Public Health (1992), 106,335-342
© The Societyof Public Health, 1992
The Society of Medical Officers of Health: a Scottish Centenary I. $. Macdonald, MD FRCPEd FFPHM (retired)
Introduction The Society of Medical Officers of Health for Scotland was formed in 1891.~ This was a Scottish body which was not initially part of the better known Society of Medical Officers of Health which had been formed in England in 1856. In January 1896 the Council of the Society in England formed a Scottish Branch, and the office bearers and Council of the Scottish Society became office bearers and Council of the Scottish Branch of the Society of Medical Officers of Health. 2 This coincided with the general convergence during the 1890s of the provisions for public health in Scotland with the longer standing provisions in England.
The Beginnings of Public Health Legislation The great Public Health Act of 1848 applied only in England and Wales. The Minister who introduced the Bill (Viscount Morpeth) explained that the Government intended to introduce similar Bills for Scotland and for Ireland. 3 A Scottish Bill was apparently drafted and a Committee of the Royal College of Physicians of Edinburgh commented on it. 4 In general terms the provisions of the Bill were welcomed by the College but the proposal which it evidently contained, that the central supervision of public health in Scotland was to be vested in the General Board of Health in London, was fiercely opposed. Nothing further seems to have been heard of the Scottish Bill, but perhaps there is more to be discovered about this episode. By 1855 there were Medical Officers of Health in 39 provincial towns and cities in England 5 and a major step was taken in that year when the Metropolitan local authorities were required to appoint Medical Officers of Health. It was this development which led to the formation of the Society of Medical Officers of Health in 1856. 6 The first steps in Scotland
In Scotland the first steps were taken in 1862 when Edinburgh appointed Dr H.D. Littlejohn as Medical Officer of Health and in 1863 when Glasgow appointed Professor W.T. Gairdner as part-time Medical Officer of Health. As there was still no general public health legislation for Scotland these appointments had to be made under local provisions.7 The absence of public health legislation which could be applied in Scotland caused increasing problems. The lawyers forced the issue because of difficulties in dealing satisfactorily in the courts with nuisances and insanitary situations. In 1867 Lord Advocate Gordon agreed to introduce a Bill which had been drafted by Sheriff Correspondence to: Dr I. S. Macdonald, 36 Dumyat Drive, Falkirk, FKI 5PA.
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Munro of Linlithgow. This became the Public Health (Scotland) Act 1867. 8 It was a competent piece of draftsmanship and is of interest because its origin lies outside the mainstream of British public health legislation. It placed central responsibility for the administration of public health in Scotland on the Board of Supervision which had been established in Edinburgh in 1845 to supervise the administration of the Poor Law in Scotland. The parishes which had local responsibility for the Poor Law became the local authorities for public health purposes. The Act gave powers to the local authorities to appoint sanitary inspectors and medical officers of health and indeed the Board could require such appointments to be made. Progress was, however, slow and perhaps the Board could have done more to stimulate the authorities to make such appointments. In fairness, though, it should be r e m e m b e r e d that the Board had to deal with over 1,000 authorities. 9 The population of most of them must have been very small. The problem of authorities which were too small for their purposes was to handicap public health for a long time. In 1868 Disraeli's Government decided to appoint a Royal Commission to enquire into public health matters. Its original terms of reference included Scotland and steps were taken to appoint members, including Professor Sir R o b e r t Christison of Edinburgh. However, Disraeli's G o v e r n m e n t fell at the end of 1868 and when the Royal Commission was finally established by Gladstone's G o v e r n m e n t in 1869 its terms of reference had been amended and Scotland was no longer included. 8,1° Nevertheless, Christison remained a m e m b e r and he, along with Gairdner of Glasgow and the Chairman of the Board of Supervision, gave evidence. The Board of Supervision had no health expertise. It consisted of a Chairman and two members appointed by the Crown, the Solicitor General for Scotland, the Sheriffs of Perthshire, Renfrewshire, and Ross and Cromarty, and the Lord Provosts of Edinburgh and Glasgow. li After the passage of the 1867 Act it made a hesitant start on public health t2 and in 1872 decided that it wanted to appoint D r Littlejohn, the M O H of Edinburgh, as a part-time medical officer at a salary of £200 a year. After a brisk battle with the Treasury, during which the Board had to point out that comparable bodies in London and Dublin were spending much larger sums on medical staff, consent was obtained s and in 1873 Dr Littlejohn began a remarkable period in his professional life. In 1873 there were only two Medical Officers of Health in S c o t l a n d - - D r Littlejohn in Edinburgh and Dr J.B. Russell who had succeeded Professor Gairdner in 1872 as the first full time M O H in Glasgow.13 D r Littlejohn was therefore called upon by the Board of Supervision to investigate and report on public health problems throughout almost the whole of Scotland. F r o m time to time, when an outbreak of infectious diseases would seem serious or persistent, or was not being handled competently, a note such as 'Dr Littlejohn to enquire and report' would appear in the Chairman's Minute B o o k (Public Health).14 That usually meant that he would visit the area and submit a report to a later meeting. Sometimes his reports were of major public health significance; at other times they revealed local mismanagement; occasionally they let us see whose heads needed to be knocked together. Not all of his reports can now be found but some have been made more accessible in a recent valuable study of the Board of Supervision and its successor from 1894, the Local G o v e r n m e n t Board for Scotland. 15 The other issue which was regularly referred to Dr Littlejohn was the approval of plans by the local authorities for the construction of fever hospitals. T h e r e was a spate of such proposals and he gave meticulous attention to each of them, even
