Peter N.

Stearns

Professionalism and Bureaucracy: English Doctors and the Victorian Public Health Administration Author(s): Steven J. Novak Source: Journal of Social History, Vol. 6, No. 4 (Summer, 1973), pp. 440-462 Published by: Peter N. Stearns Stable URL: http://www.jstor.org/stable/3786510 Accessed: 10/08/2010 14:26
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STE VEN J. ,V0 VAK

PROFESSIONALISM AND BUREAUCRACY: ENGLISH DOCTORS AND THEVICTORIAN PUBLIC HEALTH ADMINlSTRATION

U ntil recently, England's nineteenth-centuryrevolution in governmenteluded historicalanalysis.The difficultywas not to trace the beginningsof the changebut ratherto explain how and why the proliferation of bureaucratic government happenedas it did.l In the work of Oliver MacDonaghand his followers, historians found answers to these questions.2 But while many historiansembracedMacDonagh's conclusionsas a new historical orthodoxy, certainambiguities in his work remainedunexplored. MacDonagh's belief that the evolution of bureaucracies followed an inherentpatternof development, an internallogic, regardless of external influences, implied that all bureaucracies are essentially alike and all bureaucratsare simply the passive agents of an irresistibleprocess. The revolution in governmentwas thus reduced to a mere evolution.Sincethe followingessaydepartsom this interpretationand offers an alternativeapproach,a slightly moreextendedanalysisof MacDonagh's thesisis required. Seeking to ullcover the practical functioning of government administration,MacDonaghchose the PassengerActs for study becausethey were an isolated example.He justified this in words which bear repeatingfor the conceptualassumptions they reveal:

Mr. Novak is a graduate student in history at the University of California, Berkeley. He wishes to thank his teacher, Sheldon Rothblatt and he must also acknowledge Jean Peterson for discussing jointly her doctoral dissertation on the Victorian medical profession.

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Important for the purpose of a case study, emigrant protection is a comparativelysimple and unadulteratedsubject. No Wilberforce or Shaftesbury, no Chadwickor Trevelyan,directed its reform.... No jealous local authority or powerful trade society succeeded here in holding back the tide of centralizationand official regulation. All this makes it possible for us to study the indigenous development of governmentin as 'pure' and uncomplicated a state as is likely to be found.3

Clearlyhe was tryingto distill the essenceof bureaucracy from the accidentalinfluence of external factors, trying to discoverwhat might loosely be calledthe idealtype of bureaucracy. He regarded this type not as an abstraction-asa sociologistwould-but rather as the essentialreality of bureaucracy divorcedfrom its accidental qualities.4 This core of bureaucracy was not only self-sufficient but also self-propelled.
Administrationmay be, so to speak, creativeand self-generating. It may be independent, not in the sense of congealinginto forms, but in the sense of growing and breaking out in character and scope. It may gather its own momentum;it may turn unexpectedly in new directions;it may reachbeyond the control of anyone in particular.5

If MacDonaghmeant only that change was sometimes unplannedand random,his assertionwouldgo unchallenged. But this was a descriptionnot so much of how bureaucracy grewbut why it did. Bureaucratic growth was not randomat all, he maintained, but followed a five-stagemodel which underlay all of English centralization. The first stagewas simplythe passage of a remedial legislative act in responseto the exposureof a socialevil. Such acts were invariably ineffectual;hence, at the second stage, inspectors were appointed to enforce the law. At this point the process assumed its own momentum. To tighten loopholes?inspectors created an administrativeboard to centralize and strengthen control. As enforcementcontinuedto be ineffective,government officers realized that the social evil could not be correctedonce and for all but requiredflexible and continuousregulation.This realization was the fourth stage when "in place of a static and purely executive, they developed a dynamic? creativeand expert concept of administration."6 Duringthe fifth stage this dynamic outlook was expressed:"Therewas now small concernabout the multiplication on controls. As needs arose, they were simply

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satisfied-in so far as legislationor instructionsmight serve this purpose."7 The most importantaspect of MacDonagh's explanationis that bureaucratic growth is seen as continuousand almost inevitable. Once the processwas set in motion, it followed the contoursof its own internal logic. The telos of the process was progress. "Through it all ran what might be termed contingentnecessity,the 'contingent' being if emigrantprotection [in general, social melioration] were to be realized."8 Since illspectors were the agentsof this realizationand the shapers of the bureaucracies, it is important to recognize their motives and viewpoints.After all, men disagreeon what constitutes progressalld how it is to be achieved. For MacDonagh,however, such disagreementwas irrelevant. Progressand administrationwere straightforward and obvious;his bureaucrats were faceless.
In fact, the whole process required little more than that men should have reacted reasonably intelligently to established facts, and with reasonable compassionfor the sufferingof others.... It is a safe assumptionthat things fell out in essentiallythe same fashionin many other areasof life.9

Should MacDonagh's thesis be acceptedunreservedly, this field of research will be narrowand dry indeed. That the tendency of this theory is to standardize all bureaucraciescan be seen in the work of Roy M. McLeod,whose study of air pollution inspectors reinforced all of MacDonagh'sconclusions,includingthe "now familiar legislative and administrative sequenceof growth.''l By treatinghis scientistsas merebureaucrats,McLeodmissed the opportunityof discovering what impact their professionalidentity had on their behavior.This oversight was due to the common mistakeof regarding science as a purely objective and disinterested authority. MacDonaghmentioned science only briefly: it was the authority"overwhichthere could be no argument" called in to answer technical questions.l1 Another historian, David Robertsl has treated science as an irresistibleforce: "Each new [scientific] advancenot only made reformpossiblebut made it all the more necessary.''l 2 And even one as skillful in probingbeneath broadgeneralities as G. Kitson Clark wrote of "the unimpeachable voice of science.''1 3 These men committedthe commonfallacyof misplacedconcreteness by

