In Part II, I examine the relationship between Boyle's views on the limits of human reason and his conception of the task of the natural philosopher. The fact that I am now switching from an explicit discussion of theology in Boyle's thought to a discussion of his natural philosophy does not by any means involve leaving theological considerations behind; indeed, it is the central thesis of this book that Boyle's theological beliefs significantly influenced his view of the proper task of the natural philosopher. In many passages of various so-called “scientific” works, Boyle made his theological concerns quite clear, and when he did so I will be quick to note them. At other times, however, he seemed to think that he could isolate his concerns as a natural philosopher from his concerns as a lay theologian. This is evident in the fact that on numerous occasions he identified himself as speaking not as a Christian virtuoso, but as a natural philosopher who was excluding theological considerations from a given discussion. In A Disquisition about Final Causes, for example, he ended one discussion by stating that he had been speaking “meerly upon physical grounds,” and then introduced his next point by announcing that “if the revelations contained in the holy scriptures” might be admitted he could offer other arguments concerning God's ends in nature.

TYPHOID FEVER AND OYSTERS

By the middle nineties Brighton had done everything that had been thought necessary to conquer typhoid fever. It had built main intercepting sewers to divert sewage from the sea front. It had required owners to connect their houses to this system and to fill in their cesspools. Its Sanitary Department mounted an energetic inspection program to see that household drainage was properly installed and maintained. The town also provided pure water as a municipal service. Furthermore, it acted to prevent direct interpersonal transmission by requiring and closely supervising notification, isolation, and disinfection. Why then had the decline in the incidence and mortality from typhoid leveled off, leaving the town with a substantial endemic typhoid problem? Newsholme began to suspect that while the town had solved most of its old sanitary problems, some previously unappreciated factor continued to spread the contagion. Careful inquiry following notification indicated that after one excluded cases that had been acquired outside Brighton and cases for which there was a known source of infection, between 30 and 40 percent of notified cases were unaccounted for during these years.

In March 1894 Newsholme announced to the Sanitary Committee that he had found the cause of such unexplained cases. His postnotification investigation in an outbreak of eleven cases led him to conclude that the only likely cause of at least five, and perhaps as many as eight, of these cases was the consumption of sewage-contaminated oysters.

CONTRACTION: PUBLIC HEALTH ON THE HOME FRONT

Almost five of Newsholme's eleven years at the Local Government Board were occupied by the demands of the First World War. He recalled two decades later that these demands had produced contradictory effects on the Boards activities. They “impeded much valuable work” and “stifled some progressive schemes at their birth,” but they also prompted some important initiatives. We begin by looking at the way in which the war tested the public health service and made the continuance of even routine activities extremely difficult and most innovation impossible. We will then turn to two areas in which the war prompted bold initiatives and major expansions of public health services: the prevention of venereal disease and the promotion of infant welfare.

“In Britain the time-honoured association between war and disease was broken during the Great War.” J. M. Winter reminds us of the great loss of human life to infectious disease during the war in Central and Eastern Europe and suggests that in Britain the “vagaries of disease,” improvements of nutrition, and a system of recruiting of medical practitioners that preserved a skeleton of general practitioner services at home may have been responsible for a happier fate. It may be impossible to determine in retrospect why anticipated events, a series of epidemics for example, did not occur, but it is historically useful to observe whether contemporaries foresaw danger and what they did to try to forestall it. In Britain the wartime public health service was mobilized early to use all available means to prevent the spread of infectious disease.

ADMINISTRATION

No other aspect of Newsholme's activities in Brighton gave him as much personal satisfaction or added so significantly to his professional reputation as his work with tuberculosis. His success in Brighton in constructing a comprehensive preventive strategy brought him attention outside the world of public health administration and helped win him the Medical Officership of the Local Government Board. In turn the use he made in Whitehall of this local experience offers historians a good example of the influence of municipal experiments on the nation's health policy. In retrospect it is easy to find a logic in the successive administrative changes that created Brighton's tuberculosis policy. But the historical evidence suggests that Newsholme began his work against tuberculosis with no master plan. Rather, we find that over a period of nearly two decades a policy slowly emerged in response to administrative experience and changing medical ideas. In this process we find operating at two levels an interplay between epidemiological studies on the one hand and his policy recommendations on the other. At the local level, through case finding and efforts to trace infection through the community as he had done for scarlet fever, his epidemiology helped shape his policy. On a grander scale of explanation, however, his policy experience helped determine the design and the outcome of his epidemiological studies. The former work won him nearly universal respect from his professional peers. Although he put great stock in the second class of investigations, and although they were influential in some quarters, these studies, pursued so vigorously over a number of years, involved him in protracted and bitter controversy and failed to convince even some of his friends.

