Contrasting versions of Medical Police,the forerunner of Public Health,in Edinburgh in the early 19th century

Different visions of Medical Police in Edinburgh in the 19th century

The idea that nations benefited from a healthy populace was one undoubted consequence of the Enlightenment and the utilitarian position that emerged from it. The investment of the nation in the health of its population, through state-sanctioned health policy was considered good sense, since the economic value of any person to the state was increased by good health. At the individual level, good health added to a personal sense of well-being and happiness, both goals of the Enlightenment. Achieving these laudable aims required a coordinated approach, known nowadays as Public Health. This paper describes two very different approaches to this issue that arose in Edinburgh at the turn of the 19th century.

Professor Andrew Duncan, Senior (1744–1828) and Dr John Roberton (1776–1840) were Edinburgh medical figures who both thought and wrote about Medical Police, the forerunner of Public Health. At this time ‘police’ meant ‘policy’ and was related to health policy and was not concerned with our modern notions of a constabulary which enforces the law with a view to preventing criminal activity. Duncan and Roberton were influenced in different ways by Dr Johann Peter Frank (1745–1821), a true pioneer in Public Health who had written extensively on a German form of Medical Police ¹ and each had developed very contrasting approaches. This paper describes the very different characters and styles of Duncan and Roberton and their separate contributions to the Scottish version of Medical Police and eventually the science of Public Health. Duncan, a highly respected and influential figure in Edinburgh medicine, played by far the most important role in defining a Scottish version of Medical Police. Roberton, controversial in both his writings and his interactions with other members of the medical profession, was much less influential than Duncan but nevertheless did have some impact.

Professor Andrew Duncan and his form of Medical Police

Professor Andrew Duncan (Figure 1) was born near St Andrews, graduating MA from St Andrew University in 1762 and enrolling in Edinburgh University as a medical student in the same year. He was appointed to the Chair of the Institutes of Medicine, equivalent to physiology, at the University of Edinburgh in 1790. ² Duncan first delivered a lecture course at Edinburgh University in 1792, entitled Medical Jurisprudence or the Institutiones Medicinae Legalis the summary of which was published as the Heads of Lectures. ³ This ground-breaking course, containing a section on Medical Police, played a significant role in instigating the legal context of medicine in government decision-making. Thereafter, medicine in the legal context was taught as a formal subject in Scottish Medical Education. The Heads of Lectures contained the first published mention of Medical Police in the UK context and in the English language and as such is the first description of what eventually became Public Health. In the Heads of Lectures, Duncan described the functions of Medical Police, presaging its evolution into Public Health, as:

Not unfrequently, their (i.e. medical Doctor's*) advice becomes requisite for authorising the effective government, to adopt necessary and salutary measures, for the preservation of health and the prevention of disease. ³ (*Author's brackets)

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Figure 1.

Dr Andrew Duncan. (This image was obtained from the Wellcome Collection. Creative Commons Attribution (CC BY 4.0) terms and conditions https://creativecommons.org/licenses/by/4.0.)

In his approach to the issue of Medical Police, Duncan was greatly influenced by the German Johann Peter Frank (1745–1821) and paid frequent tribute to him. Frank put forward his concept of Medical Police in a huge six-volume, 6262-page work System Einer Vollstandigen Medicinischen Polizey or A Complete System of Medical Police written between 1779 and 1819. ¹ Frank's German model for Medical Police is draconian from our modern viewpoint, being comprehensive and highly intrusive into the lives of the populace and therefore required underpinning by a wide-ranging legal framework, but was never brought into full force. It is impossible to summarise Frank's magnum opus here but some idea of its breadth can be provided. It included some early attempts at eugenics by virtue of regulation regarding pre-marital medical examination, the banning of marriage between people of very different ages and the banning of marriage for ‘imperfect people’ such as ‘cripples, stunted or dwarfish persons’. There were also laws relating to sexuality, celibacy, pregnancy, unmarried mothers, extramarital procreation, alcohol intake, abortion and venereal disease. General regulations also sought to prevent alcoholism and prostitution, and there were wide-ranging rules for the promotion of proper dress as well as personal and environmental hygiene. Education, house design and the medical profession at all levels were also to be regulated. ⁴ This required a large body of law and a system for their enforcement. In fact no German state ever enacted laws along the lines required to fully realise the principles of a Medical Police as conceived by Frank. This form of Medical Police, involving large-scale intervention into the lives of the populace (what would have been in fact actual ‘policing’), required what White describes as ‘administrative absolutism’, ⁵ the political doctrine of unrestricted, centralized authority as conferred by a monarch or dictator.

