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Public Health Then and Now

Could You Starve to Death in England
in 1839? The Chadwick-Farr
Controversy and the Loss of the
"Social" in Public Health
Christopher Hamlin, PhD

Introduction On the other side was the pioneering
statistician and epidemiologist William
For better or worse, no profession Farr, recently appointed (in part at
can help but feel the dead hand of its Chadwick's urging) statistician in the
history, of choices made for understand- office of the Registrar General of Births,
able reasons but in circumstances that no Deaths, and Marriages. Farr, whose task
longer exist. The following story is about a was to analyze the causes-of-death data,
conflict that occurred during what is often took an interest in the causes ofthe disease,
seen as the formative period of modern which, in keeping with ancient canons of
public health: Great Britain in the 1830s philosophical medicine, he took to in-
and 1840s. The conflict concerned causes- clude a broad set of social (and economic)
of-death data, which began to be collected determinants of health and illness, includ-
in 1837, and it focused on what kinds of ing diet and working conditions. At the
information to collect, what to do with time, Chadwick was a well-established
such information once it was collected, bureaucrat, a public figure enforcing the
what such information indicated about exceedingly controversial poor law policy,
the state of society, and ultimately, how while Farr was a little-known physician
"social" public health should be. The with an unusual knowledge of statistics,
story illustrates the impossibility of reduc- still searching for some career niche.'
ing complicated and varying sets of circum- Ironically, Chadwick, the social adminis-
stances to a single category and the ways trator, took what may seem the more
in which political, legal, and moral deci- narrowly medical view while Farr, the
doctor, emphasized social factors.
sions necessarily underlie the very data we
choose to gather.
The protagonists were two of the The Nature of the Controversy
most important public health pioneers. In a formal sense, the controversy
On one side was Edwin Chadwick, at the exists in a set of official letters exchanged
time chief administrator of the Poor Law between Chadwick and Farr from Septem-
Commission, the agency responsible for ber 1839 to March 1840. Ostensibly, the
bringing relief to the poor throughout letters are on technical issues Farr was
England and Wales. Within a few years, encountering in classifying causes of death,
Chadwick would become champion of the on the philosophical issue of what kind or
"sanitary idea" of public health through level of explanation is appropriate in such
public works, based on the principle that an inquiry, and on the factual issue of
it is a public duty to prevent infectious whether hunger and deprivation actually
disease by providing water that is pure "caused" or contributed significantly to
and sewers that will safely remove what is mortality in England and Wales. A great
dangerous. Chadwick's "public health"
would emphasize specific transmissible The author is with the Department of History
diseases; in the controversy, he would and the Reilly Center for Science, Technology,
insist that the most important fact was the and Values, University of Notre Dame, Notre
disease from which the victim had died. Dame, Ind.
Requests for reprints should be sent to
His perspective anticipated the germ Christopher Hamlin, PhD, Department of
theory that would come to dominate History, University of Notre Dame, Notre
public health by the end of the century. Dame, IN 46556.

June 1995, Vol. 85, No. 6
Public Health Then and Now

Edwin Chadwick, age 48. Reprinted with permission from
the Illustrated London News Picture Library, London.

William Farr in later years. Reprinted from Humphreys.47
deal more was at stake, however: the
principles of social welfare policy (the
term is anachronistic yet apt), the place of
medicine within it, and, ultimately, what to the Poor Law Commission, Chadwick high, even when corrections were made
constitutes the minimally acceptable con- was, if not the final arbiter of policy, for the age distribution of the inmate
ditions of human life in an industrializing centrally and visibly involved in execu- population and for the many who were
society. The controversy took place amid ting it. diseased when they came to the work-
a political crisis. Britain was in the middle The new poor law outraged the poor, house.3 And while medical men were not
of a depression; it seemed also on the agricultural laborers, and factory workers in the vanguard of the act's critics, many,
verge of revolution. There were calls for alike. It denied them the right of living especially those employed as medical
greater democracy, regulation of working together as a family unit, and it seemed a officers to the new poor law unions, found
conditions, and abolition of tariffs on means of feeding low-wage labor into the themselves frustrated in trying to cure
imported food. Many of these social mills of industrial Lancashire and York- diseases that were fundamentally the
questions could be, and often were, shire or even of warding off a Malthusian result of poverty. It did seem that public
framed as questions of health, disease, population crisis by perpetrating a modest policy was causing premature death.
and wrongful death, and many of the genocide among the working class. The Accordingly, starvation was a touchy
complaints came to roost at Chadwick's key word in the vast stream of attacks on subject for Chadwick in the fall of 1839.
doorstep. Chadwick and his associates was "starva- At the time, he was just launching the
In 1834 Parliament had enacted a tion." On page after page of The Book of inquiry that would culminate 3 years later
Poor Law Amendment Act (commonly the Bastiles, G. R. W. Baxter's 1841 cata- in his famous Report on the Sanitary
called the "new poor law"). Based on a logue of the law's abuses, one finds Condition of the Labouring Population.
report largely written by Chadwick and statements of mothers who would choose Farr's first analysis of causes of death in
framed along principles Chadwick had to starve rather than accept "the offer of England and Wales had just appeared.
articulated, this new law discouraged the house," mixed with accounts of work- On September 30, Chadwick wrote to
claims for public relief by offering the house inmates who succumbed to progres- Registrar General T. H. Lister, Farr's
claimant life in a workhouse (and a sive debility and neglect. Even the estab- supervisor, to query the 63 deaths Farr
workhouse diet). The workhouse was lishment press, like the London Times, attributed to starvation and Farr's com-
simultaneously to be a real "safety net" labeled it "the starvation act."2 Although ment on them-that "hunger destroys a
and yet an option significantly less attrac- Chadwick claimed that workhouse diets much higher proportion than is indicated
tive to the poor than the miserable (the outcome of experiments on prison by the registers in this and in every other
accommodations and scanty diet they diets) were sufficient for health, work- country, but its effects, like the effects of
could procure on their own. As secretary house mortality was in fact remarkably excess, are generally manifested indi-

