* We are grateful for the financial support of the Wellcome Trust (grant number 044175). We would like to thank Derek Keene, Andrea Tanner, Violetta Hionidou, the editor and the anonymous referee for their helpful comments.

¹ McKeown, T.R. and Record, R.G., ‘Reasons for the decline of mortality in England and Wales during the nineteenth century’, Population Studies, 16 (1962), 94–122CrossRefGoogle Scholar; McKeown, T.R., The Modem Rise of Population (London, 1976).Google Scholar

² Landers, J., Death and the Metropolis: Studies in the Demographic History of London 1670–1830 (Cambridge, 1993), 7.CrossRefGoogle Scholar

³ Wrigley, E.A. and Schofield, R.S., The Population History of England 1541–1871: A Reconstruction (London, 1981).Google Scholar

⁴ Ibid., 484, footnote 60.

⁵ See also Finlay, R., Population and Metropolis: The Demography of London 1580–1670 (Cambridge, 1981)CrossRefGoogle Scholar; Vann, R.T. and Eversley, D., Friends in Life and Death. The British and Irish Quakers in the Demographic Transition (Cambridge, 1992)CrossRefGoogle Scholar; and Galley, C., ‘A never-ending succession of epidemics? Mortality in early modem York’, Social History of Medicine, 7 (1994), 29–57.CrossRefGoogle Scholar

⁶ ‘Mortality in the Metropolis, 1860–1920’ is a project funded by the Wellcome Trust and based at the Centre for Metropolitan History, University of London.

⁷ Omran, A.R., ‘The epidemiologie transition. A theory of the epidemiology of Population change’, Milbank Memorial Fund Quarterly, 49 (1971), 509–38.CrossRefGoogle Scholar

⁸ Luckin, B., review of A. Hardy,.The Epidemic Streets: Infectious Disease and the Rise of Preventive Medicine 1856–1900 (Oxford, 1993)Google Scholar, in Social History.19 (1994), 407–14.Google Scholar

⁹ Szreter, S.R.S., ‘The importance of social intervention in Britain's Mortality Decline c 1850–1914: a reinterpretation of the role of public health’, Social History of Medicine, 1 (1988) 10–11.Google Scholar

¹⁰ Kearns, G., ‘The urban penalty and the population History of England’ in Brändstrong, A. and Tedebrand, L.-G. (eds), Society and Health During the Demographic Transition (Stockholm, 1988), 215.Google Scholar

¹¹ Wrigley, E.A., Continuity, Chance and Change. The Character of the Industrial Revolution England (Cambridge, 1990), 89.Google Scholar

¹² See Lunn, P.G., ‘Nutrition, Immunity and Infection’, in Schofield, R.S., Recher, D. and Bideau, A. (eds), The Decline of Mortality in Europe (Oxford, 1991), 137.Google Scholar

¹³ The literature covering the ‘standard of living debate’ is now vast. See, for example, Hunt, E.H. and Botham, F.W., ‘Wages in Britain during the Industrial Revolution’, Economic History Review, 2nd ser., 40 (1987), 380–99Google Scholar; For London, Schwartz, L.D., ‘The standard of living in the long-run: London, 1700–1860’, Economic History Review, 2nd ser., 38 (1985), 26–41.Google Scholar Anthropometric studies include Floud, R., Watcher, K. and Gregory, A., Height, Health and History: Nutritional Status in the United Kingdom, 1750–1980 (Cambridge, 1990)CrossRefGoogle Scholar, and Johnson, P. and Nicholas, S., ‘Male and female living standards in England and Wales, 1812–1857: evidence from criminal height records’, Economic History Review, 2nd ser., 48 (1995), 470–81.Google Scholar On the general relationship between standards of living and nutritional status, see Livi-Bacci, M., Population and Nutrition. An Essay on European Demographic History (Cambridge, 1991), 97–9CrossRefGoogle Scholar, and more specifically, Komlos, J., ‘The secular trend in the nutritional status of the population of the United Kingdom’, Economic History Review, 2nd ser., 46 (1993), 115–44.CrossRefGoogle Scholar A demographic perspective can be found in Armstrong, W.A., ‘The trend of mortality in Carlisle between the 1780s and the 1840s: a demographic contribution to the standard of living debate’, Economic History Review, 2nd ser., 34 (1981), 94–114.CrossRefGoogle ScholarPubMed

