Mortality

Levels of mortality changed little between the 1820s and the 1870s after which they moved hesitantly downwards to the turn of the century. There were three major factors influencing health and mortality. First, socio-economic forces such as rising real wages and improved living standards and diet offered some improvement though not to the urban poor. Secondly, bio-medical factors offered few major breakthroughs in curative medicine before the late nineteenth century despite better hospital provision and improved treatment and containment of epidemic diseases especially those of childhood such as scarlet fever, diphtheria and measles. Finally, environmental conditions put great pressure on the larger towns in which an increasing proportion of the population lived but improvement was restricted. Only with effective legislation to improve sanitation, water supply and housing and to apply effective measures of preventive medicine, especially the control of epidemic diseases were these gradually eliminated.[1] Medical science may have changed slowly but improving public and private medicine and, from 1850 onwards, more and better-run hospitals improved health and life expectancy, especially among the middle-classes.[2] The introduction of school medical services in the 1900s helped through regular eye, dental and hair inspections since head lice were a universal scourge in poorer areas.[3]

While most epidemic diseases resisted cure, prevention and treatment could limit their impact. During the epidemic years of 1831-1832, 1847-1849 and in the 1860s average mortality of about 22 per thousand rose to 24-25 per thousand. Excess mortality in large cities and industrial areas was reflected in the contrast, identified by William Farr, between the ‘Healthy Districts’ (rural and suburban areas) that had an average life expectancy at birth of 51.5 years in the late 1830, and the ‘Poor Districts’ (unhealthy inner cities and many industrial areas) where it was less than 29. This gap narrowed from the 1880s when it began a slow fall to 47.5 and 66.3 years for County Boroughs and Rural Districts respectively in 1911. The close link between high population density, overcrowding and death rates, especially among infants and children underlined the continuing important of environmental and socio-economic factors in health and mortality.

The wide discrepancies in life expectancy and the principal reason for failing to improve this until after 1890 was high levels of infant mortality. Child deaths began to decline erratically from 1830 and more steadily from the 1860s; only from 1900 was there a parallel fall in infant mortality. In late nineteenth century England between 15% and 20% of deaths occurred to those under the age of one year with about 25% for those under five years. Infant mortality in the unhealthiest cities was more than double than in healthy rural areas and twice that of suburban areas. In Glasgow, intra-urban mortality in the 1870s ranged from 21 to 46 per thousand with even wider discrepancies between wards of 69 to 166 per thousand. The mortality of infants born to unmarried mothers was substantially higher than that of legitimate children and roughly one third of all infant deaths occurred during the first month of life.[4]

Over three-quarters of the fall in mortality between 1848 and 1901 was brought about by a decline in diseases such as scarlet fever, diphtheria and measles and those caused by infected water and food such as typhoid, cholera and, most significantly, dysentery and diarrhoea, a major cause of child deaths in summer months. There was also considerable improvement in the prevention of respiratory tuberculosis thanks to better housing, nutrition and nursing. There was no improvement of other bronchial deaths, including pneumonia and influenza, to which growing air pollution undoubtedly contributed. Even in the countryside substantial differences in mortality reflected environmental and nutritional contrasts. In the Fens, for example, damp and humid summer heat tainted food and increased mortality in areas where babies were weaned young.  Where children were breast fed and/or had access to fresh milk, as in many areas of upland England infant mortality was often below average.

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[1] Woods, Robert and Shelton, Nicola, An atlas of Victorian mortality, (Liverpool University Press), 1997 provides a graphic representation. Winter, J.M., ‘The Decline of Mortality in Britain, 1870-1950’, in ibid, Barker, T. and Drake, M., (eds.), Population and Society in Britain, pp. 101-120 and Millward, R. and Bell, F.N., ‘Economic Factors in the Decline of Mortality in Late Nineteenth Century Britain’, European Review of Economic History, Vol. 2, (1998), pp. 263-288 consider the evidence.

[2] Hardy, A., Health and Medicine in Britain since 1860, (Longman), 2001 and The Epidemic Streets: Infectious Disease and the Rise of Preventive Medicine 1856-1900, (Oxford University Press), 1993.

[3] Houlbrooke, R., (ed.), Death, Ritual and Bereavement, (Routledge), 1989 contains some useful papers and Barnard, S.M., To Prove I’m not Forgot: Living and Dying in a Victorian City, (Manchester University Press), 1990 provides a specific case study on Victorian attitudes to death. Woods, Robert, ‘Physician, heal thyself: the health and mortality of Victorian doctors’, Social History of Medicine, Vol. 9, (1996), pp. 1-30 looks at the medical profession.

