Death and Survival in Urban Britain

Disease, Pollution and Environment, 1800-1950

Bill Luckin

• Publisher: I.B. Tauris
• Year: 2015
• ISBN:
  9780857739773
• Edition: 1
• Topic: Storia
• Subtopic: Storia britannica

The narratives of disease, hygiene, developments in medicine and the growth of urban environments are fundamental to the discipline of modern history. Here, the eminent urban historian Bill Luckin re-introduces a body of work which, published together for the first time, along with new material and contextualizing notes, marks the beginning of this important strand of historiography. Luckin charts the spread of cholera, fever and the 'everyday' (but frequently deadly) infections that afflicted the inhabitants of London and its 'new manufacturing districts' between the 1830s and the end of the nineteenth century. A second part - 'Pollution and the Ills of Urban-Industrialism' - concentrates on the water and 'smoke' problems and the ways in which they came to be perceived, defined and finally brought under a degree of control. Death and Survival in Urban Britain explores the layered and interacting narratives within the framework of the urban revolution that transformed British society between 1800 and 1950.

PART 1

DISEASE IN THE CITY

CHAPTER 1

COUNTRY, TOWN AND
‘PLANET’ IN BRITAIN 1800–1950

An unknown historical territory

Venturing uncertainly into the history of environment and disease in the early 1970s proved an anxiety-inducing experience. Monographs were rare, specialist journals even rarer.¹ To the uninitiated, medical history seemed to offer a promising point of entry. Not so. With a handful of exceptions, scholars in the field were committed to exploring what would soon come to be known as ‘internal’ issues.² Little had been written about the grassroots historical experience of urban (or rural) death, survival and environmental deprivation. Victims of disease were barely visible.³

The early 1970s saw the emergence of a new social history of medicine. The sub-discipline focused on relationships between the medical and epidemiological past and the larger society in which they were then believed to be non-problematically located. The new field prospered. Over the next 40 years it expanded and diversified, spawning specialist journals, an international research community and hundreds of conferences.⁴ From the 1990s onwards, a minority of writers, influenced by the cultural turn, began to question the utility of the ‘social’ as an explanatory category, and to interrogate the value of a now widely used term – ‘context’ – in which everything medical was claimed to have been situated.⁵ But theoretical and methodological critique made little impact on the way in which most social historians of medicine went about their business, although theory – particularly the work of Michel Foucault – now played a larger role than 15 years earlier.⁶

Judged by numbers of books and journals published, by the new millennium the discipline had become spectacularly popular, with an ever wider range of historians gravitating towards medical or medically-inflected topics. No unitary style could be identified. But ‘eclectic empiricism’ gives a flavour of the dominant approach. In the new millennium the histories of learning difficulty and physical disability, child abuse and obesity vie with more traditional topics. In the 1970s and 1980s the nineteenth century and early modern periods attracted more attention than any others. Now increasing numbers of writers engage with twentieth century and near-contemporary topics. However, as we shall see, links between socio-medical and environmental history remain under-developed.⁷

Fifteen years before I began to ponder the histories of environment and disease, there had been a breakthrough in historical epidemiology. Thomas McKeown, a Canadian-born, Irish-educated expert in social medicine, who worked for many years at the University of Birmingham, published a cluster of journals on the nineteenth-century British mortality decline.⁸ Sceptical of the achievements of professional medicine – and indifferent throughout his career to criticisms levelled at his own contributions – in 1973 McKeown summarized his findings in The Modern Rise of Population. He argued that in late nineteenth century Britain a ‘municipal sanitary revolution’, a handful of changes in the balance between host and causative microorganisms, and, most important of all, radical improvements in nutrition, had triggered improvements in health.⁹ Little wonder that, in his sociological writings, McKeown revealed a career-long obsession with the ‘limits of medicine’.¹⁰

In the 1950s and 1960s there had also been a flurry of activity in what then tended to be called the history of public health. Three books creatively complemented McKeown's research. S.E.Finer, R.A.Lewis and R.S. Lambert published major lives of Edwin Chadwick and Sir John Simon, founding-fathers of Victorian sanitary thinking and the prevention of disease.¹¹ Finer, Lewis and Lambert identified seminal questions connected with epidemics, conceptions of the transmission of infection and the development of public utilities, notably water supply. Other highly suggestive work around this time derived from economic history, the subject I was studying at the London School of Economics in the early 1970s. E. J. Hobsbawm made a characteristically trenchant contribution to the long-running standard of living debate. He suggested that opposing camps – ‘optimists’ and ‘pessimists’ – may have fought themselves to a standstill. Ever larger quantities of quantitative data could be collected, interpreted and haggled over. But to what end? Intriguingly, from my point of view, Hobsbawm believed that greater attention should now be paid to then deeply unfashionable ‘qualitative’ topics – health and illness and environment.¹²