¹⁴ Mercer, A.J., Disease, Mortality and Population in Transition: Epidemiological-Demographic Change in England as Part of a Global Phenomenon (Leicester, 1990), 151.Google Scholar

¹⁵ Benson, B.W., ‘Mortality variation in the north of England, 1851–1910’ (unpublished Johns Hopkins University Ph.D. thesis, 1980), 51.Google Scholar Preston, S.H. and Walle, E. van de, ‘Urban French mortality in the nineteenth century’, Popuktion Studies, 32 (1978), 275–95.CrossRefGoogle ScholarPubMed

¹⁶ Preston, S.H. and Haines, M.R., Fatal Years: Child Mortality in Late Nineteenth-Century America (Princeton, 1991).CrossRefGoogle Scholar

¹⁷ McKeown, T.R., The Role of Medicine: Dream, Mirage or Nemesis (Oxford, 1979).Google Scholar See also McKinlay, J.B. and McKirday, S.M., ‘The questionable contribution of medical measures to the decline in mortality in the United States in the twentieth century’, Milbank Memorial Fund Quarterly, 55 (1977), 405–28.CrossRefGoogle ScholarPubMed

¹⁸ The professionalization of medical officers of health is dealt with in Hardy, A., ‘Public health and the expert: the London Medical Officers of Health 1856–1900’, in MacLeod, R. (ed.), Government and Expertise: Specialists, Administrators and Professionals, 1860–1919 (Cambridge, 1988), 128–48Google Scholar; and Porter, D., ‘Stratification and its discontents: professionalization and conflict in the British public health service, 1848–1914’, in Fee, E. and Acheson, R. (eds), A History of Education in Public Health: Health that Mocks the Doctors’ Rules (Oxford, 1991), 83–113.Google Scholar

¹⁹ Mercer, A.J., ‘Smallpox and epidemiological-demographic change in Europe: the role of vaccination’, Population Studies, 39 (1985), 287–308.CrossRefGoogle Scholar

²⁰ Hardy, A., ‘Smallpox in London: factors in the decline of the disease in the nineteenth century’, Medical History, 27 (1983), 111–38.CrossRefGoogle ScholarPubMed

²¹ Woods, R.I. and Hinde, P.R.A., ‘Mortality in Victorian England: models and patterns’, Journal of Interdisciplinary History, 18 (1987), 27–54CrossRefGoogle ScholarPubMed; Woodward, J., To Do The Sick No Harm: A Study of the British Voluntary Hospital System to 1875 (London, 1974)Google Scholar; Reams, G., Lee, W.R. and Rogers, J., ‘The interaction of political and economic factors in the management of urban public health’, in Nelson, M.C. and Rogers, J. (eds), Urbanisation and the Epidemiologic Transition (Uppsala, 1989), 16.Google Scholar

²² Woods, R.I. and Woodward, J.H. (eds), Urban Disease and Mortality in Nineteenth-Century England and Wales (London, 1984).Google Scholar

²³ Kearns, G., ‘Le handicap urbaine et le déclin de la mortalité en Angleterre et au Pays de Galles 1851–1900’, Annales de Démographie Historique (1993), 75–105CrossRefGoogle Scholar; Mooney, G., ‘The geography of mortality decline in Victorian London’ (unpublished University of Liverpool Ph.D. thesis, 1994)Google Scholar; Benson, , ‘Mortality variation’.Google Scholar

²⁴ Hardy, , The Epidemic Streets.Google Scholar

²⁵ ‘Introduction’, in Bynum, W. and Porter, R. (eds), Living and Dying in London. Medical History Supplement No. 11 (London, 1991), xviii.Google Scholar

²⁶ The following summary is a schematized statement of the position elaborated by Landers in Death and the Metropolis, ch. 1.

²⁷ Ibid., 13.

²⁸ Fridlizius, G., ‘The mortality decline in the first phase of the demographic transition: Swedish experiences’, in Bengtsson, T. et al. (eds), Preindustrial Population Change (Stockholm, 1984), 71–114Google Scholar; Perrenoud, A., ‘The mortality decline: a long term perspective’, in Schofield et al., Decline of Mortality in Europe, 41–69.Google Scholar

²⁹ Woods, R.I., ‘The structure of mortality in nineteenth-century England and Wales’, Journal of Historical Geography, 8 (1982), 392.CrossRefGoogle Scholar

³⁰ For a recent critique of epidemiological and demographic transition theories, see Thiltgès, E., Duchêne, J. and Wunsch, G., ‘Causal theories and models in the study of mortality’, in Lopez, A., Casselli, G. and Valkonen, T. (eds), Adult Mortality in Developed Countries: From Description to Explanation (Oxford, 1995), 21–36.Google Scholar

³¹ The figures up to 1801 are taken from Wrigley, E.A., ‘Urban growth and agricultural change: England and the Continent in the early modern period’, Journal of Interdisciplinary History, 15 (1985), 683–728.CrossRefGoogle Scholar For the nineteenth and early twentieth centuries, the ‘urban’ percentage applies to towns of over 2,500 population. This information is given in Law, C.M., ‘The growth of urban population in England and Wales, 1801–1911’, Transactions of the Institute of British Geographers, 41 (1967), 125–43.CrossRefGoogle Scholar

³² Kearns, , ‘The urban penalty’, 223Google Scholar. The estimates of life expectation at birth are taken from Woods, R.I., ‘The effect of population redistribution on the level of mortality in nineteenth century England and Wales’, Journal of Economic History, 45 (1985), 645–51.CrossRefGoogle Scholar

³³ For further empirical investigation of the urban/rural dichotomy, see Keams, , ‘Le handicap urbaine’.Google Scholar

³⁴ Woods, , ‘The effect of population redistribution’, 651.Google Scholar

³⁵ For example, in 1886–98, Paris had a crude annual death rate of 21.0 per 1,000 living population, while other French cities with more than 100,000 inhabitants had a rate of 24.2 per 1,000. G. Reams, ‘Zivilis or Hygaeia: urban public health and the epidemiologie transition’, in Lawton, R. (ed.). The Rise and Fall of Great Cities: Aspects of Urbanisation in the Western World (1989), 105Google Scholar; Williams, N. and Mooney, G., ‘Infant mortality in an “Age of Great Cities”: London and the provincial cities compared, c. 1840–1910’, Continuity and Change, 9 (1994), 195–6.CrossRefGoogle Scholar

³⁶ See Owen, D., The Government of Victorian London, 1855–1889: The Metropolitan Board of Works, the Vestries and the City Corporation, ed. MacLeod, R. (Cambridge, Mass., 1982), ch. 3.CrossRefGoogle Scholar

³⁷ Although suburbanization within London itself is not explicitly considered, see Friedlander, D., ‘London's urban transition 1851–1951’, Urban Studies, 11 (1974), 127–41CrossRefGoogle Scholar, for analysis of population concentration and dispersal between the administrative county of London and its ‘inner’ and ‘outer’ rings.

³⁸ Kearns, G., ‘Class and environment in Fatal Years’, Bulletin of the History of Mediane, 68 (1994), 121–2.Google ScholarPubMed

³⁹ Higgs, R. and Booth, D., ‘Mortality differentials within large American cities in 1890’, Human Ecology, 7 (1979), 353–70CrossRefGoogle ScholarPubMed; Meckel, R.A., ‘Immigration, mortality, and population growth in Boston, 1840–1880’, Journal of Interdisciplinary History, 15 (1985), 393–417.CrossRefGoogle Scholar

⁴⁰ That is, smallpox, measles, scarlatina, diphtheria, whooping-cough, typhus, erysipelas, influenza, diarrhoea, dysentery and cholera.