POVERTY, EVOLUTION, AND CHARACTER

During his years in Brighton Newsholme had risen to prominence in his profession. He had developed a reputation as an active and able administrator. In 1907 Edward Cox Seaton, Medical Officer of Health for Surrey County Council and lecturer at St. Thomas's Hospital Medical School, described the work of Brighton's Health Department in glowing terms and called the Brighton system a model for other local authorities to emulate. He emphasized especially Brighton's achievement in housing, its success in establishing an effective, comprehensive, tuberculosis program, and the care and economy in administration. Newsholme had proven to be a prolific writer as well as a successful administrator. By the time he left Brighton, he had published six books and at least four later editions of these, some ninety articles and chapters, two dozen annual reports, and numerous quarterly and occasional reports. His works were distinguished for their mastery of epidemiology, and he was without question one of the nation's leaders in the field.

THE MEDICAL OFFICER OF THE L.G.B.

John Burns offered Arthur Newsholme the position of Medical Officer of the Local Government Board on January 11, 1908, and Newsholme arranged to take up his duties in Whitehall on February 4, one day after testifying before the Royal Commission on the Poor Laws. He became the Board's sixth Medical Officer in a line stretching back to Sir John Simon. In making this move, Newsholme went to the nation's central health and social welfare authority, to a bureau with important responsibilities in areas where major social reforms were presently under political consideration. The appointment was a great opportunity for a reformminded Medical Officer. However, its organization, tradition, and leadership made the L.G.B. a very unlikely engine of reform.

Writing in 1936, R.C.K. Ensor sounded the tone which historians have followed for two generations in describing the L.G.B.

HOUSEHOLDS AND DRAINS

The greatest success of late Victorian health departments may well have been in the most mundane matters, the enforcing of minimum standards of sanitation in homes, certain businesses, and public spaces. This work was conducted through the periodic visits of Inspectors of Nuisances or Sanitary Inspectors, who came, sometimes unannounced, to see that sanitary regulations were being observed. No other part of the Sanitary Department's work occupied so much staff time. When Newsholme arrived in Brighton, there were more than 20,000 occupied houses in the area of the Sanitary Department's jurisdiction. By the time he left in 1908, that number was nearly 24,000. Early in his career his Department thus had one inspector for every 2,222 inhabited houses. In the middle 1890s this ratio would have placed Brighton about on the middle of the scale of London boroughs, between the Strand at one extreme with one inspector for every 358 inhabited houses and Lambeth at the other with one inspector for every 4,819 inhabited houses.

THE FACILITIES: SANATORIUM, GRANGE, AND LABORATORY

When Arthur Newsholme took up his post as Brighton's Medical Officer of Health, the town already had a municipal isolation hospital, the Brighton Sanatorium. The Sanitary Committee's intention in appointing a full-time M.O.H. was that the incumbent would also step into the posts of Medical Officer of the Sanatorium and Surgeon to the Police Force when these positions became vacant. The promise of additional income and a more unified health service was soon fulfilled. Six months later the incumbent of the Sanatorium position announced his intention of resigning by Christmas 1888, and Newsholme was appointed in his place at an additional salary of £150 per year. He never held the post with the police force, relinquishing his claim to the job in 1892 in order to secure an increase in his combined salaries from £650 to £800 per year. The loss of the appointment with the police force was not of great moment. But the fact that Newsholme was both M.O.H. and Medical Officer of the Sanatorium was of the utmost importance for his career and for the development of the public health program in Brighton. Over the next fifteen years he would direct the transformation of the institution and its place in the town's social services. From the beginning Newsholme recognized the significance of the second post. In fact, a rumor circulated in the Council for some time after his appointment that he had paid off the previous Medical Officer to secure the latter's resignation.

The fact that it had an isolation hospital in the 1880s placed Brighton in the minority of provincial towns.

ANSWERS TO THE BIOMETRICIANS

Far from sinking into a quiet retirement when he left Whitehall, Newsholme continued to be professionally very active for a decade and a half. He held a number of those largely honorary appointments reserved for elder statesmen on advisory boards: the Executive Committee of the Imperial Cancer Research Fund, the Board of Governors of the London School of Economics, the Advisory Board of the Johns Hopkins School of Hygiene and Public Health as well as offices in the British Social Hygiene Council and the Society for the Study of Inebriety and Drug Addiction. Most of his great energy, however, was channeled into public speaking and writing. His literary output in this period is remarkable. Between his retirement and his eightieth birth year, 1919 to 1937, he was the sole author of eight books totaling eleven volumes, joint author of one volume, and the author of some three dozen journal articles and chapters in books edited by others. He also brought out a new edition of his textbook on vital statistics and produced two volumes of collected public addresses. His ever-active pen was now directed to new objects. He no longer undertook epidemiological investigation or composed detailed memoranda or official reports. Instead, a fair proportion of his writing and much of his public speaking was now health advocacy and commentary on current policy. The most important of Newsholmes productions in retirement are his comparative international studies of health care systems. To this work he devoted several years to travel, observation, and reading. These writings will be the focus of the last section of this chapter.

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: