Urban Infant Mortality in Imperial Germany - Oxford Journals

3 downloads 0 Views 1MB Size Report
KEYWORDS infant mortality, Germany, urban history, nineteenth century. ... mortality in Germany declined substantially from 21 deaths per 100 births in.
© 1994 The Soarry for the Social History of Midinnt

Urban Infant Mortality in Imperial Germany By JORG P. VOGELE* SUMMARY Infant mortality in Imperial Germany started to decline in urban areas from the 1870s onwards, whereas national rates did not decrease before the beginning of the twentieth century Therefore, key explanatory factors determining the levels and trends of infant mortality are investigated in an urban context These include the decline of birth rates, the legitimacy status of infants, feeding practices, environmental conditions, and economic growth. Through a rising living standard and by creating a health-preserving environment, urban populations lost their traditional disadvantage in survival chances. This went so far that even high risk factors, such as the abandonment of breastfeeding, could be counterbalanced. In this sense, a study of past urban health conditions functions as a paradigm for the situation in industrialized societies KEYWORDS infant mortality, Germany, urban history, nineteenth century.

Infant mortality is commonly seen as one of the most sensitive indicators of socioeconomic and environmental conditions. 1 High infant mortality rates during the nineteenth century shed an informative light on contemporary living conditions. In some years only one third of all infants born survived the first year and often only one half of those born in a particular year reached maturity. Traditionally, the population of towns was a high risk group and adult men and infants were especially at risk in the urban environment. 2 Industrialization and urbanization radically changed urban living conditions. A rapidly increasing population density in the course of urbanization was accompanied by an accelerated transmission of disease. Yet, urban agglomerations of Western Europe possessed the financial potential and the innovative power to carry out adequate measures to secure health on a large scale. Therefore, the study of urban development may function as a paradigm for the general situation in industrialized societies. In the period under investigation, from 1870 to the First World War, infant mortality in Germany declined substantially from 21 deaths per 100 births in 1875 (in Prussia) to 15 deaths per 100 in the German Empire in 1913 Key explanatory factors, cited in recent studies, as determining these levels and trends of infant mortality include, for example, legitimacy status of infants, fertility, public health services, feeding practices, parental wealth and occupa* Heinnch-Heine-Umversitat Dusseldorf, Medizinische Einnchtungen, Institut fur Geschichte der Medizin, Postfach 101007, D-40001 Dusseldorf, Germany 1 This research was made possible by The Wellcome Trust, London, and the Alexander von Humboldt-Stiftung, Bad Godesberg I am grateful to W R Lee and Fiona Lewis, University of Liverpool, for general and linguistic advice I would also like to thank the referees for their valuable comments and suggestions 2 J Vogele, 'Die Entwicklung der (groB)stadtischen Gesundheitsverhaltmsse in der Epoche des Demographischen und Epidemiologischen Ubergangs', in J Reulecke and A Castell, eds , Stadt und Gesundheit Zum Wandel von " Volksgesundheit" und kommunaler Gesundheuspolitik tm 19 und fruhen 20 Jahrhundert (Stuttgart, 1991), 21-36

0951-631X Social History of Medicine 07/03/401-425

402

Jorg P. Vogele

tion, and general attitudes towards life and death. 3 Social and regional variations, as well as the course of infant mortality in Germany, have already been discussed in great detail. Imhof attributes regional differences in infant mortality to a large extent to different attitudes towards life and death. 4 The course of infant mortality in Germany has been investigated by Spree and Stockel. Spree uses infant mortality as an indicator to analyse social inequality, 5 and in his most recent contribution stresses that regional disparities were diminishing in Prussia during the late nineteenth century, whereas social inequality increased.6 Stockel discusses various factors influencing infant mortality in Berlin as a case study, and employs a wide range of quantitative and qualitative source material. 7 The most advanced methodological approach has been provided by Kintner, who has developed a model concerning the determinants of infant mortality in Imperial Germany The empirical evaluation using multiple regression analysis, however, remains unsatisfactory. Such an analysis requires a set of well-refined indicators over time and space, and the existing source material does not fulfil such a prerequisite. The following analysis therefore uses a classical approach, discussing the various indicators separately. It has to be emphasized in this context that all the factors under discussion had a plausible effect on the level and trends of infant mortality and that their relative importance changed over time and space. Existing studies have usually collected their data on the level of larger administrative units, the Regierungsbezirke, which comprised various towns and cities as well as rural areas. They were therefore heterogeneous units. However, it is important to emphasize that the decline in infant mortality started earlier and was more pronounced in towns than in rural areas, with the consequence that the traditionally high urban infant mortality rates disappeared. After the turn of the century the towns showed increasingly lower rates than rural areas or indeed, the national aggregate. In this respect the towns and especially the large cities (Grofstadte), traditionally regarded as being particularly unhealthy, operated as a role model in the dramatic change 3

For a comprehensive account see H J Kintner, 'The Determinants of Infant Mortality in Germany from 1871 to 1933', unpublished Ph D thesis, University of Michigan (1982) For the international discussion see R Woods, P A Watterson and J H Woodward, 'The Causes of Rapid Infant Mortality Decline in England and Wales', Population Studies, 42 (1988), 343-66, 43 (1989), 113-32 4 A E. Imhof, 'Unterschiedliche Saughngssterbhchkeit in Deutschland, 18 bis 20 Jahrhundert - W a r u m 5 ' Zeuschnft fur Bevolkerungswissenschaft, 7, 3 (1981), 343-82 See also U Ottmuller, Spetkmder-Gedeihkinder Kommuiukattotislheoretische Uberlegungen zu Gestalt und Funktwn fruhkindlicher Sozialisation im bauerluhen Lebenszusammenhang des deutschsprachigen 19 undfruhen 20 Jahrhunderts, Ph D thesis, University of Berlin (1986) 5 R Spree, Health and Social Class m Imperial Germany A Social Study of Mortality, Morbidity and Inequality (Oxford, 1988) R Spree, 'Die Entwicklung der differentiellen Saughngssterbhchkeit in Deutschland sen der Mitte des 19 Jahrhunderts (Ein Versuch zur Mentahtatsgeschichte), in A E Imhof, Mensch und Gesundhett m der Gcschichte (Husum, 1980), 251-78 6 R Spree, 'On Infant Mortality Change in Germany since the Early 19th Century', unpublished paper (Munich, 1993) 7 S Stockel, 'Saughngssterbhchkeit in Berlin von 1870 bis zum Vorabend des ersten Weltknegs — Eine Kurve mit hohem Maximum und starkem Gefalle', Berlin-Forschungen, 1 (1986), 219-64