⁴¹ Hardy, A., ‘Diagnosis, death and diet: the case of London, 1750–1909’, Journal of Interdisciplinary History, 18 (1988), 387–401CrossRefGoogle Scholar; idem, The Epidemic Streets, 295–301Google Scholar; and idem, ‘“Death is the cure of all diseases”: using the General Register Office cause of death statistics for 1837–1920’, Social History of Medicine, 7 (1994), 472–92.CrossRefGoogle Scholar

⁴² Luckin, W., ‘Death and survival in the city: approaches to the history of disease’, Urban History Yearbook (1980), 53–62CrossRefGoogle ScholarPubMed; and idem, ‘Evaluating the sanitary revolution: typhus and typhoid in 1851–1900’, in Woods, and Woodward, , Urban Disease, 102–19.Google Scholar

⁴³ To recalculate the mortality rate by district, the population and the deaths in the institutions (‘outlying’ workhouses and hospitals) were evenly redistributed by Farr to all registration districts within the metropolis. See Farr, W., ‘Illustrations of the method employed in the calculations of the rate of mortality …’, Ninth Annual Report of the Registrar-General, 1846 (1849), 120.Google Scholar

⁴⁴ Hardy, , ‘Death is the cure’, 481.Google Scholar

⁴⁵ Mooney, G., ‘Did London pass the “sanitary test”? Seasonal infant mortality in London, 1870–1914’, Journal of Historical Geography, 20 (1994), 158–74.CrossRefGoogle Scholar

⁴⁶ Williams, and Mooney, , ‘Infant mortality’, 188–90.Google Scholar

⁴⁷ Luckin, , ‘Typhus and typhoid’, 102–19.Google Scholar

⁴⁸ The figures for intervening years are: 1871, 18 per cent; 1881, 21 per cent; 1891, 24 per cent; 1901,31 per cent; and 41 per cent in 1910: Mooney, The geography, Table 3.8.

⁴⁹ The great majority of sanitary districts were co-extensive with the registration districts. A quinquennial résumé (1885–90) of the corrected mortality rates appearing in the annual Summaries can be found in the Decennial Supplement to the 55th Annual Report of the Registrar-General (1895), xl–xlii.Google Scholar

⁵⁰ The figure was 56 per cent in 1861 and 55 per cent in 1910.

⁵¹ Close consideration also needs to be given to the age structure of the workhouse populations, since they tended to be highly skewed towards the over 45 age-group.

⁵² See note 47.

⁵³ These Reports are available at the Greater London Record Office.

⁵⁴ The Reports of the medical officers of Hackney and Kensington are bound with the respective vestry and district board annual Reports, available at the Greater London Record Office.

⁵⁵ The Registrar-General's decennial Supplements do give causes of death for all ages including infants by registration district for ten-year periods (1851–60, 1861–70 et seq.). While indicative of broad trends, this material is generally considered to be of limited value in relation to the study of infant mortality for two reasons. First, the decennial grouping of deaths inevitably obscures important epidemiological turning-points. Secondly, the causes are only listed under about 25 headings – the exact number varied over time according to changes in the Registrar-General's classification of disease, the most significant being the catch-all ‘other causes’, which accounted for no fewer than one-third of all infant deaths in urban areas, and in some towns as many as half. ‘Other causes’ included ‘poorly diagnosed deaths together with a host of equally ambiguous descriptions, such as prematurity, atrophy and debility’. See Williams, and Mooney, , ‘Infant mortality’, 205 and Figure 10.Google Scholar