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treatingthe abstractionscience as thoughit were a physicalentity which could act in its own nght. Science is an ideal, a value, but scientistsaremortalswith theirown intereststo pursue. By studyinghow such a mixed motivationspurredthe medical profession'sinvolvementin England'spublic health administration, one can discoverthe impactof professionalism on the course of bureaucratic growth and test the applicabilityof McDonagh's model. It seems entirely natural, of course, for doctors to be concernedwith health, especiallyin a period when their inability to cure disease made it imperative to prevent it. Prevention requiredknowledgeof living conditions,and the facts uncovered by investigators stirredEngland'ssocial conscience.One historiall, in an attempt to explain the medical profession's"passionate advocacy" of public health, has stressedthe great number and influenceof doctors who weregraduates of Edinburgh University, where medicalproblemswere set in a broad social setting.'4 But while the idealism implanted by such education should not be discounted, it does not explain why doctors were not content to pursuetheir investigations and improvements at the local level or why their attention was often more directed to administrative politicsthan the everydaymattersof diseaseprevention. Previous writers have failed to appreciate that the medical professionlooked to public health for a chance to enter the civil service.1 5 Medical journalsspoke quite franklyof publichealthin these terms. "Is the profession. . . preparedto see its position in the civil service of the State reduced to a mere negation?We unhesitatinglyanswer, No.''l 6 There were two reasons for this interest in civil service.First, like any professionalbody or trade union, the medical professionhad to provide sufficient employment for its members,a need which may have been enhancedby changes in English society. One historian has contended that middle-class educationin VictorianEngland expandedmucil faster than opportunitiesfor suitable employment,producingfear of a glut in the professions.l7 Whetheror not this apprehension was well founded, it sparkeda rivalryamong professionalsfor positions of public service. Second, the factor which will be emphasized in this paper, doctors were interested in the civil service because they believed that state employment would raise the social statusof the entiremeRical profession.

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At least since 1823, whenThomasWakely foundedTheLancet, the most militantvoice in the cause of professional advancement, doctors had been acutely sensitiveabout their position in English society. Wakelywas angeredto think that the profession) "though armedwith the most righteouscausethat evernerveda greatbody of scientific men^" produced"no feeling of fear or apprehension in the mindsof its enemies."This was becauseof the profession's "meeknessand humility under oppressionX because of the dischordant opinions which its members ilave professed among themselves,-because,in a word, it is not true to itself.''1 8 Less than a decade later anotherorganization was founded,the British MedicalAssociation, and shortly thereafter its publicationThe BritishMedicalJournalS both dedicated to the "Maintenance of the Honourand Respectability of the Profession." Status anxiety was also reflected in the continuousdebateover medical education. Lyon Playfair,an M.P.with medicaltraining, complainedin 1874 that there was a "prejudice againsttechnical knowledge"in Englishsociety. "Thisdistrustof doctorsin higher administration," he said, "is simply a generalmistrustof science. And the time has now arrivedwhen science must be trusted in government.''1 9 Others reasoned that rather than change the prejudicesof English society, doctors would have to acquirethe traditionalliberaleducation before being acceptedas gentlemen. "I can see no reason,"wrote Dr. C.E. Prior,';that the amountof classical, mathematical,and historical knowledge required for entranceupon professionalstudies should be less than the moder ate demandsof our universitiesat matriculation."2 In order to achieve what one historian has described as "the protessional ideal," doctors had to stress their duties to the public and the generalvalue of their training ratherthan theirpecuniary interests or the fact that they were specialists who sometimesworkedwith their hands.2 1 But the pecuniary interests were nonetheless present. The Lancet condemned physicianswho allowed their namesto be used in drugand corsetadvertisements and asked"in allseriousness, . . . how can we expect the publicto recognizethe profession by right, as a body of educated gentlemennif we reduceourselvesto nothing better than a set of touting tradesmen?'2 2 This struggle for upward mobility was a constant preoccupation of doctorsin the nineteenthcentury.

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Such status anxiety was not limited to the medicalprofession. VictorianEnglandwas undergoinggreat social changesand men 3 were obsessed with the problem of ascribing social status.2 Thoughthe medicalprofessionmay have been risingon the social and scale,it was still in an inferiorrelationto the other professions its progressmay have been slower than the others. In 1859 the Review ranked the different professionsand put Contemporary the clergy, the bar and the militaryon top; medicinewas lower 4 The reasondoctors looked becauseit never led to-the to civil service to raise their status was that connectionwith the state was one of the surest signs of a profession'ssocial emithat the highestprofessions nence.25 There wasgeneralagreement were those regulated by law and protected from unqualified competition. A writer in 1857 noted that the highest positions went to professions"moreor less connectedwith the state"whose 6 And in 1880 another "importanceis recognizedby the observerexplained that "the professions in Englandare valued their influence, to their stability,theirremunerativeness, according 7 and theirrecognitionby the state."2 One sign of recognitionwas state regulation.Here the doctors did not fare too successfullyas it took yearsfor medicalreformers to get minimumstandardsenacted for the profession.If Parliament was not enthusiastic about such an act, neither was it particularlyopposed. After years of delay caused by divisions within the profession,a MedicalAct was finally passedin 1858. The precedentof the act was more importantthan its provisions. It did not bar the practice of quacks but only set up a Medical for doctors Councilwhich could establishminimumrequirements who wishedto be listed in the MedicalRegister.The Councilcould also suggest educational improvementsto the medical schools. Whilethe act was probablynot responsiblefor raisingthe level of to the medicaleducation,it did have a greatsymbolicimportance doctors by suggestingmedicine'sincreasinglyimportantplace in society. A more substantialmeans of recognition was through state employment.Therewere doctorsin the armyand navy,of course, but the professionaljournals felt that these were treated with "unworthy disregard and disrespect. . . contumely and in8 There were physicians to the Royal Family, but justice."2
peerage.2 law."2