Urban Infant Mortality in Imperial Germany

403

towards modern health conditions. For example, the new industrial areas of the Rhineland and Westphalia were leading the way in respect of both the organization and the actual implementation of health-related infrastructural measures. 8 At the same time these towns offered a relatively high standard of living. In Diisseldorf, for example, for many years the average wages for day labour even surpassed those paid in Berlin. It is for this reason that the mechanisms behind this development have to be investigated in the context of specific urban-industrial living conditions and urban measures undertaken to secure or improve health conditions. In order to evaluate their impact the following analysis will discuss a broad range of variables affecting infant mortality within an urban context. Therefore, the paper will first describe the influence of socio-demographic factors, namely (1) the decline of the birth rate, which started earlier in urban areas, and (2) the legitimacy status of infants. The focus will then shift to (3) comparative feeding practices, (4) improved environmental conditions as a result of sanitary reforms, and (5) the rise of urban living standards during industrialization. These potential determinants of the registered decline in infant mortality will be analysed in the following discussion within the framework of a historical epidemiology. Specific developments in the ten most populous towns (in 1910) as well as average conditions in all towns with a population exceeding 15,000 habitants, will form the basis of the following analysis. A direct comparison with rural areas, however, will be provided by other studies. Infant mortality in Germany followed a strong regional pattern with substantial variations over short distances. Therefore a reasonable urban-rural comparison could only be obtained by investigating a specific town and its surrounding rural areas, using data on the level of larger registration areas. For the largest towns, however, this is not an adequate procedure as the areas directly surrounding often had an urban character as well. Furthermore, as the conditions in the largest towns functioned as a role model, 9 the traditionally applied urban-rural dichotomy would underestimate their primary role within the context of the secular mortality decline. Therefore, the conditions in Prussia and in the German Empire will form the comparative framework, providing trends rather than exact statistics as Prussia and Germany were becoming increasingly urbanized during the period under investigation. In order to calculate infant mortality rates, the number of infants under one year of age who died within one specific year will be set into relation to the number of births within this year. Still-births were generally excluded from contemporary calculations. Their registration, however, differed regionally Whereas in Catholic areas the number of registered still-births was reduced by the accepted custom of emergency baptism, infant mortality was generally 8 A Labisch, 'Kommunale Gesundheitssicherung lm rheimsch-westfahschen Industnegebiet (1869-1934) —ein Beispiel zur Soziogenese offenthcher Gesundheitsleistungen', in H Schadewaldt and K -H Leven, eds , XXX lnternationaler Kongrefi fir Geschtchte der Medizw, Dusseldorf 31 8-5 9 1986, Actes/Proceedings (Dusseldorf, 1988), 1077-94 9 See Jorg Vogele, Urban Mortality Change m Britain and Germany, 1870-1910 (Liverpool, forthcoming)

404

Jorg P Vogele

underrated in regions where all deaths that occurred within a mandatory threeday registration period were treated as still-births according to the Civil Code.10 Data was compiled from the publications of the Kaiserhche Gesundheitsamt (Imperial Health Office), which published the number of births and deaths for all towns exceeding 15,000 inhabitants on an annual basis since 1877. The causes of death were collated from official Prussian statistics, as well as from the statistical yearbooks of individual towns. Infant Mortality Change

Infant mortality in Germany generally rose after the mid-nineteenth century and reached its pinnacle in the 1860s and 1870s (Table 1). u The rates generally fluctuated between 10 and 30 deaths per 100 births. Especially high rates were registered by the states in the south-east and the east of the German Empire. Around the mid-nineteenth century peak infant mortality rates (per 100 births) were recorded in Wurttemberg with 35.4 (1858-66), in Bavaria with 30.7 (1827-69), in Baden with 26.3 (1856-63), and in Saxony with 26.3 (1859-65). At the other end of the scale were Oldenburg with 12.3 (1855-64), SchleswigHolstein and Lauenburg with 12.4 (1855-59). Prussia with 20.4 per 100 (185964) occupied an intermediate position.12 The eastern provinces of Prussia, however, registered very high infant mortality with maximum rates between 24 and 27 recorded in Silesia after the middle of the century, in contrast to significantly lower rates in the west, which fluctuated in the Rhineland, for example, between 13 and 20 per 100.13 Due to these high infant mortality levels in certain regions, the German Empire showed up badly in an international context, especially when compared to Scandinavia or England. The situation in towns was regarded as particularly hazardous. The levels of infant mortality, however, differed widely between towns, and may have been to a large degree the result of regional factors rather than the reflection of specific local conditions in particular towns.14 In areas with high infant mortality, the rates were lower in an urban environment, in low infant mortality regions the opposite was the case. In Bavaria, Wurttemberg and Baden, i.e. the non-breastfeeding areas, infant mortality was consistently lower in urban communities when compared to rural areas 15 In the three last decades of the 10 G Mayr, 'Die Sterbhchkeit der Kinder wahrend des ersten Lebensjahres in Siiddeucschland, insbesondere in Bayern', Zettschnft des komglich bayenschett stattstischen Bureau, 2 (1870), 201-47, p 203. For frequencies and causes of late nineteenth-century still-births see F Pnnzing, 'Die Ursachen der Totgeburt', Allgemewes Stattsttsches Archw, 7 (1914), 21-49 11 F Pnnzing, 'Die Entwicklung der Kindersterbhchkeit in den europaischen Staaten', Jahrbucher fur Nattonaloleotiomie und Statisttk, III ser , 17 (1899), 577-635, pp 583-4, W R Lee, 'Germany', in W R Lee, ed , European Demography and Economic Growth (London, 1979), 14494, p 155 12 Mayr, 'Sterbhchkeit', pp 207-8 13 Pnnzing, 'Entwicklung', p 587 For a systematic analysis of regional and social differentials in Prussia see Spree, 'On Infant Mortality' 14 J Knodel, 'Town and Country in Nineteenth-century Germany A Review of Urban-Rural Differences in Demographic Behaviour', Sofia/ Science History, 1, 3 (1977), 356-82, p 377 15 Mayr, 'Sterbhchkeit', p 226, K Maier, 'Die Sterbhchkeit der Kinder lm ersten Lebensjahr

