Public Health Then and Now

Could You Starve to Death in Englandin 1839? The Chadwick-FarrControversy and the Loss of the"Social" in Public HealthChristopher Hamlin, PhD

IntroductionFor better or worse, no profession

can help but feel the dead hand of itshistory, of choices made for understand-able reasons but in circumstances that nolonger exist. The following story is about aconflict that occurred during what is oftenseen as the formative period of modernpublic health: Great Britain in the 1830sand 1840s. The conflict concerned causes-of-death data, which began to be collectedin 1837, and it focused on what kinds ofinformation to collect, what to do withsuch information once it was collected,what such information indicated aboutthe state of society, and ultimately, how"social" public health should be. Thestory illustrates the impossibility of reduc-ing complicated and varying sets of circum-stances to a single category and the waysin which political, legal, and moral deci-sions necessarily underlie the very data wechoose to gather.

The protagonists were two of themost important public health pioneers.On one side was Edwin Chadwick, at thetime chief administrator of the Poor LawCommission, the agency responsible forbringing relief to the poor throughoutEngland and Wales. Within a few years,Chadwick would become champion of the"sanitary idea" of public health throughpublic works, based on the principle thatit is a public duty to prevent infectiousdisease by providing water that is pureand sewers that will safely remove what isdangerous. Chadwick's "public health"would emphasize specific transmissiblediseases; in the controversy, he wouldinsist that the most important fact was thedisease from which the victim had died.His perspective anticipated the germtheory that would come to dominatepublic health by the end of the century.

On the other side was the pioneeringstatistician and epidemiologist WilliamFarr, recently appointed (in part atChadwick's urging) statistician in theoffice of the Registrar General of Births,Deaths, and Marriages. Farr, whose taskwas to analyze the causes-of-death data,took an interest in the causes ofthe disease,which, in keeping with ancient canons ofphilosophical medicine, he took to in-clude a broad set of social (and economic)determinants of health and illness, includ-ing diet and working conditions. At thetime, Chadwick was a well-establishedbureaucrat, a public figure enforcing theexceedingly controversial poor law policy,while Farr was a little-known physicianwith an unusual knowledge of statistics,still searching for some career niche.'Ironically, Chadwick, the social adminis-trator, took what may seem the morenarrowly medical view while Farr, thedoctor, emphasized social factors.

The Nature ofthe ControversyIn a formal sense, the controversy

exists in a set of official letters exchangedbetween Chadwick and Farr from Septem-ber 1839 to March 1840. Ostensibly, theletters are on technical issues Farr wasencountering in classifying causes of death,on the philosophical issue of what kind orlevel of explanation is appropriate in suchan inquiry, and on the factual issue ofwhether hunger and deprivation actually"caused" or contributed significantly tomortality in England and Wales. A great

The author is with the Department of Historyand the Reilly Center for Science, Technology,and Values, University of Notre Dame, NotreDame, Ind.

Requests for reprints should be sent to

Christopher Hamlin, PhD, Department ofHistory, University of Notre Dame, NotreDame, IN 46556.

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deal more was at stake, however: theprinciples of social welfare policy (theterm is anachronistic yet apt), the place ofmedicine within it, and, ultimately, whatconstitutes the minimally acceptable con-

ditions of human life in an industrializingsociety. The controversy took place amida political crisis. Britain was in the middleof a depression; it seemed also on theverge of revolution. There were calls forgreater democracy, regulation of workingconditions, and abolition of tariffs on

imported food. Many of these socialquestions could be, and often were,

framed as questions of health, disease,and wrongful death, and many of thecomplaints came to roost at Chadwick'sdoorstep.

In 1834 Parliament had enacted a

Poor Law Amendment Act (commonlycalled the "new poor law"). Based on a

report largely written by Chadwick andframed along principles Chadwick hadarticulated, this new law discouragedclaims for public relief by offering theclaimant life in a workhouse (and a

workhouse diet). The workhouse was

simultaneously to be a real "safety net"and yet an option significantly less attrac-tive to the poor than the miserableaccommodations and scanty diet theycould procure on their own. As secretary

to the Poor Law Commission, Chadwickwas, if not the final arbiter of policy,centrally and visibly involved in execu-

ting it.The new poor law outraged the poor,

agricultural laborers, and factory workersalike. It denied them the right of livingtogether as a family unit, and it seemed a

means of feeding low-wage labor into themills of industrial Lancashire and York-shire or even of warding off a Malthusianpopulation crisis by perpetrating a modestgenocide among the working class. Thekey word in the vast stream of attacks on

Chadwick and his associates was "starva-tion." On page after page of The Book ofthe Bastiles, G. R. W. Baxter's 1841 cata-logue of the law's abuses, one findsstatements of mothers who would chooseto starve rather than accept "the offer ofthe house," mixed with accounts of work-house inmates who succumbed to progres-sive debility and neglect. Even the estab-lishment press, like the London Times,labeled it "the starvation act."2 AlthoughChadwick claimed that workhouse diets

(the outcome of experiments on prisondiets) were sufficient for health, work-house mortality was in fact remarkably

high, even when corrections were madefor the age distribution of the inmatepopulation and for the many who were

diseased when they came to the work-house.3 And while medical men were notin the vanguard of the act's critics, many,especially those employed as medicalofficers to the new poor law unions, foundthemselves frustrated in trying to cure

diseases that were fundamentally theresult of poverty. It did seem that publicpolicy was causing premature death.

Accordingly, starvation was a touchysubject for Chadwick in the fall of 1839.At the time, he was just launching theinquiry that would culminate 3 years laterin his famous Report on the SanitaryCondition of the Labouring Population.Farr's first analysis of causes of death inEngland and Wales had just appeared.On September 30, Chadwick wrote to

Registrar General T. H. Lister, Farr'ssupervisor, to query the 63 deaths Farrattributed to starvation and Farr's com-

ment on them-that "hunger destroys a

much higher proportion than is indicatedby the registers in this and in every other

country, but its effects, like the effects of

excess, are generally manifested indi-

American Journal of Public Health 857

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

William Farr in later years. Reprinted from Humphreys.47

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rectly, in the production of diseases ofvarious kinds."4 Even though these 63deaths represented a tiny fraction of the148 000 deaths reported, Chadwick tookthe report as a serious threat to thepolitical viability of the new poor law.Because the workhouse was to be bothsafety net and deterrent, there should beno starvation. If people were starving,there was something about the policy thatdid not work. He demanded an explana-tion for the deaths and for Farr's claimthat the diet of agricultural laborers(Farr's own background) was inad-equate.5

In his reply at the end of November1839, Farr included registration data onthe 63 starvation deaths and on 16 othersinvolving various forms of privation. Hetook starvation in a broader sense thanhunger; it was to "imply death by priva-tion, the want of warmth, and of properfood at all ages." He explained that while"few die from the absolute want of food,... many die, or drag on a miserableexistence upon insufficient, innutritiousdiet." Relying on contemporary chemistswho were beginning to translate humannutritional requirements into quantitiesof carbonaceous and nitrogenous foods,Farr showed that the workhouse dietprovided only about three quarters theminimum requirement while that of EastAnglian agricultural laborers providedslightly more than half.6

Having reviewed the registration data,Chadwick responded at length in Febru-ary 1840. He held that Farr was inconsis-tent in his use of the word starvation andthat the term misled. Of the 63 deaths soclassified, 36 were infant deaths, manyfrom lack of breast milk and some owingto the death of the mother. In such cases,Farr's representation of starvation as aneconomic phenomenon-"want of foodimplies a want of everything else, exceptwater; as firing, clothing, every conve-nience, every necessary of life, is aban-doned at the imperious bidding of hun-ger"-was hardly candid. Other infantdeaths, Chadwick held, reflected igno-rance of infant feeding rather than depri-vation. Among the adult cases, severalpeople had succumbed to cold-anotherof Farr's senses of "starvation"-oftenwhen very drunk. There were a fewhomicides by starvation. Some starvedadults had refused relief; in only one casehad it been denied to them. Chadwickinvited Farr to investigate starvation re-

ports more fully to improve the quality ofhis tables, and he asked for copies of theoriginal returns for any deaths attributed

to "indigence." He argued that Farr hadno business speculating about widespreadmalnutrition; his job was simply to classifyregistered deaths. In effect, Chadwick wasaccusing Farr of being both too faithful tothe data (in allowing infant deaths to belisted under the misleading heading ofstarvation) and not faithful enough (inclaiming that malnutrition accounted formore mortality than was apparent). What-ever chemists might say, people did live onsuch diets, Chadwick asserted; what wasmore, they saved excess income (orwasted it in drink).7 Hence, there couldnot be a vast hunger problem. The excuseof hunger must be disallowed; it encour-aged begging and capricious charity, prob-lems the new poor law had been estab-lished to solve.