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doctors complainedthat these were neverrewarded with a seat ill the Lordsbut at best with mereknighthoods. An exampleof how thoughtlesslythe governmentcould slight the professioncame as late as 1897 when Salisbury,who hadjust madeDr. JosephLister the first medical Lord, explained that this was for his scientific attainments ratherthanhis medicalservices. Thus, entranceinto the civil servicethroughthe public healti bureaucracy meant much more to doctorsthan an opportunityto improveEngland's health. To furthertheir cause, doctors formed pressuregroups such as the Epidemiological Society (1850) tlle Society of MedicalOfficersof Health(1856) and the morewidely based Social Sciences Association (1857), which kept the profession in the thick of gover1lment debate by espousingtlle cause of publichealth. The impact of this professionalism on the publichealthbureaucracy bears little resemblanceto the processesin lMacDonagh's isolated case study. For public health was controversialand bitterly contested, and its progresswas halting alld uncertain. From the doctors' point of view, the bureaucracy went through three stages: (1) from 1848 to 1854, when they struggledfor entranceinto the bureaucracy; (2) from 1854 to 1871, when they enjoyed a virtualmonopoly in one areaof public health;and (3) the years after 1871, when tlley lost their dominance of the administration but wereeventuallyable to securelegislationwhich insured their place ill the civil service. Rather than evolving according to its own internal logic, then, the public health bureaucracywas the result of the manipulationof the medical professiolland was hence a distinctphenomenon, not just another exampleof MacDonaghSs five-stage patternof growth. Ooctors played a significant,though alwayssecondary,role in the origins of the public health administration. Two utilitarian physicians,Dr. Neil Arnott and Dr. Southwood Smitll, headed Chadwick's1838 Poor Law Commission on the relationbetween povertyand disease,while Dr. William Farrprovided accuratedata for the study of disease. But it was Chadwick himself who dominatedthe beginnings of the publichealthbureaucracy. EdwinChadwickwas a criminallawyer by training. He became an intimate friend of leremy Benthambecauseof tlleir common belief that wise legislationwould bringsocial progress. Chadwick

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had long been interested in the causes of diseaserand his first published essay dealt with the French statistician Villerme's theory that health was directly determinedby living conditions. Chadwick reproduced this theory in his 1842 publication of VictorianEngland'smost famous blue book, the Report on the Population.Herehe set forth SanitaryConditionof the Labouring the pythogenictheoryof zymotic disease.
Various forms of epidemic, endemic, and other disease [are] caused, or aggravated,or propagatedchiefly amongst the labouring classes by atmospheric impuritiesproducedby decomposinganimaland vegetablesubstances, by damp and filth, and close and overcrowdeddwellings.... Wherethose better ventilation, circumstancesare removed by drainage,proper and other means of diminishingatmosphericimpurity, the frequency and intensity of such disease is abated; and where the removal of the noxious agenciesappearsto be complete, such diseasealmost entirely disappears.29
cleaning5

This report promptedSir Robert Peel to set up a Royal Commission on the Health of Towns which ultimately led to England's firstpublichealthact in 1848. There was nothing exceptional about Chadwick'stheory of who disease.The way in whichhe appliedit, however,determined Though Chadwick should be included in the new bureaucracy. held many learnedprofessionsin contempt his greatestanimus was reserved for medicine. He saw doctors' efforts as mere obstructionsto the principlesof health. Hence, when the new was limited was set up, the role of medicalinspectors bureaucracy to ascertainingcause of death in order to provide accurate statistics.No doctor sat on the Boardof Health.Chadwickrelied instead on engineersto dispose of sewage and to provide clean water. "The chief remedies," he wrote in 1842, consist in of which medicalmen of the scienceof engineering, "application know nothing." To another he confided, "aid must be sought from the science of the Civil Engineer, not from the physi cians."3 Doctors were acutely consciousof their exclusion.Whenit was learned that no physician would sit on the Board, The Lancet reform,as applied complainedthat "the whole history of sanitary to the people at large,tells a tale of the grossestinjusticetowards medicine and medical men."31 ';No governmenthas a right,' it said, ';to converta noble professionlike that of medicineinto an

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underling.'32 Nor was the professionappeasedill 1851 when a physicianwas finally added to the Boardundertlle interllmellts act. One doctor asked,
Who would have thought that in the last decadeof advancingcivilization. . . the whimsicalexperimentshould have actually been tried of appointingthree non-medicalauthorities-two Lords and a Barrister, to preservethe health of the living; and then? after a year or so of doubtful success, calling in a physicianto bury the dead.33

On the local level, while local boardswere requiredto appoint inspectorsof nuisances,medicalofficerswereoptiollal,a11 "absurd anomaly"according to TheLancet. Rivalrybetween Chadwickand the doctors eruptedduringthe choleraepidemicof 1849. Withthe exception of Dr. John Snow7 who publishedhis now famous but then unappreciated findiIags that cholera was a water-borne contagiousdisease,34no one had any idea of how to treat the epidemic. As one doctor wrote to Chadwick,"in our profession,every new occurence,all epidemic? Ora new remedy,or an extraordinary case of disease,is attended by violentliterarysymptoms."3 5 One physicianattributedcholera to the action of magnesium saltsin water;anotherlecturedon "its dependenceon the electricstate of the atmosphere"; one soughta cure ffom an old Arabic manuscript;while another proposed treatment according to algebra.3 6 The Lancet carriedarticles proposingthe use of sulphur, chlorine, calomel, bleeding,cold affusions, electricity, transfusions,mercury,oxygen, chloroform and common salts as choleracures.3 7 This confusionis typicctl of what Tllomas S. Kuhn has termed the crisisstage ot a paradigm change,and doctors wereill the midstof "a periodof pronounced professionalinsecurity."3 8 In response to t}leirown self-doubts, doctors violently attacked the well-meaning dietary precautions published by the Board of Healthncalling them a "scurvey publication." Dr. Southwood Smith's theories were termed "zymotic gibberish," and Chadwickwas portrayed as a "dictator" surrounded by "idlelawyersand busy-body 9 Chadwick'sfall from power in 1854 was the doctors' opportunity. Alreadyin 1853 the professionllad petitio1led Parliament to appointa Royal Commission on cholera,"directedby men of high scientific attainments... to discover the most scientific
parsons."3

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The impact of the profesmethodsof controllingthe disease."4 Hall, the new sion's pressurewas felt in 1855 when Sir Benjamin of the Board,publiclydeclaredhimselfagainst President
the anomaly of leavingthe GeneralBoardof Health without any permanent medical element and thus deprivingthe Boardof all intimate connection with 1 medicalscience and the medicalprofession.4

Hallappointedtwelvedoctorsas medicalinspectorsand set up a MedicalCouncil to investigatethe epidemic. When Chadwick's ambitiousGeneralBoard of Health was dismantledin 1858, Dr. John Simon'sPapersRelatingto the SanitaryState of the People of England introduced what has been called the era of state medicine. Simon, who replacedChadwickas the centralfigurein headed public health, put forth plans for a centraladministration by a pathologist, manned by medical experts and dedicated to 2 puttingpublichealthon a firmerscientiticfooting.4 to the PrivyCouncil Officership Dr. John Simon,whose Medical followed Chadwick'sGeneralBoard of Health,was perhapsEngland'smost powerfuladvocateof medicalreformand professional advancement.He was a firm believer in science and at first perceived his task as organizing medical research rather than compellingcleanliness.His small staff of medicalinspectorswere restricted to gatheringand publishingdata and giving advice to only those communitieswhich asked for it. After the controversy was glad to give the aroused by Chadwick'sregime, Parliament doctors free play, thereby meeting demandsfor sanitaryreform without offending the water companies and local boards of guardianswho had a vested interest in the status quo. For the research doctors, the Medical Officershipwas a state-subsidized expertise. medical for grant which symbolized the state's need both Their activitiesalways servedthe dual purposeof advancing public health and the medical profession, illustratingKuhn's assertion that "the members of a scientific community see for the pursuitof a themselves. . . as the men uniquelyresponsible set of sharedgoals.'43 Indeed, Simon was unableto distinguish the interestsof the publicfromthose of the profession,and in the "Simon'soffice and the profesearly years of his administration in personneland groupswerebarelydistinguishable sional pressure that only doctors policy."4 4 In order to convincethe government

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were qualifiedto supervisepublic health, he sometimespurposely exaggeratedwhat he termed the i'peculiarlytechnical nature of our business." His desire to manipulate tl1e politicians also explains the "almost ostentatiously scientific character"of his inspectors'reports.4 5 By pushingthe interestsof the profession too far, however,Simon unwittinglyundermined his own authority. Because their functions sometimes overlapped,a rivalryhad grown up between the Local Government Act Office and Simon's Medical Officership. To end this COIlfiiCt Simon effected a behind-the-scenes administrative coup in 1869 whichgavemedical inspectorsprimacyover othergovernment officersand limitedthe Local Government Act Office to cases where doctors determined that legal actions were requiredWiththeirduties thus enlarged to include bookkeeping and enforcement, as well as researchand advice, medical inspectorswere put in the position of seekingto monopolize every aspect of sanitaryadministration. By "boldly seizing the initiative for the doctors, by ensuringthat the new health superintendenceshould be primarilymedical,"4 6 S^imon placed doctors in the indefensible position of pretending lo possesssole qualificationfor such mundanetasksas haggling with local authorities and supervising clean-up operations. Doctorsalso pressedParliament for morestrillgentpublichealti1 laws. Sanitarylegislationhad evolved without coherenceor uniformity;departments and officialsoverlapped; lawswere unevenly enforced;authoritiesfiequently differed.Half buriedbeneaththe excitementof the AmericanCivil Warand electionreformr public health found its only sponsorsin the medicalprofession.Herethe commonplacebut too often forgotten moral of Mandeville and Adam Smith must be remembered: that selfish behavioris ofXen beneficial to society. In the 1860S?in any case, the doctors' agitationsproducedpositive results. In 1868 the BritisllMedical Association and the Social Science Association founded a Joint Committee to push for sanitaryreform.Drs. H.W.Rumsey,A.P. Stewart and W.H. Michaelpersuaded the governmentto createa commissionto reviewthe sanitarystate of the country. The commissioni1lcluded some of the most prominentmedical men of the country: Thomas Acland from Oxford, JamesPaget from Cambridge,Sir Thomas Watson and Drs. Christisonand Stokes. Aclandand Christisontestified before the Commission, as

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did Simon, Rumsey,six medicalofficersand severalother doctors. As might be expected, their testimony endorsed medical domi Rumseysaid that Simon's nance of the publichealth bureaucracy. Office had "done more for the cause of public health than any very best public body in this country,and that!therefore,it is tEle 7 Local to be at the head of sanitaryaction.'s4 of all departments he continued,should be medicalmen with special administrators, Simon agreedand urgedthat medicalofficers with qualifications. special trainingbe mandatoryfor every district. Acland stressed the highlytechnicalnatureof medicine.
In the highly developing and highly developed state of chemistry, of anatomy, of physiology, and of toxicology, and with the immense mass of knowledge now collected in the department of forensic medicine, it is practically idle to suppose that a man, because he might be a good curative general practitioner, was necessarily an expert, capable of solving all the questions which might be raisedin courts of law on any of the subjectsthat I havejust named.48

It all sounded so intimidatingthat Rumseyhad to tone down his comments by assuringhis listenersthat '4Iwould particularly guardagainstthe idea that I wish to institutea medicaldespotism in this country."49 To the non-medicalwitnesses,however,this seemed an apt descriptionof what was happening.ArnoldTaylor of the LGAOtestified that a lawyeror an engineercould perform John Lambertof the Poor day-to-daybusinessand inspections.5 Law Board and Lord Penrhyndenied that medicalofficers were needed at all and claimedthat Poor Lawdoctorscould be used in the few caseswhichrequiredmedical were passedinto law, recommendations Whenthe Commission's PublicHealthAct and the 1871 Act of Government as the Local of 1872, the doctors won most of their points. But just as the profession'sinfluenceseemedgreatest,a twist of fate undercutthe power of the doctors. The new acts mergedpublichealthwith the and put them under the Local GovernPoor Law Administration ment Board. When the government decided that the Board's presidentshould be a politician Simon and his inspectors,who had been a small but virtually autonomousdepartment,found to officials who were themselvesin uncomfortablesubordination JamesStansfeld,the first to theiraspirations. often unsympathetic
opinion.5 1