Urban Infant Mortality in Imperial Germany

405

TABLE 1 Infant mortality rates w Germany (per 100 births)

Prussian provinces East Prussia West Prussia City of Berlin Brandenburg (wo Berlin) Pomerama Silesia Saxony Schleswig-Holstem Hannover Westphalia Hessen-Nassau Rhineland Hohenzoliern

Saxony

1834

1849

1864

1871

1876

1881

1889

-33

-48

-63

-70

-75

-80

-88

-95

21 22 25 19 16 22 24 20

23 24 30 19 19 24 26 21 + + 15 + + 16

22 23 30 23 20 22 26 21 15 14 15 16 17 32

22 23 27 25 20 22 26 22 15 15 15 15 18 -

22 23 25

**12 + 13

22 24 34 25 20 24 27 23 15 17 18 18 20 33

19 19 23 17 15 19 24 18 *13 _ 14 15 -

17 18 22 16 14 18 23 18 _ 14 15 -

Posen

Prussia Bavaria Wiirttemberg Baden

1819

14 16 -

16 + + 18

18 34

25 22 21 25 22 16 15 15 14 18 25

1811 -20

1821

1831

1841

1851

1861

1871

1881

-40

-50

-60

-70

-80

-90

1891 -1900

1901

-30

17 32

17 §29

18 30 _ 27

19 30 35 26

20 31 25 26

21 33 36 28 27

21 31 32 26 29

21 28 27 23 28

20 27 24 22 27

19 24 22 20 25

-

23 -

-5

1906 -10 17 22 18 17 20

* 1845-54 **1855-59 t 1853-55 ft1867-70 § 1827/28-33/34 Source* F Pnnzing, "Die Entwicklung der Kindersterbhchkeit in den europaischen Staaten', Jahrbucher fur Natioitahkotwmte

und Statnttk,

III

ser , 17 (1899), 5 7 7 - 6 3 5 , p

587, F

P n n z i n g , Handbuch der

medizuuschen

Statntik (Jena, 1931) 2nd edn , p 375, G Mayr, 'Die Sterblichkeit der Kinder wahrend des ersten Lebensjahres in Suddeutschland, insbesondere in Bayern', Zeihclmfi det komglieh bayemcheii lUtutuchen Bureau, 2 (1870), 20147, pp 208, 238, F Burgdorfer, 'Geburtenhaufigkeit und Sauglingssterblichkeit mit besonderer Berucksichtigung der bayenschen Verhaltnisse', Allgemeuiei Stati>thchei Arduv, 7 (1914), 63-154, p 103