[4] Woods, Robert, ‘On the historical relationship between infant and adult mortality’, Population Studies, Vol. 47, (1993), pp. 195-219 and Children remembered: responses to untimely death in the past, (Liverpool University Press), 2006 and Woods, R., et al., ‘The causes of rapid infant mortality decline in England and Wales, 1861-1921’, Population Studies, Vol. 42, (1988), pp. 343-366 and Vol. 43, (1989), pp. 113-132. See also, Williams N. & Mooney, G., ‘Infant Mortality in an “Age of Great Cities”: London and the English Provincial Cities Compared, c.1840-1910’, Continuity and Change, Vol. 9, (1994), pp. 175-212, Reid, A., ‘Locality or Class? Spatial and Social Differentials in Infant and Child Mortality in England and Wales, 1895-1911’, in Corsini, C.A. & Viazzo, P., (eds.), The Decline of Infant and Child Mortality: The European Experience 1750-1990, (Martinus Nijhoff), 1997, pp. 129-154 and Graham, D., ‘Female Employment and Infant Mortality: Some Evidence from British Towns, 1911, 1931 and 1951’, Continuity and Change, Vol. 9, (1994), pp. 212-246.

Malthus

In 1803, Thomas Robert Malthus (1766-1834) published a second edition of his An Essay on the Principles of Population, a work that had been first published anonymously five years earlier.[1] The main tenets of his argument were radically opposed to contemporary thinking. He drew attention to the consequences of untrammelled population growth, arguing that it would double every twenty-five years and that existing resources would not rise sufficiently to support such growth. Although the ultimate check on population for Malthus appeared to be want of food arising from the different ratios according to which population and food supplies increased, the immediate checks ‘are all resolvable into moral restraint, vice and misery’. Of these, the ‘positive checks’, as Malthus called them, included

...all unwholesome occupations, severe labour and exposure to the seasons, extreme poverty, bad nursing of children, great towns, excesses of all kinds, the whole train of common diseases and epidemics, wars, plague and famine.[2]

The ‘preventive checks’ could largely be equated with ‘restraint from marriage which is not followed by irregular gratifications’, while

...promiscuous intercourse, unnatural passions, violations of the marriage bed and improper arts to conceal the consequences of irregular connections, are preventive checks that clearly come under the head of vice.[3]

In England, Malthus argued, the checks on population were much affected by social class, the opportunities for employment and the physical, especially urban, environment. Self-imposed restraint on marriage operated with ‘considerable force throughout all the classes of the community’. The population model Malthus developed was one in which the rate of demographic growth was influenced by mortality, fertility and net migration. When the rate of population growth begins to rise there will be an increase in the price of food that will reduce the level of real wages. Lower real wages might lead to increased mortality or affect the prospects of marriage that will automatically increase the level of temporary or permanent celibacy. As a result, fertility will fall and the growth of population slow down as it would if mortality were to be increased. This is called a self-regulation or homeostatic system.

There is much in what Malthus wrote that is relevant to the post-1830 period but during the nineteenth century ways were found to escape from the weight of Malthus’ law.[4] First, the association between population growth rates and food prices appears to have been broken even during Malthus’ lifetime. Secondly, while the relationship between mortality and real wages persisted, the latter began a long-term improvement. Mortality was probably reduced as a result, though difference between classes persisted. Improved standards of living were only one of many potential reasons for falling mortality. Thirdly, marital fertility took the place of nuptiality as the principle influence on changes and variations in general levels of fertility. Family limitation came to be widely practised. Finally, the closed system described by Malthus was thrown open to new forms of destabilising influences. Cities grew at the expense of villages and the Empire at the expense of Britain.

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[1] Malthus, T.R., An Essay on the Principle of Population, Or, A View of Its Past and Present Effects on Human Happiness: With an Inquiry Into Our Prospects Respecting the Future Removal Or Mitigation of the Evils which it Occasions, various editions. Winch, Donald, (ed.), An Essay on the Principle of Population, (Cambridge University Press), 1992 is an annotated version of the 1803 edition while Gilbert, Geoffrey (ed.), An Essay on the Principle of Population, (Oxford University Press), provides an accessible copy of the 1798 edition. Winch, D., Malthus, (Oxford University Press), 1987 is a good short discussion.

[2] Ibid, Winch, Donald, (ed.), An Essay on the Principle of Population, p. 23.

[3] Ibid, Winch, Donald, (ed.), An Essay on the Principle of Population, p. 24.

[4] See, Komlos, John, ‘The industrial revolution as the escape from the Malthusian trap’, Journal of European Economic History, Vol. 29, (2000), pp. 307-331 and Thomas, Brinley, ‘Escaping from constraints: the industrial revolution in a Malthusian context’, in Rotberg, R.I. and Rabb, Theodore Kwasnik, (eds.), Population and history: from the traditional to the modern world, (Cambridge University Press), 1986, pp. 169-193.