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president,seemeddeterminedto block the profession's ambitions; and if his actionscontainedlittle real fire, they causeda greatdeal of smoke. First, Stansfeld ignored Simon and his staff. Medicalofficers were given neithera voice in shapingpolicy nor encouragement in pursuing research.As TheLancetlamented,"It may almostseem as if the MedicalDepartment createdby the PrivyCouncilis to be sacrificed."5 2 After repeated frustrations,Simon handed in a bitter resignationin 1876; and for years the place of the chief medical officer remainedat issue between the professionalld the government.Linkingthis complaintto their desirefor heightened prestige,doctors called for a Minister of Healthwho would havea permanentseat in the Cabinet.Trying to fulfill the profession's highestambition,one doctorspeculated,
It would be as consistent to give him a seat for life in the House of Lordsas it has been to find a similarseat for the Bishops of the Church;or, to give a more recent illustration,for the two Life Peerswho have been taken from the legal professionto assistthe UpperHouse in its deliberations.S 3

Whena Ministerof Health was finally createdn however he was chosen from outside the profession.And not until 1919 did the chief medicalofficer gain even the status and pay of a Permanent Secretary to the Minister.s 4 Second, Stansfeldrefused to enforce a provisionin the public health acts which required that full-time medical officers be assignedeach district.Some local boardsof guardians sidestepped this requirementby hiringphysicianspart-timeat annualsalaries of 10 to 60.55 Otherspassedthe duties of sanitaryinspection on to the Poor Law doctors. Medicalofficersdid not havepowers of compulsionand remainedsubordinateto the guardialls. Such part-timeadvisoryroles were in direct conflict with the doctors' standards of professionalism. The greatest ire, however,came when Stansfeldappoilltedtell lawyersto serveas mediatorsbetween the centralboardand local authorities. This was seen as
an unheardof, almost an infamousthing, that lay inspectorsshould have been appointed to supervisethe work of medical men who have passed medical examinations, and possessed medical knowledge and skill. It was really an insult to the profession56

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and to "lose no time in individually One journaladvisedits readers collectively offering their strenuousresistance[to the] offensive and insulting administrationof the act."57 The other journal concludedthat doctorsmust enter politicsso that
the decision of these questions should be duly influencedby the most learned of the professions, and not left, as of aforetimevto the considerationsand guidanceof pettifoggingattorneys and tipplingpublicans5 8

Stansfeld's administration,which Simon termed "a policy of retreat,"59 has been attributed either to incompetenceor to hostility towardthe medicalprofession.Orlemedicalofficer said,
If it was unfair to say of him lStansfeld] that he knew about as much of science as a cow does of conic sections, it is yet undeniablethat at that time he failed to appreciate the possibilities of preventive medicine and the importance of dealing in a comprehensivefashion with the public health of the country.60

portrayedStansfeldas the tool of Edwin And Simon'sbiographer Chadwick and Florence Nightingale,the doctors' staunch enemies.61 But several of Stansfeld's actions belied this supposed in office, he was instrumental bias. Just beforetaki1ag anti-medical him making 2,000, to 1X500 from salary raisingSimon'sannual England'shighest paid civil servant. And in the 1880s, he cooperatedwith Lyon Playfairto redistrictmedicalareasin orderto make feasible the profession'slong-soughtdemand for full-time Stansfeld'sretirementdid little medical inspectors.Furthermore, to boost the position of the medicalinspectors.Roy M. McLeod has described the later years of the bureaucracyin an article 2 of State Medicine."6 entitled"TheFrustration Stansfeld'sown explanationfor his policiescvntainedconsiderable common sense. He told the Commons that he had "no of this intention of committingthe whole sanitaryadministration country to medicalmen." The goals of "sanitaryprotection,"he said, "were cleanlinessand purity;and they did not want medical men to effect that."63 Since no specializedmedical knowledge was requiredto lay a drainor collect refuse,he advisedthe doctors that:
To maintainthe authorityof the scientific man, and to securefor him respect and even popularity,it was necessaryto reservehim for occasions when there was a sense that his specialknowledgeand serviceswere needed.64

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According to J. Donald Ki1lgsleya similarattitude pervaded Englishsociety.

The expert in the Civil Service is a sort of stepchild, regarded without enthusiasmby his administrative colleagues.For the underlying assumptionin the service as well as outside is the naturalsuperiorityof the amateur.This is a point upon which the members of the specialist classes are not a little sensitive-and some of them even rather bitter-and it explains in part the friction between them and the membersof the Administrative Class.6 5

WhyStansfeldfrustrated the doctors is less sigllificant than the fact that his policies did not jeopardizeEngland'shealth. This reversal in the authority of tlle doctors has a bearing on MacDonagh's theory of bureaucratic development. His description of administrationwhich required "little more than that men should have reacted reasonablyintelligentlyto establishedfacts" cannot adequatelyexplain the doctors' self-interested pursuitof public health. And his assertion that "contingent necessity' underlaythe course of bureaucratic growth is refuted by Stansfeld's policies which proved that medical dominance of public health was not a prerequisite of successfuladministration. As will be shownbelow, doctorssimplydid not havesufficientknowledge or skills to offer an alternativeto the programof cleanliness carriedout by Chadwickor the Local GovernmentAct Office inspectors.Sanitarysciencewas still in a rudimentary state. Hence, when doctors monopolizedpublic health, it was not due to the results they had achieved or to their deeper comprehension of disease;it was due to their success in "selling' medicine to the government. When struggling with Stansfeld, the doctors attempted to strengthen their position in the bureaucracyby stressingtheir specializedfunctions and furtherelaboratingtheir technical credentials. But when Simon's effort to monopolize public health proved ill-fated, the doctors retreated with the air of aloof expertise.Dr Rumseyadvisedinspectors:
Carefullyavoid poking your noses into your neighbors'sinks and dust-bins. Leave sewerageto the engineers,cesspool to the surveyors,pigstiesand stale fish to the nuisanceofficers. Keep your test-tubeand your microscopemainly for the diagnosisof disease.66

Dr.Michael reminded his colleagues:

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The medical officer of health is not the inspectorof nuisances,and should be careful not to arrogateto himself functions which belong to another officer and which could only be exercisedin derogationof his own properstatus and
authority.6 7