Farr replied in March. He expandedthe issue by bringing in the social circum-stances of the deaths, and he narrowed itby raising the technical issue of just whatheading in a nosology best described suchdeaths. During the period covered by hisnosological table, there had been nearly72 000 infant deaths, he noted; manyinfants died because their mothers couldnot nurse them or because the mothersthemselves were too weak to provide goodmilk. The 36 infant deaths, and probablymany more, were then starvations in thefull sense of privation; infants "starved inthe cold nights of winter, and on thecoarse, innutritious, inadequate subsis-tence of impoverished parents." He ar-gued, contra Chadwick, that medical mensaw cases of starvation regularly, and heheld that the correlation of excess deathswith unusual cold could be best under-stood in terms of a broad concept ofstarvation. Even the best medical examina-tion might not distinguish the specificeffects of food deprivation from thetotality of depressing conditions, yet Farrfound it beyond question that "if thequantity of provisions and the supply offood to the great mass of the populationcould be augmented, the mortality wouldbe reduced."8 Many deaths in whichstarvation played a role would not belisted under that heading, and many thatwere listed as starvations might involveadditional factors as well.

There were also "technical" reasonswhy the distinctions Chadwick urgedcould not be made. Causes-of-death tablescould not possibly take into account allthe "remote, incidental, or accessorycircumstances in which the direct cause ofdeath originated." Doing so would be too

messy; "want of breast milk" might not be"a disease, but it is a cause of death. It is,

in the strictest scientific sense, 'starva-tion.'" Farr denied attacking the newpoor law,9 denied making starvation an"all-pervading cause," and accused thepoor law commissioners of making moreof the matter than a short comment in along report warranted. The latter point isespecially important. While for Chadwickany starvation was a public embarrass-ment, for Farr starvation had to beconsidered in part because there was noother way of dealing with the untidyresidue of deaths that fit none of the morestraightforward pathological categories inthe nosological system he was developing.Starvation, together with even more ob-scure terms like "debility," "intemper-ance," and "sudden deaths," were sub-headings of the larger category of"sporadic diseases" of "uncertain seat."In a sense, he had to report starvationsbecause the local registrars who compiledcauses-of-disease data (often without anysignificant medical examination) reportedthem to him.'0 Yet at the same time hewas convinced, as were many contempo-rary medical men, that hunger and other"predisposing causes" bore some consid-erable responsibility for many deathsamong the poor.

There the public controversy endedalthough the issues continued to be highlysensitive for the next few years." Chad-wick, in introducing Farr's response, effec-tively had the last word, accusing Farr ofspeculation.'2 With regard to the techni-cal matters, Chadwick had prevailed. Thetheoretical perspective he representedwas in keeping with what was regarded asthe most progressive clinical science thenbeing worked out in the great hospitals ofParis. Farr himself had Parisian training,was attracted to many aspects of that newmedicine, and found himself equally un-able to develop a viable way to integrateinto causes-of-death statistics all thosefactors that might be considered "social"causes of death.'3

As well as being significant in theearly shaping of modem public health, thecontroversy is important because theissues it involved are general issues ofclassification and causation. These willarise in some way whenever we try toclassify events, deduce common causes,and make inferences for policy from ourclassifications. Throughout his career,Farr would struggle with the problem ofmaking a classification system that was

unambiguously exclusive (it should beclear under which heading a death be-longed), that was exhaustive (there shouldbe an appropriate category for all deaths),

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and that facilitated empirical inference.14Some of the problems-of splitting orlumping, of recognizing degrees of naturalrelation, and of deciding what parts ofnatural diversity to ignore-are inherentin any taxonomic endeavor.

The problems of classifying causes,which need belong to no single species,are especially complex: it will always bethe case that any cause to which a death isattributed will identify only some compo-nents of a complicated process that willinclude various combinations of actions-political as well as personal-and condi-tions-social as well as biological, chemi-cal, and even geophysical-many ofwhichmay be entirely unrecognized. Since, asFarr realized, one cannot include allantecedent factors, a question of utilityenters in. Ideally, the cause listed willimply some of these other components.For example, Farr was trying to convinceChadwick that infant deaths from starva-tion imply particular economic condi-tions.15 If one wants to maximize theinformation available from the table, itmakes sense to choose the sort of causethat most strongly implies the surround-ing circumstances. But the sort of causeone chooses is also dictated by the sort ofinformation about the state of societysuch a determination is to supply. Ques-tions of responsibility will focus attentionon some factors; questions of periodicity,preventability, or remediability will focusattention on others. Equally, the sort ofcauses one identifies may have quitedifferent meanings for persons in differ-ent positions. What for Farr was a factthat perhaps conveyed some informationabout means of prevention (e.g., moreuniform access to food and other "neces-saries of life") was to Chadwick anaccusation of irresponsibility that waspossibly criminal.

Philosophical Issues Inherentin the Controversy

At the heart of the controversy werethe political and social implications of atable that classified causes of death mainlyin terms of diseases (what Chadwickwanted Farr to stick to). These implica-tions depended on what "disease" wasconceived to be, what it meant to have adisease, and in what ways causes ofdisease related to causes of death. Heremedical traditions of the late 1830s dif-fered from today's. Much of our use ofcauses-of-death reports (or specific mor-bidity rates) in public health is based onthe assumption that diagnosis provides

knowledge of cause (often a single specificcause) and thus is essential in identifyingthe condition or activity responsible forthe disease-perhaps a source of environ-mental carcinogens or a contaminatedwell. We reason from cause of death tocause of disease to prevention. Suchinference requires both accurate diagnos-tic ability and knowledge of the particularcauses of particular diseases. Underlyingboth kinds of knowledge is the presump-tion that each disease is a distinct entitywith a distinct cause-in short, thatknowledge presumes an ontological con-

ception of disease.

Medical men in the 1830s would notmake these assumptions and inferences;as Farr effectively admitted to Chadwick,classifying deaths by disease is no satisfac-tory basis for classifying deaths by cause.

Yet it was during these years that an

older, physiological conception of diseasewas giving way to an ontological one.

"Fever," hitherto a generic term for a

group of serial changes in the nervous

system (or perhaps in the blood), evolvedinto the definite disease entities of typhusand typhoid. In this, Farr was a transi-tional figure, for highlighting hunger as a

general cause of ill health was exactly the

American Journal of Public Health 859

Farr's first nosological table for the second half of 1837. From William Farr,"[First] Letter to the Registrar General,"4 p. 82.

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kind of explanation that loomed large inthat older tradition.

That tradition did not view mostdiseases as specific entities. However, itspractitioners were much more aware ofthe philosophical complexity of the prob-lem of disease causation than their succes-sors were a few decades later or than mostpractitioners probably are today. Discus-sions of etiology in contemporary text-books treated disease as a product ofvarying combinations of different types ofcauses, an approach exemplified in chronicdiseases. (Later, acute transmissible dis-eases, presumably with single specificcauses, became paradigmatic.) A keyfeature of that approach was an invitationto take stock of how virtually all aspects ofthe living situation-diet, work, emotionalstate-affected a person's health.

This "older tradition" was, in fact, abroad framework that subsumed manydifferent pathological models with somecommon elements. It has been called"constitutional" medicine because of thecentrality of the concept of disease asinjury to the constitution, which manifestsitself differently according to the individu-al's "diathesis," or idiosyncratic suscepti-bilities. That injury can be expressed as"debility" or as a deficit of "vitality,""nervous energy," the "conservative prin-ciple," or simply "health."16 Constitu-tional medicine explained illness in termsof living conditions and personal historiesrather than as the presence of someparticular disease. In such a medicine,diagnosis had a different significance thanit does now. Mainly, the names of diseasesone finds on nosological tables were justthat-names-to designate a set of symp-toms, a sequence of changes in the body,or sometimes hidden conditions pre-sumed to give rise to those symptoms orthat sequence. Diagnosis was more impor-tant for therapy and prognosis than forthe answering of etiological questions.'7 Itdid not follow that the set of changeslabeled a "disease" was the effect of asingle discrete cause, for such medicinerecognized many kinds of causes ofdisease-"proximate" or "remote," thelatter being either "predisposing" or"exciting," there being room also for"determining" or "consecutive" causes.18

Within this framework, most dis-eases were to be regarded as problematicphysiological states rather than as ontologi-cal entities that temporarily take over a

body. The great exception, a disease thatwas a species with a unique cause, was

smallpox. Medical men disagreed abouthow many other diseases corresponded to

the smallpox model and how closely, butmost thought the number was not largeand included neither the many chronicdiseases, like the various dropsies, normany of those we now consider infectious,like consumption, scrofula, and the vari-ous fevers. Even though many would havejudged at least some varieties of fever tobe (sometimes) contagious, these stillcould be understood to be a manifestationof common causes-cold, wet, hunger,bad air, anxiety, etc.-which could alsomanifest themselves in other distinctclinical conditions.19

Any medicine based in advice onhow to modify the extemal factors thataffect one's health assumed that theindividual had control of those factors. Inlarge part, these medical ideas were theheritage of a medicine for the wealthy,who did have such control over theconditions of their lives. Applied to livingconditions during the industrial revolu-tion, however, that elite medicine hadrevolutionary implications, which washardly surprising since working-class liveswere being assessed according to upper-class standards of health. Rarely did thoseapplying this medicine intend to berevolutionary. In part, medical men be-came involved in social questions asproviders of authority. Asked to assess theeffects of new institutions such as facto-ries, they found much that was harmful tohealth. Some encountered such problemsas practitioners. Samuel Smith, on thestaff of the Leeds Infirmary, noted that"'never a year passes, but I see severalinstances where children are in the act ofbeing wom to death by thus working infactories.' " He told of telling parents thatunless they removed a child from factorywork, the child would die.20 By regardingpoverty as a cause of disease, a medicalrather than a moral problem, some of themedical officers appointed under the newpoor law to care for the poor circum-vented the harshness of that law. Forthose to whom the threat (and experi-ence) of hunger incited a greater effort towork, these officers prescribed a support-ive diet as a remedy for an illness broughton by hunger and overwork.2'

A few prominent physicians madesocial causes of disease the focal point oftheir careers as public figures or asresearchers. W. P. Alison, professor ofmedicine at Edinburgh, led a campaignfor Scottish poor law reform, arguing thatit was the physician's professional obliga-tion to act to remove sources of disease.The disease that concerned him was

typhus. Alison believed that its most

readily removable cause was hunger, andthus the Scottish practice of depending onthe (often grudging) charity of each parishwas unacceptable.22 A Manchester practi-tioner, R. Baron Howard, wrote a treatiseinstructing his colleagues how to recog-nize the symptoms and postmortem ap-pearance of chronic hunger, for he in-sisted that this, and not any specificdisease, was a major cause of deaththere.23

Clearly, constitutional medicine hadsocial implications. What they were, how-ever, was less clear, as was the question ofwhether a statistical inquiry into causes ofdeath could help to make them clear. If"'cause" were understood sufficientlybroadly, one could identify a large num-ber of antecedent events that might wellhave been crucial in whether the deathoccurred. Did that mean one shouldregister such claims as we find SamuelSmith making-that factory labor is (insome sense) a cause of death-in the sortsof tables Farr was making up? It needhardly be said that the factory system (orcapitalism) is not among Farr's headings;"starvation" and "intemperance" are themost "social" categories he used. Thosewho campaigned for reduction of workinghours or against the new poor law wereoften suspicious of statistical studies ofcauses of death. They felt they knew whatcaused preventable deaths and how toprevent them. It was pretty obvious: lesswork, cheaper food.24 The whole projectof classifying deaths by disease mightseem only a distraction.

Social Implications ofConstitutional Medicine

To sketch how social such a theoreti-cal framework could become, and tosuggest how different its approach tocauses of death (and disease) was fromthe approach that Farr was developing, Ishall review the medical evidence heardby Michael Sadler's 1832 Select Commit-tee on the Employment of Children intextile factories. Most of the medicalwitnesses were physicians or surgeonsholding prestigious London hospital ap-pointments: Sir Astley Cooper, Sir WilliamBlizard, Sir Anthony Carlisle, Sir CharlesBell, Sir George William Tuthill, SirGilbert Blane, J.H. Green, John Elliot-son, C. A. Key, P. M. Roget. Elliotsonaside, none of these was in any sense a

radical or even a reformer.25 They were

asked virtually the same questions andgave much the same answers. Typical isthe view of Sir Charles Bell, retired

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professor of anatomy of the Royal Collegeof Surgeons. Bell was asked whether,from "general principles," "analogies" ofpractice, or study, he had "any hesitationin tracing many injurious consequences tothat system of labour, consequences whichhave been described. . . at great length, asaffecting the health and the limbs, andshortening the life, of those exposed toit?" In reply, Bell stated that such work

would be very injurious to the constitu-tion, and engender a variety of diseases;the great disease, emphatically usingthat word, is scrofula: where there is awant of exercise, deficient ventilation,depression ofmind, and want of interestin the occupations, I should say, espe-cially in young persons, scrofula, in itshundred forms, would be the conse-quences.26

Bell and most of his colleagues hadnever practiced among factory children;they spoke from theory (although hospitaland dispensary appointments had giventhem some knowledge of the health of theLondon poor). As Bell notes here, it is theconstitution (not the body or a particularorgan) that is harmed by factory work.Owing to hereditary or environmentalfactors, some constitutions are strongerthan others, but all are fragile. Whatharms one constitution harms, in greateror lesser degree, anyone's constitution:overwork harms health although somecan work longer than others.27 Sir An-thony Carlisle, anatomist of the Westmin-ster Hospital, noted that children cannottake long labor in close rooms, but thatthe effects will vary

in proportion to their different constitu-tions: to some it will be fatal; as, forexample, the children of scrofulousparents; others might resist a consider-able proportion of unwholesome influ-ence with more impunity.... The evilconsequences will be in proportion tothe youth of the person, his delicacy, orotherwise, the natural constitution, thelength of time he is confined, and theconfinement of the air.28

These elite medics agreed that theeffects of the factory could appear asmany different diseases. Even scrofula,the disease Bell highlights, was not thespecific tuberculosis of the glands that wethink of but a more general condition.29Just as one cause appears as manydiseases, many causes might contribute tothis scrofula, although that does notabsolve any one of them of responsibility.One could not then, as we now do, reasonfrom diagnosis to cause. Each cause couldcontribute to many diseases; each diseasehad many causes. Further, most witnessessaw no sharp line between health and

disease. Harmful activities did not simplyput one at risk; to call them harmfulmeant that they were destroying "health,"and the deterioration they caused wouldeventually warrant a specific diagnosis.Further, the concept of disease held bythese medics was broader than ours; inCarlisle's words, it included whatever was"injurious to ... health" or a "deviationfrom health."30