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rectly, in the production of diseases of to "indigence." He argued that Farr had in the strictest scientific sense, 'starva-
various kinds."4 Even though these 63 no business speculating about widespread tion.'" Farr denied attacking the new
deaths represented a tiny fraction of the malnutrition; his job was simply to classify poor law,9 denied making starvation an
148 000 deaths reported, Chadwick took registered deaths. In effect, Chadwick was "all-pervading cause," and accused the
the report as a serious threat to the accusing Farr of being both too faithful to poor law commissioners of making more
political viability of the new poor law. the data (in allowing infant deaths to be of the matter than a short comment in a
Because the workhouse was to be both listed under the misleading heading of long report warranted. The latter point is
safety net and deterrent, there should be starvation) and not faithful enough (in especially important. While for Chadwick
no starvation. If people were starving, claiming that malnutrition accounted for any starvation was a public embarrass-
there was something about the policy that more mortality than was apparent). What- ment, for Farr starvation had to be
did not work. He demanded an explana- ever chemists might say, people did live on considered in part because there was no
tion for the deaths and for Farr's claim such diets, Chadwick asserted; what was other way of dealing with the untidy
that the diet of agricultural laborers more, they saved excess income (or residue of deaths that fit none of the more
(Farr's own background) was inad- wasted it in drink).7 Hence, there could straightforward pathological categories in
equate.5 not be a vast hunger problem. The excuse the nosological system he was developing.
In his reply at the end of November of hunger must be disallowed; it encour- Starvation, together with even more ob-
1839, Farr included registration data on aged begging and capricious charity, prob- scure terms like "debility," "intemper-
the 63 starvation deaths and on 16 others lems the new poor law had been estab- ance," and "sudden deaths," were sub-
involving various forms of privation. He lished to solve. headings of the larger category of
took starvation in a broader sense than Farr replied in March. He expanded "sporadic diseases" of "uncertain seat."
hunger; it was to "imply death by priva- the issue by bringing in the social circum- In a sense, he had to report starvations
tion, the want of warmth, and of proper stances of the deaths, and he narrowed it because the local registrars who compiled
food at all ages." He explained that while by raising the technical issue of just what causes-of-disease data (often without any
"few die from the absolute want of food, heading in a nosology best described such significant medical examination) reported
... many die, or drag on a miserable deaths. During the period covered by his them to him.'0 Yet at the same time he
existence upon insufficient, innutritious nosological table, there had been nearly was convinced, as were many contempo-
diet." Relying on contemporary chemists 72 000 infant deaths, he noted; many rary medical men, that hunger and other
who were beginning to translate human infants died because their mothers could "predisposing causes" bore some consid-
nutritional requirements into quantities not nurse them or because the mothers erable responsibility for many deaths
of carbonaceous and nitrogenous foods, themselves were too weak to provide good among the poor.
Farr showed that the workhouse diet milk. The 36 infant deaths, and probably There the public controversy ended
provided only about three quarters the many more, were then starvations in the although the issues continued to be highly
minimum requirement while that of East full sense of privation; infants "starved in sensitive for the next few years." Chad-
Anglian agricultural laborers provided the cold nights of winter, and on the wick, in introducing Farr's response, effec-
slightly more than half.6 coarse, innutritious, inadequate subsis- tively had the last word, accusing Farr of
Having reviewed the registration data, tence of impoverished parents." He ar- speculation.'2 With regard to the techni-
Chadwick responded at length in Febru- gued, contra Chadwick, that medical men cal matters, Chadwick had prevailed. The
ary 1840. He held that Farr was inconsis- saw cases of starvation regularly, and he theoretical perspective he represented
tent in his use of the word starvation and held that the correlation of excess deaths was in keeping with what was regarded as
that the term misled. Of the 63 deaths so with unusual cold could be best under- the most progressive clinical science then
classified, 36 were infant deaths, many stood in terms of a broad concept of being worked out in the great hospitals of
from lack of breast milk and some owing starvation. Even the best medical examina- Paris. Farr himself had Parisian training,
to the death of the mother. In such cases, tion might not distinguish the specific was attracted to many aspects of that new
Farr's representation of starvation as an effects of food deprivation from the medicine, and found himself equally un-
economic phenomenon-"want of food totality of depressing conditions, yet Farr able to develop a viable way to integrate
implies a want of everything else, except found it beyond question that "if the into causes-of-death statistics all those
water; as firing, clothing, every conve- quantity of provisions and the supply of factors that might be considered "social"
nience, every necessary of life, is aban- food to the great mass of the population causes of death.'3
doned at the imperious bidding of hun- could be augmented, the mortality would As well as being significant in the
ger"-was hardly candid. Other infant be reduced."8 Many deaths in which early shaping of modem public health, the
deaths, Chadwick held, reflected igno- starvation played a role would not be controversy is important because the
rance of infant feeding rather than depri- listed under that heading, and many that issues it involved are general issues of
vation. Among the adult cases, several were listed as starvations might involve classification and causation. These will
people had succumbed to cold-another additional factors as well. arise in some way whenever we try to
of Farr's senses of "starvation"-often There were also "technical" reasons classify events, deduce common causes,
when very drunk. There were a few why the distinctions Chadwick urged and make inferences for policy from our
homicides by starvation. Some starved could not be made. Causes-of-death tables classifications. Throughout his career,
adults had refused relief; in only one case could not possibly take into account all Farr would struggle with the problem of
had it been denied to them. Chadwick the "remote, incidental, or accessory making a classification system that was
invited Farr to investigate starvation re- circumstances in which the direct cause of unambiguously exclusive (it should be
ports more fully to improve the quality of death originated." Doing so would be too clear under which heading a death be-
his tables, and he asked for copies of the messy; "want of breast milk" might not be longed), that was exhaustive (there should
original returns for any deaths attributed "a disease, but it is a cause of death. It is, be an appropriate category for all deaths),

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and that facilitated empirical inference.14
Some of the problems-of splitting or
lumping, of recognizing degrees of natural
relation, and of deciding what parts of
natural diversity to ignore-are inherent
in any taxonomic endeavor.
The problems of classifying causes,
which need belong to no single species,
are especially complex: it will always be
the case that any cause to which a death is
attributed will identify only some compo-
nents of a complicated process that will
include various combinations of actions-
political as well as personal-and condi-
tions-social as well as biological, chemi-
cal, and even geophysical-many of which
may be entirely unrecognized. Since, as
Farr realized, one cannot include all
antecedent factors, a question of utility
enters in. Ideally, the cause listed will
imply some of these other components.
For example, Farr was trying to convince
Chadwick that infant deaths from starva-
tion imply particular economic condi-
tions.15 If one wants to maximize the
information available from the table, it
makes sense to choose the sort of cause
that most strongly implies the surround-
ing circumstances. But the sort of cause
one chooses is also dictated by the sort of
information about the state of society
such a determination is to supply. Ques-
tions of responsibility will focus attention
on some factors; questions of periodicity,
preventability, or remediability will focus
attention on others. Equally, the sort of
causes one identifies may have quite
different meanings for persons in differ-
ent positions. What for Farr was a fact
that perhaps conveyed some information
about means of prevention (e.g., more
uniform access to food and other "neces-
saries of life") was to Chadwick an
accusation of irresponsibility that was Farr's first nosological table for the second half of 1837. From William Farr,
possibly criminal. "[First] Letter to the Registrar General,"4 p. 82.

Philosophical Issues Inherent
in the Controversy knowledge of cause (often a single specific Medical men in the 1830s would not
At the heart of the controversy were cause) and thus is essential in identifying make these assumptions and inferences;
the political and social implications of a the condition or activity responsible for as Farr effectively admitted to Chadwick,
table that classified causes of death mainly the disease-perhaps a source of environ- classifying deaths by disease is no satisfac-
in terms of diseases (what Chadwick mental carcinogens or a contaminated tory basis for classifying deaths by cause.
wanted Farr to stick to). These implica- well. We reason from cause of death to Yet it was during these years that an
tions depended on what "disease" was cause of disease to prevention. Such older, physiological conception of disease
conceived to be, what it meant to have a inference requires both accurate diagnos- was giving way to an ontological one.
disease, and in what ways causes of tic ability and knowledge of the particular "Fever," hitherto a generic term for a
disease related to causes of death. Here causes of particular diseases. Underlying group of serial changes in the nervous
medical traditions of the late 1830s dif- both kinds of knowledge is the presump- system (or perhaps in the blood), evolved
fered from today's. Much of our use of tion that each disease is a distinct entity into the definite disease entities of typhus
causes-of-death reports (or specific mor- with a distinct cause-in short, that and typhoid. In this, Farr was a transi-
bidity rates) in public health is based on knowledge presumes an ontological con- tional figure, for highlighting hunger as a
the assumption that diagnosis provides ception of disease. general cause of ill health was exactly the

