The half century between 1885 and 1935 witnessed a significant improvement in the health of the British people. Crude death rates offer the easiest, if least sensitive, measure. When this fifty-year period opened (1881–5) the crude annual mortality rate for England and Wales was 19.4 deaths per thousand population. By the turn of the century that rate had fallen to 17.7 per thousand (1896–1900), and by 1930 to 12.1 (1926–3o). Even more revealing is the downward trend in the death toll from the chief epidemic diseases which had been the focus of the nineteenth-century public health movement – cholera, typhus, typhoid or enteric fever, smallpox, measles, scarlet fever, diphtheria, whooping cough, diarrhea, and dysentery. During the last two decades of the nineteenth century the collective rate at which these diseases killed fell by more than a third (3,408 deaths per million annually in 1871–80 to 2,142 per million annually in 1891–1900).

These same decades also saw an unprecedented expansion of preventive and therapeutic services offered by the state through its local authorities. In 1885 the public health activities of most British local authorities were rudimentary. Even the most active confined themselves, for the most part, to environmental sanitation. Among civil authorities only the Poor Law Guardians offered medical treatment paid for by taxes or by rates, local property taxes. By 1935, on the other hand, almost the entire population of England and Wales had access to a wide range of both sanitary and clinical services offered by local authorities and supported by the rates and by grants from the national Treasury.

WHY MOTHERS AND BABIES DIE

In the years between 1910 and 1916 Newsholme published five book-length official reports on infant, childhood, and maternal mortality. Collectively these reports represented the most intensive empirical studies of these subjects to date in English. They should be understood historically as part of an ongoing debate about the meaning of death among the very young that took new form with the investigations of national efficiency and physical fitness following the Boer War. As such, these reports had immediate policy intentions. Newsholme was intent not only on demonstrating that recent national initiatives, undertaken in the wake of the Boer War, to promote the health of schoolchildren through school meals, medical examination, and medical treatment should be extended to children of preschool ages, but also on answering eugenists who warned that such ameliorative efforts merely hastened the pace of the nation's physical and mental degeneration.

Newsholme's investigations may have been the most extensive, but they were not the first. Studies of infant mortality had become more common in M.O.H. reports and in medical journals, and several other monographs on infant mortality had appeared in the decade preceding 1916. The General Register Office had taken the lead by drawing attention to the problem long before the Boer War, providing the basic data and a tradition of analysis for these investigations. John Tatham, successor to William Farr and William Ogle at the G.R.O., took a special interest in infant mortality and applied to the problem the sorts of statistical and demographic analyses Farr had pioneered.

NOTIFICATION AND ITS USES

At the top of Newsholme's agenda when he joined the Local Government Board was the launching of a national tuberculosis program. His experience in Brighton led him to envision a comprehensive strategy operating on national guidelines but organized and administered by local health authorities. Notification of cases to the Medical Officer of Health would be the starting point. He never thought of notification as a mere statistical or administrative exercise. It must be the beginning of constructive action by local authorities. While M.O.H. in Brighton, he held that towns should not initiate notification of tuberculosis until they were prepared to offer the patient whose case was notified “all possible help” in return. Once in Whitehall and after notification was compulsory, he continued to insist that the justification for notification was what followed.

We have seen in Chapter 6 that there had been some professional opposition to notification of tuberculosis and a widely held apprehension that compulsory notification would be followed by social and economic discrimination against the disease's victims.

THE METHODS OF EPIDEMIOLOGY AND THE WORK OF THE M.O.H.

While still a comparatively young Medical Officer of Health, Arthur Newsholme became an authority on vital statistics and an important epidemiologist. His The Elements of Vital Statistics, which first appeared in 1889 shortly after he arrived in Brighton, seems to have been the first practical textbook of statistics for Medical Officers of Health. It was widely used during his career and remained a standard source for many years, appearing in a new edition as late as 1923. As a perusal of Newsholme's bibliography shows, his publications in vital statistics and epidemiology are both numerous and varied. He did intensive local investigations as well as sweeping international comparisons. He studied old scourges like smallpox and typhoid fever as well as diseases that had received little attention from statisticians, such as cancer. He traced epidemics, identified long-term trends in mortality, morbidity, and fertility, and he tried to identify the causes for these changes. We will consider examples of his statistical and epidemiological investigations in several of the following chapters.