Debility was a common concerninasmuch as quantities of vitality orenergy were central concepts in contempo-rary physiological theory. Fatigue anddepression were but subjective indicatorsof a somatic state of debility, which was inturn nearly the same thing as disease.31Thus, according to Sir B. C. Brodie,surgeon of St George's Hospital, "what-ever tends to debilitate the general systemwill cause the disease to become devel-oped; scrofulous diseases of all kinds, Iconclude will shew themselves amongchildren so circumstanced; scrofulous dis-eases generally appear in those who fromany causes are in a state of debility."32Carlisle explained how leaving the over-heated factory for the cold night airgenerated consumption:

Sudden alternations of heat and cold,the going out of a very hot room into adamp cold air repeatedly will inevitablyproduce slight inflammations of thelungs; those slight inflammations reiter-ated produce the groundwork of pulmo-nary consumptions, for all pulmonaryconsumptions are repetitions of littlecolds. The structure of the lungs, fromthis cause, becomes completely alteredby those slight inflammations whichdisorganize the vascular tissue; whenthat has taken place, medicine is of verylittle use; but a sure mode of producingthis malady is frequent alternationsfrom hot rooms, with thin clothing, tocold damp air.33

Witnesses accepted the interdepen-dence of the mental and the physical; onewas utterly at the mercy of the environ-ment. One (physiological) effect of factorywork would be "recourse to sensualstimulants, in order to rid the mind of itsdistressing feelings," noted James Blun-dell of Guy's Hospital; others were an"irritability of the nervous system, excit-ability of the feeling, and a certain busyplay of the ideas when the mind is roused,together with that state of the mindgenerally which constitutes fretfulnessand discontent; and I am further ofopinion, that this system has a tendency toweaken the solid strength of the mind."34Thus, attitudes and behaviors like heavydrinking (or precocious sexuality) were tobe seen not as unfortunate moral choices

but as direct physical effects of factorylabor.

Such a medical philosophy has some-times been seen as a verbose substitute forsound science. Certainly an "everything-causes-everything" presumption is hardlya workable foundation for analysis. Theexplanations of the medical elite toSadler's committee often seem arbitrary,vague, and speculative. Yet to the Sadlerwitnesses, such complicated schemes ofcausation were the mark of a trulyphilosophical medicine. These individualssaw themselves as hardheaded followersof Newton, Boyle, and Bacon in eschew-ing occult qualities, refusing to mistakewords (the names of diseases) for things,and allowing as causes only those entitiesthat common sense could invest withcausal efficacy.35 Mechanical processeswere prominent in their pathology: longperiods of standing (or of sedentary labor)had necessary and readily comprehen-sible effects. According to Blizard,

long standing in one position has a veryconsiderable influence on the circulat-ing system; the veins become, as wedenominate it, varicose or distended,and, of course the return of the blood tothe right side of the heart is not regular,nor in the right quantity or quality; andif it is either deficient in the one or theother, it is robbed of a certain degree ofits stimulus, which is necessary, that allthe other organs may be in a properstate.36

The effects of heat, or dust, were equallyevident. The action of these causes wasdeemed so clear-cut that disease arose as"a certain consequence" of them.37

Judged by canons like these, it wasthe sorts of causes hypothesized by thoselike Chadwick (and later Farr), whosearguments would culminate in the germtheory, that seemed arbitrary. In 1840 the"miasms" that Chadwick posited (or a fewyears later, the "zymes" that Farr sug-gested) were only names for hypotheticalentities supposed to cause particulardiseases. As the entities themselves wereutterly undetectable, there was little basiseven for conjecturing how they producedpathological processes. From the perspec-tive of the medical philosophy outlinedabove, even though it might be appropri-ate to hypothesize such entities, they didnot count as explanations. To say that avirus (or miasm or germ) was the cause offever was to say that one did not knowwhat caused it (and that the wholediscussion of causes of death was thus apretense) since mere words could not becauses.38

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The Rejection ofConstitutionalMedicine: Chadwick and Farr

It should be clear that in this constitu-tional medicine, causes-of-death statistics(if by these one means diagnoses ofdiseases of deceased persons) could notserve the purposes for which we now use

them. Diagnosis had a much less impor-tant place in the logic relating cause toeffect. One could not infer causal agentfrom postmortem diagnosis and then go

on to seek the means by which the agent,whatever it might be, had reached thevictim. But there was really no need to:

the causes of disease were eventually-orin greater intensity-the causes of death.Both disease and death manifested thetotality of devitalizing causes affecting theconstitution of an individual with a particu-lar "diathesis" or susceptibility. To knowthe disease present at the death told one

something about the diathesis, but it didnot tell one anything very specific aboutcauses since anything that sufficientlyweakened the constitution could trans-form the diathesis into the disease.

Accordingly, the disease was not inany strong sense the cause of death; thecauses of the disease and not the diseaseitself were the real problem. When todaywe use disease incidence to identifyunsatisfactory conditions like bad wateror bad food-handling practices, it is thefact that these conditions lead to thatdisease-that they represent opportuni-ties for infection-that is problematic. Tomedical men of the generation beforeFarr, an outbreak of disease (especiallyfever or consumption) was a measure ofthe degree to which conditions were

unsatisfactory in their own right: toThomas Bateman of the London FeverHospital, writing in 1818, or to theEdinburgh professor W.P. Alison, feverwas an indicator of the state of "misery"of a population.39 That misery, which theyunderstood physiologically as an exhaus-tion produced by cold, hunger, anxiety,and work, represented nothing less thanthe gradual wasting of bodies. The arrival(or spontaneous outbreak) of epidemicfever made the extent of that wastageevident, much as the fire that we make bytossing a match on a pile of dry hay (orthat is produced when that hay spontane-ously ignites) reveals the extent andcondition of that fuel. The wastage was

the real problem, medically as well as

socially, for it was widely held that the

contagion of fever would have little effecton a healthy population.

By contrast, to privilege the names ofdiseases; to regard them as discrete,natural entities, each having its uniquecause; and yet to have no tools either todistinguish diseases reliably from oneanother or to discover their unique hid-den causes was to indulge in obscu-rantism. To the medical elite who testifiedto Sadler, medicine had normative signifi-cance for social policy; yet transform"consumption" into the infectious diseaseof "tuberculosis" and downplay the "pre-dispositions" that led to it, and the doctoris left with nothing to say about workingconditions.40 In retrospect we can see thatthe ontological assumption and the searchfor specific causes paid off in the germtheory of disease, although arguably,much of the imperative for health was lostwith the disappearance of constitutionalmedicine. In 1840, however, to take thatontological route was either an audaciousexpression of faith in a science that wasmostly yet to come, or an attempt to steermedicine away from a political critique ofthe industrial revolution. It was both-forFarr, mainly the former; for Chadwick,mainly the latter.

Chadwick's reasons are plain. Hewas seeking to represent public sanitaryimprovement-water and sewers-as ameans of social betterment that wasconsistent with the laws of politicaleconomy because it did not interfere withthe play of the market in food or in labor.He based his case on the claim thatdiseases ranging from fever to tuberculo-sis, and social problems ranging fromintemperance to revolutionary agitation,had one "all pervading cause": concen-trated emanations of decomposing mat-ter, whose effects could be prevented byflushing the matter down the drain. Withmost diseases plausibly linked to decayingfilth, he saw no great need to break downdeaths by disease."'

