with the 
 management of the drainage of the metropolis. 
 The implication of the Report appears to be that 
 all these functions, including even the construction 
 of the apparatus of drainage and water supply in 
 houses, should devolve upon itself. For such an 
 innovation the times were not precisely ripe. The 
 Government was anxious to do something, but 
 was a great deal more anxious not to do much. 
 It therefore set a Select Committee to work, and 
 in 1852 a Bill was passed which professed to be 
 a compromise between the water companies and 
 the public, but which left things very much as 
 they were. It was not until fifty years later, in 
 1902, that the water companies were superseded by 
 the Metropolitan Water Board. 
 
 That the General Board of Health should have 
 provoked a good deal of antagonism is not sur- 
 prising. Local autonomy was a principle of govern^ 
 ment of which the roots had struck deep in the 
 nation's life. Long and bitter had been the 
 struggle by which the towns had won their civic 
 freedom, and the idea of a central authority which 
 
 34 
 
First Health Charter 
 
 should at once stimulate local authorities to action 
 and curb them when their activity was ill directed 
 was regarded not merely with distrust but with 
 detestation. The current conception of a local 
 authority was that of a body with power to do as 
 it pleased, even if it were pleased to do foolish 
 things, or to do nothing. The Board excited 
 opposition also by its interference with the sacred 
 prerogatives of "vested interests," a potent entity 
 which figures in Sir John Simon's polished diction 
 as "commercial enterprise." Nor did the Board's 
 medical and engineering theories escape challenge 
 — not altogether without reason, jaerhaps, so far as 
 the medical theories were concerned ; while the civil 
 engineers cherished a grievance because of the 
 liberty of private practice allowed to the Board's 
 engineering inspectors. The opposition from these 
 various quarters was focused upon Chadwick, and 
 we may pay him the compliment of saying that 
 in this there was no injustice. Much as the Board 
 owed to Lord Ashley and other members, it was 
 from its creator that its inspiration and energy 
 and daring were drawn. 
 
 The attacks came to a head in 1854. The 
 Public Health Act constituting the Board was 
 subject to renewal at the end of five years. That 
 period being about to end, the Government sought 
 to buy off opposition by placing the Board under 
 the control of a Secretary of State. It is significant 
 of the real merits of the controversy that Lord 
 
 35 
 
The Story of Public Health 
 
 Palmerston, in commending this proposal to Par- 
 liament, should have recognised that the Board 
 was in conflict with "the fair and legitimate 
 interests of many very intelligent and very active 
 men " — such interests, for example, as the lucrative 
 business of obtaining local Acts, the profit-making 
 of water companies, and the emoluments of local 
 engineers. Lord John Russell, now Prime 
 Minister, even admitted that Chadwick might not 
 have "observed the most conciliatory tone pos- 
 sible " towards the many persons who were 
 pecuniarily interested in opposing the Board's 
 schemes. The upshot of the debate was that the 
 proposal to renew the Board's lease of life was 
 defeated. The Government at once introduced 
 a new Bill making some amendments in the Public 
 Health Act of 1848 and continuing it subject to 
 annual renewal, and reconstituting the General 
 Board of Health as an authority consisting of cer- 
 tain Ministers with a paid President, who, in fact, 
 was himself the Board. 
 
 Chadwick was not forgiven. Parliament con- 
 sidered that the nation had no further need of the 
 services of one who could be drastic without even 
 being polite, and he was retired on a pension of 
 .£1,000 a year, which it is consoling to know that 
 he drew for five-and-thirty years. He threw 
 himself into Army sanitation, sanitary engineer- 
 ing, agricultural drainage, the provision of open 
 spaces, and tropical hygiene, and acquired a 
 
 36 
 
First Health Charter 
 
 European reputation as a sanitarian. In his nine- 
 tieth year he received from Queen Victoria a 
 K.C.B., an honour which he enjoyed for one year ! 
 
 It may be that if he had been other than he 
 was — if he had not been of so bold and eager a 
 temperament that it was impossible for him to 
 make haste slowly — Sir Edwin Chadwick might 
 have rendered still more effective service to the 
 cause that possessed his mind and soul. The 
 question is not easy of determination, nor, if it 
 were, would its discussion be of practical interest. 
 What is indisputable is that he laid the nation 
 under the greatest obligation by forcing sanitary 
 reform upon its attention early in his career, and 
 that after the close of his official life he continued 
 to render similar service of inestimable value. 
 
 The first President of the reconstituted General 
 Board of Health was Sir Benjamin Hall, who, by 
 the way, gave a bit of his name to "Big Ben" of 
 Westminster. Though he came into the Public 
 Health movement an avowed opponent of the 
 Board's centralising tendencies, he did some 
 things which demand at least passing notice. 
 Having to cope with the third cholera epidemic, 
 which was raging at this time,, he formed a tem- 
 porary Medical Council which, , for about a year, 
 until the emergency ceased, guided him with its 
 advice, and in 1855 he added to the Public Health 
 Act, as then renewed, a clause empowering the 
 Board to nominate a Medical Council from time 
 
 37 
 
The Story of Public Health 
 
 to time, as well as to appoint a salaried Medical 
 Officer. He also reorganised the local government 
 of the metropolis by setting up the Metropolitan 
 Board of Works, and constituting, in the separate 
 parishes and districts, vestries and district boards 
 which were required to appoint special sanitary 
 officers. The General Board of Health, virtually 
 reduced, as we have seen, to a membership of one, 
 breathed its last in 1858, most of its duties being 
 taken over by the Privy Council, while the others 
 were transferred to the Home Office. 
 
 38 
 
CHAPTER IV 
 
 The Era of Inquiry and Education 
 
 The fate of the General Board of Health made it 
 only too clear that the country, including the 
 Legislature, badly needed sanitary education. It 
 might have been supposed that the mere exposure 
 of the insanitary horrors that have been hinted at 
 rather than described in these pages would have 
 sufficed to convince the nation of the need for 
 drastic reform. But in these days it is hardly pos- 
 sible to catch any due sense of the gross sanitary 
 ignorance which prevailed at that time. The laws 
 of sanitation had been so long and were so habitu- 
 ally violated, and the failure to realise the con- 
 nection between such violations and the disease 
 that avenged them was so general and so 
 complete, that a long process of education, sup- 
 plemented by a course of opportune epidemics, 
 was an indispensable condition of sanitary 
 progress. 
 
 Fortunately the hour had brought the man. 
 In the year which witnessed the creation of the 
 General Board of Health the City of London chose 
 
 39 
 
The Story of Public Health 
 
 as its first Medical Officer of Health* John Simon, 
 one of the ablest and most accomplished medical 
 men of that generation, a surgeon and pathologist, 
 with a tincture of philosophy and something more 
 than a tincture of reasoned humanitarianism. In 
 that post he did "conspicuously good service, 
 organising a thorough system of sanitary inspec- 
 tion and superintendence. Before long, to quote 
 his own words, "the sanitary circumstances of tens 
 of thousands of the poorer population were sen- 
 sibly improved by the introduction of new drainage 
 and water supply, by the enforcement of periodical 
 house cleaning, by far stricter practice of scaven- 
 ging, and by general mitigation of nuisances. Not 
 least, the abomination of cesspools had come to 
 an end. At a time when cesspools were still almost 
 universal in the metropolis, and while, in the 
 mansions of the West End, they were regarded 
 as equally sacred with the wine cellars, they had 
 been abolished for rich and poor throughout all 
 the square mile of the City." 
 
 While thus making of the City a pattern for 
 the rest of the metropolis, Simon was also, by his 
 Annual Reports to the City Commission of Sewers, 
 playing a leading part in the sanitary education 
 of the whole country. It is impossible to read 
 
 * The first town to appoint a Medical Officer of Health was 
 Liverpool, which did itself that honouT in 1847, and in choos- 
 ing Dr. William Henry Duncan made a scarcely less fortunate 
 choice than did the City of London. 
 
 40 
 
The Era of Inquiry 
 
 these Reports without a feeling of admiration for 
 his insight and prescience. Thus we find him 
 enunciating the great principle that "the super- 
 vision of the public health . . . ought to be the 
 consolidated and sole charge of some one Minister, 
 who, sitting in Parliament, and being in statutory 
 relations with local authorities possessing all the 
 required sanitary powers, should be open to chal- 
 lenge in respect of every public matter concerning 
 health, and should be responsible not only for the 
 enforcement of existing laws. . . . but likewise 
 for their progress from time to time as the growth 
 of knowledge would make desirable." Simon's 
 hope at that time was that the General Board of 
 Health might be remodelled into a shape that 
 would enable it to realise his ideal. That hope was 
 doomed to speedy extinction, and the ideal of a 
 single Central Health Authority presided over by 
 a member of the Government was almost lost 
 sight of until three-quarters of a century later 
 it reappeared under the name of a Ministry of 
 Health with virtually universal acceptance. 
 
 While still Medical Officer of Health for the 
 City of London, Simon was called upon by the 
 Government to take part in inquiries into epi- 
 demics of cholera. So obvious was his competence 
 that his preferment to the Medical Officership of 
 the General Board of Health when that addition 
 was made to the Board's staff by Sir Benjamin 
 Hall in 1855 was almost a foregone conclusion, 
 
 41 
 
 
The Story of Public Health 
 
 and when three years later the Board was suc- 
 ceeded by the Lards of the Privy Council he was 
 appointed their Medical Office*. 
 
 At first Simon's position under the Privy 
 Council, was precarious in the highest degree. 
 Sanitary reform was so unpopular a cause that the 
 Public Health Act of 1858, charging the Privy 
 Council with duties to be presently enumerated, 
 was passed for a single year only. During the 
 year Lord Derby's Government actually decided 
 to let the Medical Officership lapse, but almost 
 immediately changed its mind, owing, as Simon 
 believed, to the enlightened influence of the Prince 
 Consort. Just at this time Lord Palmerston re- 
 turned to power, and before the year 1859 ended 
 Robert Lowe (afterwards Lord Sherbrooke) carried 
 a Bill, though only by a narrow majority, per- 
 petuating the office and also giving permanence 
 to the provisions of the Public Health Act of 1858. 
 Since its birth the Public Health Service had had 
 more than its average share of maladies, and had 
 narrowly escaped swelling the tables of infant 
 mortality. Now it entered upon the stage of 
 adolescence, and henceforward its career was to 
 be one of continuous if irregular growth and 
 development. 
 
 Under the Act of 1858 the Privy Council be- 
 came responsible for the public vaccination system 
 of England and Wales, and when epidemics of 
 smallpox or any other disease were rife it was its 
 - 42 
 
The Era of Inquiry 
 
 duty to issue Orders and Regulations to check 
 their progress. It also had duties to fulfil in 
 connection with the organisation of the medical 
 profession — duties of which something will be said 
 later. But with these exceptions the Public Health 
 functions of the Privy Council were those of 
 Inquiry and Report, and it was by these means 
 that it rendered its most important service to State 
 Medicine. Simon was ably seconded by Inspectors 
 whom the Privy Council engaged, at first tem- 
 porarily for occasional work, and afterwards per- 
 manently. One ■ of these officials, Dr. George 
 Buchanan, appointed a permanent inspector in 
 1869, had been since 1857 Medical Officer of Health 
 for the St. Giles District, which at the beginning 
 of his connection with it was one of the most 
 insanitary regions in the metropolis. It was a 
 Report of his to the Privy Council in 1866 that 
 brought out the direct association that obtains 
 between pulmonary tuberculosis and dampness of 
 the soil. When the Privy Council had done 
 its work as the Central Sanitary Authority, he 
 was transferred to the Local Government Board, 
 and we shall meet him again in the next chapter, 
 and with him another eminent sanitarian, Dr. 
 Thorne-Thorne, who also began his Public Health 
 career under the Privy Council. 
 
 The sixth and seventh decades of the nineteenth 
 century provided the Medical Department of the 
 Privy Council with ample opportunities for the 
 
 43 
 
The Story of Public Health 
 
 study.of epidemics. About the time when it began 
 work a violent recrudescence of diphtherial disease 
 of which that generation had had little experience, 
 excited much alarm in the country, and was not 
 stayed until seventeen counties had been involved. 
 In 1862-3 the cotton famine was associated with 
 outbreaks of typhus fever. In 1865 there were 
 fears that cerebro-spinal meningitis, in these days 
 popularly called "spotted fever," might spread 
 from the North of Europe to the British Isles, 
 where it was as yet unknown. Soon afterwards 
 cholera once more showed its horrid front. In 
 1866 there were some fifteen deaths from yellow 
 fever among the inhabitants of Swansea. All 
 these epidemics formed the subjects of inquiry. 
 Investigations were also made into enteric fever, 
 scarlet fever, and other common infections as they 
 presented themselves. Other inquiries of the 
 Medical Department related to the distribution of 
 diarrhoea and pulmonary disease and malaria, 
 and a beginning was made of the study of in- 
 fant mortality, a subject in which there is still 
 much to be learnt and yet more to be done. 
 At the same time investigations of a more general 
 character relating to food supply, habitations, 
 physical surroundings and industries, as affecting 
 the nation's health, were diligently prosecuted, and 
 much valuable information was collected. 
 
 These facts, and the inferences to which they 
 pointed, were employed by Simon in his Annual 
 
 44 
 
The Era of Inquiry 
 
 Reports as the basis of appeals for the extension 
 of sanitary law. He showed that the Nuisances 
 RemovaT Act provided quite inadequate powers of 
 summary procedure, and that even such powers as 
 it conferred were insufficiently used, so that "filth- 
 nuisances on a monstrous scale were to be seen 
 in all directions continuing under the eyes and 
 noses of authorities appointed to remove them, and 
 that filth diseases in cruel and scandalous amount 
 were being inflicted on helpless myriads of the 
 population." He pointed out that the poor, both in 
 town and in country, were atrociously ill-lodged, 
 that unwholesome and obscene overcrowding was 
 common, and that tenement houses, often inhabited 
 by as many families as there were rooms, were 
 hotbeds of disease. He insisted also upon the 
 need for legislation with a view to isolation and 
 disinfection, and the penalisation of the wanton 
 carelessness, almost universally practised, by which 
 infectious diseases were spread. Another lesson he 
 enforced was the need for measures to prevent 
 industrial diseases — measures to ensure that work- 
 shops should be ventilated and not overcrowded, 
 that the atmosphere in them should be kept free 
 from dust irritating to the respiratory organs, and 
 that precautions should be taken against absorption 
 of the poisons used in certain manufactures. Yet 
 another point to which he directed attention was 
 the effect upon infant mortality of the employment 
 of women in factories and on the land. He laid 
 
 45 
 
The Story of Public Health 
 
 stress upon the fact that the mortality in some 
 districts was three times as great as in the standard 
 districts, while in some of them infants were 
 subjected to treatment which he stigmatised as 
 "almost murderous." 
 
 One effect of these illuminating and conscience- 
 stirring documents was the erection of the next 
 great, landmark in Public Health legislation after 
 thg. Public Health Act of 1848 — the Sanitary Act 
 of 1886, first introduced by Mr. Bruce (afterwards 
 Lord Aberdare). In the confusion caused by a 
 political crisis the Bill was almost lost, but a severe 
 epidemic of cholera in London supplied a timely 
 stimulus which led the new Government, Lord 
 Derby's third Administration, to adopt the measure 
 and press it through Parliament. Under this Act, 
 as Simon says, "the grammar of common sanitary 
 legislation acquired the novel virtue of an impera- 
 tive mood." It now became the "duty" of the 
 local authorities to provide for the sanitary inspec- 
 tion of their districts and to suppress nuisances, 
 and where the sewerage or the water supply was 
 insufficient or nuisances were not removed the Act 
 gave the Secretary of State and the Court of 
 Queen's Bench power to exercise compulsion. It 
 also conferred powers against domestic over- 
 crowding, and, reinforcing provisions introduced 
 into Factory and Workshop Acts at this time, 
 forbade overcrowding and uncleanliness in in- 
 dustrial buildings and stipulated for their proper 
 
 46 
 
The Era of Inquiry 
 
 ventilation, as well as for the strict observance of 
 precautionary regulations in specially dangerous 
 industries. Further, it enabled local authorities to 
 disinfect or destroy infected things and to provide 
 isolation hospitals, and subjected to penalties 
 individual acts which promoted the dissemination 
 of infectious disease. 
 
 Another subject which engaged public attention 
 about this time and was then to a great extent lost 
 sight of has acquired special interest in these days. 
 To check the spread of venereal disease it was 
 urged by some that legislation should be introduced 
 to establish what Simon delicately terms "a sys- 
 tematic sanitary superintendence" of prostitutes. 
 To anyone who knows what manner of man he 
 was, it is no surprise that he should have felt 
 himself compelled to report against such schemes. 
 
 Two of Simon's Annual Reports are memorable 
 as sketching the outlines of the present system of 
 protecting our ports against cholera and other 
 infectious diseases. At this time, under the 
 Quarantine Act of 1825, consolidating and modify- 
 ing earlier Acts, ships arriving from ports con- 
 sidered to be infected, even if no cases of infectious 
 disease had occurred, were liable to detention, and 
 if cases actually occurred on ship the detention of 
 the vessel, with the crew and 1 any passengers, was 
 indefinitely prolonged. A system involving, such 
 an extreme degree of inconvenience and hardship 
 and pecuniary loss naturally provoked, severe 
 
 47 
 
The Story of Public Health 
 
 criticism. It had been discussed by the General 
 Board of Health in 1849 and 1852, but with an 
 abundant lack of enlightenment, though the con- 
 clusion reached was sound enough. The Board 
 gravely propounded the doctrine that epidemic 
 diseases have their "primary and essential con- 
 dition " in an "epidemic atmosphere" which may 
 extend for thousands of square miles but which 
 affects only such localities as are insanitary. It 
 was argued therefore that quarantine could give 
 only a sense of false security, and the Board 
 recommended that the system should be abolished 
 root and branch and that safety should be sought 
 in local sanitary improvements alone. 
 
 Simon's condemnation of the system was based 
 upon no such false ground. In a Memorandum 
 issued in 1865 he put the case against it on the true 
 ground of the impossibility of enforcing restrictions 
 so inconvenient and involving such serious inter- 
 ruption to commerce. "Were the country," he 
 pointed out, "ever so ready to endure these extreme 
 restrictions, without which the whole thing is 
 fruitless and absurd, the means for imposing them 
 do not exist. To extemporise a cordon sanitaire is 
 simply and totally impossible, and no partial 
 quarantine can be relied on for national purposes." 
 His plan was to trust to the same preventive 
 methods for foreign as for native infections. Every 
 local sanitary authority, whether port or inland, 
 should be empowered to defend its district against 
 
The Era of Inquiry 
 
 infectious disease, whether endemic or exotic, and 
 such powers as were employed against the former 
 should be our sole resource against the latter. As 
 we shall see in a later chapter, this plan was in 
 essence adopted within a few years. 
 
 Note must also be taken of another innovation 
 which we owe to Simon. A skilled pathologist, 
 he appreciated the importance of exploring the 
 processes as well as the causes of disease, well 
 assured that the acquisition of such knowledge, 
 even if prevention and treatment were not the 
 immediate objects in view, could not fail to be of 
 practical utility. At his suggestion laboratory 
 investigations were made for the Medical Depart- 
 ment by Dr. Burdon-Sanderson, Dr. Klein and 
 Dr. Thudichum, and in 1870, when the nation's 
 pursestrings were in the hands of Robert Lowe, a 
 true friend of medical and sanitary science, an 
 annual subsidy of ,£2,000 was granted for the 
 extension of these researches. That later Chan- 
 cellors of the Exchequer should have been so slow 
 to improve upon this lead is but one of many 
 evidences of the lack of interest in science which 
 prevails in official cii "cs. 
 
 By r iie year i£6q the country was ripe for 
 another sanitary inquiry by a Royal Commission. 
 The hostility which had given so violent a check 
 to sanitary administration in 1858 had been to a 
 great extent conciliated, a process in which Simon's 
 Report.:, so happily blending moderation with 
 
 E 49 
 
The Story of Public Health 
 
 decisiveness, and so carefully avoiding extraneous 
 matters which might have excited prejudice, had 
 played a chief part. It was now recognised that 
 the time had come for a consolidation of sanitary 
 law and for the introduction of order and con- 
 sistency into sanitary procedure. Save here and 
 there* no one local authority was charged with the 
 power to prevent and remove nuisances. Public 
 Health powers were divided between Town 
 Councils and Boards of Guardians, and in ancient 
 parishes the Home Office had created a third 
 Nuisance Authority, so that, as Simon says, in 
 some rural parishes "the privies were under one 
 Authority and the pigsties under another." And 
 there was a similar lack of unity in the Central 
 Health Administration. In 1868 a Joint Committee 
 of the British Medical and Social Science Associa- 
 tions memorialised the Government to appoint a 
 Royal Commission to explore the whole subject, 
 and in the following year a Commission, usually 
 cited as the Royal Sanitary Commission, was 
 nominated to report upon the operation of sanitary 
 law in England and Wales (except the metropolis), 
 and upon the authorities, both central and local, 
 by which the laws were administered. It was a 
 strong Commission, and it made a thorough 
 investigation. It recommended a consolidation of 
 sanitary law, which should be made "uniform, 
 universal and imperative throughout the kingdom." 
 It advised the constitution of a Central Authority 
 
The Era of Inquiry 
 
 to direct the administration of the laws relating not 
 only to Public Health but also to the relief of the 
 poor, hitherto administered by the Poor Law 
 Board. The Royal Commissioners regarded it as 
 essential that to the new Central Authority should 
 be transferred the Medical and Veterinary Depart- 
 ments of the Privy Council, the Local Government 
 Act Office (a branch of the Home Office), the 
 Registrar-General's Office, and all the general 
 sanitary powers and duties at that time exercised 
 by the Privy Council, the Home Office, and the 
 Board of Trade. As to local authorities, their view 
 was that all sanitary powers should be concen- 
 trated in one responsible body in each locality, this 
 body to have in its service at least one Medical 
 Officer of Health and at least one Inspector of 
 Nuisances. It further recommended 4hat all local 
 districts should be inspected by medical and 
 engineering experts appointed by the Central 
 Authority, so that any defects in sanitary and 
 Poor Law administration might be brought to 
 light and remedied. 
 
 It must be noted, with regard to the Central 
 Health Administration, that the Royal Commis- 
 sion was debarred by the terms of its appointment 
 from considering those branches of Public Health 
 law which were operated by other than local 
 authorities, such as the regulation . of industrial 
 employments and of the processes of chemical 
 manufacture, the control of lunatic asylums, and 
 
 5i 
 
The Story of Public Health 
 
 the constitution and discipline of the medical and 
 pharmaceutical professions. Simon was quick to 
 see that these exclusions left in existence anomalies 
 which would in time lead to further anomalies. 
 His view was that all the central responsibilities 
 relating to Public Health and all those relating to 
 local government should, without exception, be 
 consolidated and placed under one Minister, and 
 that in every affair in which both sanitary and local 
 government questions were concerned the respec- 
 tive divisions of his staff should act in concert. A 
 Department that should absorb all local govern- 
 ment and Public Health administration is certainly 
 open to the objection that in course of time it 
 would grow to unmanageable proportions; but 
 Simon's forecast of the consequences of excluding 
 certain branches of Public Health work from the 
 consideration of the problem has been abundantly 
 justified. By the second decade of the present 
 century health administration had become hardly 
 less chaotic than it was when the Royal Commis- 
 sion of 1869-71 issued its Report. 
 