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though many were very small hospitals in remote rural areas. As with many matters which came to the Board there are often revealing glimpses of other local issues. 14 The Board had a clear view that its role was an executive one, to ensure that the legislation was applied, and this was quite distinct from Dr Littlejohn's role which was to advise it. There is of course a deeper issue here, but the practical effect was that once Dr Littlejohn had made his report the Board set about ensuring that the local authority concerned implemented his advice, and woe betide any authority which did not do precisely what Dr Littlejohn had said that it should.14,15 The Public Health Act of 1875 required all local authorities in England and Wales to appoint Medical Officers of Health. In contrast, the general power available in the 1867 Act to appoint Medical Officers of Health in Scotland was used sparingly. Dr Littlejohn appears to have tried to encourage such appointments but he approached it rather delicately, perhaps because the Board showed little enthusiasm. Some appointments were certainly made, usually by Burghs which added part-time MO H responsibilities to the duties of the general practitioner who held the appointment to treat the sick poor. For example, Greenock appointed Dr Wallace sometime in the second half of the 1870s.16 Aberdeen took the important step of appointing their first MO H in 1879. This was Dr W.J.R. Simpson, who left in 1886 to become MOH of Calcutta and later completed a distinguished career in London. In 1888 the Town Council appointed Dr Matthew Hay, who was already Professor of Medical Jurisprudence at the University of Aberdeen, and he held both posts until he retired in 1923. He was to make many important contributions to public health in general and in Aberdeen and the North-east of Scotland in particular.17 Consolidation and progress
The next important development came with the Local Government (Scotland) Act of 1889 which established County Councils and County Districts within counties and required both to appoint Medical Officers of Health. Shortly after this the Burgh Police (Scotland) Act of 1892 required all towns to appoint Medical Officers of Health. Thus all local authorities, County and Burgh, had to appoint Medical Officers of Health. The major Public Health Act in Scotland remained, however, the Act of 1867. In the Counties there could be difficult relationships between the County M O H and the MOsH for districts unless the sensible step was taken of appointing the same individual. In the Burghs only the four cities were able to appoint full-time MOsH. Most of the Burghs, including numerous small ones, appointed a local general practitioner, usually the one who cared for Poor Law patients, as a part-time MO H at a small salary--often a very small salary. The problem of too many small authorities had not yet been overcome, although the number had been reduced from over 1,000 to 305. 9 During 1890 and 1891 the new County Councils proceeded to appoint their MOsH. Broadly speaking the larger counties each appointed a full-time MOH. Some of the smaller counties combined to share the services of a full-time MOH. Stifling and Dunbarton Counties joined forces to appoint Dr J.C. McVail who was, even then, one of the leading figures in public health in Scotland and later distinguished himself in the services of the Royal Commission on the Poor Law and of the National Health Insurance Commission for Scotland. Wigtown and Kirkcudbright appointed Dr W.L.
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Mackenzie. Later he was to be for 24 years the Medical M e m b e r of the Local Government Board for Scotland and its successor, the Scottish Board of Health, an appointment which might be seen as the predecessor of that of Chief Medical Officer in the Department of Health for Scotland when that was established in 1929.28 The very small county of Clackmannan combined with Fife; Banff, Moray and Nairn made a joint appointment; and West Lothian and Peebles attached themselves to the larger county of Midlothian. The 1889 Act was silent on whether M O s H had to be full time. The Counties of Orkney and Shetland, which consisted of island groups with very small populations, each appointed a part-time MOH. The County of Bute, which consisted essentially of the islands of Bute, Arran and Cumbrae, did the same. Three mainland counties-Forfar, Berwick and Haddington (later known as East L o t h i a n ) - - e a c h appointed a part-time M O H . Haddington appointed Dr T.F.S. Caverhill who had a consulting practice in Edinburgh and was also Surgeon-Major of the Lothian and Berwick Yeoman Cavalry. The latter appointment may explain why that county's provision for the treatment of infectious diseases in the early 1890s consisted of items such as hospital tents, an iron sectional hospital, a cooking hut, a cooking tent, and bell tents of army pattern.19 In 1891, on the prompting of the Royal College of Physicians of Edinburgh, 2° the Board belatedly addressed the problem of whether appointments should be full time or part time. They issued a circular which said that Counties should appoint duly qualified full-time M O s H (although they were prepared to countenance part-time appointments in the island counties of Orkney, Shetland and Bute), and that District Committees should use County staff. 21 Unfortunately, by the time the circular was issued, the first round of appointments had already been made but the Board tried to enforce this administrative action by distributing a small grant in a way which favoured those counties which had made full-time appointments. Throughout its history the Board might have been criticised for being too timid (although perhaps strictly correct) in avoiding any action which smacked of administrative policy making. When it did venture a modest step in this direction it got the timing wrong and it got itself thoroughly castigated in the House of Lords for daring to 'cripple the free will of those who have to administer the Local G o v e r n m e n t Act'. Although the Secretary for Scotland (a Ministerial post created in 1885) did not seem unhappy with what the Board had done, 22 the truth was that the Board's role did not sit easily with his responsibilities, and in 1894 it was replaced by the Local G o v e r n m e n t Board for Scotland which took account of the political changes which had taken place. These events set the scene for the formation in 1891 of the Society of Medical Officers of Health for Scotland. The first President was D r Littlejohn, the most senior M O H in Scotland. The Council included D r J.B. Russell, the M O H of Glasgow, who had been appointed in 1872 and was to succeed D r Littlejohn as President. The remainder of the Council consisted of recently appointed County MOsH. These included D r McVail of Stirling and D u n b a r t o n who has already been mentioned, and Dr J. McLintock of Lanarkshire who was one of a n u m b e r of Scottish graduates who had held public health appointments in England and had taken the opportunity to return to Scotland. H e was to become the first Medical M e m b e r of the Local G o v e r n m e n t Board for Scotland in 1894 but had to resign because of ill health in 1898 and died in 1901.25 The Treasurer was Dr Nasmyth of Fife and Clackmannan and the Secretary was D r A.C. Munro of Renfrew County who, like Dr McLintock, was a Scottish graduate who had gained experience as an M O H in England.