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kind of explanation that loomed large in the smallpox model and how closely, but readily removable cause was hunger, and
that older tradition. most thought the number was not large thus the Scottish practice of depending on
That tradition did not view most and included neither the many chronic the (often grudging) charity of each parish
diseases as specific entities. However, its diseases, like the various dropsies, nor was unacceptable.22 A Manchester practi-
practitioners were much more aware of many of those we now consider infectious, tioner, R. Baron Howard, wrote a treatise
the philosophical complexity of the prob- like consumption, scrofula, and the vari- instructing his colleagues how to recog-
lem of disease causation than their succes- ous fevers. Even though many would have nize the symptoms and postmortem ap-
sors were a few decades later or than most judged at least some varieties of fever to pearance of chronic hunger, for he in-
practitioners probably are today. Discus- be (sometimes) contagious, these still sisted that this, and not any specific
sions of etiology in contemporary text- could be understood to be a manifestation disease, was a major cause of death
books treated disease as a product of of common causes-cold, wet, hunger, there.23
varying combinations of different types of bad air, anxiety, etc.-which could also Clearly, constitutional medicine had
causes, an approach exemplified in chronic manifest themselves in other distinct social implications. What they were, how-
diseases. (Later, acute transmissible dis- clinical conditions.19 ever, was less clear, as was the question of
eases, presumably with single specific Any medicine based in advice on whether a statistical inquiry into causes of
causes, became paradigmatic.) A key how to modify the extemal factors that death could help to make them clear. If
feature of that approach was an invitation affect one's health assumed that the "'cause" were understood sufficiently
to take stock of how virtually all aspects of individual had control of those factors. In broadly, one could identify a large num-
the living situation-diet, work, emotional large part, these medical ideas were the ber of antecedent events that might well
state-affected a person's health. heritage of a medicine for the wealthy, have been crucial in whether the death
This "older tradition" was, in fact, a who did have such control over the occurred. Did that mean one should
broad framework that subsumed many conditions of their lives. Applied to living register such claims as we find Samuel
different pathological models with some conditions during the industrial revolu- Smith making-that factory labor is (in
common elements. It has been called tion, however, that elite medicine had some sense) a cause of death-in the sorts
"constitutional" medicine because of the revolutionary implications, which was of tables Farr was making up? It need
centrality of the concept of disease as hardly surprising since working-class lives hardly be said that the factory system (or
injury to the constitution, which manifests were being assessed according to upper- capitalism) is not among Farr's headings;
itself differently according to the individu- class standards of health. Rarely did those "starvation" and "intemperance" are the
al's "diathesis," or idiosyncratic suscepti- applying this medicine intend to be most "social" categories he used. Those
bilities. That injury can be expressed as revolutionary. In part, medical men be- who campaigned for reduction of working
"debility" or as a deficit of "vitality," came involved in social questions as hours or against the new poor law were
"nervous energy," the "conservative prin- providers of authority. Asked to assess the often suspicious of statistical studies of
ciple," or simply "health."16 Constitu- effects of new institutions such as facto- causes of death. They felt they knew what
tional medicine explained illness in terms ries, they found much that was harmful to caused preventable deaths and how to
of living conditions and personal histories health. Some encountered such problems prevent them. It was pretty obvious: less
rather than as the presence of some as practitioners. Samuel Smith, on the work, cheaper food.24 The whole project
particular disease. In such a medicine, staff of the Leeds Infirmary, noted that of classifying deaths by disease might
diagnosis had a different significance than "'never a year passes, but I see several seem only a distraction.
it does now. Mainly, the names of diseases instances where children are in the act of
one finds on nosological tables were just being wom to death by thus working in Social Implications of
that-names-to designate a set of symp- factories.' " He told of telling parents that Constitutional Medicine
toms, a sequence of changes in the body, unless they removed a child from factory
or sometimes hidden conditions pre- work, the child would die.20 By regarding To sketch how social such a theoreti-
sumed to give rise to those symptoms or poverty as a cause of disease, a medical cal framework could become, and to
that sequence. Diagnosis was more impor- rather than a moral problem, some of the suggest how different its approach to
tant for therapy and prognosis than for medical officers appointed under the new causes of death (and disease) was from
the answering of etiological questions.'7 It poor law to care for the poor circum- the approach that Farr was developing, I
did not follow that the set of changes vented the harshness of that law. For shall review the medical evidence heard
labeled a "disease" was the effect of a those to whom the threat (and experi- by Michael Sadler's 1832 Select Commit-
single discrete cause, for such medicine ence) of hunger incited a greater effort to tee on the Employment of Children in
recognized many kinds of causes of work, these officers prescribed a support- textile factories. Most of the medical
disease-"proximate" or "remote," the ive diet as a remedy for an illness brought witnesses were physicians or surgeons
latter being either "predisposing" or on by hunger and overwork.2' holding prestigious London hospital ap-
"exciting," there being room also for A few prominent physicians made pointments: Sir Astley Cooper, Sir William
"determining" or "consecutive" causes.18 social causes of disease the focal point of Blizard, Sir Anthony Carlisle, Sir Charles
Within this framework, most dis- their careers as public figures or as Bell, Sir George William Tuthill, Sir
eases were to be regarded as problematic researchers. W. P. Alison, professor of Gilbert Blane, J.H. Green, John Elliot-
physiological states rather than as ontologi- medicine at Edinburgh, led a campaign son, C. A. Key, P. M. Roget. Elliotson
cal entities that temporarily take over a for Scottish poor law reform, arguing that aside, none of these was in any sense a
body. The great exception, a disease that it was the physician's professional obliga- radical or even a reformer.25 They were
was a species with a unique cause, was tion to act to remove sources of disease. asked virtually the same questions and
smallpox. Medical men disagreed about The disease that concerned him was gave much the same answers. Typical is
how many other diseases corresponded to typhus. Alison believed that its most the view of Sir Charles Bell, retired