 The chief sequel to the Report was the Local 
 Government Board' Act of 1871, creating as the 
 Central Health Authority the Local Government 
 Board, which superseded the Poor Law Board and 
 the Local Government Act Office, took over most 
 of the Public Health responsibilities of the Privy 
 Council, and became formally responsible for the 
 Registrar-General's Department. In 1872 was 
 
 52 
 
The Era of Inquiry 
 
 passed an Act amending the constitution and 
 powers of the local authorities. The consolidation 
 of sanitary laws recommended by the Royal Com- 
 missioners was effected mainly by the Public 
 Health Act of 1875, which is declared by Mr. 
 Percy Ashley to be "the greatest sanitary code ever 
 enacted in any country," * and a number of other 
 consolidating and amending measures, referring 
 to the sale of food and drugs, the pollution of 
 rivers, artisans' dwellings, burials, the regulation 
 of factories and workshops, etc., were added to the 
 statute-book during the next few years. 
 
 Of the era of inquiry and education with which 
 this chapter has been concerned, Simon was the 
 leading figure, as Chadwick was of the earlier phase 
 of Public Health evolution. If Simon was for- 
 tunate in the men who co-operated with him as 
 Medical Inspectors, it was his discernment that 
 selected them, and, as we have seen, it was he who 
 urged upon the nation the reforms of which their 
 investigations revealed the need. The end of the 
 era was not the termination of his career as a 
 Public Health official. How he fared under the 
 Local Government Board will appear from the 
 next chapter. 
 
 * "Local and Central Government," p. 226. 
 
 53 
 
CHAPTER V 
 The Local' Government Board 
 
 The first President of the Local Government 
 Board was Mr. James Stansfeld, who, as President 
 of the Poor Law Board, had piloted the Act of 
 1871 through the House "of Commons. From that 
 Board the new Authority derived its President and 
 Parliamentary Secretary, its permanent secretariat, 
 and its system of provincial agencies. In relation < 
 to the interests of Public Health, it was, as Simon 
 says, "as if the Act had ordered that the old Poor 
 Law Board, subject only to such conditions of 
 consultation and reference as itself might impose 
 upon itself, should be the Central Sanitary 
 Authority of England." The Royal Sanitary 
 Commission had suggested that the Minister to 
 take charge of the combined Public Health and 
 Poor Law administration should have separate 
 secretariats. In that case the Medical Department 
 of the Privy Council and the Secretary and En- 
 gineer-Inspectors of the Local Government Act 
 Office would naturally have formed the Health 
 Division of the new Board, and the two might have 
 co-operated as they had formerly done under the 
 
 54 
 
Local Government Board 
 
 General Board of Health. Instead of this, Mr. 
 Stansfeld provided himself with a single secre- 
 tariat drawn exclusively from the Poor Law Board, 
 and afterwards the transferred inspectors of the 
 Board were appointed the "general inspectors" of 
 the new Board. As to the transferred officers of 
 the Privy Council and the Local Government Act 
 Office, they were to be used only for special con- 
 sultation and special local inquiries. 
 
 To Simon, with his clear vision of what the 
 nation's sanitary interests required, this was a 
 profound disappointment. That his mind was 
 biased by any consideration for his own dignity 
 no one who knew him personally, as it was my 
 privilege to do, or who is familiar with his writings, 
 can for a moment suspect, and his discussion of 
 the subject in " English Sanitary Institutions " is 
 absolutely free of any note of personal grievance. 
 But in the interests of Public Health he had hoped- 
 and expected that the independent powers of the 
 Medical Officer of the Privy Council and of the 
 technical experts of the Local Government Act 
 Office would be extended under the new regime. 
 "The sanitary branch of the public service," as 
 he says with unanswerable force, "had peculiarly 
 grown out of the exercise of technical observation 
 and contrivance, and would of necessity in the 
 future be dependent on the same faculties for its 
 chief means of usefulness to the public; but, 
 although the officers who during many years had 
 
 55' 
 
The Story of Public Health 
 
 been> the amassers of sanitary experience, and 
 had till then represented it in administration, had 
 been transferred to the new department, no clear 
 provision had been made for their having influence 
 in it." True, they could be consulted ; but no one 
 knew better than he that much more than mere 
 "consultability," to use his own happy expression, 
 was necessary if medical and engineering experts 
 were to exercise their due influence in the new 
 system. 
 
 The record of the Poor Law Board's medical 
 activities was not such as to warrant any confident 
 hope that a magnified Poor Law Board would start 
 on the best lines its new work of organising local 
 government and Public Health administration. 
 The Board had administered the Poor Laws since 
 1847, when it superseded the Poor Law Commis- 
 sioners appointed under the Poor Law Amendment 
 Act of 1834 — the Act which brought Poor Law 
 Unions and Boards of Guardians into existence. 
 In the discharge of its medical responsibilities it 
 had exhibited a plentiful lack of efficiency. 
 Although it had had to do so largely with affairs 
 of medical technic, for a long time it had had no 
 medical men on its staff. It had proceeded on 
 the assumption that for the Board's ordinary 
 medical business the common sense of secretaries 
 and other non-medical officials was sufficient : when 
 some occasion out of the ordinary arose, special 
 medical assistance could be requisitioned. This 
 
 56 
 
Local Government Board 
 
 curious faith in the omniscience of the secretarial 
 mind had had disastrous results upon the health 
 interests of the poor, and at last, not long before 
 the Board received its apotheosis and became the 
 Local Government Board, a Medical Officer was 
 appointed ; but even then it was not expected that 
 he should give his superiors general advice, still 
 less that he should display initiative. Like a child 
 brought up under the old method, he was only 
 to speak when spoken to. 
 
 Starting with a personnel imbued with such 
 principles as these, and under a presidency in- 
 formed by no large conception of the nation's 
 sanitary needs, it is not surprising that the Local 
 Government Board should have taken wrong turn- 
 ings and missed golden opportunities. The con- 
 ditions laid down for the appointment of Medical 
 Officers of Health by the fifteen or sixteen hundred 
 local authorities whose constitution and powers 
 were determined by the Act of 1872 resulted, in 
 the majority of instances, in appointments for areas 
 so small that the medical men concerned had to 
 be allowed to continue in private practice. Not 
 more satisfactory was the system of supervision 
 of the local authorities which the Board instituted. 
 It was an essentially non-medical system, of which 
 the agents were the general inspectors. Such 
 medical inspection as was carried out was quite 
 casual, and indeed could not have been otherwise 
 without that enlargement of the medical staff which 
 
 57 
 
The Story of Public Health 
 
 the wisdom of Mr. Stansfeld deemed a super- 
 fluity. Presently some slight concessions were 
 made to the Medical Department. It was allowed, 
 for instance, where matters primarily sanitary were 
 concerned, to take part in conferences with local 
 authorities, and the administrative officers of the 
 Board now showed a greater disposition to avail 
 themselves of its counsels; but the means allowed 
 to the Department to acquire the intimate know- 
 ledge upon which to base its advice were altogether 
 inadequate, and it was still debarred from con- 
 ducting correspondence with the local authorities 
 which required its guidance. That is to say, the 
 Department, when asked to do so, could make 
 suggestions as to the advice the Board should 
 give, but was not allowed to write even to the 
 local Medical Officers of Health. Simon neatly 
 illustrates the absurdity of this system by pointing 
 to the difficulties that would arise if a "London 
 consultant, having to suggest to his professional 
 brother in the country some different method of 
 treatment for the squire's asthma or the lady's 
 megrim, were not in direct correspondence with 
 his fellow practitioner, but must have his medical 
 suggestions adopted by the family solicitor and 
 expressed to the distant doctor in the form of a 
 lawyer's letter." 
 
 Mr. Stansfeld held the Presidency just long 
 enough to give the Board a bad start, and then, 
 in 1874, made way for Mr. George Sclater-Booth 
 
 58 
 
Local Government Board 
 
 (afterwards Lord Basing), who retained the post 
 for six years. He it was who promoted the con- 
 solidating Public Health Act of 1875 and-~the 
 other great sanitary measures which were the 
 sequelae of the report of the Royal Sanitary Com- 
 mission. But he, no more than his predecessor, 
 appreciated the importance of giving the Medical 
 Department the measure of independence and the 
 power of initiative which the situation called for, 
 and two years after his accession to the Presidency 
 Simon retired on a special allowance. His trans- 
 fer to the Local Government Board had left him 
 with some duties to perform for the Privy Council, 
 but now his connection with that body also was 
 severed, and he was free to devote himself to the 
 service of his profession and to the literary pursuits 
 for which he had so decided a bent. Early in 
 his career he had given much time to the study 
 of Art and Oriental languages and metaphysics, 
 and throughout his life he was on terms of intimacy 
 with most of the leading men of letters of the day, 
 and especially with Ruskin, whose "dear brother 
 John " he was. He was President of the Royal 
 College of Surgeons in 1878-9, held other im- 
 portant administrative positions in the profession, 
 was Vice-President of the Royal Society in 1879-80, 
 was an honoured member of many other learned 
 societies, and had showered upon him high 
 University distinctions. But it was not until 1887, 
 when Queen Victoria's Jubilee was celebrated, 
 
 59 
 
The Story of Public Health 
 
 that the State recognised his services by the be- 
 stowal of a K.C.B. In 1890 appeared the work to 
 which I have acknowledged my indebtedness in the 
 Preface to these pages.* Its author's distinguished 
 and variously useful life ended in 1904. 
 
 Sir John Simon's successor at the Local 
 Government Board was Dr. Seaton, who, like him, 
 had been transferred from the Medical Department 
 of the Privy Council; but in less than four years 
 his health broke down. His place was taken by 
 Dr. George Buchanan, who, as we saw in Chapter 
 IV., had long before made his mark as a sanitarian 
 by his Reports as one of the Privy Council's in- 
 spectors. Five years after he became Medical 
 Officer to the Board the nation had another of 
 those cholera scares which have worked together 
 for its good. At this time Sir Charles Dilke was 
 President, and at his direction the Medical Depart- 
 ment undertook first a preliminary and then a 
 more systematic cholera survey, which occupied 
 the greater part of the years 1884-6, and comprised 
 a critical examination of the arrangements at our 
 ports for dealing with infectious diseases from 
 abroad, and also an inquiry as to the sanitary 
 arrangements in as many as five hundred sanitary 
 districts, equal to one-third of the whole country. 
 Thus the Medical Department, its staff of medical 
 inspectors temporarily strengthened, had at last, 
 
 * " English Sanitary Institutions," by Sir "Join" Sdmon, 
 K.C.B. Second edition, 1897 (John Murray). 
 
 60 
 
Local Government Board 
 
 an opportunity of exercising for a specific purpose 
 the skilled inspection of the sanitary work of the 
 local authorities which ought to have been from 
 the first one of its regular duties. 
 
 Dr. Buchanan's chief assistants in carrying out 
 this memorable Survey were Dr. Ballard and Dr. 
 Blaxall, both of whom testified to the need they 
 found to exist of applying stimulus to many of 
 the local authorities, and to the influence in the 
 direction of efficiency which the medical inspectors 
 were able to exert. One significant point was 
 brought out by Dr. Ballard — the encouragement 
 which personal interviews with the inspectors had 
 afforded to many Medical Officers of Health who 
 had been striving to do their best "under multi- 
 form difficulties, discouragements and impedi- 
 ments." This is precisely the help which the 
 Board could have rendered to local sanitarians all 
 along had it not deliberately closed to itself this 
 avenue of usefulness. Instead of the survey being 
 continued until the whole country was covered, 
 it was stopped towards the end of 1886, and, as 
 Simon says, the previous system of "how not to 
 do it " was tranquilly resumed. 
 
 The medical staff, however, in spite of the 
 limitations prescribed to it, has been able to do 
 very considerable things for the advance of sani- 
 tary science. In 1874 Mr. Netten Radcliffe, 
 another of the former medical inspectors of the 
 Privy Council, prepared a valuable Report on 
 
 61 
 
The Story of Public Health 
 
 Filth Diseases and their Prevention. In 1875 Dr. 
 Ballard initiated a systematic study of effluvium 
 diseases associated with various industries, and 
 embodied the results in Reports which take high 
 rank in official sanitary literature. Five years 
 later he began an investigation extending over a 
 number of years into the nature and localising 
 conditions of epidemic diarrhoea, and in 1887 pro- 
 pounded the provisional hypothesis that the 
 disease is due to a specific micro-organism which 
 resides ordinarily in the superficial layers of the 
 earth and is able to infect the lower levels of the 
 air. His acuteness enabled him to discover that 
 this summer disease is only indirectly related to a 
 high air-temperature, through the temperature of 
 the soil. In 1880, soon after he became Medical 
 Officer, Dr. Buchanan had set Dr. Thorne-Thorne 
 and Dr. W. H. Power to work collating the ex- 
 periences of isolation hospitals and disinfection 
 establishments, besides preparing a Memorandum 
 on the sanitary rules to be observed in the estab- 
 lishment of public cemeteries. In the same year 
 Dr. Power got upon the track of the important 
 fact that the contagion of smallpox can infect the 
 air, independently of personal intercourse, to a 
 distance of at least a mile, and that within that limit 
 the intensity of the infection diminishes as the 
 distance from the focus increases. Later he made 
 the discovery, also of great importance, that cows 
 as well as human beings are susceptible to scarlet 
 
 62 
 
Local Government Board 
 
 fever, which is communicable from either to the 
 other. In 1881 Dr. Stevens, who twenty years 
 before, under the Privy Council, had taken part 
 in a thorough survey of public vaccination, made 
 a further comprehensive inquiry into the question. 
 In 1889 was published an elaborate Report by 
 Dr. F. W. Barry on the same subject apropos of 
 the great epidemic of smallpox in the two preceding 
 years. Another Report, embodying an elaborate 
 study of diphtheria by Dr. George B. Longstaff, 
 and analysing the statistics of the twenty-six years 
 preceding 1880, is of historic interest as suggesting 
 that a connection exists between human diphtheria 
 and a similar disease in certain domestic animals, 
 and that diphtheria may be conveyed, as it is now 
 known to be, by contaminated milk supplies. Much 
 other valuable work has been done by members of 
 the Board's medical staff in connection with infec- 
 tious diseases, as well as in hygiene, during the 
 present century. Thus Dr. Bruce Low has diligently 
 studied the epidemiology of plague, cholera, yellow 
 fever, and smallpox, and reports have also been 
 issued upon tuberculosis, cerebro-spinal fever, and 
 encephalitis lethargica, the mysterious disease of 
 which the first cases were mistaken for botulism — 
 poisoning with sausages and other meat foods. 
 
 The laboratory investigations begun under the 
 Privy Council by Dr. (afterwards Sir John) 
 Burdon-Sanderson, Dr. Klein, Dr. Thudichum, and 
 others, were continued under the Local Govern- 
 
 63 
 
The Story of Public Health 
 
 ment Board, and these, too, have been followed 
 by many others, the more recent ones under 
 the direction of Dr. Eastwood. The researches 
 entrusted to Dr. Thudichum were in the field of 
 organic chemistry ; those committed to Dr. Burdon- 
 Sanderson and Dr. Klein had reference, at first, 
 to infective processes in general, and afterwards 
 were directed mainly to questions of infection and 
 disinfection and prevention. Another member of 
 this band of workers was Dr. Wooldridge, whose 
 unexpected death after a few days' illness in 1889 
 cut short an original and very promising research 
 in the prophylaxis of anthrax. Dr. Klein's work 
 carried him into the front rank of bacteriologists. 
 Sir John Burdon-Sanderson, in 1869, in an article 
 on the Intimate Pathology of Contagion issued as 
 an Appendix to a Report to the Privy Council, 
 had anticipated the epoch-making discovery of 
 the microbic origin of infectious diseases generally, 
 and it was he who initiated the experimental study 
 of such diseases in this country. In 1870 he gave 
 up hospital work and private practice in order to 
 concentrate upon scientific research, and he was 
 not long in winning more than national fame 
 in experimental physiology and pathology. 
 
 Dr. Buchanan held the Medical Ofncership to 
 the Board with credit, and more than credit, for 
 thirteen years. His retirement, in 1892, when he 
 was knighted, was made the occasion of a sub- 
 scription in his honour which enabled him to endow 
 
 64 
 
Local Government Board 
 
 a Gold Medal to be granted triennially by the 
 Royal Society for distinguished service in sanitary 
 science. His own contributions to that science 
 were particularly valuable in connection with 
 typhus fever and cholera. 
 
 Sir George Buchanan found a fitting successor 
 in Dr. Thorne-Thorne, like him in having served 
 under the Privy Council, and also in having high 
 scientific attainments. The proof that typhoid 
 fever is one of the water-borne diseases was first 
 supplied by him, and he showed much energy 
 in pressing upon the local authorities the Isolation 
 Hospitals Act, which was passed the year after 
 he became Medical Officer. He received a K.C.B. 
 in 1897, and died in 1899, giving place to Dr. 
 (afterwards Sir) William Power, whose researches 
 into the dissemination of smallpox and scarlet fever 
 have been mentioned earlier in this chapter. When 
 the next appointment had to be made, in 1908, the 
 Board, for the first time, went outside its own 
 staff for its Medical Officer and chose Dr. (now 
 Sir Arthur) Newsholme, who had won his sani- 
 tarian spurs as Medical Officer of Health for 
 Brighton. Sir William Power had interested him- 
 self in the question of infant mortality, about which 
 the nation was beginning to feel uncomfortable, 
 as it had, and still has, very good reason to feel ; 
 and his successor at once grappled vigorously with 
 this grave problem and made investigations of 
 which the results are recorded in three elaborate 
 
 f 65 
 
The Story of Public Health 
 
 Reports that rank among the most valuable docu- 
 ments ever issued by the Board. It fell to him, 
 too, to make arrangements for the notification and 
 the provision of further facilities for the treatment 
 of tuberculosis, and to devise the medical measures 
 which, in 1916, the Board pressed upon the local 
 authorities for carrying out the administrative re- 
 commendations of the Royal Commission on 
 Venereal Diseases (see p. 138). He also had much 
 to do with the organisation of maternity and child 
 welfare activities, of which the scope has been 
 greatly extended by the Act of 1918. During the 
 War he and other members of the medical staff 
 cc-operated with the Army medical authorities in 
 the work of keeping the home camps healthy, and 
 in other ways, and in 1919 the Board issued special 
 regulations for the control and treatment of malaria 
 and other war diseases, as well as of pneumonia, 
 both primary and influenzal. He retired early in 
 that year, and was the last Medical Officer of the 
 Board, the office of Principal Medical Officer, with 
 the position and responsibilities of a Secretary of 
 the Board, being then created for Sir George New- 
 man, in view of the formation of a Ministry of 
 Health to absorb the Local Government Board 
 and other Central Health Authorities, as will 
 be related in the last chapter. The measured 
 review by Sir Arthur Newsholme of the progress 
 of Public Health since 187 1, which appears in his 
 Supplement to the Board's Annual Report for 
 
 66 
 
Local Government Board 
 
 1 9 1 7- 1 8, may be regarded as the swansong of the 
 Board. 
 
 The constitution and functions of the Board 
 must now, with all possible brevity, be described. 
 As a Board it was one of those official fictions in 
 which legislators and administrators appear to take 
 a strange delight. Theoretically, it consisted of the 
 President and sundry other high Ministers of State. 
 These other Ministers it is not necessary to par- 
 ticularise, for they were as innocent of responsi- 
 bility for its proceedings as the corresponding 
 members of the Mikado's Cabinet. The Board, 
 in fact, never met. The work was done by the 
 President and the Parliamentary Secretary, the 
 latter a Member of Parliament. The control which 
 it exercised over Public Health, so far from being 
 concentrated in one Department, was dispersed 
 among five distinct divisions, each with its own 
 staff and its own permanent head, who was the 
 channel of communication with the Permanent 
 Secretary and the President, and was never an ex- 
 pert sanitarian. Multifarious, as everyone knows, 
 were the Board^s sanitary responsibilities. Sewer- 
 age and"*3rainage , and scavenging, infectious 
 diseases, isolation hospitals and Poor Law infirm- 
 aries> public [Vaccination, the water supply and the 
 pollution of rivers, food and drugs, alkali works, 
 canal boats, slaughter-houses, baths and wash- 
 houses, housing and town planning, cemeteries 
 and crematoria, the notification- of births, infant 
 
 67 
 
The Story of Public Health 
 
 mortality, maternity and child welfare, the appoint- 
 ment by local authorities of Medical Officers of 
 Health, Sanitary Inspectors, Public Analysts, 
 Public Vaccinators, and Health Visitors — these are 
 only some of the Public Health matters with which 
 the Board had to do. 
 
 Among its more important duties were some of 
 a sub-legislative kind, for it could extend the scope 
 of many Acts of Parliament which confer powers 
 or impose responsibilities upon local authorities. 
 It might also constitute, or dissolve, or combine 
 port sanitary authorities, modify the areas and 
 powers of most other local authorities, and repeal 
 many local Acts of Parliament. The by-laws and 
 many of the more important proceedings of the 
 local authorities were subject to its approval. It 
 was vested with appellate jurisdiction as between 
 the local authorities and landlords and other per- 
 sons who might be aggrieved by their action, or 
 as between one local authority and another, or as 
 between, say, the Medical Officer of Health of a 
 rural district and the Medical Officer of Health 
 of the county. In many instances, before it could 
 take action, it was required to possess itself of all 
 necessary information by inspection or inquiry; 
 and where local authorities failed in their duty and 
 were irresponsive to remonstrance it could either 
 apply for a mandamus or have the work done and 
 charge the local authority with the cost. The 
 Board also exercised functions of an advisory 
 
 68 
 
Local Government Board 
 
 character. It was constantly issuing circulars and 
 memoranda explaining new departures in legis- 
 lation or in administration, and in this way 
 it afforded much valuable guidance to local 
 authorities.* 
 
 Of the medical administration of the Board 
 under the Poor Laws, little that is favourable can 
 be said. The Board's Public Health and Poor 
 Law medical activities always remained absolutely 
 independent of each other. The areas served by 
 the Medical Officers of Health of the Town 
 Councils are scarcely ever coincident with those 
 of the District Medical Officers of the Boards of 
 Guardians. Not only is there no co-operation be- 
 tween the two sets of authorities, but they pursue 
 conflicting policies, the chief object of the Boards 
 of Guardians being to deter persons from seeking 
 medical relief until driven to do so by serious ill- 
 ness and by dire destitution, while the Town 
 Councils are engaging more and more in work that 
 comes into the category of Preventive Medicine. 
 "Even to the average District Medical Officer it 
 does not seem so important to prevent the spread 
 of disease, or its recurrence in the individual 
 patients, as to relieve their present troubles. . . . 
 The provision of Poor Law Dispensaries, and the 
 consequent abandonment of half the domiciliary 
 
 * For a classified enumeration of the Board's duties and 
 powers, see Banoington's " Public ^Health Administration," 
 chap. xxv. 
 
 69 
 
The Story of Public Health 
 
 visiting, even implies the discouragement of that 
 consideration of home environment and personal 
 habits which not only helps diagnosis, but would 
 also justify the giving of hygienic advice of pre- 
 ventive character. Even the Poor Law infirmary — 
 not allowed to receive students, with a staff too 
 busily occupied for research, and seldom provided 
 with a laboratory — can think only of discharging 
 its patients as quickly as possible, without con- 
 valescent home or sanatorium to which to send 
 them, and without an outdoor visiting staff to keep 
 them under observation and give them the hygienic 
 advice as to home management for lack of which 
 the phthisical patient will soon be back in the 
 infirmary again. In short, from beginning to the 
 end of a Poor Law expenditure of over ,£4,000,000 
 annually upon the sick, there is no thought of 
 promoting medical science or medical education, 
 practically no idea of preventing the spread of 
 disease, and little consideration even of how to 
 prevent its recurrence in the individual." * 
 
 As to the general administration of the Poor 
 Laws, although, as is pointed out in Ashley's 
 "Local and Central Government," it is as highly 
 centralised a service as can be found anywhere in 
 Western Europe, the Local Government Board 
 being able, by the Orders it issued, to regulate 
 every conceivable detail of the work, it is almost 
 
 * " The State and the Doctor," by Sidney and Beatrice 
 Webb, pp. 127-8. The italics are mine. 
 