The filth explanation could not soreadily subsume starvation, however.Doubtless, filth exacerbated the pathologi-cal effects of hunger, but it seemedobviously not true that hunger in a cleanenvironment was unproblematic. Starva-tion was too irrevocably a social and apolitical issue.42 For Chadwick, to admitexistence of significant starvation was toacknowledge that a central and cherishedtheory was false. His poor law was derivedfrom the axioms of political economy,which were in turn based in universal lawsof human nature. Correct application ofthose laws and axioms guaranteed socialharmony. The optimal workhouse was notbest in the zero-sum sense of being the

best of a bad lot; it was to be ideal in allrespects, full of positive feedbacks ofgoods, with "collateral benefits" poppingup unexpectedly. It was inconceivable thatthe laws of political economy might befound incompatible with the laws ofhealth; it was tantamount to saying thatGod was both for and against the freemarket.

Yet Sadler and the surgeons andphysicians he questioned put medicine indirect opposition to political economy.J. R. Farre had been most insistent:

* [T]he only safeguard to the stateconsists in opposing this principle ofpolitical economy by the medical voice,whenever it trenches on vital economy....[I]f it does [trench on vital economy], it isguilty of homicide.

* "You purchase your advantage atthe price of infanticide; the profit thusgained is death to the child.... [Medicalmen could] never assent to life beingbalanced against wealth."43

This was no less than a rejection ofthe natural law warrant for politicaleconomy. A system in which one had towork oneself to death to eat, or starve toavoid being exhausted by work, could nothave been God's intention. Yet, arguingthat the debilitation of factory work washereditary and progressive, Carlisle hadgone so far as to claim that within a fewgenerations, the factory population wouldbe unable to reproduce.44 For Chadwick,a table of causes of death expressed inpolitically innocuous terms would help tosubvert the possibility of professionalmedicine becoming political medicine, anindependent and countervailing authorityto his own political economy.

Farr's views were more complicated.They bore the stamp of his social outlook,the research problems that most inter-ested him, his grappling with the practicalproblems of classifying deaths, and evenhis anxiety, as a junior bureaucrat in anewly established post, to secure hisfuture by claiming more utility for hiswork than it really possessed. For Farr,the heading "starvation" and, indeed, theentire nosological classification systemwere not social enough. In agreeing withChadwick that ideally one should repre-sent the variety of the cases listed as

starvation, he was not hoping to exoneratethe new poor law but to show that it hadfailed to solve a great social and medicalproblem. He wished to expose thosehidden starvations, the deaths listed un-

der diseases.

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Thus, Farr agreed with the Sadlerwitnesses that social and economic condi-tions were significant causes of death. Butgiven the limitations of contemporarystatistical methods, of number-crunchinghardware, and of uniformity in reporting,it was difficult to juggle the many factorsthat did figure in each death. Too manycategories and too much qualificationimpaired the drawing of general infer-ences. "Each case could be entered underonly one head," Farr explained to Chad-wick. It was "difficult to determine theinfluence of several concurring causes,"he added; "the registers can only beconsidered to indicate an approximationto the real number of deaths fromstarvation." Starvation was probably afactor in many unclassified deaths (morethan 7000); an identifiable disease mighthave been present in some registered asstarvation just as starvation was likely afactor in some deaths listed under particu-lar diseases; nor could one deny that otherheadings on the table-for example, "in-temperance, insanity, and malforma-tions"-had sometimes led to starva-tion.45 Recognizing how much can belearned from correlating the incidence ofdiseases with the circumstances of theiroccurrence, we are likely to endorseFarr's search for general headings thatwould allow statistical investigation. Yetin a medicine of multicausal explanation,one was sacrificing a great deal: arguably,to require that the narrative history of apatient's constitution be condensed to asingle word was to give up the possibilityof a medicine that would take an interestin, and see as problematic, the full varietyof pathological influences a person en-counters.46

It is also the case that social factorswere not central to Farr's own researchinterests at the time, which had more todo with the ancient Hippocratic questionsof the correlation of disease with climate,season, type of soil, and so forth.47 Thedata he chose to gather better suited theseissues. Whereas to Farr, "place" meantthe town in which the deceased hadresided, for W. P. Alison, chair of an 1835Scottish advisory committee on deathsregistration and most influential of the"humanitarian" physicians who stressedsocial causes of disease, "place" wasunderstood as "the exact residence, ie. notmerely the town, village or parish, but thestreet and number, or the division of aparish."48 Farr's "place" was appropriateto inquiries into effects of climate or soil;Alison's, to matters of class and standardof living.

Farr did insist, however, that histables were to serve the purpose of "socialamelioration."49 They would provide amap of unhealthy places (probably nomystery) and, by enabling the "excitingcauses" of the predominant diseases inthose places to be identified, would guideimprovement.50 They would also aid medi-cal practice as medical men would learn tomodify their therapies according to place,season, and class. (In fact, modifyinggeneral therapies to particular circum-stances was the traditional stock in tradeof the learned physician; it is not clearhow Farr's disease-specific death rateswould have improved their ability to dothat.) Physicians would also learn whetherthe so-called health resorts to which theywere sending patients were reallyhealthy.51

Farr tried also to explain "in whatsense the term 'cause of death' is hereunderstood." Yet the metaphor he chose(a broken watch)52 hardly clarified things.He contrasted deaths due to "externalviolence" like poison or fire, in whichwhat one might call the "pathologicalprocess" and its initiating causes areimmediately evident, with deaths in whichthe initiators are not evident and thepathological processes "under certain cir-cumstances spring up spontaneously inthe organization."53 The two classes are"as distinct as day and night," yet they arealso "passing into each other," whichpresumably means that there are deathsfrom conditions that are partly spontane-ous and partly violent, although Farr didnot talk about these or give examples ofthem.

This distinction effectively leaves noroom for social causes of death. Deathsbelong either in a small category ofviolentevents, most of which are not diseases atall, or in a much larger group of what areeffectively occult phenomena, things hap-pening "spontaneously" yet in "certaincircumstances." The latter class seems topresume an ontological conception ofdisease: the diseases can be described,distinguished, and perhaps even corre-lated with certain circumstances, but theycannot be genetically (causally) ex-plained, or else they would belong to theclass of violent events.54 It is noteworthythat the examples Farr chose-cancer,inflammation, and rheumatism-wereamong the more mysterious of diseases;one could not readily have substitutedfever, consumption, or scrofula. The em-phasis on spontaneity was utterly at oddswith the testimony of the Sadler witnessesonly a few years earlier, who had held that

disease was the determined product of theimpact on the constitution of the patho-logical forces to which it had beensubjected. For them, most diseases wouldhave belonged to an intermediate cat-egory, the products of a slow violencebeing done to factory children throughmechanisms quite as comprehensible asthe poisonings or fractures in Farr's morerestricted conception of violence. Thespontaneous, hidden, probabilistic ele-ments of disease were subsumed byconcepts of constitution and diathesis,concepts which, however arbitrarily theymight be used, were not inherently inacces-sible to scientific analysis.

Why was Farr so obscure? I do notthink he meant to undermine inquiry intothe social causes of disease; his sympathyis genuine. But he was by passion astatistician, and a statistician needs dis-crete units-here diseases-whose lawshe can discover. A taxonomist who seesnature as a seamless web or a geneticistwho doubts that genes determine charac-ters will not only be devoid of a reason toinquire but will also be unable to work.Farr was also a man in search of a career,having already found that medical prac-tice and medical journalism did not suit.By finding ways to maximize the signifi-cance of the information he had at hishands (in part by reframing questions tomake them answerable with those data),Farr succeeded, transforming a specialistclerkship into a senior advisorship onhealth policy.

