|The man who cleansed Edinburgh|
|Monday, 26 August 2013|
Ahead of the publication of their new book, Paul Laxton and Richard Rodger explore the remarkable life and achievements of Sir Henry Littlejohn
On 31 October 1865 Dr H D Littlejohn, a Fellow of the RCSEd since 1854 and lecturer in medical jurisprudence in the extra-mural Medical School, addressed students and practitioners at the opening of the new session:
“A doctor must not only be well skilled in his particular department of knowledge, but he must, in addition, be an educated gentleman.
'He must be able to converse with more than ordinary intelligence on the topics of the day, and to hold his own in conversation, whether he be at the bedside of his patient or at the table of the leading family in the country. He must let his weight be felt as one who has a general knowledge of the natural sciences, and who has been trained by the course of study he has passed through to be a shrewd and correct observer.” (The Scotsman 1 November 1865 6a)
Few men lived up to their own advice as Henry Littlejohn, described by an obituarist in the British Medical Journal as “one of Edinburgh’s and of Scotland’s great men”. On the day of his lecture in Surgeons’ Hall, the Town Council were commending him on his Report on the Sanitary Condition of the City of Edinburgh, published in August that year. It was a landmark in the history of the city, diagnosing with Littlejohn’s characteristic forensic precision the essential obstacles to the social and environmental condition of Edinburgh and suggesting a course of treatment which, only partially, often reluctantly and always controversially, was followed by the relevant authorities for decades to come. Its full text was reproduced in the newspapers and it was printed three times within 12 months yet, strangely, only some 25 copies survive in libraries worldwide. It is certainly more admired than read.
An extraordinary CV
Henry Duncan Littlejohn was born in Leith Street in 1826, in a prominent family of bakers. He completed his education at the Royal High School in 1841 before studying medicine at Edinburgh University as an extra-mural student at the College of Surgeons. He graduated LRCS and MD in 1847. Littlejohn married Isabella Jane Harvey (1833-86) on 6 May 1857. They had three sons and 10 daughters. He was awarded an honorary doctorate from Edinburgh in 1893, and a knighthood in 1895 ‘for services to sanitary science’. Sir Henry Duncan Littlejohn died at Benreoch, Arrochar on 30 September 1914 in his 89th year.
Remarkably, Henry Littlejohn held four concurrent posts. After a very short period as house surgeon and assistant pathologist at the Royal Infirmary, Edinburgh, and as a medical practitioner and obstetrician in the border town of Selkirk, Littlejohn’s successful admission to the Royal College of Surgeons in 1854 was quickly followed, aged 28, firstly by an appointment as Police Surgeon for Edinburgh, a post he held until 1862, when this post was combined with a second one, the newly created position of Medical Officer of Health, which he held for 46 years until his retirement in 1908. Given his impressive credentials his appointment as Scotland’s first MOH should have been straightforward. In fact, it was aggressively contested and Littlejohn was appointed in October 1862 by only a single vote; and even then the appointment was challenged, partly by those who thought nobody could undertake the work of both Police Surgeon and Medical Officer.
As Police Surgeon, Littlejohn also discharged, secondly, the responsibilities of Medical Adviser to the Crown in Scotland in murder cases and those involving sudden deaths. He was frequently called to give expert evidence in the Justiciary Courts, where judge Lord Young once remarked, “There are four classes of witnesses – liars, damned liars, expert witnesses, and Sir Henry Littlejohn.” Littlejohn’s third post was a lectureship in medical jurisprudence at the Royal College of Surgeons of Edinburgh in 1855 where he continued to teach for 42 years until appointed to the Chair of Forensic Medicine in the University of Edinburgh in 1897, a position he held until 1905. A former student, Halliday Sutherland, later revealed that “Wee Hell”, as the poor of Edinburgh called Littlejohn, was “a dapper, little man” and that his 9am class “was always crowded.”
To these positions Henry Littlejohn added, fourthly, significant further concurrent duties for the Board of Supervision as medical adviser (from 1859) and Commissioner (from 1873). This was the central agency of the Scottish Poor Law with overall responsibility for sanitary matters throughout Scotland and for whom he prepared over 700 reports and memoranda. If the work ethic was impressive, the forensic attention to detail was perhaps more so.