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professor of anatomy of the Royal College disease. Harmful activities did not simply but as direct physical effects of factory
of Surgeons. Bell was asked whether, put one at risk; to call them harmful labor.
from "general principles," "analogies" of meant that they were destroying "health," Such a medical philosophy has some-
practice, or study, he had "any hesitation and the deterioration they caused would times been seen as a verbose substitute for
in tracing many injurious consequences to eventually warrant a specific diagnosis. sound science. Certainly an "everything-
that system of labour, consequences which Further, the concept of disease held by causes-everything" presumption is hardly
have been described. . . at great length, as these medics was broader than ours; in a workable foundation for analysis. The
affecting the health and the limbs, and Carlisle's words, it included whatever was explanations of the medical elite to
shortening the life, of those exposed to "injurious to ... health" or a "deviation Sadler's committee often seem arbitrary,
it?" In reply, Bell stated that such work from health."30 vague, and speculative. Yet to the Sadler
would be very injurious to the constitu- Debility was a common concern witnesses, such complicated schemes of
tion, and engender a variety of diseases; inasmuch as quantities of vitality or causation were the mark of a truly
the great disease, emphatically using energy were central concepts in contempo- philosophical medicine. These individuals
that word, is scrofula: where there is a rary physiological theory. Fatigue and saw themselves as hardheaded followers
want of exercise, deficient ventilation, depression were but subjective indicators
depression of mind, and want of interest of Newton, Boyle, and Bacon in eschew-
in the occupations, I should say, espe- of a somatic state of debility, which was in ing occult qualities, refusing to mistake
cially in young persons, scrofula, in its turn nearly the same thing as disease.31 words (the names of diseases) for things,
hundred forms, would be the conse- Thus, according to Sir B. C. Brodie, and allowing as causes only those entities
quences.26 surgeon of St George's Hospital, "what- that common sense could invest with
Bell and most of his colleagues had ever tends to debilitate the general system causal efficacy.35 Mechanical processes
never practiced among factory children; will cause the disease to become devel- were prominent in their pathology: long
they spoke from theory (although hospital oped; scrofulous diseases of all kinds, I periods of standing (or of sedentary labor)
and dispensary appointments had given conclude will shew themselves among had necessary and readily comprehen-
them some knowledge of the health of the children so circumstanced; scrofulous dis- sible effects. According to Blizard,
London poor). As Bell notes here, it is the eases generally appear in those who from
constitution (not the body or a particular any causes are in a state of debility."32 long standing in one position has a very
organ) that is harmed by factory work. Carlisle explained how leaving the over- considerable influence on the circulat-
ing system; the veins become, as we
Owing to hereditary or environmental heated factory for the cold night air denominate it, varicose or distended,
factors, some constitutions are stronger generated consumption: and, of course the return of the blood to
than others, but all are fragile. What Sudden alternations of heat and cold, the right side of the heart is not regular,
harms one constitution harms, in greater the going out of a very hot room into a nor in the right quantity or quality; and
or lesser degree, anyone's constitution: damp cold air repeatedly will inevitably if it is either deficient in the one or the
overwork harms health although some produce slight inflammations of the other, it is robbed of a certain degree of
lungs; those slight inflammations reiter- its stimulus, which is necessary, that all
can work longer than others.27 Sir An- the other organs may be in a proper
ated produce the groundwork of pulmo-
thony Carlisle, anatomist of the Westmin- nary consumptions, for all pulmonary state.36
ster Hospital, noted that children cannot consumptions are repetitions of little The effects of heat, or dust, were equally
take long labor in close rooms, but that colds. The structure of the lungs, from
evident. The action of these causes was
the effects will vary this cause, becomes completely altered
by those slight inflammations which deemed so clear-cut that disease arose as
in proportion to their different constitu- disorganize the vascular tissue; when "a certain consequence" of them.37
tions: to some it will be fatal; as, for that has taken place, medicine is of very Judged by canons like these, it was
example, the children of scrofulous little use; but a sure mode of producing the sorts of causes hypothesized by those
parents; others might resist a consider- this malady is frequent alternations
able proportion of unwholesome influ- from hot rooms, with thin clothing, to like Chadwick (and later Farr), whose
ence with more impunity.... The evil cold damp air.33 arguments would culminate in the germ
consequences will be in proportion to theory, that seemed arbitrary. In 1840 the
the youth of the person, his delicacy, or Witnesses accepted the interdepen-
otherwise, the natural constitution, the dence of the mental and the physical; one "miasms" that Chadwick posited (or a few
length of time he is confined, and the was utterly at the mercy of the environ- years later, the "zymes" that Farr sug-
confinement of the air.28 ment. One (physiological) effect of factory gested) were only names for hypothetical
These elite medics agreed that the work would be "recourse to sensual entities supposed to cause particular
effects of the factory could appear as stimulants, in order to rid the mind of its diseases. As the entities themselves were
many different diseases. Even scrofula, distressing feelings," noted James Blun- utterly undetectable, there was little basis
the disease Bell highlights, was not the dell of Guy's Hospital; others were an even for conjecturing how they produced
specific tuberculosis of the glands that we "irritability of the nervous system, excit- pathological processes. From the perspec-
think of but a more general condition.29 ability of the feeling, and a certain busy tive of the medical philosophy outlined
Just as one cause appears as many play of the ideas when the mind is roused, above, even though it might be appropri-
diseases, many causes might contribute to together with that state of the mind ate to hypothesize such entities, they did
this scrofula, although that does not generally which constitutes fretfulness not count as explanations. To say that a
absolve any one of them of responsibility. and discontent; and I am further of virus (or miasm or germ) was the cause of
One could not then, as we now do, reason opinion, that this system has a tendency to fever was to say that one did not know
from diagnosis to cause. Each cause could weaken the solid strength of the mind."34 what caused it (and that the whole
contribute to many diseases; each disease Thus, attitudes and behaviors like heavy discussion of causes of death was thus a
had many causes. Further, most witnesses drinking (or precocious sexuality) were to pretense) since mere words could not be
saw no sharp line between health and be seen not as unfortunate moral choices causes.38

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The Rejection ofConstitutional By contrast, to privilege the names of best of a bad lot; it was to be ideal in all
Medicine: Chadwick and Farr diseases; to regard them as discrete, respects, full of positive feedbacks of
natural entities, each having its unique goods, with "collateral benefits" popping
It should be clear that in this constitu- cause; and yet to have no tools either to up unexpectedly. It was inconceivable that
tional medicine, causes-of-death statistics distinguish diseases reliably from one the laws of political economy might be
(if by these one means diagnoses of another or to discover their unique hid- found incompatible with the laws of
diseases of deceased persons) could not den causes was to indulge in obscu- health; it was tantamount to saying that
serve the purposes for which we now use rantism. To the medical elite who testified God was both for and against the free
them. Diagnosis had a much less impor- to Sadler, medicine had normative signifi- market.
tant place in the logic relating cause to cance for social policy; yet transform Yet Sadler and the surgeons and
effect. One could not infer causal agent "consumption" into the infectious disease physicians he questioned put medicine in
from postmortem diagnosis and then go of "tuberculosis" and downplay the "pre- direct opposition to political economy.
on to seek the means by which the agent, dispositions" that led to it, and the doctor J. R. Farre had been most insistent:
whatever it might be, had reached the is left with nothing to say about working
conditions.40 In retrospect we can see that * [T]he only safeguard to the state
victim. But there was really no need to: consists in opposing this principle of
the causes of disease were eventually-or the ontological assumption and the search
for specific causes paid off in the germ political economy by the medical voice,
in greater intensity-the causes of death. whenever it trenches on vital economy....
Both disease and death manifested the theory of disease, although arguably,
much of the imperative for health was lost [I]f it does [trench on vital economy], it is
totality of devitalizing causes affecting the guilty of homicide.
constitution of an individual with a particu- with the disappearance of constitutional
medicine. In 1840, however, to take that * "You purchase your advantage at
lar "diathesis" or susceptibility. To know the price of infanticide; the profit thus
the disease present at the death told one ontological route was either an audacious
expression of faith in a science that was gained is death to the child.... [Medical
something about the diathesis, but it did men could] never assent to life being
not tell one anything very specific about mostly yet to come, or an attempt to steer
medicine away from a political critique of balanced against wealth."43
causes since anything that sufficiently
weakened the constitution could trans- the industrial revolution. It was both-for This was no less than a rejection of
form the diathesis into the disease. Farr, mainly the former; for Chadwick, the natural law warrant for political
Accordingly, the disease was not in mainly the latter. economy. A system in which one had to
any strong sense the cause of death; the
Chadwick's reasons are plain. He work oneself to death to eat, or starve to
was seeking to represent public sanitary avoid being exhausted by work, could not
causes of the disease and not the disease
improvement-water and sewers-as a have been God's intention. Yet, arguing
itself were the real problem. When today
means of social betterment that was that the debilitation of factory work was
we use disease incidence to identify
consistent with the laws of political hereditary and progressive, Carlisle had
unsatisfactory conditions like bad water economy because it did not interfere with
or bad food-handling practices, it is the gone so far as to claim that within a few
the play of the market in food or in labor. generations, the factory population would
fact that these conditions lead to that He based his case on the claim that
disease-that they represent opportuni- be unable to reproduce.44 For Chadwick,
diseases ranging from fever to tuberculo- a table of causes of death expressed in
ties for infection-that is problematic. To sis, and social problems ranging from
medical men of the generation before intemperance to revolutionary agitation, politically innocuous terms would help to
Farr, an outbreak of disease (especially had one "all pervading cause": concen- subvert the possibility of professional
fever or consumption) was a measure of trated emanations of decomposing mat- medicine becoming political medicine, an
the degree to which conditions were ter, whose effects could be prevented by independent and countervailing authority
unsatisfactory in their own right: to flushing the matter down the drain. With to his own political economy.
Thomas Bateman of the London Fever most diseases plausibly linked to decaying Farr's views were more complicated.
Hospital, writing in 1818, or to the filth, he saw no great need to break down They bore the stamp of his social outlook,
Edinburgh professor W.P. Alison, fever deaths by disease."' the research problems that most inter-
was an indicator of the state of "misery" The filth explanation could not so ested him, his grappling with the practical
of a population.39 That misery, which they readily subsume starvation, however. problems of classifying deaths, and even
understood physiologically as an exhaus- Doubtless, filth exacerbated the pathologi- his anxiety, as a junior bureaucrat in a
tion produced by cold, hunger, anxiety, cal effects of hunger, but it seemed newly established post, to secure his
and work, represented nothing less than obviously not true that hunger in a clean future by claiming more utility for his
the gradual wasting of bodies. The arrival environment was unproblematic. Starva- work than it really possessed. For Farr,
(or spontaneous outbreak) of epidemic tion was too irrevocably a social and a the heading "starvation" and, indeed, the
fever made the extent of that wastage political issue.42 For Chadwick, to admit entire nosological classification system
evident, much as the fire that we make by existence of significant starvation was to were not social enough. In agreeing with
tossing a match on a pile of dry hay (or acknowledge that a central and cherished Chadwick that ideally one should repre-
that is produced when that hay spontane- theory was false. His poor law was derived sent the variety of the cases listed as
ously ignites) reveals the extent and from the axioms of political economy, starvation, he was not hoping to exonerate
condition of that fuel. The wastage was which were in turn based in universal laws the new poor law but to show that it had
the real problem, medically as well as of human nature. Correct application of failed to solve a great social and medical
socially, for it was widely held that the those laws and axioms guaranteed social problem. He wished to expose those
contagion of fever would have little effect harmony. The optimal workhouse was not hidden starvations, the deaths listed un-
on a healthy population. best in the zero-sum sense of being the der diseases.