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The Society must have moved into action quickly. On 21 D e c e m b e r 1891 they sent a deputation to wait upon the Lord Advocate and made representations about the workings of the Scottish Public Health Acts. z3 Dr Littlejohn introduced the deputation. Dr McVail spoke about some of the problems in rural communities and then Dr Russell presented a memorial from the Society. This pointed to the stagnation in general sanitary legislation in Scotland. Attention was drawn to items of legislation in England which it was claimed might be extended to Scotland without opposition. Examples given related to the acquisition of vital statistics by Medical Officers of Health. The M O s H in Scotland were not content with general aggregations but wanted details of the location of births and deaths, occupations, etc. T h e y said that this was important knowledge which lay at the root of preventive action. So, the Society was pleading for better public health legislation in Scotland. The prospect of better legislation came with the publication in 1896 of the Public Health (Scotland) Bill which became the Act of 1897. The Journal Public Health was faint in its praise but it conceded that 'on the whole the Bill was an improvement on the Act of 1867'. Apparently the Society of Medical Officers of Health for Scotland had drafted a Bill and perhaps Public Health was disappointed that the published Bill was rather different, z4 The legislation from 1889 until 1897 brought public health in Scotland broadly into line with the developments which had taken place in England. The differences which remained had more to do with differences in administrative arrangements and legal systems than with the principles of public health itself. The time was now ripe for the M O s H in Scotland to become part of the Society of Medical Officers which had been formed in England in 1856, and the more senior ones became Fellows. z5 In 1896 a Scottish Branch of that Society was formed. The first President of the Scottish Branch was Dr McVail, and Drs Littlejohn and Russell were both members of the Council. These three were never far from the centre of public health activity in Scotland in the formative period during the 1890s. The other members of that first Council were Professor Hay of Aberdeen, Dr Mackenzie who had moved from Wigtown and Kirkcudbright to Leith, Dr Ross of Dumfries and Dr McNeill of Argyll. Dr Nasmyth continued as Treasurer and Dr Munro, who had masterminded the transition from the independent Society to the Scottish Branch, remained as Secretary. 2 In these early days M O s H were much involved with infectious diseases but even a perfunctory glance at the writings of the Scottish M O s H at that time reveals a broad range of concerns. D r McLintock of Lanarkshire set out the advantages of large hospitals over small ones and cited less cost per bed, lower management and nursing costs and greater efficiency because of a more p e r m a n e n t and thoroughly equipped staff. 26 Dr Mackenzie in Wigtown and Kirkcudbright was providing health education, and was organising 'a lantern mission' with appropriate technical slides. 27 Dr Ogilvie Grant of Inverness-shire commented on the long-standing shortage of doctors in the outlying Highland areas and advocated a G o v e r n m e n t grant to provide a minimum income of £200 apart from private practice. He said that there was ample provision for paupers, but for the class who were the most n u m e r o u s - - t h e very poor not on the parish--provision was sketchy and unreliable. 28 This perceptive analysis of the situation could be applied to some parts of the world even today. Academic public health in Scotland When the first generation of Scottish M O s H are considered as a group several
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features are immediately obvious. Edinburgh graduates were present in strength throughout Scotland and there was a reasonable number of Aberdeen graduates. Glasgow graduates were relatively few in number and were scarcely to be found outside Glasgow and its immediate surroundings such as Govan, Partick and Crosshill, which were then independent of the city. St Andrews University was also under-represented. Most of the MOsH had an MD and there was a reasonable sprinkling of gold medals and prizes. As might be expected most had a public health qualification, although this was not obligatory at the beginning of the 1890s. The two most popular qualifications were the BSc (and occasionally the DSc) which Edinburgh University introduced in 1874 and the Cambridge DPH which had been introduced in 1875. 29 There is no doubt that the preponderance of Edinburgh graduates in public health was due to the long-standing tradition of high-quality teaching of the subject in that university. Academic interest in public health began in Edinburgh in the later years of the 18th century. Andrew Duncan (Senior), Professor of Physiology, is said to have submitted a memorial in 1778 urging the introduction of a course on medical police and jurisprudence into the medical curriculum. 