From his position as an establishment figure holding a powerful Chair in the University of Edinburgh, and influenced by Frank, Duncan lobbied for the first Chair of Medical Jurisprudence and Medical Police in the University of Edinburgh in 1798. He did this by writing and circulating a Memorial, ⁶ which contains a full prospectus of what Duncan envisaged as a Scottish form of Medical Police. A Regius Chair of Medical Jurisprudence and Medical Police was eventually established by Edinburgh University in 1807, ² the first Chair of its kind in the English-speaking world and Duncan's son, Andrew Duncan Junior (1773–1832), was the first incumbent of the Chair.

Duncan Senior's debt to Frank is clear and he wrote in the Memorial ‘It was reserved to the philanthropic FRANK: to collect the whole [*concept of Medical Police] into one vast and beneficent system’ ⁶ (*Author's brackets).

However, although Duncan acknowledged his debt to the work of Frank in the Memorial, administrative absolutism was not to be found in 19th century Scotland, nor indeed at any other time. Subsequently, his Scottish version of Medical Police as laid out in the Memorial states bluntly that Medical Police that suits one country will not necessarily suit another: ‘Public medical institution and the laws must be adapted to the country for which they are intended’. ⁶

In the Memorial, Duncan also lists the areas of relevance to a Scottish Medical Police which include; policy to ensure the purity of air, water, food and drink and recommendations regarding clothing and hygiene. He also recommends that the policy should extend to healthy propagation, pregnancy and care of the newborn. Also embraced are accident prevention, contagious and epidemic disease and the organization of hospitals including hospitals for the insane. It is important to emphasise that this was to be achieved, where possible, without recourse to law.

Instructing the people and convincing them of certain precautions and attentions in regard to their own and the general state of health are necessary to secure the good effects of our public institutions and regulation; to obtain respect and obedience in many things to which no express law can be adapted. ⁶

Subsequently, Andrew Duncan's Scottish version of Medical Police was in keeping with the general lack of state intervention in the lives of the Scottish population and the broadly laissez-faire environment of post-enlightenment Scotland. Referring to Medical Police in the Memorial therefore Duncan could state that ‘These good effects are not to be promoted so much by rigid laws as by recommendation and example’. ⁶

Dr John Roberton and his form of Medical Police

John Roberton (Figure 2) was a very different character to Andrew Duncan Senior and far from being an establishment figure, he was a transgressive and maverick one. Roberton was born in Hamilton, Lanarkshire of humble parents and he seems never to have gained any formal medical qualifications. ⁷ His career constantly courted scandal and notoriety through his publications on genito–urinary physiology, venereal disease and female beauty and his acrimonious disputes with other members of the medical fraternity in Edinburgh and London. ⁷ In 1809, Roberton published his book, with its very long title

Treatise on medical police, and on diet, regimen, &c: in which the permanent and regularly recurring causes of disease in general, and those of Edinburgh and London in particular, are described; with a general plan of medical police to obviate them, and a particular one adapted to the local circumstances of these cities. ⁸

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Figure 2.

Dr John Roberton. (This image is freely available from the Wellcome Collection Image Number M001453) under Creative Commons Attribution (CC BY 4.0).)

This represents the first published textbook dedicated to the subject of Medical Police in the English language.

Roberton's A Treatise on Medical Police, ⁸ is a long and rambling exposition, containing the thoughts of the author, poetry, arcane history, folklore and anecdote, all peppered with quotations from Shakespeare and others. It covers much of the same ground as Duncan's Medical Police but in a far more wordy and rambling way. Neither Duncan nor Frank nor indeed any other sources are cited even though Roberton clearly leaned extensively on them. So despite its long and rambling nature, White ⁷ concludes that: ‘Whilst the bulk of the Treatise therefore confirms Roberton's eclecticism, it added nothing to the known stock of scientific medical thought’.

