This is a formidable contribution to the new history of health and ill-health. The new history is concerned with endemic disease and illness rather than with epidemics because, even in the short run, endemic illnesses kill, disable and make wretched many more human beings than the more spectacular epidemics with their abundance of bizarre incidents and accessible evidence. Rather than merely recount the course of an epidemic, the new historians try to encompass the environmental, social and political contexts of health and ill-health and, within these contexts, to explain the responses of patients, sanitarians, doctors and ratepayers. This programme looks straightforward but until now it has rarely been attempted.
The very structure of Endangered Lives will upset readers accustomed to the old sagas of medical triumph and sanitary reform, replete with medical derring-do and victories over Asiatic cholera, with descriptions of stinking cellar-dwellings and of crass, stingy aldermen. Traditional medical history centres on the measurable mortality of adults: Wohl devotes a long second chapter to infants, by far the most vulnerable part of the population, but commonly neglected because their deaths are less surely reported and other evidence about their lives and health is patchy, indirect and often contradictory. Moreover, Wohl emphasises the fact, still seldom grasped by writers on sanitary reform and students of 19th-century matters, that the infant death-rate in Great Britain probably rose through Victoria’s reign to run at around 153/1000 during the 1890s for England and Wales and 129/1000 for Scotland (the present UK rate is around 12/1000). In the slum wards of the great cities and in mining villages these rates were almost doubled. Hitherto these facts had been hidden by the fall in the overall death-rate of adults and children from 22.2/1000 during 1851-60 to 18.2/1000 during 1891-1900.
Behind these statistics lies the shocking reality that over a hundred thousand infants aged under 12 months died annually in England and Wales through the second half of the 19th century: that is, every two years saw more infant deaths than the total loss of life ascribed to Asiatic cholera during the four major epidemics of which the first (1831-32) so preoccupies historians. Wohl traces the evil effects of malnutrition on babies and mothers, the concomitant poor stature in working-class and destitute mothers, crude and dirty childbirth practices among midwives and male accoucheurs, and the ravages of diarrhoeal and wasting illnesses associated with poverty, ignorance and the inept feeding and fostering that accompanied them. These subjects are not new, but Wohl evokes their complicated, often fatal interaction with unusual vividness. There is still much that we do not understand about these processes, particularly about the (possibly increasing) value given to infant life in Victorian Britain and Ireland, but Endangered Lives marks a striking advance in the efforts of the new health historians to put infants and mothers first.
After this splendid beginning, the book becomes more conventional. There are sound, informative chapters on the quality and quantity of food and drink, and on the horrific consequences of the lag between rapid population growth and the provision of good water supplies and the removal of wastes, especially in the great towns. Succeeding chapters describe urban atmospheric and river pollution, ‘overcrowding’ and industrial diseases. Each presents an authoritative statement of the present state of knowledge, strengthened by much new evidence which Wohl has unearthed. But he has missed an opportunity. He follows earlier historians in dwelling upon the legal and administrative problems created by these intensified and newly flagrant threats to the population’s health, and treats each in isolation from the others. The question that remains unanswered is that of their effect on one another and their impact on the life chances of particular groups in particular localities and occupations.
Wohl would be well-equipped to explore in detail the assertion that respiratory and eye infections were disproportionately common among the overcrowded working classes and poor and that these afflictions were most acute in the winter and spring when air pollution was most palpable and widespread, especially in the poverty-stricken low-lying industrial areas bordering the rivers. Skin eruptions were also plentiful, apparently among all classes but especially among the poor: bad nutrition no doubt had much to do with it, but it would be worth exploring the contemporary aversion to washing among all classes, reinforced in the case of the poor by meagre access to good water.
Wohl’s book has some memorable pages on phossy jaw, the necrosis of the lower facial bones and skin induced by phosphorus poisoning among workers in match manufactories. Their sufferings were hideous, but their numbers were few compared with the porters, wharf labourers, carriers and labourers in the building trades among whom there was a dismayingly high incidence of crippling and killing damage to spines and limbs. It is also salutary to recall that the occupational grouping which, at 44.4/1000 in the 1890s, had the highest death-rate for males over 45 was innkeepers and barmen, who destroyed themselves by consuming their own commodity. As these instances show, the exploration of industrial diseases and disabilities must begin with everyday practices in the streets and pubs, rather than in the factories which have hitherto largely monopolised attention.
The acts which protected workers in the factories and forbade adulteration of beer and spirits become, in this context, part of the clean-up that gathered momentum after 1860. Thanks to clever statutory and administrative innovations, backed by imaginative engineering and the resolute raising and spending of rates, a great purification had been effected by the end of the century. Probably it was on a much more thorough and expensive scale than comparable campaigns in France, Germany and the United States, although we still know little about this and Wohl does not pursue international comparisons. And the clean-up worked. Death-rares fell for all major water and airborne diseases (excepting influenza), dramatically so for some of the more terrible scourges such as cholera and typhus which, by 1900, had all but disappeared from Great Britain. By 1911 human beings in England and Wales had a life expectancy from birth of around 51 years, a gain of 11 years upon their forebears in 1841. Londoners could expect to live to the age of 49, rather than to a tired and worn 35, as in 1841. The ratio of deaths between large towns and the countryside during 1891-1901 was 114:100 – bad enough, but a splendid improvement upon the grim disparity of 124:100 that obtained during 1851-61.
It used to be believed that the fourfold increase of population through the 19th century was founded upon the therapeutic work of doctors and hospitals. But in a series of notable papers over the last thirty years Thomas McKeown has shattered the old arguments. His verdict is freshly endorsed by Wohl: ‘Of all the major epidemic diseases of the 19th century only smallpox was contained and turned by ... medical discovery.’ This seems indisputable, but there is another way of assessing the doctors’ contribution. Impotent though they were to immunise (except against smallpox) and cure, medical men, unsung and harassed in the cities and villages, probably made the crucial contribution to the saving of life by bravely and tirelessly pointing to what needed to be cleaned up and to ways in which the clean-up could be promoted. We know very little about this aspect of the doctors’ labours: some, we know, accepted the dirt, and others were craven, but many others, particularly the medical officers of health, were effective and heroic and have yet to achieve the recognition they deserve. Their efforts to reclaim the great towns and to preserve life, undertaken in alliance with Parliamentary sanitary reformers, enlightened local councillors and the odd crusading local newspaper editor, may well turn out to be one of the noblest achievements of the Victorian Age.