3° He delivered lectures on 'medical police' in 1791 which show that he was influenced by early continental thinking on public health. 7 His son Andrew Duncan (Junior) was appointed in 1806 to a new Regius Chair in Medical Jurisprudence at Edinburgh which had been established in spite of a certain amount of political difficulty because of suspicion at that time about ideas emanating from the Continent. 5 He was followed by W.P. Alison whose name is linked with the reform of the Poor Law in Scotland in 1845 and with opposition to Chadwick's public health reforms, which has perhaps not yet been fully understood. All this had happened before any other university in the United Kingdom had begun to concern itself with public health as an academic subject. Glasgow University introduced a DPH at quite an early stage and Regulations appeared in the University Calendar for 1876-77. However, few candidates presented themselves. This was unfortunate because of the potential for teaching in Glasgow in partnership with the City's Public Health Department under its highly respected MOH, Dr J.B. Russell. Later, in 1898, Professor John Glaister (Senior), a notable public health teacher, was appointed to the chair of Medical Jurisprudence which then included public health. Aberdeen University also provided a DPH from a fairly early date and was in a strong teaching position because of the presence of Matthew Hay as both Professor and MOH. Both of the Royal Colleges in Edinburgh and the Faculty of Physicians and Surgeons in Glasgow awarded Diplomas in Public Health. Conclusion
The 1890s were a critical period in the development of public health in Scotland. Medical Officers of Health became established throughout the country and the legislative framework was brought broadly into line with that in other parts of the United Kingdom. The stage was set for the developments of the 20th century. In looking back over the events of the 19th century there was remarkable progress in academic public health, particularly in Edinburgh, and relatively slow development of the public service. The activities under the aegis of the Board of Supervision are of great historical interest and Dr Littlejohn's prodigious efforts are a constant source of fascination, but perhaps that regime continued for too long. The alacrity with which
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the leading public health doctors in Scotland f o r m e d themselves into a Society in 1891 and pressed for changes in the public health legislation suggests that this was so. Their enthusiasm certainly gives us cause to r e m e m b e r 1891 and to try to understand the background to the events which took place around that time.
Note
This p a p e r is based on a talk given on 21 N o v e m b e r 1991 at the Annual Scottish Conference of the Faculty of Public Health Medicine at Dunblane.
References 1. 2. 3. 4.
5. 6. 7.
8. 9. 10. 11. 12. 13.
Medical Directory (1892). Public Health (1896). VIII 6, 190. Hansard (1848). 96, 3rd Series, Column 390. Craig, W. S. (1976). History of the Royal College of Physicians of Edinburgh. Oxford: Blackwell Scientific Publications, 201. White, B. (1988). Scottish doctors and the English public health. In: Dow, D. (ed). The Influence of Scottish Medicine. Carnforth: Parthenon Press. Public Health (1956). LXIX 8, 159. Brotherston, J. (1987). Scottish health services in the nineteenth century. In McLachlan, G. (ed.). Improving the Common Weal. Edinburgh: Edinburgh University Press. Spens, W. C. (1876). The Sanitary System of Scotland. Edinburgh: Edmonston and Douglas. Ferguson, T. (1958). Scottish Social Welfare. Edinburgh & London: E. & S. Livingstone, 170. Acheson, R. M. (1986). Three regius professors, sanitary science and state medicine. British Medical Journal, 298, 1602-1606. Ferguson, T. op. cit., 165. Ibid., 14. Chalmers, A. K. (1905). Public Health Administration in Glasgow. Glasgow: Maclehose & Sons, xv.
14. Scottish Record Office. Board of Supervision; Chairman's Minute Books (1857) (Public Health). HH 26 1-. 15. Scottish History Society (1988). Government and Social Conditions in Scotland 1845-1919, ed. Levitt, I. Edinburgh: Blackwood, Pillans Wilson. 16. Ferguson, T. op. cit., 401-402. 17. Rae, H. J. (1939). The Public Health Administration in Aberdeen. In: Rorie, D. (ed). The Book of Aberdeen. London: British Medical Association. 18. Macdonald, I. S. (1991). The origins of the Government's doctors in Scotland. Health Bulletin. 49/2, 118-134. 19. Ferguson, T. op. cit., 491-492. 20. Public Health (1890). III 8, 253. 21. Public Health (1891). III 11,342. 22. Hansard (1891). 356, 3rd Series, Column 1233. 23. Public Health (1892). IV 6, 175. 24. Public Health (1896). VIII 6, 190. 25. Public Health (1896). VIII 4, 1. 26. Ferguson, T. op. cit., 488. 27. Public Health (1893). V 12,384. 28. Ferguson, T. op. cit., 448-449.
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29. Acheson, R. M. (1987). The curriculum in state medicine and public health. Community Medicine, 9/4, 372-381. 30. Tait, H. P. (1974). A Doctor and Two Policemen. The History of Edinburgh Health Department. Edinburgh: Edinburgh Corporation, 229.