⁵⁶ Woods, R.I., Watterson, P.A. and Woodward, J.H., ‘The causes of rapid infant mortality decline in England and Wales, 1861–1921. Parts I and II’, Population Studies, 42 (1988), 343–66, and 43 (1989), 113–32.CrossRefGoogle Scholar

⁵⁷ Mooney, , ‘The geography’, ch. 6Google Scholar; Kearns, , ‘Class and environment’.Google Scholar

⁵⁸ Much of the published work along these lines has concentrated on the United States. Examples include Higgs and Booth, ‘Mortality differentials’; Condran, G.A. and Cheney, R.A., ‘Mortality trends in Philadelphia: age- and cause-specific death rates 1870–1930’, Demography, 19 (1982), 97–123CrossRefGoogle ScholarPubMed; Meeker, E., ‘The improving health of the United States, 1850–1915’, Explorations in Economic History, 9 (1972), 353–73.CrossRefGoogle ScholarPubMed

⁵⁹ Reves, R., ‘Declining fertility in England and Wales as a major cause in the twentieth century decline in mortality. The role of changing family size and age structure in infectious disease mortality in infancy’, American Journal of Epidemiology, 122 (1985), 112–26.CrossRefGoogle ScholarPubMed

⁶⁰ Shannon, H.A., ‘Migration and the growth of London, 1841–1891. A statistical note’, Economic History Review, 5 (1935), 79–83CrossRefGoogle Scholar; Friedlander, , ‘London's urban transition’, 127–41.CrossRefGoogle Scholar

⁶¹ McNeill, W.H., ‘Migration patterns and infections in traditional societies’, in N.F. Stanley and R.A. Joske (eds), Changing Disease Patterns and Human Infections (1980), 27–36.Google Scholar

⁶² On the use of the Medical Directory to elucidate the distribution and status of general practitioners, see Marland, H., Medicine and Society in Wakefield and Huddersfield, 1780–1870 (Cambridge, 1987)Google Scholar, ch. 7. See, also, the complementary account in Digby, A., Making a Medical Living: Doctors and Patients in the English Market for Medicine, 1720–1911 (Cambridge, 1994), Part IGoogle Scholar; Peterson, M.J., The Medical Profession in Mid-Victorian London (Berkeley, 1978)Google Scholar; Dupree, M. and Crowther, A., ‘A profile of the medical profession in Scotland in the early twentieth century: the Medical Directory as a historical source’, Bulletin of the History of Medicine, 65 (1991), 209–33Google ScholarPubMed is particularly good on both the potential and limitations of this source.

⁶³ Wilkinson, A., ‘The beginnings of disease control in London: the work of the medical officers in three parishes, 1856–1900’ (unpublished University of Oxford Ph.D. thesis, 1980).Google Scholar

⁶⁴ Although see Millward, R. and Sheard, S., ‘The urban fiscal problem, 1870–1914: government expenditure and finance in England and Wales’, Economic History Review, 48 (1995), 501–35.CrossRefGoogle Scholar

⁶⁵ Davis, J., Reforming London. The London Government Problem, 1855–1900 (Oxford, 1988).Google Scholar

⁶⁶ Research on this theme has been undertaken by Roebuck, J., Urban Development in Nineteenth Century London: Lambeth, Battersea and Wandsworth, 1838–1888 (London and Chichester, 1979)Google Scholar; Wilkinson, , ‘The beginnings’.Google Scholar

⁶⁷ MacLeod, R.M., ‘The Alkali Acts administration, 1863–84: the emergence of the civil scientist’, Victorian Studies, 9 (1965), 85–112Google Scholar; MacDonagh, O., A Pattern of Government Growth 1800–60: The Passenger Acts and Their Enforcement (London, 1961)Google Scholar; idem, Early Victorian Government 1830–1870 (London, 1977).Google Scholar

⁶⁸ Owen, , The Government, ch. 14.Google Scholar

⁶⁹ Luckin, , ‘Death and survival’.Google Scholar