 70 
 
Local Government Board 
 
 universally regarded as a failure. The Poor 
 Law Commission which was appointed in 1905 and 
 reported in 1909 made recommendations which 
 were drastic when they were not revolutionary. The 
 Majority Report called upon the Local Govern- 
 ment Board "to assume a more direct position of 
 guidance and initiative in regard to the local 
 authorities." It recommended that the Boards of 
 Guardians should be abolished, that the unit of 
 administration should be enlarged to the county 
 or county borough, and that a Public Assistance 
 Authority should be constituted in each of the new 
 areas and empowered to appoint Public Assist- 
 ance Committees in rural and urban districts to 
 carry out the work of poor relief, while medical 
 relief should be committed to Medical Assistance 
 Committees appointed by the Public Assistance 
 Authorities. The Minority Report went much 
 further. It recommended the scrapping of the 
 whole Poor Law system, and the distribution of 
 the- work of Public Assistance, both medical and 
 general, among the various committees of the 
 County and County Borough Councils. That 
 nothing was done to give effect to the recommenda- 
 tions of either Report up to the outbreak of the 
 War is to be explained by the preoccupation of the 
 country with other great social as well as with 
 burning political questions. 
 
 To visit the whole of the responsibility for a 
 radically defective system of medical relief of the 
 
 7i 
 
The Story of Public Health 
 
 poor upon the Local Government Board, as distinct 
 from the Legislature, might not be fair. But in 
 view of the fact that it had not thought fit to 
 subject the thousands of District Medical Officers 
 to supervision or inspection, that it had never in- 
 structed its Poor Law Medical Inspectors to prepare 
 an Annual Report, and that it published next to no 
 statistical information concerning patients treated 
 in the Poor Law infirmaries, having ignored a 
 recommendation to that effect made by the Com- 
 mittee on Physical Deterioration in 1904, the 
 Board cannot be acquitted of the perfunctoriness 
 which characterised the medical work of the old 
 Poor Law Board. That so ineffectual a system 
 could have been maintained for nearly half a 
 century had the Board's medical officials been 
 allowed their proper influence in its counsels is 
 inconceivable. 
 
 On the Public Health side the account is more 
 favourable to the Board. It received from, every 
 Medical Officer of Health in the land a weekly 
 return of the number of cases of infectious disease 
 notified to him, and supplied him with a weekly 
 summary of notifiable diseases for the whole 
 country.* It carried out a great deal of special 
 medical inspection relating to epidemics, food 
 adulteration, housing, etc., conducted or arranged 
 for researches into matters of hygiene, and main- 
 
 * The notification of infectious diseases was instituted in 
 1889 by an Act which was extended in 1899. 
 
 72 
 
Local Government Board 
 
 tained a pathological laboratory and the Govern- 
 ment Lymph Establishment; and the Medical 
 Officer's Annual Report contained much valuable 
 information on sanitary subjects generally. But 
 the systematic inspection of local sanitary adminis- 
 tration which ought to have been instituted in 
 187 1 was still to seek in 1919. Until Sir George 
 Newman went to the Board to take part in the 
 arrangements for its absorption in the Ministry of 
 Health, the medical was still^kept in strict sub- 
 ordination to the secretarial staff. What Sir 
 Bertrand Dawson, in "The Nation's Welfare," 
 justly calls the "baneful tradition " which debarred 
 the Board's Medical Officer from advising the Pre- 
 sident except through the intermediary of a non- 
 medical official still persisted. So almost until the 
 very end the dead hand of the Poor Law Board 
 kept its clutch upon the nation's chief Central 
 Health Authority. 
 
CHAPTER VI 
 
 Other Central Health Authorities 
 
 Besides the Local Government Board there were, 
 at the beginning of the year 1919, no less than 
 twenty Central Authorities engaged in the adminis- 
 tration of Public Health legislation. In this and 
 the next chapter I propose to give an account of 
 such of these Authorities as are most important 
 in a Public Health sense. We may first consider 
 the Authority which, as we saw in Chapter IV., 
 was for some years the principal organ of State 
 Medicine in this country. 
 
 The Privy Council 
 
 The Public Health responsibilities which were 
 transferred from the Privy Council to the Local 
 Government Board in 1872 did not include those 
 relating to the constitution and discipline of 
 the medical and pharmaceutical professions, nor 
 those connected with the prevention of contagious 
 diseases in animals, but the latter have since been 
 assumed by the Board of Agriculture. The in- 
 
 74 
 
The Privy Council 
 
 timate bearing upon Public Health of the status 
 and regulation of the medical profession makes it 
 desirable that something should be said of the 
 legislation which the Privy Council has adminis- 
 tered to that end. 
 
 Until the year 1858 the profession had no statu- 
 tory constitution in the United Kingdom. As 
 many as twenty-one corporate authorities, quite 
 disconnected from each other, had the right to 
 issue medical diplomas, and some of these bodies 
 were much more interested in the fees they re- 
 ceived Uian in iae medical competence of the 
 candidates they licensed. This situation, so full 
 of dajiger to the community, so inimical to the 
 irrtcrjs's of the profession, was greatly modified 
 by the Act of 1858. That measure provided for 
 the establishment of a Medical Register, by which 
 the public and the Courts might distinguish be- 
 tween qualified and unqualified practitioners. It 
 provided also for the creation of a Medical Council, 
 charged with the duty of removing from the 
 Register the names of practitioners convicted of 
 crime or guilty of "infamous" professional con- 
 duct, and of impeaching before the Privy Council 
 any licensing body which might grant its diploma 
 without insisting upon adequate study and ex- 
 amination, and the Privy Council was invested 
 with the power to deprive such a body of the right 
 to hold qualifying examinations. The Act was 
 amended by a later measure introduced by Sir 
 
 75 
 
The Story of Public Health 
 
 Lyon (afterwards Lord) Playfair, in 1886, modify- 
 ing the conditions under which diplomas could be 
 granted, and altering the constitution of the 
 Medical Council by adding to it a quota of 
 members elected by the general vote of the pro- 
 fession, and a further amending Act was passed 
 in 1905. 
 
 Such was the origin of the General Medical 
 Council, as it is termed "for short," more formally 
 the General Council of Medical Education and 
 Registration of the United Kingdom, the body 
 which supervises the education and maintains the 
 discipline of a profession which, including those 
 attached to the Services, now numbers some 43,000 
 members, of whom nearly 7,000 are resident in 
 London. Of the thirty-eight members of the 
 Council, fourteen are chosen by the Royal College 
 of Physicians of London, the Royal College of 
 Surgeons of England, the Apothecaries' Society of 
 London, and the English Universities — one by 
 each body; seven and six respectively by similar 
 institutions in Scotland and Ireland; six are elected 
 by the votes of registered medical practitioners, 
 and five are nominated by the Privy Council. The 
 General Medical Council is also responsible for the 
 control of the Register of Dental Surgeons and 
 the supervision of that profession. The body 
 which, under the Privy Council, attends to the 
 examination and registration of chemists in accord- 
 ance with the terms of the Pharmacy Acts is the 
 
 76 
 
The Privy Council 
 
 Pharmaceutical Society, which also advises the 
 Privy Council as to the regulation of the sale of 
 poisons. 
 
 It may be of interest to point out that the effect 
 of medical registration is to confer the right to 
 practise medicine, surgery, and midwifery in the 
 United Kingdom and (subject to any local law) in 
 any other part of the British Empire, and to recover 
 fees by legal process. A qualified medical man 
 may, however, if he pleases, practise without 
 registration, which is in the nature of a privilege 
 rather than of an obligation.. If unregistered, he 
 has no legal remedy should a patient prefer not to 
 pay his fees, is ineligible for medical appointments 
 in official and public institutions, and is liable 
 to be sued for penalties by any medical or surgical 
 corporation whose privileges he may infringe. 
 Further, except as to one group of diseases, it is 
 open to unqualified persons to engage in medical 
 practice so long as they do not falsely pretend to 
 hold specific diplomas. The one exception men- 
 tioned above relates to the treatment of venereal 
 diseases (see p. 141). That the most ignorant 
 charlatan should be free to undertake the treatment 
 of equally serious diseases, such as cancer, or 
 affections of that most delicate and complicated 
 organ the ear, is a gross anomaly, of which the 
 tragic results have been set out in a Report of the 
 Privy Council on Unqualified Practice, issued in 
 1910. There is obvious need for further legislation 
 
 77 
 
The Story of Public Health 
 
 to protect the public from the lures of cunning 
 impostors. 
 
 Another Public Health duty devolving upon the 
 Privy Council has also been performed indirectly, 
 through the Central Midwives Board, constituted 
 in 1902. The importance of the midwifery service 
 of the country is not generally appreciated. The 
 measure of its importance is the fact that of all the 
 births in England and Wales — there were, in round 
 numbers, 668,000 in 191 7 — nearly three-fourths are 
 attended by midwives. A midwife, it should be 
 understood, holds a much more responsible posi- 
 tion than a maternity nurse. The latter can work 
 only under medical supervision ; the former is free 
 to attend all cases of normal labour without a 
 medical man. It is highly necessary, therefore, 
 that she should be carefully trained, and that her 
 competence should be authoritatively certified. 
 This it is that the Central Midwives Board, nomi- 
 nated by the Royal Colleges of Physicians and 
 Surgeons and other bodies, secures. It prescribes 
 the course of training, holds the examinations 
 which midwives must pass before they can be cer- 
 tificated, and, when they are certificated, inscribes 
 them on the Roll, which now numbers some 44,000 
 names, although only about 13,500 midwives are 
 actually practising. It lays down the rules as 
 to antisepsis, etc., which they must observe, and 
 cancels the certificates of those who disregard the 
 rules or are guilty of misconduct. The Board is 
 
 78 
 
Vital Statistics 
 
 gradually raising the standard of knowledge which 
 midwives must acquire, and has recently added 
 elementary physiology to the curriculum. But 
 the midwifery service stands sorely in need of 
 State aid, and the announcement made by the 
 Central Board early in 1919 that it approved 
 generally oT the proposals to that end formulated 
 by the Association for Promoting the Training and 
 Supply of Midwives was welcomed by all who 
 properly appreciate the situation. 
 
 The General Register Office 
 
 The Registrar-General's Department, to give 
 this Office its more usual name, conducts the 
 registration of births, deaths, and marriages, and 
 analyses the figures. It was established in i",Vj, 
 twelve years before the creation of the General 
 Board of Health, under an Act which for the first 
 time made it possible for vital statistics to be 
 compiled in this country. To the second head of 
 the office, Major George Graham, who was ap- 
 pointed in 1842, must be given the credit of 
 establishing the thoroughly efficient organisation, 
 with its network of local offices, covering the whole 
 country, by which the work is done. In 1839, at 
 the instance, as Sir John Simon believed, of Edwin 
 Chadwick, Dr. William Farr had been appointed 
 Compiler of Abstracts, and had lost no time in 
 bringing his remarkable powers of analysis and 
 
 79 
 
The Story of Public Health 
 
 synthesis to bear upon the figures. To the first 
 Annual Report of the Registrar-General, published 
 in 1841, was appended a Letter addressed to him 
 by Dr. Farr on the death statistics of the first half- 
 year of civil registration and on various questions 
 arising out of the records. Such was the origin 
 of the annual studies in vital statistics which con- 
 stitute what Simon truly designates " a new branch 
 of medical literature." Presently quarterly returns, 
 anticipatory of the Annual Reports, were issued, 
 and in 1840 began the weekly returns giving the 
 life and death figures for the metropolis. When 
 Major Graham retired, in 1879, Dr. Farr was his 
 natural successor; but those with whom the ap- 
 pointment rested had other views, and Dr. Farr 
 resigned. 
 
 The member of the Department who now does 
 the work of analysis is known as the Superin- 
 tendent of Statistics, and the post is held by Dr. 
 T. H. C. Stevenson, whose annual review of the 
 whole body of statistics is a most illuminating 
 document, which is absolutely indispensable to 
 the student of Public Health. Technically the 
 General Register Office became a branch of the 
 Local Government Board in 1871, for it was one 
 of the Departments which were absorbed by that 
 Board at its creation. But the chief difference 
 between the earlier and the later General Register 
 Office was that after 1871 the Registrar-General 
 addressed his Annual Reports to the President of 
 
 80 
 
Factory Legislation 
 
 the Local Government Board, instead of, as before, 
 to the Home Secretary, and he and his staff have 
 continued to have their headquarters at Somerset 
 House. 
 
 The Home Office 
 
 For the administration of the Factory and 
 Workshops Acts, at once so comprehensive and 
 so minute in their hygienic requirements, the 
 Home Office is primarily responsible, as it also 
 is for the regulation of dangerous trades and of 
 coal mines and quarries, and for the execution 
 of the Acts limiting the hours of young persons 
 in shops. Moreover, the Prison Medical Service 
 is under its control; it regulates the institutions 
 established under the Mental Deficiency Act, 1913; 
 and it appoints Medical Referees and Certifying 
 Surgeons under the Workmen's Compensation 
 Act, 1906. The Factory and Workshops Acts 
 apply, in ordinary times, to some 123,000 factories 
 and 154,000 workshops, employing from six to 
 eight million people. That fact alone is an 
 eloquent indication of the highly important place 
 the Home Office holds among Central Health. 
 Authorities. 
 
 Some account must be given' of the development 
 
 of what is summarily called factory legislation, an 
 
 expression which includes legislation relating to 
 
 workshops. It may be well to explain at the outset 
 
 "that the distinction between a factory and a work- 
 
 g 81 
 
The Story of Public Health 
 
 shop depends mainly upon the use of mechanical 
 power. Works in which steam, water, or other 
 mechanical power is used are factories; all others 
 are workshops, with the exception of certain speci- 
 fied works, such as bleaching and dyeing works, 
 earthenware works and lucifer match works, which 
 are held to come under the denomination of 
 factories. 
 
 This kind of legislation originated in 1802 with 
 the Health and Morals of Apprentices Act, passed 
 to afford some protection to pauper apprentices in 
 cotton and woollen mills. It was introduced by 
 Sir Robert Peel, who supported it by the ingenuous 
 reason that there was gross mismanagement at the 
 expense of pauper apprentices in his own factories 
 and that, having no time to correct it himself, he 
 was glad that the State should do the work for 
 him. It limited the hours of the apprentices to 
 twelve a day, decreed the gradual discontinuance 
 of night work, made some stipulations for the 
 ventilation and cleanliness of the buildings, and 
 the observance of rudimentary decency in the sleep- 
 ing arrangements of the poor little slaves. The 
 administration of the Act was to be supervised by 
 two inspectors appointed by justices of the peace 
 from among themselves. In 1819, there having in 
 the interval been a great influx into cotton fac- 
 tories of children who were not parish appren- 
 tices, Robert Owen, as is noted elsewhere (p. 6), 
 prevailed upon the Government to pass an Act 
 
 82 
 
Factory Legislation 
 
 regulating all child labour in such factories. As 
 watered down from the Bill promoted by Owen, 
 it forbade the employment of children under the 
 age of nine, and limited the hours of those under 
 sixteen to twelve a day, and, contrary to Owen's 
 wish, its application was confined to cotton fac- 
 tories. It was amended in 1825 ; but still nothing 
 was done for child labour in other factories until, 
 as the result of an agitation in which the chief 
 actors were Richard Oastler, Michael Sadler, and 
 Lord Ashley (afterwards Earl of Shaftesbury), the 
 Act of 1833 was passed, applying to practically all 
 textile factories. In such factories it now became 
 unlawful to employ any child under nine, or to 
 keep children between the ages of thirteen and 
 eighteen at work for more than twelve hours a day 
 or sixty-nine hours a week, or to put them to night 
 work, and there were further restrictions of hours 
 for children between nine and thirteen. 
 
 The Act of 1833 thus took a long step forward. 
 But it is a still more salient landmark in factory 
 legislation in that it committed the administration 
 of the Act not to amateur inspectors but to paid 
 itinerant inspectors appointed by the Government 
 who were invested with full rights of entry and 
 inquiry and with the power to frame such rules 
 and issue such Orders as might be considered 
 necessary, and were instructed to report twice a 
 year and to confer together with a view to uni- 
 formity of action. This important departure, the 
 
 83 
 
The Story of Public Health 
 
 germ of the elaborate inspectorial system of this 
 branch of the Home Office, has been attributed to 
 the influence of Edwin Chadwick, a member of 
 the Parliamentary Commission upon whose re- 
 commendations the Act was founded. "The 
 introduction," as Hutchins and Harrison remark,* 
 "of an external authority, free from local bias and 
 partiality, greatly improved the administration of 
 the law, lessened the friction between manufacturers 
 and operatives, and provided a medium of com- 
 munication between the Government and the people 
 at a time when knowledge of industrial matters 
 was scanty in the extreme." The reports of the 
 inspectors, these authors point out, constituted "an 
 invaluable continuous record of industrial con- 
 ditions by trained observers . . . whose business 
 it was to renew their visits at stated periods 
 and note what changes took place within their 
 view." 
 
 The effect of this system of inspection is plainly 
 to be traced in the Factory Act of 1844, which was 
 to a great extent based upon suggestions made 
 by the Inspectors. It made many alterations in 
 detail to secure the more effectual carrying out of 
 the Act of 1833. It provided for the safeguarding 
 of machinery in the interests of childrien and 
 young persons and women, and in other respects 
 
 * " A History of Factory Legislation, " by B. L. Hutchins 
 and A. Harrison (Mrs. F. H. Spencer), D.Sc. (Econ.). 
 Second Edition. 1911. 
 
 84 
 
Factory Legislation 
 
 also brought women into the same category as 
 young persons, it being even decreed that women, 
 like young persons, must not work more than 
 twelve hours a day. For this restriction of the 
 labour of women, the cause of much searching of 
 heart among orthodox political economists, a 
 precedent had recently been created by an Act 
 promoted by Lord Ashley excluding women of all 
 ages, as well as young children, from mines. The 
 Act of 1844 also introduced the half-time system 
 for children, and as a counterpoise reduced the 
 employable age to eight. Three years later, after 
 a long and bitter struggle, a Ten Hours Bill was 
 passed, restricting women and young persons to 
 ten hours' work a day. 
 
 Gradually, between 1845 and 1861, the indus- 
 tries allied to textile manufactures were brought 
 within the scope of factory legislation. During the 
 sixties many distinctly non-textile industries were 
 included, and factory legislation was extended to 
 the whole country, so^ that it applied to small work- 
 shops no less than to mammoth mills. So wide 
 was the net cast that even dwelling-houses and 
 single rooms used as workplaces were caught 
 within its meshes, though it was not until long 
 afterwards that sanitary control of these domestic 
 workshops began to be effective. In the 'seventies, 
 and later, the regulations which sought to secure 
 the health and safety of the workers were extended 
 and made more stringent. In 1880, when Lord 
 
 85 
 
The Story of Public Health 
 
 Morley published his Life of Cobden, he was 
 able, in an eloquent sentence, to show how precise 
 and far-reaching was the protection afforded to 
 labour in both those directions. "Buildings," he 
 wrote, "must be kept pure of effluvia; dangerous 
 machinery must be fenced; children and young 
 persons must not clean it while in motion; their 
 hours are not only limited but fixed; continuous 
 employment must not exceed a given number of 
 hours, varying with the trade, but prescribed by 
 the law in given cases; a statutable number of 
 holidays is imposed; the children must go to 
 school, and the employer must every week have 
 a certificate to that effect; if an accident happens, 
 notice must be sent to the proper authorities; 
 special provisions are made for bakehouses, for 
 lace-making, for collieries, and for a whole schedule 
 of other special callings; for the due enforcement 
 and vigilant supervision of this immense host of 
 minute prescriptions there is an immense host of 
 inspectors, certifying surgeons, and other authori- 
 ties whose business it is to ' speed and post o'er 
 land and ocean ' in restless guardianship of every 
 kind of labour, from that of the woman who plaits 
 straw at her cottage door to the miner who descends 
 into the bowels of the earth and the seaman who 
 conveys the fruits and materials of universal in- 
 dustry to and fro between the remotest parts of the 
 globe." * 
 
 * " The Life of Richard Cobden," i. 303. 
 86 
 
Factory Legislation 
 
 To-day the statutes under which above-ground 
 industries are regulated are the Factory and Work- 
 shops Acts of 1901 and 1907. By these statutes 
 the employment of children under twelve is for- 
 bidden. Above that age they may work for half- 
 time, subject to conditions, but must attend school 
 for the other half. Not until they become young 
 persons* are they eligible for full employment. 
 The hours of these young persons and of women 
 are also limited, and holidays and restrictions as 
 to continuous spells of work are prescribed for 
 them as for children. f Now, too, it is illegal for 
 a woman to return to work within four weeks after 
 childbirth. 
 
 ' As an extension of the law regulating labour in 
 domestic workshops, special control is now exer- 
 cised over a multitude of kinds of home work 
 defined by an Order issued by the Home Secretary 
 in 191 1. The employer has to send the names and 
 addresses of all home workers to the inspecting 
 authority, and if the dwellings are insanitary, or 
 if infectious disease occurs, he is prohibited from 
 giving out work to be done in them. 
 
 In the case of dangerous trades, such as those 
 in which poisons are used, or in which there is 
 
 *The ages of "young persons" are 14-18; of "children," 
 12-14. "Women " are all females above the age of 18. 
 
 + The provisions relating to children and young persons, as 
 is noted on p. 89, have been carried further by the /Education 
 Act of 1918, which, however, was not to come into full 
 operation immediately. 
 
 87 
 
The Story of Public Health 
 
 exposure to infections such as anthrax, the strictest 
 precautions are enforced. Cases of anthrax are still 
 reported from time to time ; but phosphorus poison- 
 ing has almost disappeared since the use of white 
 phosphorus in the making of lucifer matches was 
 forbidden. The safeguarding of machinery has 
 been the constant care of the Inspectors. Certain 
 dangerous employments are closed to children and 
 young persons; and machinery or plant or 
 processes to which special risk attaches may be 
 prohibited altogether. By an Act passed in 1909 
 the Legislature has even made a beginning with 
 the regulation of wages in sweated industries. 
 That Act is administered not by the Home Office 
 but by the Board of Trade, and is primarily 
 economic in motive, though not without a distinct 
 relation to Public Health. 
 
 The Employment of Children Act, 1903, may 
 be noticed here, although it is applicable to multi- 
 tudes of children who are not employed in factories. 
 It enables the local authorities to make by-laws 
 controlling the labour of children under fourteen 
 who do not come under the Factory Acts, and of 
 boys and girls under sixteen who are engaged 
 in street trading. No child may be employed in 
 night work, or in carrying heavy weights, or in 
 occupations otherwise injurious, nor may any 
 child under the age of eleven be put to street trad- 
 ing. In so far as these provisions apply to children 
 in factories and workshops they are supervised by 
 
 88 
 
Factory Legislation 
 
 the Home Office Inspectors ; in other cases by the 
 local authorities. By the great Education Act of 
 19 18 certain of these provisions are modified in 
 the right direction. The employment of children 
 under the age of twelve is disallowed; the hours 
 of labour of those between twelve and fourteen are 
 restricted; until the age of fourteen is attained no 
 child may be employed in factories, workshops, 
 mines, or in street trading, and, on a report from 
 the School Medical Officer, the local education 
 authority may modify or prohibit altogether the 
 employment of a child on grounds of health. 
 
 During the War it was found necessary to relax 
 certain of the time-regulations in factories and 
 workshops. On the other hand, special measures 
 were instituted not merely to protect the health 
 but also to promote the well-being of factory 
 workers, so enormously augmented in number to 
 meet the call for munitions. In 1915 the Home 
 Office and the Ministry of Munitions co-operated 
 in the appointment of the Health of Munition 
 Workers Committee to promote these objects. The 
 Committee conducted investigations into such 
 questions as that of fatigue and made recommenda- 
 tions of permanent value, and in its Final Report, 
 on Industrial Health and Efficiency, published in 
 1918, it lays down the great principle that "the 
 subject of industrial efficiency in relation to health 
 and fatigue is in a large degree one of preventive 
 medicine, a question of physiology and psycho- 
 
 89 
 
The Story of Public Health 
 
 logy, of sociology and industrial hygiene." Under 
 the powers of an Act passed in 1916 the Home 
 Office has issued Orders for the institution and 
 enforcement of what are known as "welfare con- 
 ditions." The Chief Inspector of Factories reports 
 that the desirability of having competent super- 
 visors for this work is increasingly recognised, and 
 special courses of training for these posts have been 
 started in many large industrial centres after con- 
 ferences at the Home Office with high educational 
 authorities. So the work of humanising industry 
 and of raising the hygienic standard in factories 
 and workshops takes a great leap forward as a 
 direct result of the War. 
 