Much of the Treatise is not about Public Health but is overtly clinical, given over to descriptions of diseases, including his opinion of their origins (mostly miasma), the symptoms and the best treatments. When he does address Public Health, he is overwhelmingly informed by his strong belief that disease is caused by miasma. that is, gases emerging from filth and decaying organic matter. For such a miasmatist, the sanitarian approach of cleansing air, water and the environment generally, provides a solution which should eliminate disease. His treatise contains extensive sections regarding the role of miasma and its relation to poverty, building design and overcrowding. He also has sections on diseases of occupation and diseases caused by ‘modes of living’, such as the ‘luxurious lifestyle’. Roberton's sanitarian version of Medical Police, with its emphasis on cleanliness, can be seen as an early preventative approach. Aimed at reducing the production of, or exposure to, miasma, he believed this approach would eradicate disease and so had the power to eliminate the need for hospitals: ‘There can be no doubt that were the legislature to give that attention to the removal of the causes of disease which they ought, to the necessity of hospitals, fever houses etc would easily be dispensed with’. ⁸

Enactment and enforcement of the requisite laws were central to Roberton's version of Medical Police, including the suggestion that ‘A series of plain and obvious instructions for the poor, in particular, should be drawn up, and left in every house, and a punishment inflicted for inattention to them’. ⁸ Enforcement of this rather severe-sounding system would have entailed an army of medical inspectors and councils of health to be appointed in Scottish cities, whose aim would be to enforce sanitary regulations. He thus firmly believed that an extensive legal framework for regulating Medical Police was essential, since the state-appointed inspectors would need to enter homes and premises and interfere in people's lives. Roberton was conscious of the likely impact that such draconian laws and interference in their lives might imply and so states that the ‘lower orders in particular’ be persuaded that – ‘it was not by the iron rod of oppression that they were to be swayed, but by the soft and persuasive advice of friendship’. ⁸

Roberton's model sits somewhere between Duncan and Frank as regards the need for legislation and enforcement, implying much more than Duncan but still much less than Frank.

Conclusion

Although both Duncan and Roberton were under Frank's influence, each had a very different vision for the future of Public Health in Scotland and the UK. Duncan championed and finally secured the Regius Chair of Medical Jurisprudence and Medical Police at Edinburgh University, the first Chair in Legal Medicine in the English-speaking world. By installing his son in that Chair and by teaching his pioneering course on ‘Institutiones Medicinae Legalis’, Duncan's legacy passed on and flourished. His form of Medical Police depended on education and self-interest with minimal regulation and was in keeping with social attitudes in post-enlightenment Scotland and the developing roles of local councils in sanitation. The Regius Chair of Jurisprudence and Medical Police in Edinburgh eventually divided into the Chair of Public Health and a Chair of Forensic Medicine in 1898. The first incumbent of the new Chair of Public Health was Charles Hunter Stewart (1854–1924).

Roberton's focus was almost solely on miasma and the elimination of its sources and had aspects that seem extreme, for example, demolition of houses considered unfit. However, he advanced some novel and creative solutions, such as ‘armies’ of inspectors and a programme of taxation to pay for it and he championed the notion of disease prevention. In the end, however, his approach was too interventional for 19th century Scotland, where local authorities were taking on sanitarian roles including sewage management and housing control, which were crucial parts of Roberton's Medical Police.

Roberton's maverick tendencies finally overwhelmed him and he was expelled from the Edinburgh Medical Society for writing obscene remarks on voting papers and writing offensive letters to the society. ⁷ This effectively ended his career in medicine in Edinburgh and he left for London in 1810, the year after publication of his book. He never again published on the topic of Medical Police or lectured on the topic. In London, he focused on his best-selling book On Diseases of the Generative System, ⁹ with its sensational content, explicit illustrations and its association with the pornographer/publisher John Joseph Stockdale (1750–1814). Roberton's marginalisation by the London medical establishment was inevitable and his outsider status was not helped by his subsequent book Kalogynomia, or the Laws of Female Beauty, ¹⁰ written under the pseudonym T Bell; Kalogynomia has been described as a sex manual. ¹¹

The motivation for Roberton's venture into Medical Police is puzzling as he had never published or lectured on this topic before his book and never did again. White ⁵ has suggested a ‘personal consideration’ in that Roberton, as a minimally qualified medical practitioner, may have seen for himself a career as a member of the force of inspectors that his book recommended to enforce his Medical Police in Edinburgh and London. Roberton's treatise did meet with some success and went into a second edition but in the end, his version of Medical Police was too interventional and heavy-handed for post-enlightenment Scotland. Even though Roberton was the first to address the nature of Medical Police in a book in the English language, he has faded from view although his contribution to Medical Police has been re-evaluated more favourably in recent years, while not escaping criticism.^7,12