© The Societyof Public Health, 1992
The Society of Medical Officers of Health: a Scottish Centenary I. $. Macdonald, MD FRCPEd FFPHM (retired)
Introduction The Society of Medical Officers of Health for Scotland was formed in 1891.~ This was a Scottish body which was not initially part of the better known Society of Medical Officers of Health which had been formed in England in 1856. In January 1896 the Council of the Society in England formed a Scottish Branch, and the office bearers and Council of the Scottish Society became office bearers and Council of the Scottish Branch of the Society of Medical Officers of Health. 2 This coincided with the general convergence during the 1890s of the provisions for public health in Scotland with the longer standing provisions in England.
The Beginnings of Public Health Legislation The great Public Health Act of 1848 applied only in England and Wales. The Minister who introduced the Bill (Viscount Morpeth) explained that the Government intended to introduce similar Bills for Scotland and for Ireland. 3 A Scottish Bill was apparently drafted and a Committee of the Royal College of Physicians of Edinburgh commented on it. 4 In general terms the provisions of the Bill were welcomed by the College but the proposal which it evidently contained, that the central supervision of public health in Scotland was to be vested in the General Board of Health in London, was fiercely opposed. Nothing further seems to have been heard of the Scottish Bill, but perhaps there is more to be discovered about this episode. By 1855 there were Medical Officers of Health in 39 provincial towns and cities in England 5 and a major step was taken in that year when the Metropolitan local authorities were required to appoint Medical Officers of Health. It was this development which led to the formation of the Society of Medical Officers of Health in 1856. 6 The first steps in Scotland
In Scotland the first steps were taken in 1862 when Edinburgh appointed Dr H.D. Littlejohn as Medical Officer of Health and in 1863 when Glasgow appointed Professor W.T. Gairdner as part-time Medical Officer of Health. As there was still no general public health legislation for Scotland these appointments had to be made under local provisions.7 The absence of public health legislation which could be applied in Scotland caused increasing problems. The lawyers forced the issue because of difficulties in dealing satisfactorily in the courts with nuisances and insanitary situations. In 1867 Lord Advocate Gordon agreed to introduce a Bill which had been drafted by Sheriff Correspondence to: Dr I. S. Macdonald, 36 Dumyat Drive, Falkirk, FKI 5PA.
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Munro of Linlithgow. This became the Public Health (Scotland) Act 1867. 8 It was a competent piece of draftsmanship and is of interest because its origin lies outside the mainstream of British public health legislation. It placed central responsibility for the administration of public health in Scotland on the Board of Supervision which had been established in Edinburgh in 1845 to supervise the administration of the Poor Law in Scotland. The parishes which had local responsibility for the Poor Law became the local authorities for public health purposes. The Act gave powers to the local authorities to appoint sanitary inspectors and medical officers of health and indeed the Board could require such appointments to be made. Progress was, however, slow and perhaps the Board could have done more to stimulate the authorities to make such appointments. In fairness, though, it should be r e m e m b e r e d that the Board had to deal with over 1,000 authorities. 9 The population of most of them must have been very small. The problem of authorities which were too small for their purposes was to handicap public health for a long time. In 1868 Disraeli's Government decided to appoint a Royal Commission to enquire into public health matters. Its original terms of reference included Scotland and steps were taken to appoint members, including Professor Sir R o b e r t Christison of Edinburgh. However, Disraeli's G o v e r n m e n t fell at the end of 1868 and when the Royal Commission was finally established by Gladstone's G o v e r n m e n t in 1869 its terms of reference had been amended and Scotland was no longer included. 8,1° Nevertheless, Christison remained a m e m b e r and he, along with Gairdner of Glasgow and the Chairman of the Board of Supervision, gave evidence. The Board of Supervision had no health expertise. It consisted of a Chairman and two members appointed by the Crown, the Solicitor General for Scotland, the Sheriffs of Perthshire, Renfrewshire, and Ross and Cromarty, and the Lord Provosts of Edinburgh and Glasgow. li After the passage of the 1867 Act it made a hesitant start on public health t2 and in 1872 decided that it wanted to appoint D r Littlejohn, the M O H of Edinburgh, as a part-time medical officer at a salary of £200 a year. After a brisk battle with the Treasury, during which the Board had to point out that comparable bodies in London and Dublin were spending much larger sums on medical staff, consent was obtained s and in 1873 Dr Littlejohn began a remarkable period in his professional life. In 1873 there were only two Medical Officers of Health in S c o t l a n d - - D r Littlejohn in Edinburgh and Dr J.B. Russell who had succeeded Professor Gairdner in 1872 as the first full time M O H in Glasgow.13 D r Littlejohn was therefore called upon by the Board of Supervision to investigate and report on public health problems throughout almost the whole of Scotland. F r o m time to time, when an outbreak of infectious diseases would seem serious or persistent, or was not being handled competently, a note such as 'Dr Littlejohn to enquire and report' would appear in the Chairman's Minute B o o k (Public Health).14 That usually meant that he would visit the area and submit a report to a later meeting. Sometimes his reports were of major public health significance; at other times they revealed local mismanagement; occasionally they let us see whose heads needed to be knocked together. Not all of his reports can now be found but some have been made more accessible in a recent valuable study of the Board of Supervision and its successor from 1894, the Local G o v e r n m e n t Board for Scotland. 15 The other issue which was regularly referred to Dr Littlejohn was the approval of plans by the local authorities for the construction of fever hospitals. T h e r e was a spate of such proposals and he gave meticulous attention to each of them, even