Differences between quantitative and qualitatively-oriented research in the 1960s and 1970s resonated with much earlier debates between John and Barbara Hammond and the distinguished Cambridge economic historian, Sir John Clapham. The best-selling Hammonds argued that tragically large numbers of working-class inhabitants of new towns had fallen victim to the squalid environments in which they had been forced to live.¹³ In the late 1920s they contested Clapham's quantitatively-based assessment of the fortunes of typical members of the working-classes during the first great period of urbanization: these findings, they argued, were too heavily dependent on exclusively statistical data. Clapham acknowledged the force of the point, but doubted whether either optimistic or pessimistic hypotheses could be decisively proven or disproven. The Hammonds accepted that Clapham had clinched the quantitative case but insisted that the social aspect remain open.¹⁴

What, meanwhile, of the state and status in the early 1970s of what would later come to be known as urban-environmental history? Other things being equal, one would have expected these years to have seen an upsurge in interest in this field. The world oil crisis, pollution, the negative side-effects of rapid economic growth and the unconstrained expansion of world population, generated wide-ranging political debate and an impressive social scientific literature.¹⁵ Contemporary problems invariably shape the questions historians ask about the past. Not in this case. Perhaps the influence of the British arts–science divide, the focus of a heated debate between C.P. Snow and F.R. Leavis in the 1950s, provided a part-explanation.¹⁶ In addition, senior urban and social historians in the 1970s made it clear that environmental and epidemiological research should be left to scientifically-trained specialists.¹⁷ As I would soon discover, things were different in the United States. In the early 1970s a small group of scholars – with Joel Tarr of Carnegie-Mellon University in Pittsburgh in the lead – began to publish on urban-environmental problems in the nineteenth and twentieth century city.¹⁸ The message spread slowly. European and Scandinavian scholars lagged behind. Britain brought up the rear.¹⁹

Tracing patterns of disease

The first chapter in this book, originally published in 1980, was heavily influenced by McKeown and Hobsbawm. It concentrated on McKeown's hypothesis that a handful of infections – notably scarlet fever and possibly typhus – had entered a late nineteenth century period of decline following a sudden shift in the balance between host and causative microorganism.²⁰ The chapter also assessed problems associated with annual cause- and age-specific mortality data. McKeown's work had relied on national decennial material and had thrown little light on differentials between town and country, the fortunes of individual urban centres, and different parts of the same locality.²¹ I could hardly have guessed that my tentative foray into McKeown territory would generate enough problems to keep me occupied for the next 30 years. Either directly or indirectly, each of the chapters in this book engages with issues first raised in that chapter.

In 1983 I tackled the McKeown typhus hypothesis head-on. (Typhoid provided a kind of control. As McKeown had argued, the decline of the bacterial infection had been closely linked to successive waves of Victorian and Edwardian environmental intervention. Human agency, rather than ecological change, had been decisive.²²) The existence or otherwise of a change in case-fatality rates proved central to the typhus issue. Cross-cutting between the reports of medical officers of health, the medical press, hospital data, Poor Law records, and the annual cause-specific data provided by the GRO allowed me to construct an index of a wide range of urban disease experiences.²³ The trend seemed to confirm McKeown's theory. However, something different was clearly happening in the urban north-east, where serious outbreaks of the disease continued intermittently to attack poverty-stricken communities. Crucially, in Sunderland and Newcastle in the 1880s as many individuals were failing to survive out of every hundred contracting the infection as in the violently fever-prone aftermath of the Napoleonic Wars, the poverty-plagued 1840s and the final large-scale national epidemic of the 1860s.²⁴

Could there be a connection between north-eastern exceptionalism and the natural history of the infection in Ireland? Pools of typhus survived in rural areas in that country and streams of migrants were known to carry the disease into Belfast, Cork and Dublin, before setting sail for England.²⁵ Another point. In the later nineteenth century the urban north-east received far larger numbers of first-generation Irish than any other part of England. My work on typhus now reminds me of a classic Chinese box puzzle: every problem led on to another of greater evidential complexity. A few years later my conclusions were convincingly challenged by Anne Hardy.²⁶ However, the exercise deepened my awareness of a cluster of problems first glimpsed in the 1970s – changing nineteenth century conceptions of infectious disease, preventive priorities in the aftermath of the cholera and fever years and subsequent efforts to track and explain cause-specific mortality and morbidity. One other point. The typhus research clarified the depth of pessimism and panic experienced and expressed by earlier nineteenth century social reformers and medical men: at any moment, they feared, the new urban civilization might be decimated by a new outbreak of ‘plague-like’ infection. As if to fulfil worst expectations, cholera struck in 1831–2, 1848–9, 1854–5 and 1866. Would early and mid-Victorian cities slip back towards the epidemiological misery experienced in the era of the bubonic plague or, at best, the epidemic-ravaged seventeenth and eighteenth centuries?²⁷