862 American Journal of Public Health June 1995, Vol. 85, No. 6
Public Health Then and Now

Thus, Farr agreed with the Sadler Farr did insist, however, that his disease was the determined product of the
witnesses that social and economic condi- tables were to serve the purpose of "social impact on the constitution of the patho-
tions were significant causes of death. But amelioration."49 They would provide a logical forces to which it had been
given the limitations of contemporary map of unhealthy places (probably no subjected. For them, most diseases would
statistical methods, of number-crunching mystery) and, by enabling the "exciting have belonged to an intermediate cat-
hardware, and of uniformity in reporting, causes" of the predominant diseases in egory, the products of a slow violence
it was difficult to juggle the many factors those places to be identified, would guide being done to factory children through
that did figure in each death. Too many improvement.50 They would also aid medi- mechanisms quite as comprehensible as
categories and too much qualification cal practice as medical men would learn to the poisonings or fractures in Farr's more
impaired the drawing of general infer- modify their therapies according to place, restricted conception of violence. The
ences. "Each case could be entered under season, and class. (In fact, modifying spontaneous, hidden, probabilistic ele-
only one head," Farr explained to Chad- general therapies to particular circum- ments of disease were subsumed by
wick. It was "difficult to determine the stances was the traditional stock in trade concepts of constitution and diathesis,
influence of several concurring causes," of the learned physician; it is not clear concepts which, however arbitrarily they
he added; "the registers can only be how Farr's disease-specific death rates might be used, were not inherently inacces-
considered to indicate an approximation would have improved their ability to do sible to scientific analysis.
to the real number of deaths from that.) Physicians would also learn whether Why was Farr so obscure? I do not
starvation." Starvation was probably a the so-called health resorts to which they think he meant to undermine inquiry into
factor in many unclassified deaths (more were sending patients were really the social causes of disease; his sympathy
than 7000); an identifiable disease might healthy.51 is genuine. But he was by passion a
have been present in some registered as Farr tried also to explain "in what statistician, and a statistician needs dis-
starvation just as starvation was likely a sense the term 'cause of death' is here crete units-here diseases-whose laws
factor in some deaths listed under particu- understood." Yet the metaphor he chose he can discover. A taxonomist who sees
lar diseases; nor could one deny that other (a broken watch)52 hardly clarified things. nature as a seamless web or a geneticist
headings on the table-for example, "in- He contrasted deaths due to "external who doubts that genes determine charac-
temperance, insanity, and malforma- violence" like poison or fire, in which ters will not only be devoid of a reason to
tions"-had sometimes led to starva- what one might call the "pathological inquire but will also be unable to work.
tion.45 Recognizing how much can be process" and its initiating causes are Farr was also a man in search of a career,
learned from correlating the incidence of immediately evident, with deaths in which having already found that medical prac-
diseases with the circumstances of their the initiators are not evident and the tice and medical journalism did not suit.
occurrence, we are likely to endorse pathological processes "under certain cir- By finding ways to maximize the signifi-
Farr's search for general headings that cumstances spring up spontaneously in cance of the information he had at his
would allow statistical investigation. Yet the organization."53 The two classes are hands (in part by reframing questions to
in a medicine of multicausal explanation, "as distinct as day and night," yet they are make them answerable with those data),
one was sacrificing a great deal: arguably, also "passing into each other," which Farr succeeded, transforming a specialist
to require that the narrative history of a presumably means that there are deaths clerkship into a senior advisorship on
patient's constitution be condensed to a from conditions that are partly spontane- health policy.
single word was to give up the possibility ous and partly violent, although Farr did
of a medicine that would take an interest not talk about these or give examples of Conclusion
in, and see as problematic, the full variety them.
of pathological influences a person en- This distinction effectively leaves no The actions taken at this time had
counters.46 room for social causes of death. Deaths far-reaching implications for public health.
It is also the case that social factors belong either in a small category ofviolent A "political medicine," with status equal
were not central to Farr's own research events, most of which are not diseases at to that of political economy in shaping
interests at the time, which had more to all, or in a much larger group of what are public policy, failed to develop. The
do with the ancient Hippocratic questions effectively occult phenomena, things hap- public health field, along with medicine
of the correlation of disease with climate, pening "spontaneously" yet in "certain more generally, achieved significant au-
season, type of soil, and so forth.47 The circumstances." The latter class seems to tonomy, yet it did so by sacrificing the
data he chose to gather better suited these presume an ontological conception of claim to speak with authority on many
issues. Whereas to Farr, "place" meant disease: the diseases can be described, social issues. It has reclaimed some of that
the town in which the deceased had distinguished, and perhaps even corre- authority, but with difficulty; Chadwick's
resided, for W. P. Alison, chair of an 1835 lated with certain circumstances, but they border between medical and social re-
Scottish advisory committee on deaths cannot be genetically (causally) ex- mains hard to erase.
registration and most influential of the plained, or else they would belong to the From time to time since the days of
"humanitarian" physicians who stressed class of violent events.54 It is noteworthy Chadwick and Farr, questions have arisen
social causes of disease, "place" was that the examples Farr chose-cancer, about how "social" medicine should be
understood as "the exact residence, ie. not inflammation, and rheumatism-were (and equally about what issues and ac-
merely the town, village or parish, but the among the more mysterious of diseases; tions a social medicine involves or im-
street and number, or the division of a one could not readily have substituted plies). Throughout this century, many
parish."48 Farr's "place" was appropriate fever, consumption, or scrofula. The em- public health leaders have urged the
to inquiries into effects of climate or soil; phasis on spontaneity was utterly at odds importance of social determinants of
Alison's, to matters of class and standard with the testimony of the Sadler witnesses illness and health.55 Yet I fear that little of
of living. only a few years earlier, who had held that that concern has stuck to become part of