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though many were very small hospitals in remote rural areas. As with many matters which came to the Board there are often revealing glimpses of other local issues. 14 The Board had a clear view that its role was an executive one, to ensure that the legislation was applied, and this was quite distinct from Dr Littlejohn's role which was to advise it. There is of course a deeper issue here, but the practical effect was that once Dr Littlejohn had made his report the Board set about ensuring that the local authority concerned implemented his advice, and woe betide any authority which did not do precisely what Dr Littlejohn had said that it should.14,15 The Public Health Act of 1875 required all local authorities in England and Wales to appoint Medical Officers of Health. In contrast, the general power available in the 1867 Act to appoint Medical Officers of Health in Scotland was used sparingly. Dr Littlejohn appears to have tried to encourage such appointments but he approached it rather delicately, perhaps because the Board showed little enthusiasm. Some appointments were certainly made, usually by Burghs which added part-time MO H responsibilities to the duties of the general practitioner who held the appointment to treat the sick poor. For example, Greenock appointed Dr Wallace sometime in the second half of the 1870s.16 Aberdeen took the important step of appointing their first MO H in 1879. This was Dr W.J.R. Simpson, who left in 1886 to become MOH of Calcutta and later completed a distinguished career in London. In 1888 the Town Council appointed Dr Matthew Hay, who was already Professor of Medical Jurisprudence at the University of Aberdeen, and he held both posts until he retired in 1923. He was to make many important contributions to public health in general and in Aberdeen and the North-east of Scotland in particular.17 Consolidation and progress
The next important development came with the Local Government (Scotland) Act of 1889 which established County Councils and County Districts within counties and required both to appoint Medical Officers of Health. Shortly after this the Burgh Police (Scotland) Act of 1892 required all towns to appoint Medical Officers of Health. Thus all local authorities, County and Burgh, had to appoint Medical Officers of Health. The major Public Health Act in Scotland remained, however, the Act of 1867. In the Counties there could be difficult relationships between the County M O H and the MOsH for districts unless the sensible step was taken of appointing the same individual. In the Burghs only the four cities were able to appoint full-time MOsH. Most of the Burghs, including numerous small ones, appointed a local general practitioner, usually the one who cared for Poor Law patients, as a part-time MO H at a small salary--often a very small salary. The problem of too many small authorities had not yet been overcome, although the number had been reduced from over 1,000 to 305. 9 During 1890 and 1891 the new County Councils proceeded to appoint their MOsH. Broadly speaking the larger counties each appointed a full-time MOH. Some of the smaller counties combined to share the services of a full-time MOH. Stifling and Dunbarton Counties joined forces to appoint Dr J.C. McVail who was, even then, one of the leading figures in public health in Scotland and later distinguished himself in the services of the Royal Commission on the Poor Law and of the National Health Insurance Commission for Scotland. Wigtown and Kirkcudbright appointed Dr W.L.
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Mackenzie. Later he was to be for 24 years the Medical M e m b e r of the Local Government Board for Scotland and its successor, the Scottish Board of Health, an appointment which might be seen as the predecessor of that of Chief Medical Officer in the Department of Health for Scotland when that was established in 1929.28 The very small county of Clackmannan combined with Fife; Banff, Moray and Nairn made a joint appointment; and West Lothian and Peebles attached themselves to the larger county of Midlothian. The 1889 Act was silent on whether M O s H had to be full time. The Counties of Orkney and Shetland, which consisted of island groups with very small populations, each appointed a part-time MOH. The County of Bute, which consisted essentially of the islands of Bute, Arran and Cumbrae, did the same. Three mainland counties-Forfar, Berwick and Haddington (later known as East L o t h i a n ) - - e a c h appointed a part-time M O H . Haddington appointed Dr T.F.S. Caverhill who had a consulting practice in Edinburgh and was also Surgeon-Major of the Lothian and Berwick Yeoman Cavalry. The latter appointment may explain why that county's provision for the treatment of infectious diseases in the early 1890s consisted of items such as hospital tents, an iron sectional hospital, a cooking hut, a cooking tent, and bell tents of army pattern.19 In 1891, on the prompting of the Royal College of Physicians of Edinburgh, 2° the Board belatedly addressed the problem of whether appointments should be full time or part time. They issued a circular which said that Counties should appoint duly qualified full-time M O s H (although they were prepared to countenance part-time appointments in the island counties of Orkney, Shetland and Bute), and that District Committees should use County staff. 21 Unfortunately, by the time the circular was issued, the first round of appointments had already been made but the Board tried to enforce this administrative action by distributing a small grant in a way which favoured those counties which had made full-time appointments. Throughout its history the Board might have been criticised for being too timid (although perhaps strictly correct) in avoiding any action which smacked of administrative policy making. When it did venture a modest step in this direction it got the timing wrong and it got itself thoroughly castigated in the House of Lords for daring to 'cripple the free will of those who have to administer the Local G o v e r n m e n t Act'. Although the Secretary for Scotland (a Ministerial post created in 1885) did not seem unhappy with what the Board had done, 22 the truth was that the Board's role did not sit easily with his responsibilities, and in 1894 it was replaced by the Local G o v e r n m e n t Board for Scotland which took account of the political changes which had taken place. These events set the scene for the formation in 1891 of the Society of Medical Officers of Health for Scotland. The first President was D r Littlejohn, the most senior M O H in Scotland. The Council included D r J.B. Russell, the M O H of Glasgow, who had been appointed in 1872 and was to succeed D r Littlejohn as President. The remainder of the Council consisted of recently appointed County MOsH. These included D r McVail of Stirling and D u n b a r t o n who has already been mentioned, and Dr J. McLintock of Lanarkshire who was one of a n u m b e r of Scottish graduates who had held public health appointments in England and had taken the opportunity to return to Scotland. H e was to become the first Medical M e m b e r of the Local G o v e r n m e n t Board for Scotland in 1894 but had to resign because of ill health in 1898 and died in 1901.25 The Treasurer was Dr Nasmyth of Fife and Clackmannan and the Secretary was D r A.C. Munro of Renfrew County who, like Dr McLintock, was a Scottish graduate who had gained experience as an M O H in England.