I will argue that Newsholme's epidemiology and his administrative work were intimately related. The latter frequently suggested the subjects for the former and often supplied the data. The former provided the direction and credibility for the latter. It was Newsholme's view that “epidemiology is the centre and main spring of all public health work.” That assessment was made in 1918 in the midst of planning the postwar reorganization of the central British health authority, the planning that led to the creation of the Ministry of Health.

THE APPOINTMENT OF A NEW M.O.H.

On May 17, 1888, the Town Council of Brighton met to select the town's first full-time Medical Officer of Health (abbreviated M.O.H.). The position had been advertised the previous month, and there was a large field, seventy-four medically qualified men in all. A committee of councillors and aldermen cut that number first to fifteen and then to six, all of whom were then serving elsewhere as Medical Officers of Health (also abbreviated M.O.H.). After interviewing these six, the committee placed two names before the Town Council: Henry Tomkins, M.D., M.O.H., for Leicester, and Arthur Newsholme, M.D., M.O.H., for the London vestry of Clapham. At age thirty-two Newsholme was slightly younger, and unlike Tomkins, he had served only part-time for a vestry not full-time for a borough. But Newsholme made a stronger initial impression, and his supporters on the Council contended that his was the more impressive set of academic credentials. The Council was not used to judging professional qualifications, and there was much joking in the meeting about brainpower and cleverness:

During the last forty years several preoccupations have driven historians to examine the work of public health authorities in Britain. Most recently it has been the effort to explain the fall in mortality during the nineteenth century. The issue has been raised in its contemporary form by the well-known works of Thomas McKeown and associates, who grant to conscious human intervention – clinical medicine, public health, or social welfare – only a small part in the mortality decline before the twentieth century. While conceding that the construction of sewage systems, the provision of protected water supplies, and vaccination for smallpox had some effect on human mortality and suggesting that spontaneous changes in the virulence of its agent accounted for the diminished mortality from scarlet fever, these authors have argued that only improvements in the standard of living, especially in nutrition, could account for the magnitude of the mortality decline. For some years historians accepted this analysis with little question, showing particular appreciation for McKeown's demonstration that clinical intervention could not possibly account for mortality decline on such a scale. But recently they have turned their attention to the most debatable part of McKeown's thesis, the role played by mass intervention by public authorities. So important has this issue become, that it dominates the discussion of public health in the new Cambridge Social History of Britain. For England and Wales some of the most interesting recent work is by Simon Szreter and Anne Hardy.

If Naturphilosophie promised to transform medicine into a true Wissenschaft, it was a decidedly odd brand of medical science that would emerge from the metamorphosis. For Naturphilosophie treated medicine in a way that was virtually oblivious to the practical concerns and social milieu that physicians confronted in their everyday working lives. That was part of its attraction: its siren call was the unity of knowledge through a transcendental poetics of life, with Schelling and his followers playing the role of bards who would sing its truths. But to physicians who did not seek to pursue a larger vision of Wissenschaft, and who identified more with medicine as healing than with the avant-garde of Jena Romanticism, the pretensions of the Naturphilosophen were not merely by degrees silly or outrageous, they were also fundamentally inimical to the true nature of medicine and medical science. Partly in response to the Naturphilosophen, but partly too as their own contribution to shaping public consciousness about the profession, these physicians gave voice to a different version of medicine, one emphasizing its healing mission.

This chapter will explore that alternative vision for medicine, as seen through the writings of physicians who in no way sympathized or identified with the aims of the Naturphilosophen. The picture that emerges from these sources consists of three intimately connected elements: first, a justification of the dignity and social worth of the profession; second, an epistemology of medical practice; and finally, a program of medical education.

The previous chapter described how the eighteenth-century medical profession was shaped by (and in turn gave form to) reformist impulses that were proclaimed under the banners of Enlightenment, social welfare, and the pragmatic uses of knowledge. The responses formulated by physicians to those impulses, as that chapter suggested, were a complex amalgam of defensive and offensive postures. At the most general level, those responses were structured by two issues. The first issue, hinted at by the discussion of Bildung, consisted of how someone conceived of the profession's relationship to the state. Did medicine exist to promote the state's enlightened ends (for example, by means of public health), or should physicians stake their identity on a more individual and personal level, for example in terms of their selfless service to patients, or their claim to cultivation of personal freedom through Bildung? The second issue concerned physicians’ sense of the relationship between theory and practice in medicine. Should theory be cultivated with an eye toward its application at the bedside, or could medical theory rightly lay claim to being a profound inquiry into the mysteries of organic nature? How in fact did bedside practice represent an “application” of a physician's theoretical knowledge?