 While the legislation described in this section 
 is administered primarily by the Home Office, 
 through its large staff of expert Factory Inspectors, 
 which since 1893 has included women Inspectors, 
 as it ought to have done long before, the local 
 sanitary authorities are responsible for the sani- 
 tation of workshops (and also, in some details, of 
 factories), of bakehouses, and of dwellings in 
 which home workers are employed. But even in 
 workshops and workplaces there are certain sani- 
 tary requirements which are enforced by the 
 Factory Inspectors. The local sanitary authorities 
 were first charged with this duty in the 'sixties, 
 when all workshops were brought within the scope 
 of factory legislation, it being obviously impos- 
 sible for the multitude of workshops in the country 
 
 90 
 
Factory Legislation 
 
 to be inspected by the officers of the Central 
 Authority. At first the experiment was a failure, 
 and after a few years the local authorities were 
 relieved of a duty they were unwilling to discharge. 
 The staff of the Home Office was greatly strength- 
 ened, but it was still impossible for the Inspectors 
 to get through the immense mass of work con- 
 fronting them, and by the Factory Act of 1891 
 workshops were brought under the Public Health 
 Acts and the sanitary authorities and their officers 
 were invested with the same powers as Factory 
 Inspectors. In the larger towns and in London 
 boroughs the local authorities have appointed 
 special inspectors of workshops, women as well as 
 men, but in many smaller areas they have not 
 risen to their responsibilities, and it cannot be 
 claimed for the system of local inspection that it has 
 been more than a partial success.* It has, how- 
 ever, to be accepted as inevitable. There has 
 certainly been no fault on the part of the Home 
 Office. Its Factory Inspectors, distributed among 
 the great industrial centres, have on the whole 
 done their work zealously and efficiently, and to 
 them must be allotted no small share of the credit 
 for the successive extensions of factory legislation. 
 For twenty-one years, until 1917, the post of Chief 
 Inspector of Factories and Workshops was held 
 with distinction by Sir Arthur Whitelegge, 
 
 * For a judicial discussion of tlie question, see Hutchins 
 and Harrison, ibid., Chap. xi. 
 
 9* 
 
The Story of Public Health 
 
 K.C.B., who began his Public Health career as 
 Medical Officer of Health for Nottingham, and 
 was afterwards County Medical Officer of Health 
 for the West Riding of Yorkshire. To him suc- 
 ceeded the Deputy Chief Inspector, Mr. H. M. 
 Robinson, I.S.O. 
 
 92 
 
CHAPTER VII 
 Other Central Health Authorities 
 
 ( Concluded) 
 
 The Board of Education 
 
 The School Medical Service administered by the 
 Board of Education through the local education 
 authorities is the most successful development of 
 the Public Health system which this generation 
 has witnessed — and even that, perhaps, is saying 
 too little. It was foreshadowed some sixty years 
 ago by the prescience of Edwin Chadwick, who 
 advocated not merely sanitary surroundings for 
 school children, but medical inspection and physi- 
 cal training. In connection with the Education 
 Commission of 1861 he wrote that "a special 
 sanitary service applicable to schools is needed, 
 for the correction of the common evils of their 
 construction and the protection of the health of 
 children therein." The construction of schools has 
 been carefully supervised for many years, but it was 
 not until the passing of the Education (Adminis- 
 trative Provisions) Act in 1907 that a systematic 
 effort for "the protection of the health of children 
 
 93 
 
The Story of Public Health 
 
 therein," in the large sense, was made by the 
 organisation of a Service to carry out the medical 
 inspection of all elementary school children and 
 correct the physical defects thus discovered. This 
 country may, however, plume itself upon the fact 
 that if it did not originate this great movement, 
 it was the first to erect the framework of a national 
 School Medical Service. 
 
 The system which the Medical Department of 
 the Board has carried out is comprehensive and 
 many-sided. It provides in the first place for the 
 medical inspection of the child by the School 
 Medical Officer, which must be done during the 
 first year of school life, again between the ages of 
 eight and nine, and a third time towards the end 
 of the school period. Children whose health is 
 found to be defective are referred to a private 
 practitioner, or receive treatment in a school clinic, 
 or in a hospital with which the local education 
 authority* has a working arrangement, or in 
 centres for dealing with physical deformity, while 
 those who suffer from the grosser infirmities, the 
 blind, the deaf, the dumb, the feeble-minded, the 
 epileptic, and also the tuberculous, are relegated 
 to special schools. The best school clinics, such 
 as those in Sheffield, Birmingham, and Bradford, 
 are divided into seven departments, according to 
 the treatment needed. Of the special schools, 
 
 * The constitution of local education authorities is described 
 on p. it 6. 
 
 94 
 
School Medical Service 
 
 the most novel are those which provide open-air 
 education for children who are dull and backward, 
 anaemic and debilitated, ill-nourished and stunted. 
 The climate of this country is not too propitious to 
 this kind of education, but by securing that the 
 children are kept warm and dry and are well fed 
 it has been carried out to a much greater extent 
 than might have been thought possible. Classes 
 are held in the school playgrounds, or in public 
 parks or open spaces, or schools and class-rooms 
 are specially constructed so as to assume an open- 
 air character; children are taken for weekly or 
 fortnightly excursions to rural or seaside places; 
 there are sanatorium schools for the tuberculous, 
 and residential schools for children who have 
 some chronic ailment that needs a prolonged 
 sojourn in a healthy environment, or for whom 
 no open-air school is available. 
 
 Medical inspection is now in practice not only 
 in all elementary schools, but also in many 
 secondary schools, both those established by the 
 local education authorities and those under the 
 jurisdiction of Boards of Governors. In many of 
 these higher schools the inspection is on the same 
 lines as in primary schools, in others it is much 
 more perfunctory. The War, by diverting so 
 many medical men to military service, compelled 
 a suspension or modification of inspection in some 
 secondary schools, but the check was only tem- 
 porary, and in the future, under the Education Act 
 
 95 
 
The Story of Public Health 
 
 of 1918, efficient medical inspection and treatment 
 will be provided by the local education authorities 
 in all their own secondary schools, and ultimately, 
 no doubt, in all other schools of this grade. 
 
 By a logical extension, School Hygiene has for 
 some years included the feeding of hungry child- 
 ren. This office, as hygienic as it is humane, the 
 local education authorities were authorised to 
 perform by the Education (Provision of Meals) 
 Act, 1906, which leaves much to the discretion of 
 the individual authority. Thus it may provide meals 
 itself, or may contract for their provision, or may 
 assist a voluntary committee which undertakes the 
 duty. Again, it may provide the meals free of 
 charge, or may require payment from parents or 
 guardians. Under an amending Act passed in 
 1914 it may even provide meals during holidays 
 or on days when the schools are not open, and 
 may take action without obtaining the sanction of 
 the Board of Education. The powers conferred by 
 these Acts have been most used in the county 
 boroughs, of which, up to the end of 1917, 68 out 
 of 82 had provided meals; next in the roll of 
 honour come the urban districts — 32 out of 48. 
 The counties lag miserably in the rear, only 15 
 out of 62 having exercised the privilege, and only 
 one having attempted to provide food for all the 
 necessitous children in its area. This is a matter 
 which the nation must see to in the immediate 
 future. 
 
 96 
 
School Medical Service 
 
 The measures by which the School Medical 
 Service seeks to remedy uncleanliness are the 
 systematic inspection of children in their homes 
 by school nurses, the carrying out of compulsory 
 cleansing where parents refuse to do their 
 duty, and the institution of proceedings against 
 defaulters. The problem is one of great difficulty, 
 and the probability is, as Sir George Newman 
 believes, that little is to be hoped from further 
 legislation or penalisation, and that the solution is 
 to be found rather in the co-ordinated action of the 
 School Medical Service, of the public nursing and 
 home visiting service, and of the school attendance 
 officers, so that moral pressure may be brought to 
 bear upon parents and a love of cleanliness instilled 
 into children. 
 
 Another feature of School Hygiene is physical 
 education. In all Elementary Training Colleges a 
 course of physical training is now compulsory for 
 teachers of both sexes, but this kind of education 
 is not left entirely to the ordinary staff, for, in spite 
 of war difficulties, some forty local education 
 authorities have appointed trained teachers of 
 gymnastics in response to the offer of the Board 
 of Education to bear 50 per cent, of the cost. The 
 local education authorities are expected to provide 
 facilities for games, and to see that sports are 
 sufficiently varied, and they are now being urged 
 to have simple forms of dancing taught — a most 
 admirable kind of physical education. Evening 
 
 h 97 
 
The Story of Public Health 
 
 Play Centres which are recognised by the Board 
 have been formed by voluntary effort in some fifty 
 areas. Many of the education authorities now 
 furnish facilities for instruction in swimming — an 
 acquirement which ought to be regarded as in- 
 dispensable for every boy and girl ; and under the 
 Education Act of 1918 they can provide holiday 
 or school camps. 
 
 The Board of Education concerns itself with the 
 health of school children not only directly but also 
 indirectly, by recognising and subsidising schools 
 for mothers, where they are taught simple hygiene 
 and mothercraft. Lessons in mothercraft are also 
 given to the elder girls in elementary schools, as 
 well as in secondary and continuation schools. 
 Grants, too, are made to day nurseries. 
 
 The personnel of the School Medical Service 
 includes School Medical Officers of both sexes, 
 private practitioners who undertake work in the 
 school clinics or apart from them by arrangement 
 with the education authorities, and school nurses. 
 But the Service elicits the co-operation of the 
 teachers, and also of the school attendance officers, 
 and it avails itself gladly of the help of Children's 
 Care Committees and of other voluntary agencies. 
 In no branch of Public Health has voluntary effort 
 been turned to better account than in the School 
 Medical Service. 
 
 This admirable Service completed its first 
 decennium in 1917, and some figures denoting the 
 
 98 
 
School Medical Service 
 
 progress it has made appear in Sir George New- 
 man's Report for that year. In spite of the dis- 
 turbing influence of the War, it is a story of 
 splendid achievement. A national system, opera- 
 tive in some measure in all the 318 education areas 
 of England and Wales, and in all the 21,000 public 
 elementary schools, as well as in many of the 
 schools of higher grade, it is more universal in 
 scale than can be found in any other country. In 
 1915, before the War had levied its toll upon the 
 personnel, every local education authority in the 
 land had its school medical staff, and there were 
 855 School Medical Officers and Assistant School 
 Medical Officers engaged in the routine work of 
 inspection and treatment, while 455 were doing 
 ophthalmic, aural, dental, and other specialist 
 work, a total of 1,300. In the same year the staff 
 of school nurses numbered 1,500, appointed in 291 
 out of the 318 education areas. In 1917, 231 local 
 education authorities had provided between them 
 512 school clinics, and 95 had made financial 
 arrangements with hospitals; 151 had established 
 a school dental service, comprising 300 dental 
 clinics and 200 school dentists. There were 413 
 special schools of the kind mentioned on p. 94, 
 accommodating upwards of 31,000 children. 
 Finally, meals for necessitous children were pro- 
 vided in 150 education areas with a population of 
 three-and-a-half million school children. 
 
 Truly a cheering record. But while much has 
 99 
 
The Story of Public Health 
 
 been done, much still remains to be done. It is 
 estimated, for example, that of the multitudes of 
 children found by medical inspection to be de- 
 fective in health, only 60 per cent, are receiving 
 treatment. To give but one other instance, while 
 more than 31,000 children are being educated in 
 special institutions adapted to their infirmities, in 
 two of these groups alone accommodation is needed 
 for an additional 40,000 children. Much more, 
 therefore, must be done before the powers available 
 are fully exercised. By the Education Act of 1918, 
 which raises the age for full-time school attendance 
 to fourteen, and makes attendance at a free con- 
 tinuation school, or the utilisation of equivalent 
 educational opportunities, obligatory up to the age 
 of eighteen, besides insisting upon medical in- 
 spection and treatment in such schools, further 
 opportunities of developing this Service have been 
 opened up. By the time it has completed its 
 second decennium the first will perhaps be looked 
 back upon as the day of small things. So may 
 it be! 
 
 The National Insurance Commissioners 
 
 The National Insurance Act of 191 1, amended 
 in 1913 and again in 1917, has been administered 
 centrally by separate National Insurance Commis- 
 sions for England, Wales, Scotland, and Ireland, 
 with a co-ordinating Joint Committee on which the 
 Chairmen of the four Commissions have seats. 
 
 100 
 
Health Insurance 
 
 The Commissions, provided with staffs of Medical 
 Officers and Inspectors, have controlled the work 
 of the County and County Borough Insurance Com- 
 mittees and of the Approved Societies (see p. 104), 
 which between them do the detailed work of ad- 
 ministration. The Commissions appear to have 
 been constituted on the principle of giving repre- 
 sentation to the more or less divergent interests 
 involved in the National Insurance scheme — the 
 Friendly Societies, the Insurance Offices, the 
 British Medical Association, the insured persons, 
 the Treasury, and so forth. In a perfect world the 
 Commissioners might have been chosen solely 
 for their ability and determination to make this 
 great departure subserve the ends of Preventive 
 Medicine, but in the actual circumstances, with 
 interests to conciliate whose conflicting claims had 
 almost wrecked the scheme in its translation into 
 law, it is difficult to see how Parliament could have 
 acted otherwise than as it did. However this may 
 be, one must allow that while National Health 
 Insurance has done much for Public Health by 
 vastly increasing the facilities for prompt and early 
 medical treatment, and by the work of the Medical 
 Research Committee, it has been more concerned 
 with palliative than with preventive medicine. 
 
 The Medical Research Committee comprises 
 men of proved capacity for the investigation of 
 hygienic and pathological problems. The National 
 Medical Research Fund, amounting to ^60,000 a 
 
 101 
 
The Story of Public Health 
 
 year, is divided between work done in the Com- 
 mittee's Central Research Department and work 
 which it commits to the laboratories of universities 
 and medical schools, of general and special hos- 
 pitals, etc. During the few years of its existence 
 the Committee has done or organised a considerable 
 amount of research bearing upon very diverse 
 aspects of the nation's health. Tuberculosis in the 
 adult, rickets in the child, disabling diseases of the 
 heart and nervous system, the purity of the milk 
 supply, industrial diseases — these are among the 
 subjects it has explored. When the War came 
 it at once began to grapple with many urgent 
 problems presented by battlefield and camp. It 
 took control of the Army Medical statistics, and 
 has accumulated the material for a medical history 
 of the War. It has investigated many pathological 
 questions relating to new war diseases, such as 
 trench fever and trench foot, as well as to gas- 
 poisoning and gas-gangrene, cerebro-spinal fever 
 and paratyphoid fever, functional nervous mala- 
 dies, and the best methods of antisepsis. It has 
 also given much thought to the health of the 
 munition worker, and discovered how such dangers 
 as that of trinitrotoluene poisoning may be com- 
 bated. "Future years alone," as Sir George Newman 
 says in his Memorandum on Medical Education 
 in England, "can prove the strength and soundness 
 of the foundations now being laid, but there is 
 every indication that both foundations and super- 
 
 102 
 
Health Insurance 
 
 structure will be entirely creditable to the fore- 
 sight of the promoters of this scheme for the 
 application of the scientific method." 
 
 The National Insurance Act is one of the greatest 
 Public Health measures ever inscribed upon the 
 statute roll. It makes insurance against sickness 
 compulsory upon all employed persons between the 
 ages of sixteen and seventy who are earning not 
 more than ^160 a year, and anyone under the age 
 of sixty-five working on his own account whose 
 income falls within that limit may insure himself 
 voluntarily. In the case of employed persons the 
 contributions entitling them to the benefits be- 
 stowed by the Act are payable by themselves, their 
 employers, and the State, and the State also bears 
 the entire cost of central administration. The 
 benefits, which are kept free of all suggestion of 
 Poor Law relief, fall under five heads : (i) Medical 
 treatment by a doctor selected by the insured person 
 from a "panel " in his district, with medicine and 
 certain specified surgical appliances ; * (2) a money 
 allowance during sickness; (3) a money allowance 
 during disablement up to the age of seventy, when 
 the insured person becomes eligible for an old-age 
 pension ; (4) treatment in a sanatorium or dispen- 
 sary or other institution in cases of tuberculosis; 
 and (5) for women who are insured, or whose 
 husbands are insured, a maternity benefit of 30s. 
 on the birth of a child, even if the insured woman 
 *In Ireland these " medical benefits" are not provided. 
 103 
 
The Story of Public Health 
 
 is unmarried. Additional benefits, such as dental 
 treatment, or medical treatment for the dependents 
 of insured persons, are payable out of the surplus 
 funds of Approved Societies. Under the Act of 
 191 7 medical and sanatorium benefits are avail- 
 able for discharged soldiers and sailors who are 
 uninsured. 
 
 An Approved Society is a friendly society, in- 
 surance office, trade union, or other organisation 
 which is authorised by the Insurance Commis- 
 sioners to receive contributions and distribute 
 sickness benefits, etc. Insured persons who are 
 not accepted by or do not elect to join an Approved 
 Society are known as deposit contributors, and 
 their benefits are administered by the Insurance 
 Committee for the county or county borough to 
 which they belong, composed of nominees of 
 the County or County Borough Council and 
 of the Insurance Commissioners, representatives of 
 the doctors, etc. The Insurance Committees also 
 administer all medical and sanatorium benefits, as 
 well for the members of Approved Societies as for 
 the deposit contributors. 
 
 Not the least valuable feature of the National 
 Insurance Act is the provision it makes for the 
 treatment of tuberculosis. It is the duty of the 
 Insurance Committees to make arrangements to 
 the satisfaction of the Commissioners for the pro- 
 vision of sanatoria and other institutions for the 
 reception of tuberculous patients, and the Finance 
 
 104 
 
Health Insurance 
 
 Act of 191 1 allocated a sum of ,£1,500,000 for the 
 purpose, divided between the four parts of the 
 United Kingdom according to their respective 
 populations. When the War broke out many 
 schemes for institutional treatment had been framed 
 by the Committees and approved, but the limitation 
 of capital expenditure which had then to be im- 
 posed and the difficulties of obtaining supplies of 
 material and labour have seriously impeded such 
 enterprises. Institutional accommodation is still 
 very far from adequate, and it will probably be 
 years before the nation's needs in this direction 
 are fully supplied. 
 
 The functions of the principal Central Health 
 Authorities have now been briefly sketched. 
 It is not necessary to enumerate all the rest, but 
 the Board of Agriculture watches over the purity 
 of milk, butter, and cheese, supervises margarine 
 factories, and takes steps to control contagious 
 diseases in animals; the Board of Trade fulfils 
 very important health functions at our ports, the 
 Ministry of Pensions cares for the health of 
 disabled soldiers, the Colonial Office wages war 
 upon tropical diseases, the Board of Customs 
 regulates the sale of patent medicines and pro- 
 prietary foods, the Board of Control is responsible 
 for the inspection of lunatic asylums, etc., and the 
 Treasury keeps a jealous eye on the expenditure 
 upon sanatoria and medical benefits under the 
 
 i°5 
 
The Story of Public Health 
 
 Insurance Acts. During the War, Public Health 
 work has been undertaken by the Ministry of 
 Munitions, the Ministry of Food, the Central 
 Control (Liquor Traffic) Board, and the Ministry 
 of Reconstruction. Had there been one Central 
 Health Authority, capable of indefinite expansion 
 as the need arose, instead of one-and-twenty, there 
 would have been no occasion for these temporary 
 Departments to complicate their gigantic tasks with 
 the consideration of health problems. That, in spite 
 of this multiplicity of Central Health Authorities, 
 our Public Health service as a whole should have 
 attained so high a standard of efficiency is to be 
 explained largely by the national genius for 
 practical affairs — a genius which has enabled us 
 to avert the worst effects of administrative con- 
 fusion — and by the devoted service of the great 
 army of voluntary workers. 
 
 106 
 
CHAPTER VIII 
 Local Health Authorities 
 
 It may be well to begin this chapter with a 
 recapitulation of facts concerning the creation of 
 the organs of local health administration. By 
 the Public Health Act of 1848, the nation's 
 first Health Charter, the General Board of Health 
 was empowered, on petition of the ratepayers, 
 or without such petition where there was an 
 average death-rate as high as 23 per thousand, 
 to set up Local Boards to provide for elementary 
 sanitary requirements (p. 30). In 1866 was 
 passed the Act which declared it to be the 
 duty of local sanitary authorities to conduct sani- 
 tary inspection and provide a water supply, and 
 gave the Home Secretary power to perform these 
 offices at the charges of such authorities as 
 neglected them (p. 46). More important, how- 
 ever, than either of these measures was the Public 
 Health Act of 1872 (p. 53), which for the first 
 time applied sanitary law to the rural parts of the 
 country. It divided the whole country into urban 
 and rural sanitary districts. In urban districts the 
 sanitary authorities were on the one hand to be 
 
 107 
 
The Story of Public Health 
 
 the Town Councils of municipal boroughs, and on 
 the other hand the Local Boards of Health or the 
 Improvement Commissions which had been called 
 into existence in non-municipal towns; in the rural 
 districts the Boards of Guardians took over from 
 vestries the whole business of sanitary adminis- 
 tration. In 1888 came the Act which, by creating 
 County Councils, revolutionised rural government, 
 and this was followed in 1894 by tne Act which 
 established Urban and Rural District Councils 
 throughout the country, and also, by setting up 
 Parish Councils, revived the parish as the unit of 
 local self-government. The Urban District Coun- 
 cils replaced the Local Boards of Health and Im- 
 provement Commissions which had administered 
 sanitary law in non-municipal boroughs, while in 
 municipal boroughs the Town Councils were to 
 exercise their sanitary powers as Urban District 
 Councils; the Rural District Councils took over 
 the sanitary duties of Boards of Guardians, which, 
 however, were still left with some important Public 
 Health responsibilities in addition to their work 
 under the Poor Law. 
 
 The area of a County Council, styled an ad- 
 ministrative county, is usually identical with that 
 of a geographical county ; but certain large coun- 
 ties — Yorkshire, Lincolnshire, Suffolk, and Sussex 
 — have two or three County Councils, and the Isle 
 of Ely, the Soke of Peterborough, the Isle of 
 Wight, and the metropolis have each a County 
 
 168 
 
Local Health Authorities 
 
 Council. The sanitary powers of County Councils 
 are of a general character, relating mainly to the 
 establishment of hospitals for infectious diseases, 
 the provision of facilities for the treatment of tuber- 
 culosis and venereal diseases, the prevention of 
 river pollution, the administration of the Conta- 
 gious Diseases (Animals) Act, and the analysis of 
 foods, drugs, and fertilisers. They are also re- 
 sponsible for the supervision of midwives, and for 
 the initiation and execution of maternity and child- 
 welfare schemes. They make by-laws, have some 
 powers of supervision over Urban and Rural Dis- 
 trict Councils, may bring pressure to bear upon 
 such of them as are slack in the performance of 
 their duties, and may report them to the Central 
 Health Authority. On the other hand, their writs, 
 so to speak, do not run in county boroughs (towns 
 with a population of not less than 50,000 or with 
 sheriffs and special judiciary powers), and only 
 partially in municipal boroughs. At first County 
 Councils were not compelled to appoint County 
 Medical Officers of Health; since 1909 this has 
 been obligatory. They must also appoint County 
 Analysts, and many of them have added to their 
 staffs Sanitary Inspectors (Inspectors of Nuisances). 
 County Borough Councils and Municipal 
 Borough Councils (Town Councils) exercise all the 
 multifarious sanitary functions of an Urban Dis- 
 trict Council, as described in the next paragraph. 
 In addition, they are invested with the powers 
 
 109 
 
The Story of Public Health 
 
 reserved from Unban District Councils in favour 
 of County Councils, except that in the smaller 
 boroughs the Acts relating to the contagious 
 diseases of animals and the sale of food and drugs 
 are operated by the county authority. 
 