Dr. Buchanan, who succeeded Simon, envisioned the ideal medical officers as "an army of scientific watchmen... intent upon discoveringthe hidden workingsof the causesof disease." But as The Times, though sympathetic to the profession, was forced to observe,"in the presentstate of the medicalprofession watchmenhavenot only to be found but havealso Dr. Buchanan's 8 Here was the rub. It was not by to their work."6 educated be to "contingent necessity" that doctors had advancedin the public Had but by their strenuousself-promotion. health administration skillsthey claimed, medicalmen reallypossessedall the specialized their legitimacyas experts would neverhavebeen questioned.But they did not yet though they could hardlyadmit it to themselves, have such skills. Hence, to justify their place in the civil service, they could only createan artificialbody of experts-doctorswith the form but not the reality of technical expertise. If my interpretationis correct, this differentiationof knowledge and function was not the natural result of scientific advancesbut of ratheran artificialmeansof insuringthe continuedrecog1lition doctorsin the civil service. Although doctors did not regain control of the bureaucracy, to the they did guaranteetheir place in it. In an 1886 amendment MedicalAct, they obtainedofficial permissionto grantdiplomas to the public in public health. And two years lateran amendment would have officers health act stipulatedthat henceforthmedical to be "holdersof a diplomain sanitaryscience, public health, or was now officiallyrecognized,as 9 Specialization State medicine.6 by the profession. campaign the resultof a determined The first demand for special diplomasin state medicine was made by Dr. Rumsey to the MedicalCouncilin 1868. In 1874 a special committeeof the BritishMedicalAssociationcalledParliaof State medicine, ment's attention to "the special characteristics When as contrastedwith those of ordinarycurativemedicine."7 repeatedlyfailed to act, Dr. Ransomecomplained the government of medicalofficersmade that its indifferenceto the qualifications it seem "as if it had been the intention of our Governmentto

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degradethe office of State Physicianas much as possible."7 1 He proposed that every candidatefor public health be requiredto pass through a special college. In 1877 the Joint Committeeon State Medicine and the Social Science Association petitioned Prime MinisterDisraelito the effect that "all officers of healtll should be debarred from private practice and be holders of diplomasin State medicine.'72 Before special diplomas could be mandatory,medical schools had to bestow them. In 1874 the University of Edinburgh was the first to grant post-doctoralcertificatesill public health. By 1878 the universitiesof Cambridge,London, Durham,Glasgow and Dublin had followed suit. These diplomaswere given for passing an examinationin chemistry,physics,statistics,publichealthlaws and theoriesof pathology. Whereas in 1869 doctors had confessedthat "the workhas still to be written whicll should be made a textbook for studentsof State Medicine."73suddenly there was a great rush to publish. The first real textbook was Dr. EdwardSmith's 1873 Manualfor MedicalOfficersof Health. Five years later Dr. CorneliusB. Fox brought out his thoroughSclnitary Examinationsof Water Air, and Food, A Handbook for the Medical Officers csf Health. Numerouspublicationsfell into an indeterminate category-partly technical, partly historical, largelyexhortative.Pure popularizations of preventivemedicinewere Dr.Parker's book PublicHealth (1876) and Benjamin WardRichardson's Healthand Life (1878). It might appearthat this proliferation of knowledgewas due to the new germ theoryof Pasteurand Koch on the Continentwhich made possible the discoveryof precise causesof diseaseand the innoculatiorl of patients against them. Butn on the contrary England'screation of public health experts occurredin almost total isolation from these scientific breakthroughs. Not until the end of the centurywere the new findi1lgs acceptedin England. Dr. Fox's text consideredevery possiblecauseof disease-from emanations to meteorologicalconditions. Disease remained tor Simon an environmental condition. Simon championedMax von Petterkofer'stheory that cholera was determinedby the water level of the subsoil.7 4 In his reports of 1865 and 1866, he co1lcludedthat "excrement-sodden soil, excrement-reeking air, excrement-tainted water,thereare tor us the causesof cholera."7 5

AND BUREAUCRACY PROFESSIONALISM

457

old theories. The professionfailed to advancebeyond Chadwick's air caused foul breathing that believe to Doctors continued yellow fever,typhusand cholerawere classedas disease.Diptheria, "zymotic diseases,"which one doctor describedas "excremental pollution diseases,"caused by "drinkingwater and breathingair 6 Simon's contaminated by it in a state of decomposition."7 was forcedto admitof the medicalofficers: biographer
Their most usual long-term recommendations-sewerageand pure waterrepresentno advanceon those made by the GeneralBoard'sinspectors;and as for precise etiological knowledgeof some majordiseaseslike scarletfever and diptheria, Simon confessed himself almost equally in the dark as his 7 predecessors.7

must," wrote Simon, "be reckonedas the deadliest "Uncleanliness 8 But thoughdoctors of our presentremovablecausesof disease."7 for beliefs, they werenow givingdiplomas revertedto Chadwick's this knowledge. It is in this sense that they were innovators, experts in form but not reality. Differentiationresulted solely socialaspirations. from the medicalprofessional's Though the doctors succeeded in pushingtheir way into tlle civil service, in two respects their effort was a failure. The reselltmentin of their ambitionscausedconsiderable transparency againstmedicine governmentcircleswhich added to the prejudice in England.The PrincipleClerk of the Treasury,for example, accused the Medical Department of going 4'far beyond any and of trying to "set up a reasonableaction" in its investigations be enormouslycostly would which Medicine State of department and of which they of course would be the exponents." His who agreedthat in comparisonwith the engineers, correspondent "the MedicalDeparthad work thrust upon them by Parliament, ment have rathercourtedwork with a view of creatinga Depart9 The doctors also failed in their ment of State Medicine."7 attempt to discoverthe causes of cholera and other contagious diseases. It was a blow to their patriotism as well as their to have Continentalscientistsbeat them to these professionalism discoveries.Even thoughthey blamedthe state for its shortsighted neglect of research, it is doubtful that their attempt to mix was with routine duties of administration scientific investigations a majorscientificbreakthrough. well suitedto producing