June 1995, Vol. 85, No. 6 American Journal of Public Health 863
Public Health Then and Now

the mainstream or core of public health. Georgia Press, 1982). On the views of the Hobbs to Times (London), September 1,
To a midwestem layman like myself, the newspapers, see Finer, Sir Edwin Chad- 1840, p. 3; "Examination in the Case of
efforts of a doctor from the Centers for wick, 99-101, 128-129. Elizabeth Friry," The Lancet, November
3. S.Q. Sprigge, The Life and Times of Thomas 28, 1840, pp.348-349.
Disease Control and Prevention to treat Wakley (London, England: Longmans, 12. Poor Law Commission, Official Circulars,
guns as a public health problem (or of Green, 1897),483-484. May 18,1840.
Physicians for Social Responsibility to 4. William Farr, "[First] Letter to the Regis- 13. A reviewer in the Edinburgh Medical and
make the same point about nuclear trar General," First Annual Report of the SurgicalJournal generally sympathized with
Registrar-General, Parliamentary Papers, Chadwick's perspective ("Review of First
weapons) seem in some vague way a 1839, vol. 16, no. 187, app. P, p. 75. and Second Annual Reports to the Regis-
trespass of medical territory.56 Their argu- Ostensibly, Chadwick wrote on behalf of trar General," Edinburgh Medical and
ments persuade me, but I have trouble the Poor Law Commission to Registrar Surgical Joumal 54 [1841]: 179-183. On
shrugging off that dead hand, according to General T. H. Lister, yet the controversy is Parisian clinical medicine, see W.F. By-
which issues of economic justice or vio- clearly between Chadwick and Farr. Under num, Science and the Practice of Medicine in
the heading "Relief of Destitution," the the Nineteenth Century [Cambridge, En-
lence (domestic, local, international) be- entire correspondence was printed by gland: Cambridge University Press, 1994],
long to one category with one set of Chadwick in the Poor Law Commission's chap. 2. On Farr's Parisian experience, see
institutions, and medical issues belong to Official Circulars for March 9, 1840, and Eyler, Victorian Social Medicine, 1-2).
another. Perhaps the "social" is too May 18, 1840. The correspondence is also 14. Eyler, Victorian Social Medicine, 54-64.
reprinted in D. V. Glass, Numbering the 15. It might be argued here that one should not
amorphorous, ill-defined, or diffuse, but I People: The Eighteenth Century Population expect causes-of-death statistics to reflect
think we are also trapped by the inertia of Controversy and the Development of Census social causes of death, that they were not
a history that informs both professional and Vital Statistics in Britain (Famborough, intended to have any relations to questions
culture and expectations among the pub- England: Saxon House, 1973), 150-167. of urban or occupational health, and that
lic at large. In that history, the drama of The entire set of circulars has been perhaps other sets of statistics-such as
reprinted: Poor Law Commission, Official general mortality rates, age tables, or
the conquest of epidemic disease has Circulars of Public Documents and Informa- infant mortality among certain groups-
loomed largest. In medical histories (and tion Directed by the Poor Law Commission- should have been the indicators of social
even in histories of public health), the ers to be Printed, chiefly for the Use ofBoards causes of death. Yet because they did not
matter of hunger and overwork as medical of Guardians and Their Officers, Ten Vol- purport to represent causes of death, those
umes in Two, 1840-1851 (New York, N.Y.: statistics did not unambiguously provide
problems is often ignored, treated as Augustus M. Kelley, 1970). See also Eyler, the relevant political facts, either.
marginal, or regarded as a recognition of Victorian Social Medicine, 25-26. 16. Sir G. Blane, Elements of Medical Logick,
the 20th century. I find a visit to the Sadler 5. Ironically, Farr had made this last claim as 2nd ed. (London, England: Underwood,
witnesses exhilarating because they repre- part of an argument comparing health in 1821), 37-41; James Copland, "Disease:
the country to health in the towns, an the Causation and Doctrine of," in A
sent a time when medical professionals argument in which he deferred absolutely Dictionary ofPractical Medicine, Comprising
did not have to apologize for thinking that and uncritically to Chadwick's controver- General Pathology, vol. 1 (London, En-
social policy affected public health. The sial doctrines about the relative impor- gland: Longman, Brown, 1858), 557-558.
split that Chadwick and Farr effected had tance of poverty and filth as causes of fever. The following discussion draws much from
not yet taken place. O See Farr, "Letter to the Registrar Gen- several works by Lester King, particularly
eral," 78. his Medical Thinking: A Historical Preface
6. Farr to Chadwick, November 29, 1839, in (Princeton, N.J.: Princeton University Press,
Poor Law Commission, Official Circulars, 1982). I have given this subject more
Acknowledgment March 9, 1840. detailed consideration in "Predisposing
Causes and Public Health in Early Nine-
An earlier version of this paper was presented 7. Chadwick to the Registrar General, Febru-
at the Conference on the History of the ary 24, 1840, in Poor Law Commission, teenth Century Medical Thought," Social
Registration of Causes of Death, November Official Circulars, March 9, 1840. This History of Medicine 5 (1992): 43-70. On the
1993, Bloomington, Ind. economic argument is Chadwick's princi- specific application of this perspective to
pal evidence for the adequacy of diet. mortality, see John Reid, The Philosophy of
8. Farr to Lister, March 17,1840, in Poor Law Death, or a General Medical and Statistical
References Commission, Official Circulars, May 18, Treatise on the Nature and Causes of Human
1. Major biographies of Edwin Chadwick are 1840. Mortality (London, England: S. Highly,
S.E. Finer, The Life and Times of Sir Edwin 9. Chadwick's accusation (see his letter to the 1841).
Chadwick (London, England: Methuen, Registrar General of February 24) that 17. Yet even a single diagnosis did not warrant
1952); R.A. Lewis, Edwin Chadwick and Farr was "against the administration of the a particular therapy. John Armstrong made
the Public Health Movement, 1832-1854 New Poor Law" is interesting as an clear that the same species of fever
(London, England: Longmans, Green, indication of his hypersensitivity. Farr's warranted depletative therapies in some,
1952); and Anthony Brundage, England's testimony to the select committee on the supportive therapies in others, according to
"Prussian Minister". Edwin Chadwick and poor law act concerned the conditions of the patient's constitution (John Arm-
the Politics of Govemment Growth, 1832- employment of medical officers, and while strong, Practical Illustrations of Typhus
1854 (University Park, Pa.: Pennsylvania it suggested revisions, it can hardly be Fever, of the Common Continued Fever and
State University Press, 1988). The major construed to have been "against the admin- of Inflammatory Diseases, 3rd ed. (London,
modern biography of William Farr is John istration" of the act (46th Report of the England: Baldwin, Craddock, and Joy,
M. Eyler, Victorian Social Medicine: The Select Committee on the Operation of the 1819), 294-295.
Ideas and Methods of William Farr (Balti- Poor Law Amendment Act, Parliamentary 18. This was pretty much true no matter which
more, Md.: Johns Hopkins University Papers, 1838, vol. 18, pt III, no. 518, qq of the several theoretical systems of medi-
Press, 1979). 15703-15841). cine of the day one followed. The exception
2. G.R.W. Baxter, The Book of the Bastiles; or 10. For Farr's nosological table, see Farr, is when one was talking of the "proximate
the History of the Working of the New "Letter to the Registrar General," 82. On cause," which is nothing other than the
Poor-Law (London, England: John Ste- the problems of certifying causes of death, disease: "We call the thing first conceived
phens, 1841). See also John Knott, Popular see Eyler, Victorian Social Medicine, 44-45. the cause, and that which comes next the
Opposition to the 1834 New PoorLaw (New 11. See "Alleged Death from Starvation: Singu- effect; not because there is any real
York, N.Y.: St. Martin's Press, 1986), and lar Inquiry," Times (London), August 26, difference between the cause and the
M.A. Crowther, The Workhouse System, 1840, p.7; William Farr to Times (London), effect, since the cause is inseparable from
1834-1929, the History of an English Social August 31, 1840, p. Se; C. Fowell to Times the effect.... The cause of disease is the
Institution (Athens, Ga.: University of (London), August 25, 1840, p. 3; R. H. same thing with the disease itself' (Dr.