Even before the shock of the ‘final catastrophe’ in 1866, described in Chapter 4, attitudes had begun to shift. At meetings of the Epidemiological Society, the Meteorological Society, the Society of Metropolitan Medical Officers and the Sanitary (later Royal Sanitary) Institute, new approaches began to emerge.²⁸ Progressive health officials in London – and Liverpool – now started to focus on multi-causal explanations of the spread of disease.²⁹ In the capital reformers emphasized the central importance of effective communication between local medical officers, the General Register Office and the capital-wide Metropolitan Asylums Board (MAB).

This latter organization served as a multi-centre facility for very poor patients – initially paupers – suffering from what were believed to be dangerously infectious conditions.³⁰ There was a growing consensus that London's preventive system possessed the potential to defeat cholera, typhus and typhoid. Human and animal filth must continue to be regularly removed from ill-ventilated streets and alleys, individuals suffering from dangerous conditions taken to isolation hospitals, and working-class dwellings stricken by infection ‘closed down’ and declared uninhabitable.³¹ (Scandalously little, however, was done to rehouse the exceptionally large numbers thrown out of house and home.³²) If measures of this kind were carried out in every centre, life in early twentieth century urban Britain might be healthier and happier for every social class. By now, the epidemiological bar was beginning to be raised. Greater attention was paid to conditions which, year in, year out, killed many more people, particularly among the youngest age-groups, than infections like cholera, typhus and typhoid. Morbidity, as well as mortality, were more rigorously monitored. For centuries, working men and women had contracted serious illnesses, recovered and then slowly returned to a kind of health. But physical resilience was invariably compromised. A worker who had recovered from a serious attack of typhoid might never again be able to do a demanding manual job.³³ Knock-on effects could be extreme. Wages declined and lower family take-home pay involved moving further down the housing ladder.³⁴ Sub-standard living conditions, and inadequate diet, increased the likelihood of a weakened constitution succumbing to further infection or chronic illness. The only alternatives might be odd-jobbing, street-selling or scavenging. From that narrow ledge, ‘dependency’ – the workhouse – threatened ominously.³⁵

The final third of the nineteenth century also saw increased scrutiny of the spatial incidence of disease. Medical officers charted the ways in which administrative sub-divisions had obscured the precise distribution of poverty, infection and death. The mapping of islands of deprivation in the midst of plenty or relative plenty generated disturbing questions about the maldistribution of wealth – and health – in the greatest and, as many said, the richest city in the world. ³⁶ By the end of the 1870s, we detect the beginnings of an understanding of the processes that might underlie appallingly high levels of mortality from the infections of infancy and childhood: the debate continued into the Edwardian period and the depression-ravaged 1930s.³⁷ During this period, also, scientists and medical men gradually began to use a wide range of terms – ‘poison’, ‘germ’, ‘fungus’ – to bestow a clearer identity on the minute entities that probably played a central or supportive role in transmitting infection and triggering traumatic outbreaks of disease.³⁸

Interrogating this latter theme in the context of the ‘final catastrophe’ – the cholera epidemic that struck the East End of London in 1866 – Chapter 4 examines the numerous ways in which metropolitan medical officers of health attempted to make conceptual sense of a devastating tragedy. Water lay at the heart of the narrative. Edward Frankland, chemist and unofficial metropolitan water analyst, worked in close collaboration with William Farr, John Simon and John Netten Radcliffe, a pioneering epidemiologist and collaborator of Simon's at the Medical Office of the Privy Council. After numerous investigations, the East London Water Company was condemned ‘before the bar of public opinion’. By drawing on sub-standard reserves and pumping cholera into stand-pipes in some of the poorest and most vulnerable parts of the city, it had breached legislation passed a decade and half earlier. The government delivered a muted reprimand and asked the company to behave better in the future. During and after the epidemic, medical officers – and Simon and Farr but not the arch-progressive Radcliffe – hedged their theoretical bets.

A clear majority acknowledged the importance of the ‘water factor’ but denied that it provided a full explanation. A number of medical officers floated logically irrefutable alternatives. Henry Letheby, Simon's successor as Medical Officer of the City of London, ...

Table of contents

• Front Cover
• Title Page
• Copyright
• Dedication
• Contents
• Figures and Tables
• Preface
• Acknowledgements
• Part 1 Disease in the City
• Part 2 Pollution and the Burdens of Urban-Industrialism
• Notes
• Bibliography
• Back cover