The applications of state medicine, in the 19th century, found their inspiration in England in two sources, and their expression in legislation. The twofold inspiration came from the recurrent outbreaks of cholera and consequent com missions of inquiry, and from popular demand for reform, which was realised after each of the four extensions of the franchise (1832-1918). The Legislature placed on the statute book a won derful series of enactments. The alarm caused by the ravages of cholera in 1831 led to the first steps in administrative sanitary reform ; in 1849 there was a second visitation of cholera, and in 1854 a third. These cholera epidemics led to a new appreciation of the unsanitary condition of the country as a whole, to an un derstanding of the nature of the disease and its epidemicity, to the establishment of "cholera dispensary stations" and to the Infectious Diseases Prevention Act 1855.
Concurrently with and following upon these epidemics there were various commissions of investigation. In 1838-9 the Poor Law Commissioners drew attention to the prevalence of epi demic disease and its relation to poverty. The reports by Neil Arnott, Kay, Southwood Smith and Chadwick were the prede cessors of another famous series of investigations in 1859-65 by Greenhow and his colleagues under the Privy Council into epi demic diarrhoea, pulmonary disease, infant mortality and ague ; and also into the four "elementary requisites of popular healthi ness," viz., adequate food supply, sufficient house accommodation, healthy physical surroundings and wholesome industrial circum stances. They led the way to the new application of medicine for the removal of nuisances, the prevention of contagion and infec tion and industrial hygiene and welfare.
In 1843 Sir Robert Peel, at the instigation of Edwin Chadwick, advised appointing a Royal Commission to inquire into the out breaks of disease in large towns and the best means of improving the public health, the report of which led to the passing of the comprehensive sanitary measure in 1848, the establishment of the General Board of Health and the appointment of medical officers of health. In 1869 was appointed the Royal Sanitary Commission, on which sat Thomas Watson, James Paget, Henry Acland, Robert Christison and William Stokes, and before which Simon, Budd and Farr gave evidence. Speaking broadly, the 1843 commission found the existence of a serious national evil of insanitation and ill-health, and recommended a legislative remedy, whereas the 1869 commission found that the remedy had proved ineffective and recommended that "the present fragmentary and confused sanitary legislation should be consolidated." They pro posed, in fact, for the first time, a Ministry of Health, and though the case miscarried, and the Local Government Board was cre ated in 1871, a comprehensive Ministry of Health was at last established in 1919. The commission's summary of the national sanitary minimum of "What is necessary for civilized social life" provided the grand inventory of that period (1871) and was as follows:— I. The supply of wholesome and sufficient water for drinking and washing.
2. The prevention of the pollution of water.
3. The provision of sewerage and utilisation of sewage.
4. The regulation of streets, highways and new buildings.
5. The healthiness of dwellings.
smoke.
7. The inspection of food.
8. The suppression of causes of diseases, and regulations in cases of epidemics.
. 9. The provision for the burial of the dead without injury to the living.
50. The regulation of markets, etc., public lighting of towns.
The programme of 1871 represented the most enlightened thought of the time regard ing the sphere and scope of preventive medicine. Even now it is almost a complete summary of the elements of a sanitary en vironment. The commission also showed how it could be worked out in practice by laying down the general principles to be fol lowed and by drafting a new statute. They diagnosed with unfail ing accuracy the causes of imperfect sanitary administration— (a) the variety and confusion of authorities concerned in the public health, (b) the want of sufficient motive power in the cen tral authority, (c) the non-coincidence of areas of various kinds in local sanitary government, (d) the number and complexity of enactments, (e) the needless separation of subjects, (f) the leav ing some general Acts to voluntary adoption and the permissive character of other Acts and (g) the incompleteness of the law. Finally, the commissioners lent all the power and prestige of their position and experience in unreserved support of the great prin ciple of local self-government.
The Public Health Act of 1875, which emerged from the labours of the Royal Sanitary Commis sion, may be regarded as marking a great advance in the develop ment of sanitary administration. Before that time sanitation was interpreted in large measure as a negative policy—in a word, the removal of nuisances ; after that time sanitation received a new connotation, positive, constructive, remedial. That is the reason why this Act forms the great line of division, the watershed in the progress of modern preventive medicine, on its environmental side. The report of Sir Robert Peel's Commission, in 1845, con tains a significant suggestion in its recommendation that each local governing body should have a medical officer whose duty it should be "to ascertain the true causes of disease and death, more especially of epidemics increasing the rates of mortality, and the circumstances which originate and maintain such diseases, and injuriously affect the public health." No one can read the preamble of the report of the commission of 1869 on the history of the sanitary laws enacted up to that date without being im pressed with their character. They dealt, almost monotonously with nuisances and their removal, sewerage and drains, sewage utilisation, the paving, lighting and cleansing of streets, common lodging-houses, the supervision of artisans' dwellings, smoke nui sances, local government and the burial of the dead. The only group of laws directly concerned with disease were the Vaccination Acts. Then came the Public Health Act of 1875, which in con ception and working led for 20 years to enactments on the pre vention of river pollution, the protection of water supplies, the provision of housing accommodation and isolation hospitals, and the notification and prevention of infectious disease. The ele mentary Education Act of 187o, and the Public Health Act of 1875, were forms of germinative legislation bearing fruit in a single generation.