 Urban and Rural District Councils exercise all 
 sanitary functions except those mentioned as re- 
 served to County Councils. They are responsible 
 for the inspection and abatement of nuisances, for 
 drainage, sewerage, and the removal and disposal 
 of refuse, for the inspection of food and the pro- 
 vision of a water supply, for the inspection of 
 common lodging-houses, dairies, cowsheds, and 
 milkshops, workshops and workplaces, laundries 
 and bakehouses, for the regulation of new build- 
 ings, for town planning and housing, for the 
 isolation of infectious disease, disinfection, and 
 the provision of hospitals, mortuaries, cemeteries 
 and crematoria, as well as of open spaces. In 
 addition to all these duties, incident upon Urban 
 and Rural District Councils alike, Urban District 
 Councils regulate slaughter-houses and offensive 
 trades, see to the cleansing and scavenging of 
 streets, and provide baths and washhouses under 
 Acts which are of the adoptive class. Upon both 
 Urban and District Councils the appointment of 
 Medical Officers of Health and Sanitary Inspectors 
 is obligatory. In some areas women are now ren- 
 dering valuable service as Sanitary Inspectors or 
 Assistant Sanitary Inspectors. This innovation 
 
 no 
 
Local Health Authorities 
 
 began with the appointment of women by the 
 Kensington Borough Council to inspect laundries 
 under the Factories and Workshops Acts. Every 
 Borough Council in London now has one or more 
 women Sanitary Inspectors, and similar appoint- 
 ments have been made in many of the larger 
 provincial towns, but in the smaller urban and 
 rural districts women are seldom appointed to 
 this office. They are also doing excellent work 
 as Health Visitors and Tuberculosis Visitors, as 
 Inspectors of Midwives, and as Tuberculosis Dis- 
 pensary Nurses and School Nurses. 
 
 Rural parishes may, or must, according to the 
 population, elect a Parish Council ; but parishes 
 may be united, divided, or altered by the County 
 Councils and the Central Authority. The Parish 
 Council has limited powers as to water supply and 
 nuisance prevention, and right of complaint against 
 the Rural District Council. This latter authority 
 may delegate to a Parish Council certain of its 
 powers. 
 
 Boards of Guardians, first established in 1834, 
 are only separately elected in urban unions or in 
 the rural portions of mixed unions; in a rural 
 union the Rural District Councillors represent their 
 parishes on the Board. Each Board must appoint 
 one or more Medical Officers to attend the sick 
 poor. We saw in a previous chapter (p. 71) that 
 even the more conservative Majority Report of the 
 Poor Law Commission (1909) recommended the 
 
 in 
 
The Story of Public Health 
 
 abolition of these Boards, and this recommendation 
 has been confirmed by the Local Government Com- 
 mittee of the Ministry of Reconstruction. Their 
 disappearance will involve the assumption by some 
 other authority of two duties that have no connec- 
 tion with the relief of the poor : (i) The appointment 
 of registrars of births, deaths, and marriages; and 
 (2) the execution of the Vaccination Acts and the 
 appointment of vaccination officers. Vaccination, 
 of which the origin has already been related 
 (p. 21), was provided gratuitously in 1840, was 
 made compulsory in 1854, and has been carried out 
 by paid vaccination officers from the time of the 
 pandemic of 1871. But in 1898 the stringency of the 
 law began to be relaxed in favour of conscientious 
 objectors, and now a parent or guardian has only 
 to make a statutory declaration to the vaccination 
 officer to secure exemption for a child. In 1912 
 not more than half of the children born in England 
 and Wales were being vaccinated, and now the 
 proportion is probably less, perhaps much less. 
 I shall return to this subject later (p. 129). 
 
 The same Act (1872) which divided England 
 and Wales into urban and rural sanitary districts 
 provided for the formation of Port Sanitary 
 Authorities to guard against the introduction of 
 infectious disease from abroad. The whole of the 
 coast line and the shores of navigable rivers are 
 included either in a port sanitary district or a 
 riparian sanitary district, and each authority must 
 
 112 
 
Local Health Authorities 
 
 appoint a Medical Officer of Health and a Sanitary 
 Inspector, and must, either singly or in combina- 
 tion with similar authorities, provide an isolation 
 hospital and make separate provision for smallpox. 
 It has been noted (p. 47) that the old system of 
 "constructive infection," by which vessels arriving 
 from an infected port, although they themselves 
 had a clean bill of health, were subject to deten- 
 tion, was condemned by Sir John Simon in 1865. 
 From that time the opinion gained ground among 
 English sanitarians that the maintenance of a high 
 standard of sanitation in our ports, and in the 
 country generally, was the best safeguard against 
 the introduction of infections from abroad. Gradu- 
 ally the old quarantine law, based upon the 
 Quarantine Act of 1825, fell into dTsuse, and the 
 last vestige of it was repealed by, the Public 
 Health Act of 1896. Other nations were less ready 
 to adopt the principle that the treatment of a ship 
 should be determined by the health of the persons 
 on board and not by the health of the port of de- 
 parture, but most of them have now fallen into 
 line. Suspected ships must bring up at a board- 
 ing station, where they are visited by the Port 
 Medical Officer of Health, and either classed as 
 healthy and given release, or, if infectious disease 
 is discovered, sent to a mooring station for 
 thorough disinfection ; the patients are removed to 
 an isolation hospital, but " contacts " are only re- 
 quired to give the addresses to which they are 
 1 113 
 
The Story of Public Health 
 
 proceeding, so that they may be kept under sur- 
 veillance until the incubation period is past ; those, 
 however, who are regarded as specially dangerous 
 are kept under scrutiny in observation shelters 
 or elsewhere until the situation is cleared up. The 
 system, while it places no unnecessary restrictions 
 on the movements of "contacts" or on import 
 trade, has, as Dr. Bruce Low claims, been 
 eminently successful. "Notwithstanding Britain's 
 great trade, by shipping, with infected ports, it 
 has so far escaped the development, to any extent, 
 of epidemics which have ravaged other countries 
 that have placed their reliance on the more restric- 
 tive methods based upon quarantine."* 
 
 The Public Health administration of London 
 has been reserved for separate treatment, for it 
 differs in some respects from that of any other 
 city. The City of London proper, over which 
 the Lord Mayor rules, maintains its independence 
 of the rest of the metropolis. It is represented on 
 the London County Council, but the City Corpora- 
 tion, through its Health Department, which has 
 superseded the City Commission of Sewers, does 
 its own sanitary work, though it has no separate 
 main drainage. It is also the sanitary authority 
 for the Port of London, which extends from Ted- 
 dington to the mouth of the Thames. Outside the 
 City the units of the system are the twenty-eight 
 
 * Appendix 13 to the Forty-seventh Annual Report of the 
 Local Government Board, 1917-18. 
 
 114 
 
Local Health Authorities 
 
 Borough Councils, whose powers are somewhat 
 less extensive than those of provincial Town 
 Councils, being limited by the control exercised 
 by the London County Council and the Local 
 Government Board. The Borough Councils date 
 from 1899, when they superseded the vestries and 
 district boards (p. 38). The London County 
 Council was created ten years earlier, to replace 
 the less directly representative Metropolitan Board 
 of Works, which had been the principal organ of 
 local government since 1855. The greatest of all 
 the County Councils has very extensive sanitary 
 powers, of which it has made vigorous use under 
 the inspiration of Sir Shirley Murphy, the former 
 Medical Officer of Health, and of Dr. W. H. 
 Hamer, his successor. It can compel the Borough 
 Councils to perform certain duties under the Public 
 Health (London) Act, 1891, has appellate juris- 
 diction as between the Borough Councils and 
 aggrieved private persons, makes sanitary by-laws, 
 is the main drainage authority for the whole 
 metropolis, and generally discharges the sanitary 
 duties devolving upon County Councils. But it 
 has nothing to do with the water supply, which 
 is in the hands of the Metropolitan Water Board, 
 nor with the prevention of river pollution, which 
 is undertaken by the Thames Conservancy Com- 
 mission, nor with the provision of isolation hos- 
 pitals, for which the Metropolitan Asylums Board 
 is responsible. This latter Board, constituted in 
 
 US 
 
The Story of Public Health 
 
 1867, is a highly anomalous authority, for while 
 its funds are derived from the poor-rates and it 
 is composed largely of representatives of Boards 
 of Guardians, it is treated, both legislatively and 
 administratively, as a Public Health and not as a 
 Poor Law body, and no civic disability is incurred 
 by those who enter its institutions. This Board, 
 it may be added, is what is known as a joint 
 authority, and there are many similar joint Boards 
 in the provinces for the provision of isolation 
 hospitals and other purposes. 
 
 In these pages it is impossible to define more 
 minutely the relations existing between the many 
 local authorities that have been summarily de- 
 scribed, or to enter into the details of local health 
 administration.* It must, however, be said that 
 much of the work of these bodies, and especially 
 of the County Councils, is done by Committees, 
 which may or may not include others than members 
 of the authorities. One example is furnished by 
 the local education authorities. These consist of 
 the County and County Borough Councils and 
 (for elementary education only) the Councils of 
 the larger boroughs and urban districts. Each of 
 these bodies appoints an Education Committee, 
 which directs the School Medical Service and does 
 all the work of educational administration, but 
 has no power to raise rates or borrow money. In- 
 
 * For such information see Banninigton's " English Public 
 HeaJth Administration." 
 
 1 16 
 
Local Health Authorities 
 
 surance Committees, again, are composed largely 
 of nominees of County or County Borough 
 Councils, with representatives of other interests 
 (see p. 104). 
 
 As provision for the health of the people has 
 been extended, the bodies responsible for adminis- 
 tering it locally have multiplied, until now, in the 
 words of Sir George Newman, "in each town and 
 village of the country there are some eight or ten 
 governing bodies concerned with Public Health."* 
 The result is much overlapping on the one hand 
 and the existence of gaps on the other hand, with 
 no lack of opportunities for friction. These defects 
 are met with, not in connection with the suppres- 
 sion of nuisances but in the arrangements for the 
 treatment of disease. As Bannington points out, 
 there are districts in which members of the same 
 household may be "undergoing treatment in the 
 institutions or at the hands of the Sanitary 
 Authority, the Guardians of the Poor, the Educa- 
 tion Committee, the Insurance Committee, and 
 some one or more of the Voluntary Hospitals and 
 Nursing Associations. On the other hand, there 
 are districts where, unless a person is destitute or 
 insured, there is practically no treatment provided." 
 How this chaotic state of things might be remedied 
 will be considered in a later chapter (p. 151). 
 
 *" Memorandum on Medical Education in England," 1918. 
 
 117 
 
CHAPTER IX 
 Bacteriology and Infection 
 
 The development of the Public Health organisa- 
 tion of this country in its various branches, 
 central and local, has now been traced from its 
 beginnings down to the point at which it takes a 
 new departure in the creation of a Ministry of 
 Health. Before that subject is considered it is 
 appropriate that some account should be given 
 of the light that has been shed upon the nature 
 of those infective diseases which it is a main object 
 of the Public Health Service to suppress, or at any 
 rate to keep in check. That and the problems 
 which it presents will be the theme of the present 
 chapter, while the next chapter will be concerned 
 with certain infections which, until quite recently, 
 have been ignored by Public Health administration 
 and are invested by the circumstances of the times 
 with a peculiar importance. 
 
 When the nation received^ its first Health 
 Charter, in 1848, the essential cause of infective 
 disease was as great a mystery as it had been in 
 the days of Hippocrates, the Father of Medicine. 
 That there was some relation between such diseases 
 
 118 
 
Bacteriology and Infection 
 
 and bad sanitation was obvious, but beyond that 
 nothing was known. The clue was furnished in the 
 years 1850-60 by Pasteur's brilliant researches into 
 putrefaction and fermentation, which triumphantly 
 proved that those processes were entirely due to 
 the action of minute forms of life. Now, the process 
 of infectious disease is a form of fermentation, and 
 Pasteur was quick to see the bearing upon it of his 
 great generalisation. "The etiology of infectious 
 disease," he wrote, "is on the eve of having un- 
 suspected light thrown upon it." 
 
 Speedily was the prediction fulfilled. Con- 
 vinced that the suppuration which had been the 
 customary sequel of surgical operations up to that 
 time was due to micro-organisms with a bent for 
 mischief, Lister, by a long series of patient in- 
 vestigations and ingenious experiments, devised 
 means to destroy these pathogenic germs in situ, 
 and thus stone by stone built up the edifice of anti- 
 septic surgery. In the year in which Pasteur began 
 his epoch-making researches Davaine had observed 
 the presence of rod-like organisms in the blood 
 of animals dead of anthrax, but had failed to 
 appreciate its significance. Now its meaning was 
 clear to him, and soon he discovered by experiment 
 that only blood which contained those organisms 
 was capable of communicating the disease. There 
 could be little doubt, therefore, though the 
 evidence fell short of demonstration, that this 
 bacterium was the cause of anthrax. It was the 
 
 119 
 
The Story of Public Health 
 
 first to be causally associated with a disease, and 
 it owes its primacy to the facts that, tiny as it is, 
 it is a giant compared with most bacteria, and that 
 it is easy of artificial cultivation. It can boast a 
 stature of bVot of an inch, whereas some other 
 bacilli measure only 25600 of an inch, and others 
 even less. The micro-organism of glanders was 
 identified by Loftier and Schiitz in 1862, that of 
 leprosy by Hansen in 1872, that of gonorrhoea by 
 Neisser in 1879. The virus of typhoid was the 
 next important germ to be isolated, by Eberth 
 and Gaffky. In 1882 Koch convicted the tubercle 
 bacillus, and in 1883 the bacillus of cholera. About 
 the same time Klebs and Loffler proved the case 
 against the bacillus of diphtheria ; and since then a 
 verdict of guilty has been returned against the 
 germs of epidemic pneumonia, cerebro-spinal fever, 
 tetanus, and plague. 
 
 All these germs are bacteria — that is, they 
 belong to the lowest group of organisms, consist- 
 ing of but a single cell, in the vegetable kingdom. 
 But there are others, known as protozoa, which, 
 as the name implies, belong to the lowest group of 
 organisms in the animal kingdom. Such are the 
 haemamoeba of malaria, discovered by Laveran in 
 1880, the spirochetes of relapsing fever, of syphilis, 
 and of yaws — a disease somewhat akin to syphilis 
 prevailing in certain warm climates — and the try- 
 panosome of the long-drawn-out disease of which 
 sleeping sickness is the terminal stage ; and analogy 
 
Bacteriology and Infection 
 
 suggests, as Sir Patrick Manson has pointed out, 
 that the germ of yellow fever, when discovered, 
 will prove to be a protozoon. Dysentery requires 
 three different kinds of germs — a protozoon, a bac- 
 terium, and a microscopic worm— to account for 
 all the evil it does. 
 
 Some pathogenic germs need an intermediate 
 host to enable them to fulfil the maleficent law of 
 their being. Thus the germ of malaria passes 
 through some of its phases in certain species of 
 mosquito, and can only be transmitted to man 
 by the bite of one of those insects, and only when 
 the germ has arrived at a particular stage of its 
 evolution. The germ of yellow fever can only be 
 communicated by the bite of other species of mos- 
 quitoes. The spirochaete of relapsing fever is 
 transmitted by the bites of ticks, lice, and other 
 insects; the germs of typhus fever and trench fever 
 by lice ; the trypanosome by the bite of the tse-tse 
 fly ; the bacillus of plague by the bites of fleas that 
 have first bitten plague-infected rats. The germs 
 of most of the infective fevers, however, are inde- 
 pendent of the good offices of intermediaries. Some 
 of them are conveyed by the breath, and the germs 
 of one group of these fevers can be carried for some 
 distance by currents of air. Others are conveyed 
 by exhalations from or by particles of the skin, 
 by the secretions of the mouth or the excretions 
 of the body, by milk, water, or food, by infected 
 articles of clothing, or by infected or simply con- 
 
 121 
 
The Story of Public Health 
 
 taminated flies, while some, such as the germs of 
 venereal diseases, are communicated by physical 
 contact, direct or indirect, and are therefore called 
 contagious diseases. 
 
 In the above enumeration of germs that have 
 been identified with particular diseases, those of 
 smallpox, measles, typhus fever, and whooping- 
 cough do not appear. The reason is that they have 
 not yet been discovered, and the presumption is 
 that they are too minute to be revealed by the 
 highest powers of the microscope. It is probably 
 not without significance that in these diseases, or 
 most of them, the infection is air-borne. Sir 
 Archdall Reid* regards this air-borne character as 
 indicating an extreme degree of minuteness, and 
 he suggests that these organisms may never be 
 discovered because they may be beyond the powers 
 of devisable microscopes. That, of course, is only 
 a speculation, which may presently be disproved; 
 but it was published so long ago as the year 1896, 
 and although bacteriological technique has made 
 advances since that time, it has not yet been 
 negatived. The micro-organism of scarlet fever 
 ought probably to be added to the list of undis- 
 covered germs, for although several bacteria have 
 been accused, none of them has been convicted 
 by the general verdict of bacteriologists. The germ 
 of epidemic influenza, again, has not yet been con- 
 clusively identified, if indeed that protean disease 
 * " The Present Evolution of Man." 1896. 
 12a 
 
Bacteriology and Infection 
 
 is due to a single germ. Nor has the micro- 
 organism of rabies (hydrophobia) been "caught," 
 although it clearly does not belong to the air-borne 
 group. 
 
 It may not be without interest to explain in 
 untechnical language the conditions that have to 
 be fulfilled before it can be demonstrated that a 
 micro-organism is specific to a particular disease. 
 They were formulated long ago by Koch, to whose 
 ingenuity bacteriological technique is under the 
 greatest obligation. In the first place, the organ- 
 ism must be present in the blood or tissues in 
 every case of a given disease. In the second place, 
 it must be grown in pure culture — that is, free 
 from admixture with other organisms- — on an 
 artificial medium, such as agar, for successive 
 generations. This separation of the germ from all 
 others is what is meant by isolation, and it is 
 obviously a crucial part of the identification, for 
 it seldom happens that only one kind of organism 
 is present in a case of disease, and unless the 
 suspected virus is separated from its associates 
 its responsibility cannot, of course, be brought 
 home to it. In the third place, inoculation of a 
 susceptible animal with the last of the successive 
 cultivations must reproduce the disease. Finally, 
 from every animal so inoculated the same germ 
 must be recovered, distributed in the same way, 
 and capable of again reproducing the disease. 
 These are what are known as "Koch's postulates." 
 
 123 
 
The Story of Public Health 
 
 In some diseases — those, for instance, to which 
 the lower animals are insusceptible — they are not 
 all fulfilled, but none the less the proof may be 
 sufficient, although not carried to the point of 
 demonstration. 
 
 The discovery of the germ origin of infective 
 disease has led to the preparation of vaccines and 
 serums which are used both preventively and 
 remedially. These forms of treatment are based 
 upon the beautiful but very complex theory of 
 immunity, of which a simple exposition may here 
 be attempted. 
 
 There is, to begin with, a natural immunity to 
 infectious disease, and this natural immunity may 
 be either racial or individual. Thus, man is 
 immune to swine fever, and the lower animals are 
 immune to leprosy. These are instances of racial 
 immunity. To give an example of individual im- 
 munity : two persons are exposed to the same 
 amount of infection, say of scarlet fever, and while 
 one "takes" the infection, the other escapes it, 
 being immune — it may be only temporarily — to 
 that disease. 
 
 So much for natural immunity. Acquired im- 
 munity may be the result of a previous attack of 
 a disease, or may be induced artificially by inocu- 
 lation with the causal germ or its poisons. In 
 both cases alike the system is stimulated to the 
 production of substances antagonistic to the 
 disease, known as antibodies. This is the active 
 
 124 
 
Bacteriology and Infection 
 
 form of acquired immunity, and it is so called 
 because a person who acquires immunity in either 
 of these ways, that is, by a previous attack or by 
 inoculation, creates his own antibodies. In the 
 passive form of acquired immunity the work is 
 done for him— that is to say, the antibodies are 
 furnished by the serum of animals that have been 
 actively immunised by inoculation with the germ 
 or its poisons, and he is injected with these anti- 
 bodies in order that they may reinforce his own 
 defensive powers. An example of passive immunity 
 is that resulting from the use of diphtheria anti- 
 toxin, consisting of serum from the blood of horses 
 that have been inoculated with the poisons of the 
 diphtheria bacillus so that they may create anti- 
 bodies for the benefit of human sufferers. 
 
 The substances used to produce active immunity 
 are called vaccines, and the process by which they 
 are introduced into the system is known as vac- 
 cination or inoculation. The substances by which 
 passive immunity is effected are called serums or 
 antitoxins. An antitoxin is really a serum, but, 
 as the name implies, it is efficacious only against 
 the poisons of a germ, while other serums are 
 capable of destroying the germs themselves. The 
 latter, therefore, are bactericidal serums, while 
 antitoxins are antitoxic serums. 
 
 Long before the theory of immunity was elabo- 
 rated, vaccination was practised as a measure of 
 prevention against smallpox, as already related 
 
 125 
 
The Story of Public Health 
 
 (p. 21). That was a purely empirical procedure, 
 and no further progress was made in the direction 
 of vaccinal prophylaxis until infectious disease was 
 proved to be of microbic origin. The life-history 
 and toxins of pathogenic organisms and the re- 
 actions to which they give rise in the body were 
 now studied, vaccination was placed upon a rational 
 basis, and one after another the vaccines and 
 serums so extensively used against infectious 
 disease were prepared. Vaccines have won their 
 most brilliant triumphs in the prevention of small- 
 pox, typhoid fever, and rabies, but they have some 
 degree of preventive efficacy also in plague and 
 in cholera. As to serum treatment, its value in 
 diphtheria is great beyond calculation, and its 
 employment against tetanus during the War was 
 the means of saving multitudes of wounded soldiers 
 from the attacks of that terrible disease. It is 
 successful also in the bacillary form of dysentery, 
 and it is the most efficacious treatment yet devised 
 for cerebro-spinal meningitis. 
 
 Enough has, perhaps, been said to suggest the 
 invaluable results which have Mown from the dis- 
 covery of the microbic nature of infectious disease, 
 both preventively and remedially. But there is still 
 much to be learnt in connection with infectious 
 disease. The problem is one of extreme intricacy. 
 The causal organisms are only one of its factors. 
 They are often spoken of as the seed. There is 
 also the soil — the human body in which the seed 
 
 126 
 
Bacteriology and Infection 
 
 is sown — to be taken into account. And further, 
 there is the environment, by which both seed and 
 soil are influenced. Each of these factors is com- 
 plex in a high degree ; it is not surprising, there- 
 fore, that there should be many things in the 
 behaviour of infectious disease that are not easy 
 of elucidation. Why outbreaks should occur 
 at periodic intervals; how far they are determined 
 by seasonal or telluric influence; why at times 
 epidemics should spread over so large a part of 
 the globe as to> become pandemic; why epidemics 
 of the same disease should vary in severity; why 
 even the same epidemic should be mild at one 
 stage and severe at another ; why certain infections 
 have diminished both in severity and in preval- 
 ence, and others in severity but not in prevalence 
 — these are some of the phenomena that require 
 explanation. 
 