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The Society must have moved into action quickly. On 21 D e c e m b e r 1891 they sent a deputation to wait upon the Lord Advocate and made representations about the workings of the Scottish Public Health Acts. z3 Dr Littlejohn introduced the deputation. Dr McVail spoke about some of the problems in rural communities and then Dr Russell presented a memorial from the Society. This pointed to the stagnation in general sanitary legislation in Scotland. Attention was drawn to items of legislation in England which it was claimed might be extended to Scotland without opposition. Examples given related to the acquisition of vital statistics by Medical Officers of Health. The M O s H in Scotland were not content with general aggregations but wanted details of the location of births and deaths, occupations, etc. T h e y said that this was important knowledge which lay at the root of preventive action. So, the Society was pleading for better public health legislation in Scotland. The prospect of better legislation came with the publication in 1896 of the Public Health (Scotland) Bill which became the Act of 1897. The Journal Public Health was faint in its praise but it conceded that 'on the whole the Bill was an improvement on the Act of 1867'. Apparently the Society of Medical Officers of Health for Scotland had drafted a Bill and perhaps Public Health was disappointed that the published Bill was rather different, z4 The legislation from 1889 until 1897 brought public health in Scotland broadly into line with the developments which had taken place in England. The differences which remained had more to do with differences in administrative arrangements and legal systems than with the principles of public health itself. The time was now ripe for the M O s H in Scotland to become part of the Society of Medical Officers which had been formed in England in 1856, and the more senior ones became Fellows. z5 In 1896 a Scottish Branch of that Society was formed. The first President of the Scottish Branch was Dr McVail, and Drs Littlejohn and Russell were both members of the Council. These three were never far from the centre of public health activity in Scotland in the formative period during the 1890s. The other members of that first Council were Professor Hay of Aberdeen, Dr Mackenzie who had moved from Wigtown and Kirkcudbright to Leith, Dr Ross of Dumfries and Dr McNeill of Argyll. Dr Nasmyth continued as Treasurer and Dr Munro, who had masterminded the transition from the independent Society to the Scottish Branch, remained as Secretary. 2 In these early days M O s H were much involved with infectious diseases but even a perfunctory glance at the writings of the Scottish M O s H at that time reveals a broad range of concerns. D r McLintock of Lanarkshire set out the advantages of large hospitals over small ones and cited less cost per bed, lower management and nursing costs and greater efficiency because of a more p e r m a n e n t and thoroughly equipped staff. 26 Dr Mackenzie in Wigtown and Kirkcudbright was providing health education, and was organising 'a lantern mission' with appropriate technical slides. 27 Dr Ogilvie Grant of Inverness-shire commented on the long-standing shortage of doctors in the outlying Highland areas and advocated a G o v e r n m e n t grant to provide a minimum income of £200 apart from private practice. He said that there was ample provision for paupers, but for the class who were the most n u m e r o u s - - t h e very poor not on the parish--provision was sketchy and unreliable. 28 This perceptive analysis of the situation could be applied to some parts of the world even today. Academic public health in Scotland When the first generation of Scottish M O s H are considered as a group several
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features are immediately obvious. Edinburgh graduates were present in strength throughout Scotland and there was a reasonable number of Aberdeen graduates. Glasgow graduates were relatively few in number and were scarcely to be found outside Glasgow and its immediate surroundings such as Govan, Partick and Crosshill, which were then independent of the city. St Andrews University was also under-represented. Most of the MOsH had an MD and there was a reasonable sprinkling of gold medals and prizes. As might be expected most had a public health qualification, although this was not obligatory at the beginning of the 1890s. The two most popular qualifications were the BSc (and occasionally the DSc) which Edinburgh University introduced in 1874 and the Cambridge DPH which had been introduced in 1875. 29 There is no doubt that the preponderance of Edinburgh graduates in public health was due to the long-standing tradition of high-quality teaching of the subject in that university. Academic interest in public health began in Edinburgh in the later years of the 18th century. Andrew Duncan (Senior), Professor of Physiology, is said to have submitted a memorial in 1778 urging the introduction of a course on medical police and jurisprudence into the medical curriculum. 