ConclusionThe actions taken at this time had

far-reaching implications for public health.A "political medicine," with status equalto that of political economy in shapingpublic policy, failed to develop. Thepublic health field, along with medicinemore generally, achieved significant au-tonomy, yet it did so by sacrificing theclaim to speak with authority on manysocial issues. It has reclaimed some of thatauthority, but with difficulty; Chadwick'sborder between medical and social re-mains hard to erase.

From time to time since the days ofChadwick and Farr, questions have arisenabout how "social" medicine should be(and equally about what issues and ac-tions a social medicine involves or im-plies). Throughout this century, manypublic health leaders have urged theimportance of social determinants ofillness and health.55 Yet I fear that little ofthat concern has stuck to become part of

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the mainstream or core of public health.To a midwestem layman like myself, theefforts of a doctor from the Centers forDisease Control and Prevention to treatguns as a public health problem (or ofPhysicians for Social Responsibility tomake the same point about nuclearweapons) seem in some vague way atrespass of medical territory.56 Their argu-ments persuade me, but I have troubleshrugging off that dead hand, according towhich issues of economic justice or vio-lence (domestic, local, international) be-long to one category with one set ofinstitutions, and medical issues belong toanother. Perhaps the "social" is tooamorphorous, ill-defined, or diffuse, but Ithink we are also trapped by the inertia ofa history that informs both professionalculture and expectations among the pub-lic at large. In that history, the drama ofthe conquest of epidemic disease hasloomed largest. In medical histories (andeven in histories of public health), thematter of hunger and overwork as medicalproblems is often ignored, treated asmarginal, or regarded as a recognition ofthe 20th century. I find a visit to the Sadlerwitnesses exhilarating because they repre-sent a time when medical professionalsdid not have to apologize for thinking thatsocial policy affected public health. Thesplit that Chadwick and Farr effected hadnot yet taken place. O

AcknowledgmentAn earlier version of this paper was presentedat the Conference on the History of theRegistration of Causes of Death, November1993, Bloomington, Ind.

References1. Major biographies of Edwin Chadwick are

S.E. Finer, The Life and Times of Sir EdwinChadwick (London, England: Methuen,1952); R.A. Lewis, Edwin Chadwick andthe Public Health Movement, 1832-1854(London, England: Longmans, Green,1952); and Anthony Brundage, England's"Prussian Minister". Edwin Chadwick andthe Politics of Govemment Growth, 1832-1854 (University Park, Pa.: PennsylvaniaState University Press, 1988). The majormodern biography of William Farr is JohnM. Eyler, Victorian Social Medicine: TheIdeas and Methods of William Farr (Balti-more, Md.: Johns Hopkins UniversityPress, 1979).

2. G.R.W. Baxter, The Book of the Bastiles; orthe History of the Working of the NewPoor-Law (London, England: John Ste-phens, 1841). See also John Knott, PopularOpposition to the 1834 New PoorLaw (NewYork, N.Y.: St. Martin's Press, 1986), andM.A. Crowther, The Workhouse System,1834-1929, the History of an English SocialInstitution (Athens, Ga.: University of

864 American Journal of Public Health

Georgia Press, 1982). On the views of thenewspapers, see Finer, Sir Edwin Chad-wick, 99-101, 128-129.

3. S.Q. Sprigge, The Life and Times ofThomasWakley (London, England: Longmans,Green, 1897),483-484.

4. William Farr, "[First] Letter to the Regis-trar General," First Annual Report of theRegistrar-General, Parliamentary Papers,1839, vol. 16, no. 187, app. P, p. 75.Ostensibly, Chadwick wrote on behalf ofthe Poor Law Commission to RegistrarGeneral T. H. Lister, yet the controversy isclearly between Chadwick and Farr. Underthe heading "Relief of Destitution," theentire correspondence was printed byChadwick in the Poor Law Commission'sOfficial Circulars for March 9, 1840, andMay 18, 1840. The correspondence is alsoreprinted in D. V. Glass, Numbering thePeople: The Eighteenth Century PopulationControversy and the Development of Censusand Vital Statistics in Britain (Famborough,England: Saxon House, 1973), 150-167.The entire set of circulars has beenreprinted: Poor Law Commission, OfficialCirculars ofPublic Documents and Informa-tion Directed by the Poor Law Commission-ers to be Printed, chieflyfor the Use ofBoardsof Guardians and Their Officers, Ten Vol-umes in Two, 1840-1851 (New York, N.Y.:Augustus M. Kelley, 1970). See also Eyler,Victorian Social Medicine, 25-26.

5. Ironically, Farr had made this last claim aspart of an argument comparing health inthe country to health in the towns, anargument in which he deferred absolutelyand uncritically to Chadwick's controver-sial doctrines about the relative impor-tance of poverty and filth as causes of fever.See Farr, "Letter to the Registrar Gen-eral," 78.

6. Farr to Chadwick, November 29, 1839, inPoor Law Commission, Official Circulars,March 9, 1840.

7. Chadwick to the Registrar General, Febru-ary 24, 1840, in Poor Law Commission,Official Circulars, March 9, 1840. Thiseconomic argument is Chadwick's princi-pal evidence for the adequacy of diet.

8. Farr to Lister, March 17,1840, in Poor LawCommission, Official Circulars, May 18,1840.

9. Chadwick's accusation (see his letter to theRegistrar General of February 24) thatFarr was "against the administration of theNew Poor Law" is interesting as anindication of his hypersensitivity. Farr'stestimony to the select committee on thepoor law act concerned the conditions ofemployment of medical officers, and whileit suggested revisions, it can hardly beconstrued to have been "against the admin-istration" of the act (46th Report of theSelect Committee on the Operation of thePoor Law Amendment Act, ParliamentaryPapers, 1838, vol. 18, pt III, no. 518, qq15703-15841).

10. For Farr's nosological table, see Farr,"Letter to the Registrar General," 82. Onthe problems of certifying causes of death,see Eyler, Victorian Social Medicine, 44-45.

11. See "Alleged Death from Starvation: Singu-lar Inquiry," Times (London), August 26,1840, p.7; William Farr to Times (London),August 31, 1840, p. Se; C. Fowell to Times(London), August 25, 1840, p. 3; R. H.

Hobbs to Times (London), September 1,1840, p. 3; "Examination in the Case ofElizabeth Friry," The Lancet, November28, 1840, pp.348-349.

12. Poor Law Commission, Official Circulars,May 18,1840.

13. A reviewer in the Edinburgh Medical andSurgicalJournal generally sympathized withChadwick's perspective ("Review of Firstand Second Annual Reports to the Regis-trar General," Edinburgh Medical andSurgical Joumal 54 [1841]: 179-183. OnParisian clinical medicine, see W.F. By-num, Science and the Practice ofMedicine inthe Nineteenth Century [Cambridge, En-gland: Cambridge University Press, 1994],chap. 2. On Farr's Parisian experience, seeEyler, Victorian Social Medicine, 1-2).

14. Eyler, Victorian Social Medicine, 54-64.15. It might be argued here that one should not

expect causes-of-death statistics to reflectsocial causes of death, that they were notintended to have any relations to questionsof urban or occupational health, and thatperhaps other sets of statistics-such asgeneral mortality rates, age tables, orinfant mortality among certain groups-should have been the indicators of socialcauses of death. Yet because they did notpurport to represent causes of death, thosestatistics did not unambiguously providethe relevant political facts, either.

16. Sir G. Blane, Elements of Medical Logick,2nd ed. (London, England: Underwood,1821), 37-41; James Copland, "Disease:the Causation and Doctrine of," in ADictionary ofPractical Medicine, ComprisingGeneral Pathology, vol. 1 (London, En-gland: Longman, Brown, 1858), 557-558.The following discussion draws much fromseveral works by Lester King, particularlyhis Medical Thinking: A Historical Preface(Princeton, N.J.: Princeton University Press,1982). I have given this subject moredetailed consideration in "PredisposingCauses and Public Health in Early Nine-teenth Century Medical Thought," SocialHistory ofMedicine 5 (1992): 43-70. On thespecific application of this perspective tomortality, see John Reid, The Philosophy ofDeath, or a General Medical and StatisticalTreatise on the Nature and Causes ofHumanMortality (London, England: S. Highly,1841).