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But if the impact of civil serviceon the medicalprofessionwas disappointing,the force of professionalism was a majorfactcirin shaping the public health bureaucracy. And here is where MacDonaghoverlookedone of the majorinfluenceson the revolution in government,by focusingprimarily on the stagesof growthand by assuming that these stageswererequired for successfuladministration.The energyrequiredto changeEnglishsociety was not due exclusivelyto impersonal forces such as industrialization or urbanization. Scientists,engineers,doctors and lawyersall used the civil service as a means of promoting their own interests. Because doctors had a vested interest in public health, Simon was rightin his conclusion:
For the further developmentof our sanitaryinstitutions and their workingS the educational onward impulses may be expected to come pretty continuously from membersof the MedicalProfession,and are perhapsnot in any essentialsense to be expected largelyexcept from these.80

Although self-interest played its part, the idealism of doctors should not be slighted. Preventive medicine became almost a religion to doctors, and they saw themselvesquite literally as a new clergy.In place of theology, Richardson spokeof the "higher principle of prevention.''8l Millenialvisions crept into the last pagesof Simon'sEnglish Sanitary Institutions wherethe principle of preventionwas extended to social relations.In his speecht"A Homily,Clerico-Medical,t' Richardson assertedthat therewas little difference between ministers of the body and ministersto the soul.82 "It sometimesappears to us," wrote TheLancet, "that the State, as it tends to severitself more and more from theology-as it clearly does-tends to connect itself more a1ld more with Medicine."8 3 Thus it was no exaggeration when HerbertSpencer chargedin the 1892 edition of SocialStaticsthat "there is an inclination on the part of the medical profession to get itself organizedafter the fashion of the clergy.Little do the public at largeknow how activelyprofessional publications areagitatingfor State-appointed overseersof the public health."8 4 Spencerknew from experience that professionalzeal was a dynamicelement ill the courseof bureaucratic growth.
FOOTNOTES 1. The beginning,for conveniencesake, is markedby the FactoryAct of 1833, which providedthe first permanentinspectors,and by the Poor Law of 1834, which created the first centralboardwith supervisory powersoverthe counties.

AND BUREAUCRACY PROFESSIONALISM

459

Revolution in Government:A Re2. Oliver MacDonagh,"The Nineteenth-Century appraisal," 771e Historical Journal, I (1958), 52-67. For a good survey of later investigations see Gillian Sutherland, "Recent Trends in AdministrativeHistory," Studies,XIII (1970), 408-11. Victorian Acts A Psttern of GovetnmentGrowth,1800-60, ThePassenger 3. OliverMacDonagh, and theirEnforcement(London,1961), pp. 7-8. 4. The distinction is made in Max Weber, 7the Aeory of Social and Economic claimedtoo muchfor (New York, 1964 ed.), p. 109, thoughI thinkWeber Organization sociology. op. cit., p. 53. Revolutionin Government," "The Nineteenth-Century 5. MacDonagh, Growth,op. cit., p. 345. A Patternof Government 6. MacDonagh, 7. Ibid. 8. Ibid., p. 346. 9. Ibid., p. 9. of the 1863-84: the Emergence 10. Roy M. McLeod,"The Alkali Acts Administration, Studies,IX (December,1965), pp. 111, 112. CivilScientist,"Victorian Growth,p. 329. A Patternof Government 11. MacDonagh, State (New Haven,1960), p. of the BritishWelfare 12. David Roberts, VictorianOrigins 103. Mass., 1962), p. 13. G. Kitson Clark, The Makingof VictorianEngland (Cambridge? 104. of Reporton the SanitaryCondEhon 14. M.W.Flynn, introductionto EdwinChadwick, 1965), pp. 22, 18-26. This is a the LabouringPopulationof GreatBritain (Edinburgh, thoughtful and detailed summaryof the backgroundto Chadwick'sreport. Flynn's againstdoctors is based on events priorto assertionthat Chadwickwas not prejudiced the competition for positions in the GeneralBoard of Health and is not necessarily accuratefor these lateryears. 15. My use of the phrase"medicalprofession"is intendedto includethe most articulate and outspoken promotersof the profession but not to imply that the professionwas was hotly disputedbetween the Medical more united than it actually was. Leadership Council, created by the 1858 Medical Act, the British MedicalAssociationand the medicalschools. But conflict was not overwhat shouldbe done but overwho shoulddo it. All three groups sought educationalreform, state regulationand entranceinto the civil service.Becauseeach group espousedmedicaldominanceof public health, my use includesall of the majorspokesmenof the Englishdoctors. of the term "profession" 16. TheLancet 1873:2, p. 158. Italicsadded. Education and Employment in the Nineteenth 17. See F. Musgrove,"Middle-Class Century," The Economic History Review, 2nd series, XII, 99-111; H.J. Perkin, Educationand Employmentin the NineteenthCentury:A CriticalNote." "MiddleXlass "Middle-Class The EconomicHistoryReview, 2nd series,XIV, 122-30;and F. Musgroven Educationand Employmentin the NineteenthCentury:A Rejoinder,"The Economic HistoryReview, 2nd series,320-29.

460
18. TheLancet 1844:1, p. 659.

journalof social history

19. The Bntish Medical Journal 1874:2, p. 461. Charles Erolution of MedicalEducationin the Nineteenth Century Newman's standardThe (London, 1957)?is tive to the socialimplications of education.Thisneglectis correctedin S.W.R. insensiHolloway, 'iMedicalEducationin England,1830-1858: A Sociological Analysis,"History, XLIX (Oct. 1964). 20. TheBritishMedical Journal1868:2, p. 82. 21. Sheldon Rothblatt, The Revolution of the Dons, Cambridge and Society in VictorianEngland (London, 1968), pp. 86-93. See also G. Kitson Clark.op. cit."pp. 258-74. 22. TheLancet 1858:1, p. 318. 23. G. KitsonClark,op. cit., p. 253. 24. Quoted in W.J. Reader,Professional Men, the Rise of the ProfessionalClassesin Nineteenth-Century England(New York, 1966), pp. 149-51. For professional demands thata doctor be madea Lordsee TheLancet 1858:2, p. 558; 1872:1, pp. 339, 340; and TheBritishMedicalJournal1876:1, pp. 93, 182. 25. Reader, Professional Men, p. 23. 26. H. Byerly Thomson, The Choice of a Profession ( 1857), quoted in Reader, Professional Men,p. 149. 27. T.H.S. Escot, England. its People, Polity and Pursuits (1885), quoted in Reader, Professional Men, pp. 150, 151. 28. TheLancet 1860, quoted in Reader, Professionsl Men, p. 65. 29. Quoted in E.N. Williams, A Documentry Historyof England,vol. 2 (1559-1931 ) (Baltimore, 1965), p. 239. 30.Quoted in S.E. Finer, The Life and Timesof Sir EdwinChadwick (London, 1952), p. 218. 31 . TheLancet 1848:2 (October21, 1848), p. 457. 32.7he Lancet 1848:2 (September 9, 1848), p. 294. 33.Dr. Rumsey'sEssayson StateMedicine(1856) quoted in W.M.Frazer, A Historyof English PublicHealth,1834-1939 (Lond on, 1950), p. 48. 34. On the Modeof Communication of Cholera,2nd edition
7 95

(London, 1855). 35. Dr. Sutherlandto Chadwick, 1848, quoted in R.A. Lewis,EdwinChadwick and the Public HealthMovement(London 1 2), p. 193. 36. Ibid. 37. TheLancet 1849:2, Index pp. 708, 709. 38 ThomasS. Kuhn, lke Structureof ScientificRevolutions, 2nd ed. (Chicago,1970), pp. 67, 68.

PROFESSIONALISM ANDBUREAUCRACY
39. TheLancet 1849: 2, pp.129,458. 40. TheLancet 185 3:2, pp.439,393.

461

41. Draft of a letter from Hall to the Treasury,August, 1855,quoted in Royston

Lambert, Sir John Simon, 1816-1904, and English Social Administration(London,

1963), p. 229.

thesis were suggestedto me by a careful 42. Many of my criticismsof MacDonagh's readingof Lambert's detailedbiography.For the most part,however,Lambettaccepted MacDonagh's model as fully applicableto his data. "I owe much," he wrote, "to Dr. into the self-generating processesof MacDonagh's remarkable and pioneeringresearches governmental growth"(p. 169n). He saw public health as carriedalong by an"internal dynamic," though he noted that it was often in danger of termination,met much by opposition,and continuedlargelybecauseof the pressureplaced on the government was the medical profession. In one telling passagehe admitted that the bureaucracy his a priorinotions shapedby the doctorsandnot vice versa."Simon'slargepersonality, only of the MedicalDepartment and ambitions,his idiosyncrasies makethe development a partialexemplificationof the trend of governmentgrowth so excellentlyanalyzedby Dr. MacDonagh" (p. 460n). But he followed this admissionwith anotherreaffirmation of MacDonagh's modeland used the schemethroughoutthe biography. 43. Kuhn,op. cit., p. 177. 44. Lambert, op. cit., p. 302; see also pp. 314, 315. 45. Lambert, op. cit., p. 292; see also 437. 46. Lambert, op. cit., pp. 421-23. 47. First Report of the Royal Sanitary Commission(1869) (London, 1870) Irish University Pressed., p. 235, query4303. 48. Ibid., p. 320, query 5682. Note how specializedeven the general practitioner sounds. 49. Ibid., p. 240, query4376. 50. Ibid., p. 55, query 886. 51. Ibid., p. 262, query4732; and p. 419, queries4877-4880. 52. TheLancet 1873:2, p. 158; see also TheBritishMedicalJournal1874:1, p. 178. 53. Benjamin WardRichardson, A Ministryof Health (London, 1879), p. 27. op. cit., p. 610. 54. Lewis,op. cit., pp. 195, 196. Lambert, 55. TheLancet 1872:2, pp. 66, 360. 56. TheBritishMedicalJournal1873:2, p. 192. 57. TheBritishMedicalJournal1872:2, p. 13. 58. TheLancet 1872:2, p. 642. Italicsadded. S9. John Simon,EnglishSanitary Institutions,2nd ed. (London, 1897), p. 392.

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60. Herbert Preston-Thomas, The Workand Play of a Government Inspector (Edinburgh,1909), p. 50. 61. Lambert, op. cit., p. 522 and passim. 62. Roy M. McLeod,"TheFrustration of State Medicine,1880-1899,"Medical History, XI (Jan. 1967), pp. 15-40. 63. Hansard,3rd series,ccxii, col. 1268. 64. The Times,January12, 1875, p. 7. 65. J. Donald Kingsley,Representative Bureaucracy, An Interpretation of the British C>vil Service(YellowSprings, Ohio, 1944), p. 175. See ch. 8. 66. TheBritishMedical Journal1872:2, p. 282. 67. TheBritishMedicalJournal1873: 2, p. 650. 68. The Times,October20, 1875, p. 9. 69. ParliamentaryPapers, 1888, IV, 155. 70. TheBritishMedicalJournal 1874:2,pp.244-46. 71. I71e BritishMedical Journal1877:2 pp. 214-18. 72. TheBritishMedicalJournal1877:2, p. 247. 73. Quoted in Roy M. McLeod, "The Anatomy of State Medicine:Concept and Application,z'in F.N.L. Poynter (ed.), Medicineand Science in the 1860s (London, 1968), p. 215. McLeod'sarticle is an importantoverviewof differentconceptionsof state medicine. 74. Simon,EnglishSanifary Institutions,pp. 261-63, 287, 465. 75. Quoted in R. Thorne Thorne, On the Progressof PreventiveMedicine in the Victorian Era (London,1888), p. 58. 76. TheBritishMedicalJJurnal1879:2, p. 220. 77. Lambert, op. cit., pp. 431-32. 78. John Simon,Filth Diseasesand theirPrevention(Boston, 1876), p. 12. 79. F.A. zCourtBergneto William Culley (n.d., ca. April 20, 1887); William Culley to WelbyApril21, 1887, quoted in Mcl,eod,"TheFrustration of State Medicine." p. 25. 80. John Simon,EnglishSanitary Institutions,p. 474. 81. BenjaminWardRichardson,The Future of SanitaryScience (London, 1878), pp. 36, 37. 82. Benjamin Ward Richardson, A Ministry of Health, op. cit., ch. III. 83. The Lancet 1870:1, p. 14. Note that this was written before Stansfeldheaded the administration . 84. HerbertSpencer,Social Statics ( 1892 ed.) and Manvs the State (New York, 19 13), p. 202.