 One deduction yielded by the history of in- 
 fectious disease is that pathogenic bacteria, like 
 other forms of life, both vegetable and animal, 
 undergo evolutionary variations in response to 
 changes of environment. Experimental bacteri- 
 ology has proved that their virulence can be 
 attenuated by passing' them through the bodies of 
 more resistant animals, and that they are materially 
 affected by temperature, by light, by oxygen, by 
 chemical action, and by food — that is, the medium 
 on which they are grown. It is antecedently prob- 
 able, therefore, that they are modified both in 
 
 127 
 
The Story of Public Health 
 
 virulence and in activity under the varying con- 
 ditions of nature. Hence it is, presumably, that 
 epidemics of the same disease vary in severity, 
 and that the same epidemic may exhibit a rise or 
 fall in severity at different stages. This evolu- 
 tionary modification is the most likely explanation, 
 also, of the disappearance of leprosy from this and 
 other Western countries where it was once endemic, 
 and of the decline in the severity of diseases so 
 unlike each other as scarlet fever and syphilis. 
 With a rising prevalence, scarlet fever is now 
 usually of so mild a type as to be less fatal than 
 measles or whooping-cough; the decline in the 
 average severity of syphilis during the last half- 
 century is unquestionable. The complete disap- 
 pearance of typhus fever from the southern and 
 midland parts of this country is predominantly due, 
 no doubt, to improved sanitary conditions, for this 
 is pre-eminently a filth disease. But even here there 
 may have been an evolutionary change in the germ, 
 for it is communicated by lice, and it is difficult to 
 believe that there are not enough filthy and lice- 
 infested people congregated in the poorer parts of 
 London, for example, to keep the disease going, if 
 the micro-organism had not lost some of its activity. 
 The lessened virulence of smallpox, again, 
 though partly explained by the effect of vaccina- 
 tion, may be due also to evolutionary modification 
 of the virus. Vaccination begins to lose its pro- 
 tective efficacy after a few years, and a large 
 
 128 
 
Bacteriology and Infection 
 
 proportion of the population are never re-vacci- 
 nated; some other influence, therefore, would 
 appear to have contributed to this decline in viru- 
 lence. There has been a remarkable diminution 
 also in the prevalence of smallpox. That vaccina- 
 tion, supplemented by improved sanitation, is the 
 chief factor in the reduction of smallpox to the 
 status of a rare disease I do not doubt, but this 
 can hardly be the full explanation. Since the 
 stringency of the vaccination laws was relaxed, 
 enormous numbers of children have escaped 
 vaccination altogether (see p. 112), yet the formid- 
 able epidemics which it was confidently predicted 
 would avenge the concession have not arrived. I 
 cannot, however, agree with those who suggest 
 that vaccination has done its work as a measure 
 of routine prophylaxis and may now be reserved 
 for the protection of those who are exposed to in- 
 fection during an epidemic. Until we have had a 
 much more prolonged experience of the effect of 
 allowing a large part of the community to avoid 
 vaccination, the prudent course, in my opinion, 
 is to urge upon the public the propriety of accept- 
 ing the protection which it undoubtedly affords. 
 
 If there is ground for believing that pathogenic 
 germs are the subjects of pronounced evolutionary 
 change, it is still less open to doubt that, with 
 exposure during many generations to infectious 
 disease, their human host has been undergoing an 
 evolution against it. What other hypothesis so 
 
 j 129 
 
The Story of Public Health 
 
 well explains the facts that diseases which infect 
 a comparatively small proportion of a race that 
 has long been exposed to their attacks run like 
 wildfire through a race unaccustomed to them, and 
 that diseases — measles, for example — which usually 
 have a slight mortality-rate in a community habitu- 
 ated to them will decimate a people that offers to 
 them a virgin soil ? In the very able work already 
 cited, Sir Archdall Reid shows with great detail 
 that the invasion of the New World by the in- 
 fectious diseases of the Old World in the train of 
 conquerors, colonists, missionaries, and traders is 
 the reason why so many races of the Western 
 Hemisphere and the Antipodes have died out or 
 are fast dying out. The Caribs and Tasmanians 
 and other races have vanished entirely; the Red 
 Indians, the Polynesians, the Australians, and the 
 Maories are far on the road to extinction. The 
 facts are not to be accounted for by the mere effect 
 of contact Between civilised and savage modes of 
 life. If that were so, savage tribes of the Old 
 World would perish as they come into touch with 
 civilisation. But perish they do not, and the reason 
 is that they have not to encounter unfamiliar in- 
 fections. To complete the proof, it is found that 
 such Europeans as have not been exposed to 
 malarial infection contract that disease in a malarial 
 region more readily and in severer forms than do 
 the natives. 
 
 The principle to which these facts point is that 
 130 
 
Bacteriology and Infection 
 
 the resistive power of a race to an infectious disease 
 is proportionate to its familiarity with that disease. 
 The immunity evolved is not of the acquired kind, 
 but i's natural, innate, and therefore transmis- 
 sible from one generation to another. It is an 
 example, in fact, of Natural Selection. A person 
 born with a complete immunity to a disease escapes 
 it altogether and transmits the immunity to his 
 offspring; if the immunity is less complete he 
 may contract the disease in a mild form and, sur- 
 viving, transmit his partial immunity; whereas 
 those who start with no natural immunity tend to 
 succumb to the disease, or if they survive they 
 transmit the susceptibility. So, as the generations 
 pass, those who are non-immune tend to die out, 
 and those who are immune — the "fittest" — tend 
 to survive. 
 
 The fall in the death-rate of tuberculosis in this 
 and other civilised countries may be an example 
 of acquired as distinct from natural immunity, 
 associated with variation in the bacillus. Improved 
 hygiene and open-air treatment and the dispensary 
 system cannot have been without some influence, 
 but alone they do not account for the facts. The 
 fall in this country began about the middle of the 
 last century, some thirty years before the modern 
 methods of combating tuberculosis were initiated, . 
 and it is shared by countries where those methods 
 are little practised. The theory that it is largely 
 due to acquired immunity originated with Metch- 
 
 r 3i 
 
The Story of Public Health 
 
 nikoff. It is founded mainly upon the facts that a 
 vast majority of children who are subjected to the 
 tuberculin test are proved by it to be tuberculous 
 though the disease is inactive, and that in post- 
 mortem examinations of those who have died from 
 other causes healed lesions of tuberculosis are 
 found in all but a small proportion of cases. Metch- 
 nikoff 's view is that most children are attacked by 
 attenuated strains of the tubercule bacillus, that 
 their natural powers of resistance enable them to 
 repel the attack, and that the antibodies evoked in 
 the process confer upon them a measure of im- 
 munity against further attacks. The theory, 
 though not generally accepted, accords with the 
 general doctrine of immunity, and may be pro- 
 visionally adopted. 
 
 We have now considered some aspects of two 
 of the factors of the problem of infectious disease, 
 the microbe and the man. The third factor, en- 
 vironment, is a many-sided one, which includes, 
 as Sir George Newman has pointed out in his 
 Memorandum on Medical Education, "the con- 
 ditions and customs of society, peace or war, food 
 or famine, the prevalence or otherwise of disease, 
 the physical and climatic conditions, dryness or 
 moisture, prevailing winds or autumnal tempera- 
 ture, urban or rural life, healthy or unhealthy 
 occupation." It is with environment that Public 
 Health activities are chiefly concerned. The evolu- 
 tion of the human race against infectious disease, 
 
 132 
 
Bacteriology and Infection 
 
 and the variation of pathogenic germs, are pro- 
 cesses of Nature, which for the most part are 
 independent of man's voluntary action. Over 
 environment, however, he has a large measure of 
 control. And no bacteriological ritual will com- 
 pensate for failure to provide the community with 
 a healthy environment. 
 
 In the early days of bacteriology some sani- 
 tarians were slow to appreciate the r&le of 
 pathogenic organisms. More recently the pen- 
 dulum has sometimes swung too far to the other 
 side, and Sir William Collins is not without 
 justification for the epigrammatic warnings he has 
 administered from time to time against the danger 
 of underrating "the potency of filth and remov- 
 able conditions as factors in disease production 
 and propagation." * Which is the more important 
 — that cows should be kept in clean cowsheds and 
 be free from disease," and that scrupulous cleanliness 
 should characterise the whole process of dairying, 
 or that infected milk should be sterilised? That 
 water should be drawn from pure sources, or that 
 reliance should be placed wholly on filtration and 
 purification ? That water and food should be un- 
 contaminated by the typhoid virus, or that the 
 effects of the pollution should be counteracted by 
 anti-typhoid inoculation? If in the social code 
 cleanliness comes next to godliness, in the sanitary 
 
 * See, for example, " The Mian, versus the Microbe," Journal 
 of the Royal Sanitary Institute, xxiii. 335. 
 
 133 
 
The Story of Public Health 
 
 code it comes next to nothing. It is the first and 
 greatest of the commandments. The final cause 
 of sanitary effort is the prevention of disease. It 
 is not enough that disease should receive prompt 
 treatment when it occurs, whether by serums or 
 by other methods. It is not enough, even, that its 
 propagation should be checked by isolation and 
 notification and disinfection. What the sanitarian 
 has to keep steadily in mind is that the occurrence 
 of disease has to be prevented, not merely by pro- 
 phylactic vaccination, which as yet has but a 
 limited sphere of usefulness, but still more by 
 furnishing man with a favourable environment — 
 fresh air, abundant sunlight, pure water, whole- 
 some and sufficient food, good housing, well- 
 ventilated workshops, and so at once shielding him 
 from the attacks of his invisible foes and strength- 
 ening his powers of resistance. The vigour of his 
 own life, as Dr. Farr long ago declared, is his best 
 security against the invasion of pathogenic germs. 
 
 134 
 
CHAPTER X 
 The Crusade against Venereal Disease 
 
 The diseases which Public Health administration 
 so long refused to recognise (p. 1 18) are syphilis 
 and gonorrhoea. Until the year 1916 the British 
 public was aware neither of their extensive pre- 
 valence nor of their gravity. Explicit reference to 
 them in the Press or in books intended for general 
 reading was considered improper. The nation had, 
 in fact, entered into a conspiracy of silence which, 
 though unavowed and more or less unconscious, 
 was highly effectual in giving unchecked course 
 to diseases which were reacting most perniciously 
 upon its well-being and efficiency. From time to 
 time warning notes were sounded by the medical 
 profession and by sociologists, but little heed was 
 given to them. Towards the end of 1913, however, 
 as the result of emphatic medical representations 
 which had behind them the authority of the In- 
 ternational Congress of Medicine, held in London 
 in the summer of that year, the Government 
 appointed a Royal Commission to explore the 
 whole subject. The Report of the Commission, 
 issued early in 1916, set out the facts in language 
 which all could understand. The country was 
 
 135 
 
The Story of Public Health 
 
 startled to find that in large towns at least 10 per 
 cent, of the inhabitants were estimated to be 
 infected with syphilis, and a far larger proportion 
 with gonorrhoea. It learnt with dismay that while 
 syphilis was one of the most incapacitating and life- 
 destroying of diseases, and was the sole cause of 
 the incurable general paralysis of the insane from 
 which 15 per cent, of the male patients in the 
 asylums of great towns suffer, there was good reason 
 for holding gonorrhoea responsible for one-fourth 
 of all the blindness in the land ; that while syphilis 
 is transmissible to children and is a most frequent 
 cause of miscarriage and stillbirth, gonorrhoea is 
 accountable for 50 per cent, of all the sterility of 
 women, besides sometimes causing sterility in men ; 
 and that these diseases are also the cause of many 
 other serious and disabling affections, such as 
 deafness, degeneration of the arteries, inflamma- 
 tions of internal organs, and mental and nervous 
 disorders. It was made clear also that, so far 
 from syphilis and gonorrhoea being confined to 
 those who violate the law of sexual morality, they 
 claim between them a great multitude of innocent 
 victims — the children who are born syphilitic or 
 to whom gonorrhceal ophthalmia is communicated 
 in the act of or shortly after birth, Wives who are 
 infected by unfaithful husbands, husbands who are 
 infected by unfaithful wives, and midwives, nurses, 
 and surgeons who have to manipulate syphilitic 
 patients. 
 
 136 
 
Venereal Diseases 
 
 For such facts as these the Royal Commis- 
 sioners demanded the widest publicity. They 
 called upon parents, school teachers, voluntary 
 associations, and the Press to engage in a cam- 
 paign of enlightenment. And they propounded a 
 bold and far-reaching administrative scheme by 
 which sufferers from these diseases might be cured 
 and rendered non-infective. It was based upon the 
 principle of rendering the necessarily costly means 
 of diagnosis and treatment available, free of charge, 
 to all. It assumed that, venereal disease once 
 acquired, whether innocently or guiltily, it is both 
 the duty and the interest of the State to see that 
 it is promptly and effectually treated, so that the 
 patient may cease to be a source of infection, may 
 not be incapacitated from taking his due part in 
 the nation's work, and may not become a charge 
 upon the public funds. The Government was 
 therefore advised to urge the local authorities to 
 provide centres for gratuitous diagnosis and treat- 
 ment throughout the land and to charge 75 per 
 cent, of the cost to the Exchequer, the remaining 
 25 per cent, to fall upon the local rates. 
 
 More than a year before the Royal Commission 
 reported, the National Council for Combating 
 Venereal Diseases, embracing many leaders of the 
 medical profession, representatives of the Churches 
 and of educational, social, and philanthropic 
 organisations, had been formed, under the pre- 
 sidency of Sir Thomas Barlow; and when the 
 
 i37 
 
The Story of Public Health 
 
 Commission was dissolved; seven of its members 
 joined the Council, while Lord Sydenham, the 
 distinguished Chairman of the Commission, 
 accepted nomination as President. Thus rein- 
 forced, the Council took up the task of educating 
 the country and bringing to bear upon the Govern, 
 ment whatever salutary pressure might be needed. 
 A few weeks after the publication of the Report it 
 sent a deputation to the then President of the 
 Local Government Board, Mr. Walter Long, who 
 informed it that the Government had decided to 
 adopt the plan recommended by the Royal Com- 
 mission, and that the Board was preparing to 
 invite the local authorities to submit for approval 
 schemes for carrying it out. The invitations were 
 promptly issued, many of the local authorities made 
 quick response, and by this time there are few 
 areas in which some provision has not been made 
 for combating these diseases. 
 
 In most of the more populous areas, where there 
 are general hospitals, the schemes are in active 
 operation, though on far too small a scale; but 
 in areas with a scattered population a much larger 
 number of treatment centres must be provided. 
 The need for them has been rendered more acute 
 by demobilisation. In the past the rural parts of 
 the kingdom have been comparatively free from 
 venereal disease, but with the return to them of 
 tens of thousands of men after long service with 
 the colours, it is to be feared that this will be so 
 
 138 
 
Venereal Diseases 
 
 no longer. Most important is it, therefore, that in 
 rural areas no less than in the large towns ample 
 facilities should be provided for the treatment of 
 men who leave the Army uncured of venereal 
 disease. For the rural folk of this country to be 
 infected venereally on a considerable scale would 
 be one of the most lamentable by-effects of the 
 War. Armageddon has had some reactions which 
 were not definitely foreseen, but of this danger, at 
 any rate, the nation has had abundant warning, 
 and it Will be little to the credit of the local authori- 
 ties if the measures so persistently pressed upon 
 their attention are neglected. 
 
 The activities of the National Council are so 
 much in evidence that they need be only briefly 
 described. It has brought unceasing pressure to 
 bear upon such local authorities as were apathetic. 
 It has offered wise guidance upon the difficult and 
 delicate questions that have demanded considera- 
 tion, and has steadily discouraged developments 
 which, by ignoring the moral aspects of venereal 
 disease, would have estranged the sympathies of 
 many who are rendering most valuable service.* 
 
 * The thorniest of these questions is that between prophy- 
 laxis and eaxly preventive treatment. There are those who hold 
 that what are called " prophylactic outfits " should be supplied 
 to any who wish to have them, so that as soon, as exposure to 
 infection has taken place self-disinfection may be practised. 
 This policy is strongly opposed by others as tending to the 
 encouragement of immorality. In their view, public authorities 
 are not justified in doing more than providing the means of 
 
 139 
 
The Story of Public Health 
 
 It trains lecturers to diffuse accurate knowledge of 
 this subject among both civilians and soldiers. For 
 the latter it has made special efforts, and in order 
 that they may have full warning of the dangers 
 of venereal disease it has drawn up a Syllabus 
 which has been adopted by the War Office. Many 
 hundreds of lectures have been given to some two 
 millions of soldiers, and vigorous action has been 
 taken to lessen the dangers accompanying de- 
 mobilisation. Suitable courses of lectures have 
 been organised for teachers, so that they may be 
 qualified to give judicious warning to boys and 
 girls as they leave school. Conferences to this end 
 have been held with all the principal authorities 
 in the educational sphere, and it is hoped that the 
 time will soon come when no boy or girl will go 
 out into the world ignorant of the sexual perils 
 that have to be encountered. Nurses, again, are 
 instructed as to the precautions they must take to 
 avoid the accidental infection to which their work 
 exposes them. Besides its lecturing operations, the 
 Council is carrying out a strenuous propaganda 
 by the printed word. It issues authoritative books 
 
 disinfection at venereal clinics, and urging that those who 
 have succumbed to temptation should ait once repair to such a 
 clinic and receive early preventive treatment, i.e. he disinfected. 
 The National Council discountenances prophylaxis while stren- 
 uously advocating the provision of the fullest facilities for early 
 preventive treatment. A reversal of this policy, by affronting 
 the moral feeling of the country and antagonising the Churches, 
 would, in my opinion, be disastrous. 
 
 140 
 
Venereal Diseases 
 
 and pamphlets on a large scale, and, the more 
 effectually to reach the masses, it displays posters 
 in suitable places and inserts arresting advertise- 
 ments in the newspapers. Local branches of the 
 Council, each of them a centre of activity, have 
 been formed in many parts of Great Britain, and 
 Central Councils have been or are being formed 
 in the Dominions and in India. The National 
 Council is recognised by the Government, and 
 works in consultation with it, and the income 
 provided by subscriptions and donations is sup- 
 plemented by grants from the public purse. 
 
 In the crusade against venereal diseases legis- 
 lation has come to the help of administration. 
 When the schemes of the local authorities were 
 first started there was nothing to prevent un- 
 qualified persons from undertaking the treatment 
 of syphilis or gonorrhoea and advocating their 
 so-called remedies broadcast. Such unauthorised 
 treatment has been carried out on a very large 
 scale, not only by herbalists and other quacks, but 
 also by many chemists, who from their training 
 might have been expected to know better. The re- 
 sult is that in many instances syphilis is never de- 
 tected in its early stages, these persons being unable 
 to employ the highly technical diagnostic tests now 
 available. Even when it is detected the treatment, 
 as a rule, is ludicrously ineffectual, for the in- 
 jection of salvarsan is a procedure which no 
 unskilled person dare attempt. When at last the 
 
 141 
 
The Story of Public Health 
 
 development of serious symptoms forces the patient 
 to seek qualified advice, the disease has reached 
 a stage at which effectual treatment is very difficult 
 and in many cases impossible. Thus not only is 
 the chance of cure missed, but the patient remains 
 infective — a centre of danger to others. In "The 
 Nation's Health " I ventured to express the opinion 
 that if Parliament should make the unauthorised 
 treatment of venereal disease a penal offence, the 
 measure would probably commend itself to the 
 common sense of a community which, having to 
 find the money for the policy that had just been 
 inaugurated, had the right to demand that nothing 
 should be tolerated which militated against its 
 success. The prediction was fulfilled sooner than I 
 expected. In May, 191 7, the Venereal Disease Act 
 was passed, prohibiting under penalty the advertis- 
 ing of venereal remedies, and making it illegal, in 
 any area in which a treatment scheme has been 
 brought into operation by the local authorities, for 
 an unqualified person to treat or prescribe for 
 venereal diseases. Unauthorised treatment is still, 
 however, extensively practised in secrecy, in spite 
 of the prohibition, and unremitting vigilance will 
 be required if it is to be completely suppressed. 
 
 Although this movement has been successful 
 beyond the anticipations of the most sanguine, the 
 victory is far from having been won. Both legis- 
 latively and administratively there is much still 
 to be done. With measures directed against women 
 
 142 
 
Venereal Diseases 
 
 aldhe I have no sympathy, and the National 
 Council has offered determined opposition to all 
 such suggestions. But it ought not to be im- 
 possible to make penal the crime of wilfully 
 communicating venereal disease, whether com- 
 mitted by women or by men. In the future, also, 
 though not perhaps until the nation has been 
 further educated to understand the grave effects of 
 these diseases and the ease with which they can 
 be communicated by patients who have not been 
 cured, Parliament may decide to compel those who 
 have accepted treatment to continue it until they 
 have ceased to be infective, which at present many 
 fail to do. As for administration, the facilities for 
 treatment, and especially for "early preventive 
 treatment " — that is, treatment after exposure to 
 infection but before the appearance of symptoms — 
 must be greatly extended. Vastly more must be 
 done, too, to prevent congenital syphilis by pro- 
 vision for the treatment of infected expectant 
 mothers. Finally, the educational activities of the 
 National Council must be redoubled. This work of , 
 enlightenment will have to be prosecuted in per- 
 petuity. Even when legislation and administration 
 have done their utmost to suppress venereal 
 diseases, there will still be need of such a body 
 as the National Council to go on spreading the 
 light, to see that the law is not evaded, and to 
 ensure that there is no lowering of the adminis- 
 trative standard. 
 
 H3 
 
CHAPTER XI 
 The Ministry of Health 
 
 In the first eight chapters of this book the evolu- 
 tion of our Public Health system has been traced 
 from its humble beginnings ; but even as the words 
 were being written a measure was going through 
 Parliament by which a Ministry of Health has 
 been created to supersede the Local Government 
 Board and other Central Health authorities. That 
 measure, long advocated by the leaders of the 
 medical profession, was greeted with almost 
 universal acclaim. Seldom, indeed, has so vast 
 an administrative change aroused so little an- 
 tagonism. Opposition there has been, but it was 
 an opposition limited to official circles and 
 modestly shunning notoriety. So far as public 
 opinion is concerned, the need for a Ministry of 
 Health has been treated as a self-evident pro- 
 position. 
 
 Is it, then, to be said that our Public Health 
 Service, as it existed when the Ministry of Health 
 Bill was introduced, had been a huge failure? 
 Before that view could be substantiated, it would 
 be necessary to explain away certain rather for- 
 
 144 
 
The Ministry of Health 
 
 midable facts. Thus, the infant-mortality rate, 
 which in 1867 was 153 per thousand births, had 
 fallen in 1917 to 96 per thousand births. Again, 
 comparing the death-rate at different ages from all 
 causes in 1871-80 and in 1911-15, we find that there 
 has been at all ages up to 45 a reduction of from 
 42 to 50 per cent., and a substantial reduction also 
 at every later age-period. Moreover, if the English 
 Life-table of 1871-80 is compared with that of 1910- 
 12 there is seen to have been an increase in the 
 average expectation of life of ten years for males 
 and of nearly eleven years for females. During 
 the latter period the deaths each year were 234,955 
 fewer than they would have been had the death- 
 rates of the former period prevailed, and the 
 persons whose lives were thus saved each year 
 had the expectation, with the Life-table experience 
 of 1910-12, of living in the aggregate an additional 
 9,612,600 years. Further, of the more than a 
 quarter of a million lives saved each year, 64 per 
 cent, are attributable to a lessened mortality from 
 those infectious diseases against which Public 
 Health activities are so largely directed.* For the 
 reasons set out in Chapter IX., this lessened 
 mortality from infectious diseases must not be put 
 entirely to the credit of Public Health operations. 
 But that it is largely due to them, though it tran- 
 scends the wit of man to fix the precise proportion, 
 
 * For equally significant figures, see Section I. of the Forlty- 
 eeventh Annual Report of the Local Government Board, 1917-18. 
 