Measuring and mapping Edinburgh
From 1855 civil registration of deaths at last made systematic mortality data available but in their published form they were of limited value in relation to an analysis of the sanitary conditions of Edinburgh. The five registration districts made little sense of the social geography of Edinburgh. Littlejohn drew up 19 sanitary districts to reflect well-established and distinctive social areas that would be well understood by councillors and opinion makers, and were large enough for statistical, epidemiological and practical sanitary purposes. Littlejohn knew his city intimately and most of his districts would still be recognised today.
Persuading the Town Council to pay the registrars to supply summaries of death certificates — age, sex, cause and place of death — Littlejohn and his part-time clerk allocated the data to the new districts, and tabulated the information. But this description understates the prodigious labour required of Littlejohn and his clerk. The population of the city was also reassigned to the sanitary districts so that Littlejohn could calculate crude, as well as age- and cause-specific death rates. Moreover, for the appendix to his Report, he tabulated these data for over 1000 individual closes and streets and, for good measure, added historical data on cholera and typhus epidemics in the 1840s. Such an exercise would challenge a researcher today yet Littlejohn completed it with extraordinary precision in months with no calculator or spreadsheet — just logarithmic tables and perhaps a slide rule.
Littlejohn’s approach to a sanitary city
This statistical exercise was the essential prelude to a Herculean sanitary cause; and it is here that Littlejohn differed from Chadwick, Simon, Duncan and other leading English sanitarians whose emphasis was on physical investment in drains and water supplies. Littlejohn’s priorities were strategic and pragmatic. The impact of morbidity on family life was as important to Littlejohn as the monitoring of mortality. Above all, as a student of W. P. Alison, he was alert to a holistic view of poverty and its relationship with employment and public health; strict regulation and technology were only partial solutions. He identified repeatedly with his fellow citizens – a telling phrase – in what was possible rather than ideal. This was a man with very well-tuned political and social antennae.
As a result of his holistic approach Littlejohn’s Report on the Sanitary Condition of the City of Edinburgh conveys something of the everyday lives of citizens. Topics included cemeteries; byres; dairies; drains and drainage; water supply; waste management – both animal and human; food adulteration; nuisances; smoke pollution; inspection and regulation; licensing; lodging houses; epidemic disease; vaccination; asylums and fever hospitals; charity and poor law administration; overcrowding; urinals; boundaries and jurisdictional issues; and of course, detailed statistical analysis of deaths, the causes of death, housing and water-closet provision in each of the 19 new sanitary districts.
Many of these topics, and certainly the approach to them, are live concerns for the renewed public interest in local public health administration at the start of the 21st century. His recommendations – he termed them ‘suggestions’ – focused on the achievable, the affordable, and those that would provide the widest benefit to those who needed them most.
In 1872, a decade after Littlejohn’s appointment as MOH, the Council established a Health Committee; only from this date had he his own power base and official channels through which to pursue his wide-ranging public health agenda. The seeds of a Health Department with trained staff were being sown. Littlejohn had another 36 years to go as Medical Officer.
Littlejohn’s legacy in the reformation of Edinburgh, and indeed Scotland, has yet to be fully assessed. He used his terms as President of the RCSEd (1875-76) and the Edinburgh Medico-Chirurgical Society (1884-85) to advance important causes for medical reform – compulsory notification, the use of the press for weekly reports of mortality, the handling of uncertified deaths, relieving medical officers from private practice, and more. But he also bequeathed a less tangible legacy through the thousands of medical students who attended his legendary lectures. As his obituary in the BMJ put it, “for forty-two years he edified and delighted successive generations of students with lectures and what may be called field demonstrations on medical jurisprudence and public health, which certainly have never been surpassed for their vividness, raciness, indestructible memorability, and compacted contents.” The children of the Cowgate who received Saturday pennies from ‘the Doctor’ doubtless also learned
The poor of Victorian Edinburgh were not safely distanced from the centres of government and influence but in crowded tenements surrounding the High Street and the Police Chambers where Littlejohn had his office. He was a religious man of liberal sentiments whose day started with family prayers. His mission was to cleanse not only the streets and closes but the bodies and habits of the teeming poor he encountered daily, those sections of society who had no voice yet sought the means to improve both the length and quality of their lives.
A facsimile of Littlejohn’s Report will be published in autumn 2013 as part of a major new interpretation by Paul Laxton and Richard Rodger entitled Insanitary City: Henry Littlejohn and the Condition of Edinburgh (Carnegie Publishing, Lancaster, 2013. ISBN 978-1859362206). Copies can be sent to subscribers to Surgeons’ News for £20 including UK postage. Overseas members may order from the publisher at carnegiepublishing.co.uk