864 American Journal of Public Health June 1995, Vol. 85, No. 6
Public Health Then and Now

Boerhaave's Academical Lectures on the focused on long hours and child labor in See, for example, C.T. Thackrah of Leeds,
Theory of Physic Being a Genuine Transla- factories; those representing industrial in- the main contemporary authority on occu-
tion of His Institutes and Explanatory Com- terests saw the key health problem as pational disease: the "factory system re-
ments Collated and Adjusted to Each Other, protective tariffs on food, which kept prices duces the nervous power, in other words,
as They Were Dictated to His Students at the high and starved the poor. On the interplay the vigour of the constitution, that it
University of Leyden, vol. 5, Pathology of at least the first two of these issues, see renders persons more feeble, more subject
[London, England: W. Innys, 1746], 372- Eric J. Evans, The Forging of the Modem to suffer from attacks of disease.... [Those]
373. See also Copland, Dictionary of Practi- State: Early Industrial Britain, 1783-1870 constantly so employed are shorter-lived
cal Medicine, 558). (London, England: Longman, 1983). Over- than others"; they are "liable to attacks of
19. Contagion implied transmissibility and clini- crowded housing and filth were politically disease to which they would not have been
cal similarity. It did not imply a specific more innocuous; in part they could be subject, or under which they would not
transmissible entity, in the sense in which readily acknowledged as problems (espe- have succumbed" (Wing, Evils of the
the "virus" of small pox was considered. cially the former) precisely because it was Factory System, 232-233). See also J.H.
Bateman held that the contagion of fever not clear that they were the fault or Green: "the child of the most healthy
need be nothing more than "morbid responsibility of any one group in particu- constitution may, by continued exposure to
exhalations and secretions" capable of lar. these causes, acquire a disposition to the
"constituting a medium of infection ca- 25. On the political views of this group, see disease, and become actually the victim of
pable of generating fever." Thomas Bate- Adrian Desmond, The Politics ofEvolution: it; whilst those who might have been
man, A Succinct Account of the Contagious Morphology, Medicine and Reforn in Radi- subject to it from an original fault of the
Fever of This Country Exemplified in the cal London (Chicago, Ill.: University of constitution may by the careful preserva-
Epidemic Now Prevailng in London (Lon- Chicago Press, 1989), and Sprigge, Thomas tion from these causes [i.e., the debilitation
don, England: Longman, Hurst, 1818), Wakley. of factory labor] remain exempted from the
13-14, 142-144. On contemporary fever 26. Wing, Evils of the Factory System, 112. In disease" (Ibid., 154).
pathology, see J.M. Good, The Study of general, on the role of medicine in the 31. "Debility," in Copland, Dictionary ofPracti-
Medicine, 2nd ed., vol.2 (London, England: factory controversy, see Robert Gray, cal Medicine, 473-474. Copland held that
Baldwin, Craddock, and Joy, 1825), 42-76. "Medical Men, Industrial Labour and the debility was so "intimately connected with
20. Charles Wing, Evils of the Factory System State in Britain, 1830-1850," Social History diseases as to be virtually disease itself." Its
Demonstrated by Parliamentary Evidence 16 (1991): 19-43. synonyms were "asthenia, atonia, ady-
(London, England: Saunders and Otley, 27. It is significant that a focus on the differing namia, all slightly different, but overlap-
1837), 214-215. According to working-class responses of individuals to a particular set ping greatly." Its causes in children were
witnesses, factory labor was being directly of conditions was not, as it sometimes has hereditary, "through the exhaustion of
cited as a cause of disease by practicing been, a means to divert attention from their parents," as well as induced due,
medical men. For instance, J. Hebergam of social causes of illness by relocating prob- among other factors, to bad or insufficient
Huddersfield, when asked to what cause lems in individuals, for whose idiosyncra- food, "abstraction of the animal warmth,"
the death of his brother was "attributed by cies society could not be held responsible absence of light, air, and exercise.
[his] mother and the medical attendants," (the "blame-the-worker" response). 32. Wing, Evils of the Factory System, 128.
answered "that he died from working such 28. Wing, Evils of the Factory System, cxii. 33. Ibid., 137.
long hours, and that it had been brought on 29. Cf. J.H. Green, professor of anatomy at 34. Ibid., 123, 126. For Blundell this is a
by the factory" (Wing, Evils of the Factory King's College, as quoted in Wing, Evils of deduction of a nervous system-based pa-
System, 59). James Paterson of Dundee the Factory System, 154: "[It is] scarcely thology. Through the metaphor of organiza-
similarly reported that his brother had died possible to present in any brief summary tion, the same phenomena could be ex-
from consumption attributed by a doctor to the many dire effects of scrofulous disease, plained within a solidist framework:
"being confined at that work" (Ibid, 72). It but we may mention, first, that the mesen- according to Sir William Blizard, surgeon
is important also to note that the major teric glands are often the seat of disease, to the London Hospital, "whatever affects
vindication of the factory owners, the favoured by the irritation of unwholesome one particular important organ tends to
Report of the Factory Commission of 1833, and ill-digested food, shewing itself in disorganize the whole frame; there is a
which held that factory workers had better weakness, emaciation, protuberant abdo- dependence of one organ upon another"
health than town residents generally, was men, and slow fever. Next, the absorbent (Ibid., 118).
the work principally of Chadwick. glands about the neck, the inflammatory 35. Cf., Blane's condemnation of the elabora-
21. Ruth G. Hodgkinson, The Orgins of the swelling, excited, perhaps, by variations of tion of "terms," "visionary and gratuitous"
National Health Service: The Medical Ser- temperature; for the particular seat of the (Elements ofMedical Logick 141).
vices of the New Poor Law, 1834-1871 disease, or its development in any particu- 36. Wing, Evils of the Factory System, 116.
(London, England: Wellcome Historical lar organ, may be determined by accidental 37. By 1830, the need to maintain combustion
Medical Library, 1967), chap. 1. circumstances. Then we find that the in the "the engine of the body," or to keep
22. W.P. Alison, "Preface," in Observations on disease attacks the skin in the form of scaly up its temperature or avoid loss of its
the Management of the Poor in Scotland, and eruptions, cracks, stops, ulcerations, and nervous "energy" were equally acceptable,
Its Effects on the Health of Great Towns, 2nd slowly suppurating tubercles. Again, that and especially in the wake of the chemical
ed. (Edinburgh, Scotland: Blackwood, the eyes become affected in the various revolution, the vitiating effects of re-
1840). forms of scrofulous opthalmy, and often breathed air was no less clear (Green,
23. R. Baron Howard, An Inquiry into the end in blindness, or the bones, and quoted in Wing, Evils of the Factory System,
Morbid Effects of Deficiency of Food Chiefly especially the joints, become diseased, 153).
with Reference to Their Occurrence amongst terminating in caries of the spine and white 38. Cf., Alfred Hudson, "An Inquiry into the
the Destitute Poor (London, England: Simp- swellings. Then, that the internal viscera Sources and Mode of Action of the Poison
kin, Marshall, and Co., 1839),1-3. are affected with tubercles, as the liver, of Fever," in Alfred Hudson and William
24. On the ideology of the early statistical brain, spleen etc. And, lastly, that the lungs Davidson, Essays on the Sources and Mode
movement, see M. J. Cullen, The Statistical become the seat of this destructive disease ofAction of Fever (Philadelphia: A. Waldie,
Movement in Early Victorian Britain: The in the form of that incurable complaint of 1841), 142. Hudson quotes Magendie's
Foundations of Empirical Social Research our climate, pulmonary consumption." criticism of Devergie: that "'we attribute
(New York, N.Y.: Barnes and Noble/ 30. Wing, Evils of the Factory System, 132. This this odor to miasma, that is to say to a cause
Harvester, 1975). Because constitutional perspective did not preclude the concep- void of meaning, because we are ignorant
medicine generated so rich an assemblage tion of at least some diseases, such as of the nature of the object which it
of causes, "obvious" solutions were virtu- contagious fevers, as entities that attacked represents.' "
ally limitless. While many medical men people, but in highlighting a predisposition 39. "The character of an epidemic, therefore,
highlighted poor food and overwork along or induced debility due to factory work, it is in some measure a test or index of the
with crowded housing and filth, political tended to relegate that contagion to second- situation and circumstances of the popula-
writers tended to select solutions. Those ary status in explaining the incidence of tion among which it occurs" (Bateman, A
representing agricultural interests often disease and the death it might produce. Succinct Account, vi); "The existence of