 K 145 
 
The Story of Public Health 
 
 is questioned by no one. And it is the more re- 
 markable because all the time that these results 
 have been accruing the nation has been developing 
 in the direction of urbanisation, which presents 
 conditions so favourable to the diffusion of infec- 
 tion. Is it not obvious that if, with this ever- 
 increasing aggregation of people in large towns, 
 there had not been a sanitary service of reasonable 
 and growing efficiency, the mortality tables would 
 have told a very different tale ? 
 
 If, instead of bringing our Public Health 
 Service to the test of such statistics as those cited, 
 we compare it with the sanitary services of other 
 civilised nations, must we speak with bated breath 
 and whispering humbleness? That suggestion 
 has indeed been made by one whose words com- 
 mand the widest publicity. In a speech delivered 
 in the autumn of 1918 Mr. Lloyd George doubted 
 whether there was any first-class country in the 
 world where " less had been done " in the way of 
 "intelligent organisation of the forces which have 
 special charge of the health of the nation — 
 national, municipal, and medical," than in this 
 country. Having had some opportunities of 
 observing the Public Health arrangements of most 
 European countries, as well as of the United States 
 and Canada, I make bold to say that that utter- 
 ance, guarded as it was in form, was hasty and 
 ill inspired. That it provoked so little challenge 
 is a flagrant example of our national foible of 
 
 146 
 
The Ministry of Health 
 
 belittling ourselves. It did, however, elicit a 
 protest, as dignified as it was cogent, from a dis- 
 tinguished epidemiologist who, with no official 
 predilections to bias his judgment, has had almost 
 unrivalled opportunities of systematically investi- 
 gating the Public Health systems of other lands, 
 and has for many years been a diligent student 
 of the world's Public Health laws and official 
 literature. With these incontestable claims to 
 authority, Dr. Arthur Shadwell asserted* that 
 there was no country in the world, first-class or 
 other, in which so much had been done for the 
 intelligent organisation of Public Health as in 
 this. If, he declared, the general level of achieve- 
 ment all round be compared, and like be com- 
 pared with like, the English standard, as distinct 
 from the standard of Ireland and parts of Scot- 
 land, is "immeasurably above that of other 
 countries, and very far above that of most of 
 them." "England," he added, "is the great 
 pioneer of health and sanitation ; all the cardinal 
 discoveries and measures originated here, and for 
 a long time England stood alone in their applica- 
 tion. Other countries have been coming up, with 
 all the advantages of maturer knowledge and a 
 virgin field, and have here and there surpassed 
 us; but to-day the Public Health system and 
 service in England are still the most complete 
 and efficient in the world." 
 
 * In a letter to The Times, September 18, 1918. 
 147 
 
The Story of Public Health 
 
 That declaration I unhesitatingly endorse. It 
 is especially true of factory regulation and of the 
 School Medical Service, as is pointed out in 
 earlier chapters, but it is also true of our sanita- 
 tion in general. We have seen that the Local 
 Government Board was so started upon its career 
 as to have missed precious opportunities and taken 
 some wrong turnings; but we have seen also how 
 much has been done by its medical staff, within 
 the limits unfortunately prescribed to it, to advance 
 sanitary science, both pure and applied. And of 
 our Public Health Service as a whole, both central 
 and local, the true view is not that it has failed 
 to do great things, but that if it had been properly 
 co-ordinated years ago, and if the sanitary expert 
 had been allowed a freer hand, it would have done 
 far greater things. That is the case for the creation 
 of a Ministry of Health. 
 
 The provisions of the Ministry of Health Act, 
 which was piloted through the House of Commons 
 by Dr. Addison as last President of the Local 
 Government Board, may now be briefly outlined. 
 To the new Ministry are assigned the powers and 
 duties of the Local Government Board, of the 
 Insurance Commissioners of England and of 
 Wales, and of the Lords of the Privy Council 
 under the Midwives Acts. It relieves the Board 
 of Education of responsibility (i) for the medical 
 inspection and treatment of school children and 
 young persons, and (2) for the care of the health 
 
 148 
 
The Ministry of Health. 
 
 of expectant and nursing mothers and of children 
 under five; but in view of the practical difficulties 
 of an immediate transfer of the first of those re- 
 sponsibilities, the Ministry is authorised to dele- 
 gate them for the present to the Board. The 
 Ministry is also charged with the supervision, 
 under Part I. of the Children Act, 1908, of infant 
 life protection, hitherto exercised by the Home 
 Secretary. But the Medical Research Committee 
 appointed by the Insurance Commissioners (p. 
 101) is transferred not to the Ministrv of Health 
 but to the Privy Council. In the Standing Com- 
 mittee to which the Bill was referred it was urged 
 that the Research Committee should come under 
 the Ministry's control; but on behalf of the 
 Government it was maintained that as the Ministry 
 was to have jurisdiction in England and Wales 
 only, the result would be that medical research 
 would be narrowed in scope, whereas under the 
 Privy Council it would be able to develop not 
 merely on national but on Imperial lines. It was 
 pointed out also that the Ministry of Health 
 would be responsible in the future for the research 
 work hitherto carried out by the Local Govern- 
 ment Board; and words were inserted in the 
 Bill expressly including the initiation and direc- 
 tion of research among its duties. The plan of the 
 Government was not further challenged. I con- 
 fess I regard it with some misgiving, as involving 
 duality where unity might have been attained; 
 
 149 
 
The Story of Public Health 
 
 but it will be for time to show how the system 
 works. 
 
 The most considerable branch of Public Health 
 work withheld from the Ministry is that relating 
 to labour in factories and workshops, mines and 
 shops, which for the time being remains with the 
 Home Office. Lord Haldane's Machinery of 
 Government Committee recommended that these 
 responsibilities should be allocated to the Minister 
 of Labour, and the same view is taken by the 
 Association of Certifying Factory Surgeons, which 
 lays stress upon the service the Labour Exchanges 
 could render in securing for young people employ- 
 ment suited to their physical condition. On this 
 and all similar questions the country will look 
 to the Ministry of Health for guidance. The Act 
 confers wide powers for the transference to it of 
 health responsibilities in the future. The powers 
 and duties of the Minister of Pensions with respect 
 to the health of disabled officers and men, and 
 those of the Home Secretary relating to lunacy 
 and mental deficiency, are specifically mentioned, 
 but, in the words of the statute, "any powers and 
 duties in England and Wales of any Government 
 Department which appear to His Majesty to relate 
 to matters affecting or incidental to the health 
 of the people " may be transferred, simply by 
 Order in Council, and it is to be assumed that 
 these powers will be exercised with no undue loss 
 of time. On the other hand, by the same process 
 
 15° 
 
The Ministry of Health 
 
 the Ministry can disembarrass itself of functions 
 not relating to health, and it is expressly stated 
 to be the intention of the Act that, when the law 
 governing the relief of the poor undergoes re- 
 vision, everything connected with poor relief which 
 is not concerned with health is to be handed over 
 to other Departments. 
 
 Another power exercisable by Order in Council 
 is that of establishing Consultative Councils for 
 giving advice and assistance to the Minister of 
 Health, and it is stipulated that every such Council 
 shall include women as well as men, and shall 
 be constituted of persons having practical experi- 
 ence of the matters referred to these bodies. Thus 
 the Ministry will be able to avail itself as freely 
 as it pleases of the special knowledge of members 
 of the medical profession and other hygienic and 
 sanitary experts. 
 
 In Wales the Act is to be administered, under 
 the direction of the Minister of Health, by a Board 
 of Health appointed by him. As introduced into 
 the House of Commons, the measure had no refer- 
 ence to Ireland, but under pressure from Irish 
 members a clause was introduced constituting the 
 Chief Secretary Minister of Health for that part 
 of the United Kingdom, and imposing upon him 
 duties similar to those devolving upon the Minister 
 of Health for England and Wales. 
 
 One of the tasks confronting the new Ministry 
 is that of working out a scheme for co-ordinating 
 
 151 
 
The Story of Public Health 
 
 local health administration. In a careful discus- 
 sion of this question Dr. Brend* recommends the 
 formation of a local health council for each 
 district, to absorb the health duties of all the 
 existing authorities, to control the Medical Officer 
 of Health, the sanitary inspectors, the tuberculosis 
 officers and health visitors, etc., to organise a 
 medical service for the treatment and care of the 
 sick, to take over municipal hospitals, sanatoria, 
 Poor Law infirmaries, school clinics and all similar 
 institutions, and, where it may seem desirable, 
 to make such arrangements with voluntary hos- 
 pitals as would be mutually acceptable. Generally, 
 this conception of the functions of the local health 
 authority of the future seems to me sound and 
 sufficient, and I am especially in agreement with 
 it in its suggestion for the utilisation of voluntary 
 hospitals without depriving them of their in- 
 dependence. My faith in voluntary effort debars 
 me from sympathising with schemes for nationalis- 
 ing or municipalising these institutions, which 
 on their present basis have long done and are still 
 doing a work so valuable that it should save them 
 from such revolutionary handling. On one point, 
 however, I find it difficult to agree with Dr. Brend. 
 To confide duties so considerable and so important 
 as those enumerated to an authority not directly 
 elected by the ratepayers would seem to be a pro- 
 ceeding of dubious wisdom. A body which would 
 
 * " Health apd .the State," Chapter XI. 
 152 
 
The Ministry of Health 
 
 have the spending of so large a part of the pro- 
 ceeds of local taxation ought surely to be directly 
 representative of those who have to find the money. 
 
 Other tasks which lie before the Ministry of 
 Health are the initiation of a systematic inspection 
 of the work of local health authorities; the codi- 
 fication of sanitary law, which, by the multiplica- 
 tion of statutes and departmental regulations, etc., 
 during a long course of years! has once more 
 come to stand in urgent need of simplification ; 
 the systematisation and study of Public Health 
 statistics, which at present are almost incredibly 
 chaotic and incomplete; the energetic prosecution 
 of research work; the adoption of far more 
 stringent measures to protect the public from 
 impure and adulterated food and milk ; the prompt 
 and more vigorous execution of the Housing and 
 Town Planning Acts ; the development of the mid- 
 wifery and nursing services; and the promotion 
 of work for the benefit of expectant and nursing 
 mothers, of infants and young children, and of 
 school children and "young persons," so that the 
 fullest use may be made of the beneficent powers 
 conferred by the Maternity and Child Welfare 
 Act of 1918 and the Education Act of the same 
 year. 
 
 The new Ministry begins its work under con- 
 ditions peculiarly favourable. Recent advances in 
 health legislation, now well ahead of health ad- 
 ministration, present it with magnificent oppor- 
 
 i53 
 
The Story of Public Health 
 
 tunities of service. That spirit of humanity which 
 from the beginning has been the mainspring of 
 Public Health effort was never so mighty as it 
 is to-day, nor were voluntary health workers ever 
 so numerous. The country is rapidly coming 
 to a sense of the supreme importance of health 
 as the pre-requisite of national prosperity and 
 well-being. As sanitary knowledge becomes more 
 widely diffused it will not suffice merely to make 
 ample provision of skilled treatment and nursing 
 for the sick. The ideal of the prevention of 
 disease, the ultimate aim of Public Health activi- 
 ties, will emerge into greater and greater salience. 
 The nation's fan is in its hand ; conditions inimical 
 to health will one after the other be swept away, 
 and it will not rest content until all "old shapes 
 of foul disease " have been exorcised and England 
 has become as healthy as she is free. 
 
 154 
 
INDEX 
 
 Aberdare, Lord, 46 
 
 Anthrax, 88; discovery of germ 
 
 of, 119 
 Antibodies, 124 
 Antitoxins, 125 - 
 Approved Societies, 104 
 Army hygiene, Sir John Pringle 
 and, 16; Dr. Edmund 
 Parkes and, 17 
 sanitation, Florence Night- 
 ingale and, 10 
 Arnott, Dr. Neil, 26 
 Ashley, Lord (see Shaftesbury, 
 
 7th Earl of) 
 Ashley's " Local and Central 
 
 Government," references to, 
 
 S3> 7° 
 Assistant School Medical Offi- 
 cers, 99 
 Association for Promoting 
 Training and Supply of 
 Mid wives, 79 
 of Certifying Factory Sur- 
 geons, 150 
 
 Bacteria, definition of, 120 (see 
 also Germs, pathogenic) 
 
 Ballard, Dr., investigations of, 
 61, 62 
 
 Bannington's " Public Health 
 Administration," references 
 to, 69, 116, 117 
 
 Barlow, Sir Thomas, 137 
 
 Barry, Dr. F. !W., and small- 
 pox, 63 
 
 Bentham, Jeremy, 4, 25, 26 (foot- 
 note) 
 
 Blane, Sir Gilbert, and naval 
 hygiene, 18 
 
 Blaxall, Dr., and cholera sur- 
 vey, 61 
 
 Blindness, gonorrhoea and, 136 
 Blomfield, Bishop, 27 
 Board of Agriculture, health 
 duties of, 74, 105 
 
 of Control, and inspection 
 
 of lunatic asylums, 105 
 
 of Customs, and sale of 
 
 patent medicines, etc., 
 
 IO S 
 
 of Education, and School 
 
 Medical Service, 93 ; and 
 Ministry of Health, 148 
 
 of Trade, health duties of, 
 
 105 
 
 Boards of Guardians, creation 
 of, 56 ; and medical relief, 69 ; 
 Poor Law Commission and, 
 71 ; and Rural District Coun- 
 cils, 108 ; mode of election of, 
 1 1 1 ; proposed abolition of, 
 in; appointment of regis- 
 trars of births, marriages, and 
 deaths by, 112; execution of 
 Vaccination Acts by, 112 
 
 Borough Councils, Metropoli- 
 tan, appointment of women 
 sanitary inspectors by, in; 
 creation and sanitary powers 
 of, 115 
 
 Brend's " Health and the 
 State," reference to, 152 
 
 Buchanan, Six George, early 
 sanitary career of, 43 ; ap- 
 pointed Medical Officer of 
 Local Government Board, 60 ; 
 retirement of, 64 
 
 Burdon-,Sanderson, Sir John, 
 investigations of, 49, 63, 64 
 
 Burials in towns, prohibition 
 of, 33 
 
 Burke, Edmund, 3 
 
 J 55 
 
Index 
 
 Central Control (Liquor Traf- 
 fic) Board, 106 
 
 health authorities, inco-or- 
 
 dination of, in 1S69, 50; 
 partial co-ordination of, 
 in 1871, 52; multiplicity 
 of, in 1919, 74, 106; and 
 Ministry of Health Act, 
 
 i44 
 
 Midwives Board, 78 
 
 Cerebrospinal meningitis, 44; 
 
 isolation, of germ of, 120; 
 
 serum treatment of, 126 
 Cesspools, prevalence of, in 1837, 
 
 25 
 
 Ohaidwick, Sir Edwin, founder 
 of English State Medicine, 9 ; 
 conceives the " sanitary idea," 
 25; appointed a Commissioner 
 of Inquiry into operation of 
 Poor Laws, 25 ; foreshadows 
 principle of employers' lia- 
 bility, 26; appointed Secre- 
 tary of Poor Law Commission, 
 26; writes "General Report 
 on Sanitary Condition of the 
 Labouring Population of Great 
 Britain," 27; shepherds the 
 Royal Sanitary Commission 
 of 1843-5, 2 9> * 3 appointed 
 a member of the General 
 Board of Health, 32 ; opposi- 
 tion to, 35 ; end of official 
 career of, 36; unofficial ser- 
 vice of, to sanitation, 36 ; 
 obligation of nation to, 37; 
 and General Register Office, 
 79 ; and factory inspection, 
 84; foreshadows a School 
 Medical Service, 93 
 Chemists, treatment of venereal 
 
 disease by, 141 
 Child labour, in factories, 
 abuses of, 5 ; regulation 
 of, 82, 83, 84, 87, 88, 89 ; 
 other forms of, 88, 89 
 welfare, 66, 149, 153 
 
 Children's Care Committees, 98 
 Cholera, epidemics of, 32, 37, 
 
 44, 60; isolation of germ 
 
 of, 120 
 
 survey, 60 
 
 City Commission of Sewers, 114 
 
 Corporation, Health De- 
 
 partment of, ri4 
 
 Sewers Act, 30 
 
 Clarkson, Thomas, 3 
 
 Cleanliness, place of, in sanitary 
 code, 133 
 
 Coal mines and quarries, regu- 
 lation of, 81 
 
 Collins, Sir William, on Edwin 
 Chadiwick, 25 ; on importance 
 of environment, 133 
 
 Colonial Office, and tropical 
 diseases, 105 
 
 Commissions of Sewers, 24 
 
 Compiler of Abstracts, appoint- 
 ment of, 79 
 
 Conolly, John, and asylum re- 
 form, 3 
 
 Consultative Councils, estab- 
 lishment of, 151 ; to include 
 women, 151 
 
 Contagious diseases, 122 
 
 Cook, Captain, as sanitarian, 18 
 
 County Analysts, 109 
 
 Borough Councils, duties 
 
 and powers of, 109 
 
 -- Councils, creation of, 108 ; 
 
 areas of, 108; powers 
 and duties of, 109 
 Medical Officers of Health, 
 
 109 
 Cowpox, protective 
 smallpox, 21 
 
 against 
 
 Dancing, as physical educa- 
 tion, 97 
 
 Dangerous trades, control of, 87 
 
 Davaine, and germ of anthrax, 
 119 
 
 Dawson, Sir Bertrand, on Local 
 Government Board, 73 
 
 156 
 
Index 
 
 Death-rate, .general, decline of, 
 145 
 
 Dental clinics for school chil- 
 dren, 99 
 
 Register, 76 
 
 Dilke, Sir Charles, institutes 
 cholera survey, 60 
 
 Diphtheria, 44 ; investigation of, 
 63 ; isolation of germ of, 120 ; 
 serum treatment of, 126 
 
 Disablement allowance, 103 
 
 Dispensary treatment of tuber- 
 culosis, 131 
 
 District Boards, Metropolitan, 
 
 , 38, "5 
 
 Medical Officers, 69, 72, in 
 
 Duncan, Dr. W. H., first Medi- 
 cal Officer of Health, 40 {foot- 
 note) 
 Dysentery, germs of, 121 ; 
 serum treatment of, 126 
 
 Early preventive treatment of 
 venereal disease, .139 (foot- 
 note) ; need for further facili- 
 ties for, 143 
 
 Elbertb and Gaffky, and germ 
 of typhoid fever, 120 
 
 Education Act (1918), 89, 96, 
 100, 153 
 
 (Administrative Provisions) 
 
 Act, 93 
 
 Committees, 116 
 
 ■ (Provision of Meals) Acts, 
 
 96 
 
 Elementary schools (see School 
 Medical Service) 
 
 Employment of Children Act 
 (1903). 88 
 
 Encephalitis lethargioa, 63 
 
 " English Sanitary Institu- 
 tions," Simon's, 14, 55, 60 
 
 Enteric fever (see Typhoid 
 fever) 
 
 Environment, as a factor of in- 
 fectious disease, 132; man's 
 control over, 133; importance 
 
 iS7 
 
 of, 133; improvement of, in 
 the future, 154 
 
 Epidemic diarrhoea, investiga- 
 tion of, 62 
 
 Epidemics, fear of, a stimulus 
 to Public Health movement, 5 ; 
 in the 'sixties, 44; problems 
 connected with, 127. (See also 
 Cholera) 
 
 Evening Play Centres, 98 
 
 Expectant and nursing mothers, 
 care of health of, in future, 149 
 
 Expectation of life, increase in, 
 MS 
 
 Factories, as distinct from 
 workshops, 82 
 
 Factory and workshop legisla- 
 tion, 81 ; origin of, 82 ; exten- 
 sion of, to textile factories, 83 ; 
 extension of, toother industries 
 and to workplaces generally, 
 85 ; extension of, to home work, 
 87. (See also Home Office) 
 
 Farr, Dr. William, 79, 134 
 
 Fleas, and transmission of dis- 
 ease, 121 
 
 Flies, and transmission of dis- 
 ease, 122 
 
 Food, need for further mea- 
 sures to secure purity of, 153 
 
 Fox, Charles James, 3 
 
 Fumigation, 16 
 
 General Board of Health, crea- 
 tion of, 30; functions of, 
 32; work of, 33; and 
 intramural interments, 
 33 ; and water supply of 
 London, 34; antagonism 
 to, 34; reconstitution of, 
 36; end of, 38; Simon 
 appointed Medical Offi- 
 cer of, 41 ; and port 
 quarantine, 48 
 
 Medical Council, 75 
 
 paralysis of the insane, 136 
 
Index 
 
 General Register Office, 79 
 
 Germs, pathogenic, discovery of, 
 119; modes of transmission of, 
 121 ; air-borne group of, 121, 
 122; identification of, 123; sig- 
 nificance of " isolation " of, 
 123 ; evolutionary modification 
 of, 127 
 
 Glanders, isolation of germ of, 
 120 
 
 Gonorrhoea, isolation of germ of, 
 120; prevalence of, in large 
 towns, 136 ; effects of, 136. 
 (See also Venereal diseases) 
 
 Government Departments, and 
 Public Health develop- 
 ments, 11 
 
 Lymph Establishment, 72 
 
 Governments, and Public Health 
 developments, 9 
 
 Graham, Major George, 79 
 
 Green, J. R., on the " new 
 humanity," 1 
 
 Guardians (see Boards) 
 
 H.emamceba of malaria, discov- 
 ery of, 120; intermediate host 
 of, 121 
 
 Hall, Sir Benjamin, and Gen- 
 eral Board of Health, 37 
 
 Hamer, Dr. W. H., and Lon- 
 don County Council, 115 
 
 Hansen, and germ of leprosy, 
 120 
 
 Health and Morals of Appren- 
 tices Act, 82 
 
 " and 'the State," Brend's, 
 
 reference to, 152 
 
 charter, ithe nation's first, 
 
 legislation, in advance of 
 
 health administration, 
 
 '53 
 
 of 'Munition Workers Com- 
 mittee, 89 
 
 ■ of Towns Association, 8 
 
 Holiday Camps, 98 
 
 Home Office, health duties of, 
 81; and factory legisla- 
 tion, 81 ; and inspection 
 of factories, 84, 91 ; and 
 supervision of dangerous 
 trades, 88; and Employ- 
 ment of Children Act, 
 89; and welfare condi- 
 tions, 90; and future ad- 
 ministration of indus- 
 trial laws, 150 
 
 work, control of, 87 
 
 Hospitals, voluntary, and local 
 education authorities, 99 ; 
 valuable work of, 152 
 Housing and Town Planning 
 Acts, need for vigorous execu- 
 tion of, 153 
 Howard, John, as prison re- 
 former, 2, 19; as housing re- 
 former, 20 
 Humanisation of industry, 90 
 "Humanity, new" {see "New 
 
 humanity ") 
 Hutchins and Harrison's "His- 
 tory of Factory Legislation," 
 references to, 84, 91 
 Hygiene, School (see School 
 
 Medical Service) 
 Hygienic investigations of Privy 
 Council, 44; of Local Gov- 
 ernment Board, 63 
 
 Immunity, doctrine of, 124 
 Improvement Commissions, 108 
 Industrial diseases, Thackrah. 
 and, 22 ; Simon on, 45 ; pre- 
 cautions against, 88 
 Infant life protection, and Min- 
 istry of Health, 149 
 
 mortality, 44 ; Simon on, 
 
 45 ; Sir A. News- 
 holme and, 65 
 
 1 — -rate, decline 01, 145 
 
 Infectious diseases, discovery of 
 causation of, 119; modes of 
 transmission of, 121 ; immunity 
 
 158 
 
Index 
 
 to, 124; problems of, 126; 
 factors in, 126; evolutionary 
 modification of germs of, 127; 
 evolution of man against, 129 ; 
 environment and, 133; pre- 
 vention of more important 
 than treatment, 134; lessened 
 mortality from, 145 
 
 Insane, movement for humane 
 treatment of, 3 
 
 Insects, and transmission of 
 germs, 121 
 
 Insurance Commissions, consti- 
 tution of, 100; and [Min- 
 istry of Health, 148 
 