17. Yet even a single diagnosis did not warranta particular therapy. John Armstrong madeclear that the same species of feverwarranted depletative therapies in some,supportive therapies in others, according tothe patient's constitution (John Arm-strong, Practical Illustrations of TyphusFever, of the Common Continued Fever andofInflammatory Diseases, 3rd ed. (London,England: Baldwin, Craddock, and Joy,1819), 294-295.

18. This was pretty much true no matter whichof the several theoretical systems of medi-cine of the day one followed. The exceptionis when one was talking of the "proximatecause," which is nothing other than thedisease: "We call the thing first conceivedthe cause, and that which comes next theeffect; not because there is any realdifference between the cause and theeffect, since the cause is inseparable fromthe effect.... The cause of disease is thesame thing with the disease itself' (Dr.

June 1995, Vol. 85, No.6

Boerhaave's Academical Lectures on theTheory of Physic Being a Genuine Transla-tion ofHis Institutes and Explanatory Com-ments Collated andAdjusted to Each Other,as They Were Dictated to His Students at theUniversity of Leyden, vol. 5, Pathology[London, England: W. Innys, 1746], 372-373. See also Copland, Dictionary ofPracti-cal Medicine, 558).

19. Contagion implied transmissibility and clini-cal similarity. It did not imply a specifictransmissible entity, in the sense in whichthe "virus" of small pox was considered.Bateman held that the contagion of feverneed be nothing more than "morbidexhalations and secretions" capable of"constituting a medium of infection ca-pable of generating fever." Thomas Bate-man, A Succinct Account of the ContagiousFever of This Country Exemplified in theEpidemic Now Prevailng in London (Lon-don, England: Longman, Hurst, 1818),13-14, 142-144. On contemporary feverpathology, see J.M. Good, The Study ofMedicine, 2nd ed., vol.2 (London, England:Baldwin, Craddock, and Joy, 1825), 42-76.

20. Charles Wing, Evils of the Factory SystemDemonstrated by Parliamentary Evidence(London, England: Saunders and Otley,1837), 214-215. According to working-classwitnesses, factory labor was being directlycited as a cause of disease by practicingmedical men. For instance, J. Hebergam ofHuddersfield, when asked to what causethe death of his brother was "attributed by[his] mother and the medical attendants,"answered "that he died from working suchlong hours, and that it had been brought onby the factory" (Wing, Evils of the FactorySystem, 59). James Paterson of Dundeesimilarly reported that his brother had diedfrom consumption attributed by a doctor to"being confined at that work" (Ibid, 72). Itis important also to note that the majorvindication of the factory owners, theReport of the Factory Commission of 1833,which held that factory workers had betterhealth than town residents generally, wasthe work principally of Chadwick.

21. Ruth G. Hodgkinson, The Orgins of theNational Health Service: The Medical Ser-vices of the New Poor Law, 1834-1871(London, England: Wellcome HistoricalMedical Library, 1967), chap. 1.

22. W.P. Alison, "Preface," in Observations ontheManagement ofthePoor in Scotland, andIts Effects on the Health ofGreat Towns, 2nded. (Edinburgh, Scotland: Blackwood,1840).

23. R. Baron Howard, An Inquiry into theMorbid Effects ofDeficiency ofFood Chieflywith Reference to Their Occurrence amongstthe Destitute Poor (London, England: Simp-kin, Marshall, and Co., 1839),1-3.

24. On the ideology of the early statisticalmovement, see M. J. Cullen, The StatisticalMovement in Early Victorian Britain: TheFoundations of Empirical Social Research(New York, N.Y.: Barnes and Noble/Harvester, 1975). Because constitutionalmedicine generated so rich an assemblageof causes, "obvious" solutions were virtu-ally limitless. While many medical menhighlighted poor food and overwork alongwith crowded housing and filth, politicalwriters tended to select solutions. Thoserepresenting agricultural interests often

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focused on long hours and child labor infactories; those representing industrial in-terests saw the key health problem asprotective tariffs on food, which kept priceshigh and starved the poor. On the interplayof at least the first two of these issues, seeEric J. Evans, The Forging of the ModemState: Early Industrial Britain, 1783-1870(London, England: Longman, 1983). Over-crowded housing and filth were politicallymore innocuous; in part they could bereadily acknowledged as problems (espe-cially the former) precisely because it wasnot clear that they were the fault orresponsibility of any one group in particu-lar.

25. On the political views of this group, seeAdrian Desmond, The Politics ofEvolution:Morphology, Medicine and Reforn in Radi-cal London (Chicago, Ill.: University ofChicago Press, 1989), and Sprigge, ThomasWakley.

26. Wing, Evils of the Factory System, 112. Ingeneral, on the role of medicine in thefactory controversy, see Robert Gray,"Medical Men, Industrial Labour and theState in Britain, 1830-1850," Social History16 (1991): 19-43.

27. It is significant that a focus on the differingresponses of individuals to a particular setof conditions was not, as it sometimes hasbeen, a means to divert attention fromsocial causes of illness by relocating prob-lems in individuals, for whose idiosyncra-cies society could not be held responsible(the "blame-the-worker" response).

28. Wing, Evils ofthe Factory System, cxii.29. Cf. J.H. Green, professor of anatomy at

King's College, as quoted in Wing, Evils ofthe Factory System, 154: "[It is] scarcelypossible to present in any brief summarythe many dire effects of scrofulous disease,but we may mention, first, that the mesen-teric glands are often the seat of disease,favoured by the irritation of unwholesomeand ill-digested food, shewing itself inweakness, emaciation, protuberant abdo-men, and slow fever. Next, the absorbentglands about the neck, the inflammatoryswelling, excited, perhaps, by variations oftemperature; for the particular seat of thedisease, or its development in any particu-lar organ, may be determined by accidentalcircumstances. Then we find that thedisease attacks the skin in the form of scalyeruptions, cracks, stops, ulcerations, andslowly suppurating tubercles. Again, thatthe eyes become affected in the variousforms of scrofulous opthalmy, and oftenend in blindness, or the bones, andespecially the joints, become diseased,terminating in caries of the spine and whiteswellings. Then, that the internal visceraare affected with tubercles, as the liver,brain, spleen etc. And, lastly, that the lungsbecome the seat of this destructive diseasein the form of that incurable complaint ofour climate, pulmonary consumption."

30. Wing, Evils ofthe Factory System, 132. Thisperspective did not preclude the concep-tion of at least some diseases, such ascontagious fevers, as entities that attackedpeople, but in highlighting a predispositionor induced debility due to factory work, ittended to relegate that contagion to second-ary status in explaining the incidence ofdisease and the death it might produce.

Public Health Then and Now

See, for example, C.T. Thackrah of Leeds,the main contemporary authority on occu-pational disease: the "factory system re-duces the nervous power, in other words,the vigour of the constitution, that itrenders persons more feeble, more subjectto suffer from attacks of disease.... [Those]constantly so employed are shorter-livedthan others"; they are "liable to attacks ofdisease to which they would not have beensubject, or under which they would nothave succumbed" (Wing, Evils of theFactory System, 232-233). See also J.H.Green: "the child of the most healthyconstitution may, by continued exposure tothese causes, acquire a disposition to thedisease, and become actually the victim ofit; whilst those who might have beensubject to it from an original fault of theconstitution may by the careful preserva-tion from these causes [i.e., the debilitationof factory labor] remain exempted from thedisease" (Ibid., 154).