Two points must be made to clarify these issues. First, in some ways their presentation as choices between alternatives is deceptive, because they did not necessarily represent mutually contradictory stances.

In recent years, the professions have been a subject of growing fascination for historians and sociologists. The reasons are not difficult to find. Talcott Parsons may have overstated the centrality of the professions when he claimed in 1968 that they were “the most important single component” in modern society, but there is no denying the prominent position occupied by professional “experts” of various stripes. One has only to take in the nightly news broadcast on public television, where it seems that nearly every matter of current interest is rendered as a debate between experts, to appreciate the role they play in our world. Or consider that in 1993, when Hillary Rodham Clinton began putting together a proposal for reforming America's health care system, her first act was to gather together a group of professional experts on various aspects of health care to discuss the framework of such a plan. It is not that fundamental political and ideological issues – such as the desirability of guaranteeing medical care to every citizen – were thereby rendered meaningless or unimportant in the face of such consultations. But the political questions were shaped in significant ways by what those experts had to say about the way the world is.

The reference to medicine is an appropriate one, because in one sense this book is about the origins of the modern medical profession. Put that way, of course, the project sounds a little grandiose.

Revolutions do not conform to a single historical pattern. Some follow a logic of development that builds to a radical denouement, while others may incorporate moments of radicalism, but never reach a climactic resolution. Instead, they simply lose energy gradually, like a hurricane whose force is spent by traveling over land. Beyond any question, the Brunonian revolution resembled the second kind. As the first years of the nineteenth century slipped by, the energy and rancor of the debate over Brunonianism diminished noticeably. This was so much the case that by 1811, when Andreas Roschlaub published a letter in the Journal der practischen Heilkunde declaring in effect that he no longer held to the principles of Brunonianism, the gesture had little dramatic impact. Hufeland, the editor of the Journal, permitted himself a smug, self-congratulatory observation to mark the occasion, but the moment passed largely unnoticed.

Although the final act of the Brunonian revolution may have played before a nearly empty house, its impact on German medical theory and practice was substantial. At least for the short term, the most significant product of the controversies over Brunonianism was the construction of a stout wall between theory and practice. The great majority of physicians who wrote on practice after 1810 continued to speak of it in terms of a Kunst characterized by the physicians' creative synthesis of judgment, experience, and talent.

Of necessity, the image of mid-eighteenth century German medicine presented in the preceding chapter was one frozen in time. Yet the constituents of that picture – the intimate connection between medical profession and the universities, and the location of both in the larger society – should be conceived of dynamically, not statically. For all its seeming clarity, as soon as the depth provided by time is added to the picture, the details begin to blur and lose their sharp outline. At no time were there ever institutions such as “the medical profession” or “the universities” for which we can give a precise description. Rather, such institutions are always a more or less discordant blend of meanings and functions, incessantly driven in new directions by unfulfilled expectations (which can themselves be dissonant) and held back by the weight of established practices. If these institutions appear stable at mid-century, it is only in comparison to the changes that would overtake them in the years around 1800.

It is worth remembering this when we consider the forces that acted upon the universities and the medical profession, propelling them into a new relationship. These forces did not act on inert matter. There was no reform “movement” that suddenly arose in the 1700s to resuscitate a group of “outmoded” universities and incompetent physicians.

For all the real disagreements – especially regarding medical education – that existed between the Naturphilosophen and those who believed medicine to be a vocation to healing, in a curious way the two groups could tolerate each other fairly well. That is because both implicitly accepted a degree of separation between theory and practice. For their part, the Naturphilosophen were not especially interested in designing their theories to provide useful guides to practice. Even a theorist who did seek to close such links, such as Johann Christian Reil, contented himself with alluding only in the most general way to the therapeutic implications of the system described in “Von der Lebenskraft”, recognizing that a real unification of theory and practice lay somewhere in the future. Until such a time should arrive, Reil readily accepted the “empirical” methods of practice advocated by Hecker and Gruner. On the other side, Christoph Wilhelm Hufeland too claimed on occasion to see a future when medical practice would become an applied science, although he held deep misgivings over its desirability. Hufeland's image of that future therefore tended to be far more remote than Reil's. These doubts about a unified science of medicine did not prevent Hufeland from attributing some value to theory, and he proclaimed medical theories welcome for their service in broadening physicians’ perspectives on the phenomena of disease.

Although neither of these groups chose the most radical of the possibilities offered in the 1790s, other physicians did.