 Committees, 104 
 
 Intramural interments, prohibi- 
 tion of, 33 
 
 Ireland, and Ministry of Health 
 Act, 151 
 
 Isolation Hospitals Act, 65 
 
 Jenner, Edward, and vaccina- 
 tion, 21 
 
 Joint Coimtaittee, National In- 
 surance Commissions, 100 
 
 health authorities, 116 
 
 Journal of Royal Sanitary in- 
 stitute, quoted, 25, 133 
 
 Kay-Shuttleworth, Sir J. P., 
 
 26 
 Klebs and Loffler, and germ of 
 
 diphtheria, 120 
 Klein, Dr., laboratory work of, 
 
 49. 63, 64 
 Koch, and isolation of germs of 
 
 tuberculosis and cholera, 120 
 " Koch's postulates," 123 
 
 Laveran, and germ of malaria, 
 120 
 
 Leprosy, isolation of germ of, 
 120; disappearance of, from 
 this and other countries, 128 
 
 Lice, and transmission of dis- 
 ease, 121, 128 
 
 1 
 
 Life-tables, English, of 1871-80 
 
 and 1910-12, compared, 145 
 Lind, James, and naval hygiene, 
 
 Lister, Lord, and antiseptic 
 
 surgery, 119 
 Liverpool, first city to appoint 
 a Medical Officer of Health, 
 40 {footnote) 
 Lloyd George, Mr., on Public 
 
 Health Service, 146 
 Local Boards of Health, 108 
 — — education authorities, 116 
 *— — Government Act (1888), 
 108; (1894), 108 
 
 Office, 54 
 
 Board, creation of, 
 
 52 ; derivation of, 
 from Poor Law 
 Board, 54 ; position 
 of Medical Officer 
 and other experts 
 under, 55 ; and ap- 
 pointment of Me- 
 dical Officers of 
 Health, 57 ; and 
 supervision of local 
 authorities, 57; re- 
 tirement of Simon 
 from, 59 ; cholera 
 survey of, 60; in- 
 vestigations of Medi- 
 cal Department of, 
 61; constitution and 
 functions of, 67 ; 
 Poor Law Medical 
 administration of, 
 69 ; general Poor 
 Law administration 
 of, 70 ; Public 
 Health administra- 
 tion of, 72; ser- 
 vices of medioal 
 department of,, to 
 sanitary science, 
 148 ; supersession 
 of, 148 
 
 59 
 
Index 
 
 local Government Board Act, 52 
 
 health authorities, in 1869, 
 
 50; and Public Health 
 Act of 1872, 53; inade- 
 quate supervision of, by 
 Local Government 
 
 Board, 57, 73; and sani- 
 tation of workshops and 
 factories, 90 ; appoint- 
 ment of women inspec- 
 tors of workshops by, 
 91 ; creation of, 107 ; de- 
 scription of, 108; com- 
 mittees of, 116; overlap- 
 ping between, 117; 
 scheme for unification of, 
 152; need for systematic 
 inspection of, 153 
 
 ■ Health Council scheme, 152 
 
 Loftier and Schiitz, and germ 
 
 of glanders, 120 
 London County Council, pow- 
 ers and duties of, 115 
 Public Health administra- 
 tion of, 114 
 Long, Mr. Walter, and control 
 
 of venereal diseases, 138 
 Longstaff, Dr. George B., and 
 
 diphtheria, 63 
 Lord Haldane's Machinery of 
 Government Committee, 150 
 Low, Dr. Bruce, epidemiologi- 
 cal studies of, 63; on port 
 quarantine, 114 
 Lowe, Robert (see Sherbrooke, 
 
 Lord) 
 Lucifer matches, manufacture 
 
 of, 88 
 Lunacy laws, future adminis- 
 tration of, 150 
 
 Machinery of Government Com- 
 mittee, on future administra- 
 tion of industrial laws, 150 
 
 Malaria, 66 ; germ of, 120 ; mos- 
 quitoes and, 121 ; evolution of 
 man against, 130 
 
 Manson, Sir Patrick, and germ 
 
 of yellow fever, 121 
 Maternal welfare and Ministry 
 
 of Health, 149 
 Maternity and Child Welfare 
 Act (1918), 66, 153 
 
 — benefit, 103 
 
 Mead, Dr. Richard, a Public 
 Health pioneer, 14 
 
 Measles, germ of, not discov- 
 ered, 122; evolution of man 
 against, 130 
 
 Medical Acts (1858, 1886), 75, 76 
 
 benefits, 103 
 
 ' Council, General, 75 
 
 temporary, appoint- 
 ment of, during 
 third cholera epi- 
 demic, 37 
 
 inspection and treatment 
 
 of school children, 94, 
 
 95. 99 
 Officer of Health, first, 40 
 
 • Officers of Health, appoint- 
 ment of, under Act of 
 1872, 57; under Act of 
 1909, 109 
 
 — — profession, constitution 
 and discipline of, 75 
 
 — Referees and Certifying 
 
 Surgeons under Work- 
 men's Compensation Act, 
 81 
 Register, establishment of, 
 
 75 
 
 registration, effect of, 77 
 
 research, under Privy 
 
 Council, 49; under 
 Local Government 
 Board, 63 ; under 
 Insurance Commis- 
 sioners, ioi ; need 
 for further, 153 
 
 Committee, 101 ; work 
 
 of, 102 ; transfer- 
 ence of, to Privy 
 Council, 149 
 
 160 
 
Index 
 
 Mental Deficiency Act, 1913, 81 
 
 future administration 
 
 of laws relating to, 
 150 
 
 Metchnikoff, on decline in sever- 
 ity of tuberculosis, 131 
 
 Methodist Societies, foundation 
 of, 2 
 
 Metropolis, Public Health ad- 
 ministration of, 114 
 
 Metropolitan Asylums Board, 
 
 "5 
 
 Board of Works, creation 
 
 of, 38 ; supersession of, 
 
 "5 
 
 Borough Councils (see 
 
 Borough Councils) 
 
 Commission of Sewers, 
 
 creation of, 30 
 
 district boards, creation 
 
 of, 38; abolition of, 115 
 
 Interments Act (1850), 31 
 
 vestries, creation of, 38 ; 
 
 abolition of, 115 
 
 Water Board, 34, 115 
 
 Midwifery service, importance 
 
 of, 78 ; State aid for, 79 ; need 
 
 for development of, 153 
 Milk, inadequacy of measures 
 
 to secure purity of, 153 
 Mines, regulation of, by Home 
 
 Office, 81 ; exclusion of women 
 
 and children from, 85 
 Ministry of Food, as a Central 
 Health Authority, 106 
 
 of Health, creation of, 
 
 144 ; and Local Govern- 
 ment Board, 148; and 
 Insurance Commissions, 
 148 ; and Board of Edu- 
 cation, 148; and Part I. 
 of Children Act (1908), 
 149 ; and medical re- 
 search, 149 ; and admin- 
 istration of industrial 
 laws, 150; transfers of 
 further health responsi- 
 
 bilities to, 150; powers 
 of, to surrender functions 
 not relating to health, 
 151 ; and relief of poor, 
 151 ; and Consultative 
 Councils, 151; and 
 Wales, 151 ; and local 
 he a 1 1 h administration, 
 152; other tasks for, 153; 
 opportunities of, 153 
 Ministry of Health Act, provi- 
 sions of, 148 ; adminis- 
 tration of, in Wales, 
 151 ; application of, to 
 Ireland, 151 
 
 of Labour, and future ad- 
 
 ministration of indus- 
 trial laws, 150 
 
 of Munitions, health duties 
 
 of, 89, 106 
 
 of Pensions, and disabled 
 
 soldiers, 105, 150 
 
 of Reconstruction, health 
 
 duties of, 106 
 Montagu, Lady Mary Wortley, 
 
 21 
 Morley, John (Lord), on factory 
 
 legislation, 86 
 Morpeth, Lord (Earl of Car 
 
 lisle), 31 
 Mothercraft, teaching of, 98 
 Municipal Borough Councils 
 
 (see Town Councils) 
 Murphy, Sir Shirley, and Lon- 
 don County Council, 115 
 
 National Association for Pre- 
 vention of Consumption, 9 
 
 Council for Combating 
 
 Venereal Diseases, 9 ; 
 constitution of, 137 j 
 work of, 139 ; local 
 branches of, 141 ; sub- 
 sidised by the Govern- 
 ment, 141 ; need for 
 redoubled activities of, 
 '43 
 
 161 
 
Index 
 
 National Insurance Acts, 100; 
 benefits under, 103 ; 
 local administra- 
 tion of, 104 ; and 
 institutional treat- 
 ment of tubercu- 
 losis, 104 ; and 
 benefits for dis- 
 charged soldiers 
 and sailors, 104 
 
 — Commissions, 100; 
 
 constitution of, 101 ; 
 and medical re- 
 search, 1 01 
 
 Vaccine Board, 24 
 
 Natural Selection, and in- 
 fectious disease, 131 
 
 Naval hygiene, foundations of, 
 
 '7 
 
 Neisser, and germ of .gonor- 
 rhoea, 120 
 
 "New humanity," first mani- 
 festation of, 2 ; and prison 
 reform, 2 ; and government of 
 India, 3 ; and humane treat- 
 ment of insane, 3 ; and aboli- 
 tion of slavery, 3 ; and miti- 
 gation of penal code, 3 ; and 
 political reform, 4 ; and Public 
 Health movement, 5 ; and 
 child labour, 5 ; present 
 potency of, 154 
 
 Newman, Sir George, and 
 School Medical Service, 1 1 ; 
 on voluntary workers for 
 school hygiene, n ; appointed 
 Principal Medical Officer of 
 Local Government Board, 66, 
 73 ; on uncleanliness in school 
 children, 97 ; on progress of 
 School Medical Service, 99; 
 on Medical Research Com- 
 mittee, 102 ; on confusion in 
 local health administration, 
 117; on environment, r32 
 
 Newsholme, Sir Arthur, on 
 dependence of Public Health 
 
 system on public opinion, 12 ; 
 as Medical Officer of Local 
 Government Board, 65 ; re- 
 tirement of, 66 
 
 Nightingale, Florence, and 
 Army sanitation, ro 
 
 Notification of tuberculosis, 
 66 ; of infectious diseases 
 generally, 72 (footnote) 
 
 Nuisances, prevalence of, in 
 1837, 24 ; provisions for 
 suppression of, 30, 32, 46 
 
 Removal, and Diseases 
 
 Prevention Act (1848), 
 
 3°. 3 2 > 45 
 Nursing service, need for de- 
 velopment of, 153 
 
 Oastlee, Richard, 83 
 
 Open-air treatment of tubercu- 
 losis, 131 
 
 Ophthalmia, gonorrhoeal, 136 
 
 Origins of Public Health 
 system, 1 
 
 Owen, Sir Richard, 29 
 
 — Robert, and child labour, 
 
 6, 82 
 
 Palmerston, Lord, and General 
 
 Board of Health, 36 
 Parish Councils, 108 
 Parkes, Dr. Edmund, 17 
 
 Museum, 17 (footnote) 
 
 Pasteur's discovery of clue to 
 
 causation of infectious disease, 
 
 119 
 Peel, Sir Robert, and factory 
 
 legislation, 82 
 Penal code, reform of, 3 
 Pharmaceutical Society, 76 
 Phosphorus, industrial use of, 88 
 Physical education in schools, 97 
 Plague, isolation of germ of, 
 
 r2o; inoculation against, r26 
 Playfair, Lyon (Lord Playfair), 
 
 and Buccleuch Commission, 
 
 29; and Medical Act (1886), 76 
 
 162 
 
Index 
 
 Pneumonia, epidemic, 66 ; isola- 
 tion of germ of, 120 
 
 Poor Law administration, medi- 
 cal, 69, 72; general, 
 70 
 
 •■ Amendment Act 
 
 (1834), 26, 56 
 
 Board, 52, 54; ab- 
 
 sorption of, by 
 Local Government 
 Board, 52 ; inefficient 
 medical administra- 
 tion of, 56 
 
 Commissioners, 26 ; 
 
 reports of, on sani- 
 tary condition of 
 Great Britain 
 (1842), 27 ; super- 
 session of, 56 
 
 r infirmaries, 70 
 
 Unions, creation of, 
 
 56 
 
 relief, and Ministry of 
 
 Health, 151 
 Port of London, 114 
 
 Sanitary Authorities, 
 
 creation of, 112; duties 
 of, 113 
 
 Power, Sir William, investiga- 
 tions of, 62 ; appointed Medi- 
 cal Officer of Local Govern- 
 ment Board, 65 
 
 Prevention of disease the final 
 cause of sanitary effort, 134 
 
 Prince Consort, 42 
 
 Pringle, Sir John, and military 
 hygiene, 16 
 
 Prison Medical Service, 81 
 
 Privy Council, succeeds General 
 Board of Health, 38, 42 ; 
 appointment of a Medical 
 Officer by, 42 ; Public Health 
 duties of, 42; and vaccina- 
 tion, 42 ; investigations of, 
 43; health duties of, trans- 
 ferred to Local Government 
 Board, 52 ; and medical and 
 
 pharmaceutical professions, 
 74 ; and contagious diseases in 
 animals, 74; and midwifery 
 service, 78; duties of, under 
 Midwives Adts, transferred to 
 Ministry of Health, 148 
 " Prophylactic outfits," 139 
 
 (footnote) 
 Protozoa, definition of, 120 
 Public Health Act (1848), 25, 30, 
 
 33. 35. 37 
 
 (1858), 42 
 
 ('872), 53> i°7 
 
 (i87S). 53. 59 
 
 (1896), 113 
 
 Service, efficiency of, 
 
 106 ; comparison of, 
 with services of 
 other countries, 
 146 ; Mr. Lloyd 
 George on, 146 ; 
 Dt. Arthur Shad- 
 well on, 147 
 
 statistics, need for 
 
 systematisation of, 
 '53 
 
 Quackery (see Unqualified prac- 
 tice) 
 
 Quarantine, early, 24, 47 ; con- 
 demnation of, by Simon, 48 ; 
 modification of, 113; present 
 method of, 113 
 
 Rabies, inoculation against, 126 
 
 Radcliffe, Mr. Netten, on Filth 
 Diseases and their Pre- 
 vention, 61 
 
 Rats, r61e of, in plague, 121 
 
 Reform, political, 4 
 
 Registrar General's Depart- 
 ment, creation of, 79; and 
 Local Government Board, 80 
 
 Reid, Sir Archdall, on air-borne 
 germs, 122 ; on evolution of 
 man against infectious dis- 
 ease, 130 
 
 163 
 
Index 
 
 Relapsing fever, germ of, 120, 
 121 
 
 Robinson, Mr. H. M., 92 
 
 Romilly, Sir Samuel, 3 
 
 Royal Commission on Poor 
 Laws (1905-9), Re- 
 ports of, 71 
 
 on Venereal Diseases, 
 
 Report of, 135, 137, 
 
 138 
 
 Sanitary Commission 
 
 (1843-5). 29 
 
 (1869-71), inqui- 
 ries of, 50 ; re- 
 commendations 
 of, 50 ; inade- 
 quacy of terms 
 of reference of, 
 51 ; legislative 
 sequelae of its 
 Report, 52 
 
 Institute, 17 (footnote) 
 
 Rumsey, Dr., 3r 
 
 Rural District Councils, creation 
 of, 108; duties of, no 
 
 sanitary districts, 107, 108 
 
 Russell, Lord John, on Edwin 
 
 Chadwick, 36 
 
 Sadler, Michael, 83 
 Sanatorium treatment, 103 
 Sanitarians, and Public Health 
 
 developments, 10 
 Sanitary Act (1866), 46 
 " idea," Chadwick's, 25 
 
 inspectors, 109, no; women 
 
 as, no 
 law, need for codification 
 
 of, 153 
 
 Scarlet fever, investigation of, 
 62 ; germ of, 122; lessened 
 severity of, probable cause of, 
 128 
 
 School attendance officers, 98 
 
 camps, 98 
 
 clinics, 94, 99 
 
 Medical Officers, 98, 99 
 
 School iMedical Service, n; es- 
 tablishment of, 93 ; a 
 national system, 94 ; 
 and medical inspec- 
 tion and treatment 
 in elementary 
 schools, 94 ; and 
 school clinics, 94, 
 99 ; and special 
 schools, 94, 99 ; and 
 open-air education, 
 95 ; and medical in- 
 spection in second- 
 ary schools, 95 ; and 
 feeding of hungry 
 children, 96, 99 ; 
 and uncleanliness, 
 97 ; and physical 
 education, 97 ; and 
 Evening Play 
 Centres, 98 ; and 
 schools for mothers, 
 98; and lessons in 
 mothercraft, 98 ; 
 personnel of, 98, 99 ; 
 utilisation of volun- 
 tary agencies by, 
 98 ; achievements 
 of, in first de- 
 cennium, 99 ; future 
 of, 100 
 
 nurses, 98, 99 
 
 Sclater-Booth, George, 58 
 Scurvy, preventives against, 18 
 Seaton, Dr., 60 
 Secondary schools (see School 
 
 Medical Service) 
 Serums, 125, 126 
 Shadwell, Dr. Arthur, on Public 
 
 Health Service, 147 
 Shaftesbury, 7th Earl of, and 
 factory legislation, 6, 9, 83 ; 
 a member of the General 
 Board of Health, 31 
 Sherbrooke, Lord, and Public 
 Health Act (1858), 42; and 
 medical research, 49 
 
 64 
 
Index 
 
 Sickness allowance, 103 
 
 Simon, Sir John, 14, 24, 35 ; ap- 
 pointed Medical Officer of 
 Health of City of London, 
 40; prescience of, 41 ; cholera 
 investigations of, 41 ; ap- 
 pointed Medical Officer of 
 General Board of Health, 41 ; 
 transferred to Privy Council, 
 42; Annual Reports of, 44; 
 on abatement of nuisances, 
 45 ; on industrial diseases, 
 45 ; on infant mortality, 45 ; 
 on venereal diseases, 47 ; on 
 port quarantine, 47; promotes 
 laboratory investigations, 49 ; 
 effect of Reports of, 49; on 
 terms of reference of Royal 
 Sanitary Commission, 52 ; 
 educative value of work of, 
 53; Medical Officer to the 
 Local Government Board, 53 ; 
 dissatisfaction of with the new 
 system, 55 ; retirement of, 59 ; 
 literary and professional 
 activities of, 59 ; publishes 
 "English Sanitary Institu- 
 tions," 60; death of, 60 
 
 Slavery, abolition of, 3 
 
 Sleeping sickness, 120 
 
 Smallpox, variolation and, 21 ; 
 infection of, 62 ; germ of, not 
 discovered, 122; lessened viru- 
 lence and prevalence of, causes 
 of, 128. {See also Vaccination) 
 
 Smith, Dr. Southwood, 26; on 
 insanitary conditions in Lon- 
 don, 27 ; appointed a member 
 of General Board of Health, 31 
 
 Spirochetes, 120 
 
 Stansfeld, Mr. James, first 
 President of Local Govern- 
 ment Board, 54, 55, 58 
 
 Sterility, venereal diseases and, 
 136 
 
 Stevens, Dr., and vaccination, 
 
 63 
 
 Stevenson, Dr. T. H. C, and 
 vital statistics, 80 
 
 Sweated industries, regulation 
 of wages in, 88 
 
 Sydenham, Lord, 138 
 
 Syphilis, germ of, 120; a con- 
 tagious disease, 122; decline 
 in average severity of, prob- 
 able cause of, 128; prevalence 
 of, in large towns, 136; dis- 
 abling effects of, 136. (See 
 also Venereal diseases) 
 
 Ten Hours Bill, 85 
 
 Tetanus, isolation of germ of, 
 120; serum treatment of, 126 
 
 Thackrah, C. Turner, and in- 
 dustrial diseases, 22 
 
 Thames Conservancy Com- 
 mission, 115 
 
 Thome-Thome, Sir Richard, 
 early sanitary career of, 43; 
 investigations of, 62 ; ap- 
 pointed Medical Officer of 
 Local Government Board, 65 
 
 Thudichum, Dr., laboratory in- 
 vestigations of, 49, 63, 64 
 
 Town Councils, 108 ; duties and 
 powers of, 109 
 
 Treasury, as a Central Health 
 Authority, 105 
 
 Trypanosomiasis, 120 
 
 Tuberculosis, dampness of soil 
 and, 43 ; notification of, 66 ; 
 isolation of germ of, 120 ; less- 
 ened severity of, causes of, 131 
 
 Tuke, William, and asylum re- 
 form, 3 
 
 Typhoid fever, Sir R. Thome- 
 Thome and, 65; germ of, 
 120; inoculation agajnst, 126 
 
 Typhus fever, Sir John Pringle 
 and, 17; outbreaks of, in 
 1862-3, 44; germ of, not dis- 
 covered, 122 ; diminished 
 prevalence of, probable causes 
 of, 128 
 
 '65 
 
Index 
 
 Uncleanliness in school 
 
 children, 97 
 Unqualified practice, need for 
 further legislation against, 77 ; 
 report of Privy Council on, 
 77 ; and venereal disease, 141 
 Urban District Councils, 
 creation of, 108; duties 
 of, no 
 
 sanitary districts, 107 
 
 Vaccination, origins of, 21 ; 
 surveys of, 63 ; Tecent history 
 of, 112; and lessened preva- 
 lence of smallpox, 129; unwis- 
 dom of abandonment of, 129 
 
 Vaccines, 125, 126 
 
 Vaccinia, protective against 
 smallpox, 21 
 
 Variolation, 21 
 
 Venereal Disease Act, 142 
 
 diseases, Simon and, 47 ; 
 
 and conspiracy of silence, 
 135; exploration of, by 
 Royal Commission, 135 ; 
 innocent victims of, 136 ; 
 administrative measures 
 for controlling, 137 ; 
 danger of spread of, in 
 rural areas, 138; "early 
 preventive treatment" of, 
 139 {footnote), 143 ; un- 
 qualified treatment of, 
 141 ; penalisation of wil- 
 ful communication of, 
 143; need for further 
 education as to, 143 
 
 Vestries, Metropolitan, 38, 115 
 
 Vital statistics, 79 
 
 Voluntary hospitals (see Hospi- 
 tals, voluntary) 
 
 workers for Public Health, 
 
 8; under Ministry of 
 
 Health, 12; and School 
 Medical Service, 98 ; 
 value of services of, 106 
 
 Wales, Board of Health for, 151 
 
 Water supply of London, 34 
 
 Webb, Sidney, on factory legis- 
 lation, 7 
 
 and Beatrice, on Poor 
 
 Law medical ser- 
 vice, 69 
 
 Welfare conditions in factories 
 and workshops, 90 
 
 Welsh Insurance Commission, 
 supersession of, 148 
 
 Wesley, John and Charles, and 
 the "new humanity," 2 
 
 Whitelegge, Sir Arthur, 91 
 
 Whooping-cough, germ of, not 
 discovered, 122 
 
 Wilberforce, William, 3 
 
 Women, exclusion of, irom 
 mines, 85; factory legislation 
 in interests of, 85, 87 ; as 
 inspectors of factories and 
 workshops, 90, 91 ; as sanitary 
 inspectors, no; as health 
 visitors, etc., in 5 and Con- 
 sultative Councils, 151 
 
 Wooldridge, Dr., 64 
 
 Workhouse children, and factory 
 labour, 6 
 
 Workshops, as distinct from 
 factories, 81. (See also Fac- 
 tory and workshop legislation) 
 
 Yaws, germ of, 120 
 
 Yellow fever, 44; probable 
 nature of germ of, 121; com- 
 munication of, by mosquito 
 bite, 121 
 
 " Young persons," and factory 
 legislation, 84, 85, 87, 88 
 
 Printed bt Cassell & Company, Limited, La Belle Sauvace, London, E.C.4 
 
 P20.619