3° He delivered lectures on 'medical police' in 1791 which show that he was influenced by early continental thinking on public health. 7 His son Andrew Duncan (Junior) was appointed in 1806 to a new Regius Chair in Medical Jurisprudence at Edinburgh which had been established in spite of a certain amount of political difficulty because of suspicion at that time about ideas emanating from the Continent. 5 He was followed by W.P. Alison whose name is linked with the reform of the Poor Law in Scotland in 1845 and with opposition to Chadwick's public health reforms, which has perhaps not yet been fully understood. All this had happened before any other university in the United Kingdom had begun to concern itself with public health as an academic subject. Glasgow University introduced a DPH at quite an early stage and Regulations appeared in the University Calendar for 1876-77. However, few candidates presented themselves. This was unfortunate because of the potential for teaching in Glasgow in partnership with the City's Public Health Department under its highly respected MOH, Dr J.B. Russell. Later, in 1898, Professor John Glaister (Senior), a notable public health teacher, was appointed to the chair of Medical Jurisprudence which then included public health. Aberdeen University also provided a DPH from a fairly early date and was in a strong teaching position because of the presence of Matthew Hay as both Professor and MOH. Both of the Royal Colleges in Edinburgh and the Faculty of Physicians and Surgeons in Glasgow awarded Diplomas in Public Health. Conclusion
The 1890s were a critical period in the development of public health in Scotland. Medical Officers of Health became established throughout the country and the legislative framework was brought broadly into line with that in other parts of the United Kingdom. The stage was set for the developments of the 20th century. In looking back over the events of the 19th century there was remarkable progress in academic public health, particularly in Edinburgh, and relatively slow development of the public service. The activities under the aegis of the Board of Supervision are of great historical interest and Dr Littlejohn's prodigious efforts are a constant source of fascination, but perhaps that regime continued for too long. The alacrity with which
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the leading public health doctors in Scotland f o r m e d themselves into a Society in 1891 and pressed for changes in the public health legislation suggests that this was so. Their enthusiasm certainly gives us cause to r e m e m b e r 1891 and to try to understand the background to the events which took place around that time.
Note
This p a p e r is based on a talk given on 21 N o v e m b e r 1991 at the Annual Scottish Conference of the Faculty of Public Health Medicine at Dunblane.
References 1. 2. 3. 4.
5. 6. 7.
8. 9. 10. 11. 12. 13.
Medical Directory (1892). Public Health (1896). VIII 6, 190. Hansard (1848). 96, 3rd Series, Column 390. Craig, W. S. (1976). History of the Royal College of Physicians of Edinburgh. Oxford: Blackwell Scientific Publications, 201. White, B. (1988). Scottish doctors and the English public health. In: Dow, D. (ed). The Influence of Scottish Medicine. Carnforth: Parthenon Press. Public Health (1956). LXIX 8, 159. Brotherston, J. (1987). Scottish health services in the nineteenth century. In McLachlan, G. (ed.). Improving the Common Weal. Edinburgh: Edinburgh University Press. Spens, W. C. (1876). The Sanitary System of Scotland. Edinburgh: Edmonston and Douglas. Ferguson, T. (1958). Scottish Social Welfare. Edinburgh & London: E. & S. Livingstone, 170. Acheson, R. M. (1986). Three regius professors, sanitary science and state medicine. British Medical Journal, 298, 1602-1606. Ferguson, T. op. cit., 165. Ibid., 14. Chalmers, A. K. (1905). Public Health Administration in Glasgow. Glasgow: Maclehose & Sons, xv.
14. Scottish Record Office. Board of Supervision; Chairman's Minute Books (1857) (Public Health). HH 26 1-. 15. Scottish History Society (1988). Government and Social Conditions in Scotland 1845-1919, ed. Levitt, I. Edinburgh: Blackwood, Pillans Wilson. 16. Ferguson, T. op. cit., 401-402. 17. Rae, H. J. (1939). The Public Health Administration in Aberdeen. In: Rorie, D. (ed). The Book of Aberdeen. London: British Medical Association. 18. Macdonald, I. S. (1991). The origins of the Government's doctors in Scotland. Health Bulletin. 49/2, 118-134. 19. Ferguson, T. op. cit., 491-492. 20. Public Health (1890). III 8, 253. 21. Public Health (1891). III 11,342. 22. Hansard (1891). 356, 3rd Series, Column 1233. 23. Public Health (1892). IV 6, 175. 24. Public Health (1896). VIII 6, 190. 25. Public Health (1896). VIII 4, 1. 26. Ferguson, T. op. cit., 488. 27. Public Health (1893). V 12,384. 28. Ferguson, T. op. cit., 448-449.
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29. Acheson, R. M. (1987). The curriculum in state medicine and public health. Community Medicine, 9/4, 372-381. 30. Tait, H. P. (1974). A Doctor and Two Policemen. The History of Edinburgh Health Department. Edinburgh: Edinburgh Corporation, 229.