31. "Debility," in Copland, Dictionary ofPracti-cal Medicine, 473-474. Copland held thatdebility was so "intimately connected withdiseases as to be virtually disease itself." Itssynonyms were "asthenia, atonia, ady-namia, all slightly different, but overlap-ping greatly." Its causes in children werehereditary, "through the exhaustion oftheir parents," as well as induced due,among other factors, to bad or insufficientfood, "abstraction of the animal warmth,"absence of light, air, and exercise.

32. Wing, Evils ofthe Factory System, 128.33. Ibid., 137.34. Ibid., 123, 126. For Blundell this is a

deduction of a nervous system-based pa-thology. Through the metaphor of organiza-tion, the same phenomena could be ex-plained within a solidist framework:according to Sir William Blizard, surgeonto the London Hospital, "whatever affectsone particular important organ tends todisorganize the whole frame; there is adependence of one organ upon another"(Ibid., 118).

35. Cf., Blane's condemnation of the elabora-tion of "terms," "visionary and gratuitous"(Elements ofMedical Logick 141).

36. Wing, Evils ofthe Factory System, 116.37. By 1830, the need to maintain combustion

in the "the engine of the body," or to keepup its temperature or avoid loss of itsnervous "energy" were equally acceptable,and especially in the wake of the chemicalrevolution, the vitiating effects of re-breathed air was no less clear (Green,quoted in Wing, Evils ofthe Factory System,153).

38. Cf., Alfred Hudson, "An Inquiry into theSources and Mode of Action of the Poisonof Fever," in Alfred Hudson and WilliamDavidson, Essays on the Sources and ModeofAction ofFever (Philadelphia: A. Waldie,1841), 142. Hudson quotes Magendie'scriticism of Devergie: that "'we attributethis odor to miasma, that is to say to a causevoid of meaning, because we are ignorantof the nature of the object which itrepresents.' "

39. "The character of an epidemic, therefore,is in some measure a test or index of thesituation and circumstances of the popula-tion among which it occurs" (Bateman, ASuccinct Account, vi); "The existence of

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epidemic fever in any great community,particularly if there be neither war norfamine to explain it, becomes a mostimportant test to the legislator of thedestitute condition of the poor, and, as Ishall endeavour to shew, of the deficiencyof the funds which, in a better regulatedstate, are applied to their support" (Alison,Observations on the Management, 18). Farr'snotion of disease as the "iron index ofmisery" seems to belong to this traditionbut seems out of place in the context of anontological conception of disease ("Letterto the Registrar General," 65).

40. One could also describe this transforma-tion as turning from a focus on the personto a focus on the disease agent in etiology,from health and well-being to disease inmedical practice, and from degenerativeconditions such as consumption to infec-tious epidemic diseases in public health.

41. Eyler shows Chadwick to have been inter-ested in deaths registration only because itwould make the job of poor law medicalofficer more attractive (Victorian SocialMedicine, 45).

42. It could be held, however, that adequateintake did not have its adequate nutritiveeffect when the nervous system (the diges-tion) was disturbed by sewer emanations.Had Farr split the 63 deaths between"debility" and "intemperance" (which helegitimately could have done), there prob-ably would have been no problem.

43. Wing, Evils of the Factory System, 146-150.B.C. Brodie, along with many other wit-nesses, was asked "in a medical point ofview, and consulting the feelings andprinciples of humanity" [italics mine],whether it was not as essential to protectfactory children as it had been to protectWest Indian slaves (Ibid., 128).

44. Wing. Evils of the Factory System, 134-135.45. Farr to Lister, March 17, 1840, in Poor Law

Commission, Official Circulars, May 18,1840.

46. In designing forms for registering deaths,Farr does invite identification of "primaryand secondary diseases," although only theprimary diseases figure in the tables (Eyler,Victorian Social Medicine, 51). It is alsoillustrative to consider Henry Rumsey'scriticism of Farr on this issue. Rumsey heldthat the solution to the oversimplificationwas even more simplification (Ibid., 61).

47. Farr did take data on occupation andproduced studies of occupational mortalityin some later reports. See Noel A. Hum-phreys, ed., Vital Statistics: A MemorialVolume of Selections from the Reports andWnitings of William Farr (1885; reprint, witha new introduction by Mervyn Susser andAbraham Adelstein, Metuchen, N.J.: NewYork Academy of Medicine/ScarecrowPress, 1975).

48. The Edinburgh Sub-Committee, "Reporton the Registration of Deaths," FifthReport of the BAAS for 1835 (London,England: John Murray, 1836), 251. It isnoteworthy here that causes of death andcauses of disease are seen as the sameproblem. Alison's committee acknowl-edged, in keeping with multicausal think-ing, that "every individual case of disease,or of death from disease, is probablydetermined by several external causes." Bycollecting large numbers of cases of particu-lar diseases, however, one could determine"the respective influence" of each cause(253). Alison also insists that it was crucialto distinguish "whether the fatal diseasewas acute or chronic" (254), but he doesnot explain why this is so important."Acuteness" might be seen to distinguishthe effects of a sudden invasion of somemysterious and accidental influence fromthe state of "health" produced by theindividual's general conditions of living.

49. In his "Letter to the Registrar General,"Farr speaks of districts where people were"constantly sick, and the energy of thewhole population is withered to the roots.Their arms are weak, their bodies wasted,and their sensations embittered by priva-tion and suffering. Half the life is passed ininfancy, sickness, and dependent helpless-ness" (65).

50. Farr does not say how one is to inferexciting cause from the information in thetables. He does suggest that comparisonsbetween places of high and low mortalityfrom a disease will indicate the amount ofdisease that is preventable; however, interms ofboth contemporary medical theory,with its emphasis on individual diatheses,and Farr's own belief in the importance ofgross geographical factors, it does notfollow that, under a proper public healthregime, all places and peoples would havethe same low mortality.

51. Farr, "Letter to the Registrar General,"63-64.

52. Contemporaries would have recognizedthis as an inversion of William Paley's useof the same metaphor in his well-knownwork on Natural Theology (1802). Paleymaintained that, just as one would assumethat a watch found in the grass was theproduct of an intelligent designer, so toocould one assume that the marvelousadaptations of plants and animals were thework of a benevolent Creator.

53. It is clear from context and also from Farr'snosological table that he does not mean"poisons" to include "morbid poisons"-that is, the presumed agents of specifictransmissible diseases. A category for "vio-lent deaths" with 4845 entries in the firstreport included deaths from eating poison-ous plants, breathing fumes or carbonicacid, overdosing on drugs, being killed byanimals, etc. (Farr, "Letter to the RegistrarGeneral," 82-83). I thank an anonymousreviewer for pointing out this possibility.

54. "Spontaneous" is ambiguous because itcan refer either to randomness or, as in"spontaneous combustion," to an eventthat requires no external cause but ispresumed to result from the normal causalaction of internal causes. In the formersense, it is incompatible with "certaincircumstances." In either case, the exis-tence of disease is rendered much moremysterious than it is to the Sadler wit-nesses.

55. George Rosen, "What Is Social Medicine:A Genetic Analysis of the Concept,"Bulletin ofthe History ofMedicine 21 (1947):674-733; Elizabeth Fee, "Designing Schoolsof Public Health for the United States," inA History of Education in Public Health:Health That Mocks the Doctor's Rules, ed.Elizabeth Fee and Roy Acheson (Oxford,England: Oxford University Press, 1991),155-194; Elizabeth Fee and Barbara Rosen-krantz, "Professional Education for PublicHealth in the United States," in Fee andAcheson, eds., History of Education, 230-271; Stephen J. Kunitz, "Explanations andIdeologies of Mortality Patterns," Popula-tion and Development Review 13 (1987):379-403.

56. "A Social Disease," Mother Jones (May-June 1993): 26-28.

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