June 1995, Vol. 85, No. 6 American Journal of Public Health 865
Public Health Then and Now

epidemic fever in any great community, 47. Farr did take data on occupation and 51. Farr, "Letter to the Registrar General,"
particularly if there be neither war nor produced studies of occupational mortality 63-64.
famine to explain it, becomes a most in some later reports. See Noel A. Hum- 52. Contemporaries would have recognized
important test to the legislator of the phreys, ed., Vital Statistics: A Memorial this as an inversion of William Paley's use
destitute condition of the poor, and, as I Volume of Selections from the Reports and of the same metaphor in his well-known
shall endeavour to shew, of the deficiency Wnitings of William Farr (1885; reprint, with work on Natural Theology (1802). Paley
of the funds which, in a better regulated a new introduction by Mervyn Susser and maintained that, just as one would assume
state, are applied to their support" (Alison, Abraham Adelstein, Metuchen, N.J.: New that a watch found in the grass was the
Observations on the Management, 18). Farr's York Academy of Medicine/Scarecrow product of an intelligent designer, so too
notion of disease as the "iron index of Press, 1975). could one assume that the marvelous
misery" seems to belong to this tradition 48. The Edinburgh Sub-Committee, "Report adaptations of plants and animals were the
but seems out of place in the context of an on the Registration of Deaths," Fifth work of a benevolent Creator.
ontological conception of disease ("Letter Report of the BAAS for 1835 (London, 53. It is clear from context and also from Farr's
to the Registrar General," 65). England: John Murray, 1836), 251. It is nosological table that he does not mean
40. One could also describe this transforma- noteworthy here that causes of death and "poisons" to include "morbid poisons"-
tion as turning from a focus on the person causes of disease are seen as the same that is, the presumed agents of specific
to a focus on the disease agent in etiology, problem. Alison's committee acknowl- transmissible diseases. A category for "vio-
from health and well-being to disease in edged, in keeping with multicausal think- lent deaths" with 4845 entries in the first
medical practice, and from degenerative ing, that "every individual case of disease, report included deaths from eating poison-
conditions such as consumption to infec- or of death from disease, is probably ous plants, breathing fumes or carbonic
tious epidemic diseases in public health. determined by several external causes." By acid, overdosing on drugs, being killed by
41. Eyler shows Chadwick to have been inter- collecting large numbers of cases of particu- animals, etc. (Farr, "Letter to the Registrar
ested in deaths registration only because it lar diseases, however, one could determine General," 82-83). I thank an anonymous
would make the job of poor law medical "the respective influence" of each cause reviewer for pointing out this possibility.
officer more attractive (Victorian Social (253). Alison also insists that it was crucial 54. "Spontaneous" is ambiguous because it
Medicine, 45). to distinguish "whether the fatal disease can refer either to randomness or, as in
42. It could be held, however, that adequate was acute or chronic" (254), but he does "spontaneous combustion," to an event
intake did not have its adequate nutritive not explain why this is so important.
effect when the nervous system (the diges- "Acuteness" might be seen to distinguish that requires no external cause but is
tion) was disturbed by sewer emanations. the effects of a sudden invasion of some presumed to result from the normal causal
Had Farr split the 63 deaths between mysterious and accidental influence from action of internal causes. In the former
"debility" and "intemperance" (which he the state of "health" produced by the sense, it is incompatible with "certain
legitimately could have done), there prob- individual's general conditions of living. circumstances." In either case, the exis-
ably would have been no problem. 49. In his "Letter to the Registrar General," tence of disease is rendered much more
43. Wing, Evils of the Factory System, 146-150. Farr speaks of districts where people were mysterious than it is to the Sadler wit-
B.C. Brodie, along with many other wit- "constantly sick, and the energy of the nesses.
nesses, was asked "in a medical point of whole population is withered to the roots. 55. George Rosen, "What Is Social Medicine:
view, and consulting the feelings and Their arms are weak, their bodies wasted, A Genetic Analysis of the Concept,"
principles of humanity" [italics mine], and their sensations embittered by priva- Bulletin of the History ofMedicine 21 (1947):
whether it was not as essential to protect tion and suffering. Half the life is passed in 674-733; Elizabeth Fee, "Designing Schools
factory children as it had been to protect infancy, sickness, and dependent helpless- of Public Health for the United States," in
West Indian slaves (Ibid., 128). ness" (65). A History of Education in Public Health:
44. Wing. Evils of the Factory System, 134-135. 50. Farr does not say how one is to infer Health That Mocks the Doctor's Rules, ed.
45. Farr to Lister, March 17, 1840, in Poor Law exciting cause from the information in the Elizabeth Fee and Roy Acheson (Oxford,
Commission, Official Circulars, May 18, tables. He does suggest that comparisons England: Oxford University Press, 1991),
1840. between places of high and low mortality 155-194; Elizabeth Fee and Barbara Rosen-
46. In designing forms for registering deaths, from a disease will indicate the amount of krantz, "Professional Education for Public
Farr does invite identification of "primary disease that is preventable; however, in Health in the United States," in Fee and
and secondary diseases," although only the terms of both contemporary medical theory, Acheson, eds., History of Education, 230-
primary diseases figure in the tables (Eyler, with its emphasis on individual diatheses, 271; Stephen J. Kunitz, "Explanations and
Victorian Social Medicine, 51). It is also and Farr's own belief in the importance of Ideologies of Mortality Patterns," Popula-
illustrative to consider Henry Rumsey's gross geographical factors, it does not tion and Development Review 13 (1987):
criticism of Farr on this issue. Rumsey held follow that, under a proper public health 379-403.
that the solution to the oversimplification regime, all places and peoples would have 56. "A Social Disease," Mother Jones (May-
was even more simplification (Ibid., 61). the same low mortality. June 1993): 26-28.

866 American Journal of Public Health June 1995, Vol. 85, No. 6