nineteenth century urban-rural differences in infant mortality were predominantly marked in towns by a higher risk of dying after the initial month (postneonatal mortality).16 Still-births and neonatal mortality were consistently higher in rural areas, yet urban-rural differences were much less pronounced.17 Taking all German towns over 15,000 inhabitants, infant mortality declined in the last decades of the nineteenth century, and this trend accelerated after the turn of the century. In contrast, the decline for the whole of Prussia did in Bayern', JournalforKinderkrankheiten, 57 (1871), 153-98, p 181, A Wiirzburg, 'Die Sauglingssterblichkeit im Deutschen Reiche wahrend der Jahre 1875 bis 1877', Arbeiten aus dent Kaiserlichen Cesmidheitsamte, 2 (1887), 208-22, 343-6, 4 (1888), 28-108, p 363, F Pnnzing, 'Die Kindersterbhchkeit in Stadt und Land', Jahrbucher fur Natwualokoitonue und Slatistik, III ser , 20 (1900), 593644, p 633 16 Preufiische Slatistik, 188 (1904), p 126, Pnnzing, 'Kindersterbhchkeit', pp 610-12 17

H

Bleicher, Statistische Beschreibung der Stadt Frankfort am Mam und threr Bevolkerung (=

Beitrage zur Statistik der Stadt Frankfurt am Main, Vol 1, Part II) (Frankfurt a M., 1895), pp 476—7, A. Schlossman, 'Studien uber Sauglingssterblichkeit', Zeitschnft for Hygiene und Infektwnskranleheiten, 24 (1897), 93-188, pp 126-9, Pnnzing, 'Kindersterbhchkeit', pp 602-9, Knodel, 'Town and Country', p 373

406

Jbrg P. Vogele Death rate (per 100 births)

" Towns > 15,000 inh

°' Prussia/German Emp

FIG 1 Infant mortality in German towns and in Prussia/German Empire 1877-1913 (Prussia 1877-1900, German Empire 1901-1913)

not begin before the first decades of the twentieth century (Figure I). 1 8 In the course of the twentieth century the situation changed and infant mortahty rates in towns dropped below those in rural areas:19 for example, in Berlin infant mortality was 90.1 in 1924-26 (per 1,000 births), in comparison to 103.8 in Prussia as a whole. 20 Even the death rate of illegitimate infants — with traditionally very high rates — declined in an urban environment, whereas it increased in the countryside 21 In order to gain some insight into the mechanisms behind these changes, the causes of death among infants have to be taken into account Such an analysis, however, is confronted with two problems, namely (1) the official certification of death, and (2) the causes-of-death classification itself. 1) Apart from Prussia, official death certification was obligatory in the larger German states. However, it was only carried out by a doctor if the person had been in medical treatment. As a doctor was rarely consulted in the case of a sick infant, 22 it is most likely that most causes of death among infants were not certified by an expert, but often registered according to information 18

Sources

Veroffentlichungeii des Kaiserluhen Gesutidheitsamtes (Balaget:), (1878-1914), F

Rothenbacher, 'Zur Entwicklung der Gesundheitsverhaltmsse in Deutschland seit der Industnallsierung', in E Wiegand and W Zapf. eds . IVandel der Lebensbedmgungen in Deutschland Wohlfahrtsentuncklung sett der Industnahsierung (Frankfurt/M , 1982), 335—124, p 396 19 R Kuczynski, Zug nach der Stadt Statistische Stitdien uber Vorgange der Bevolkenmgsbewegung iMI Deutschen Reiche (Stuttgart. 1897). pp 198-214, Vogele, ' E n t w i c k l u n g ' , p 26 20 F P n n z i n g . Handbuch der medizimschen Statistik (Jena, 1931) 2nd edn , p 569 21 P n n z i n g , 'Kindersterbhchkeit', p 613 and Table 3 22

Schlossmann, 'Studien', p 178

Urban Infant Mortality m Imperial Germany

407

23

proffered by parents or relatives. In Lower Bavaria in 1866-67 a doctor was only consulted in 3 per cent of all cases of infant sickness.24 In Wiirttemberg only 38 per cent of all infants dying in 1900 received medical treatment, in comparison to 70 to 90 per cent in the higher age-groups. 2D In Dresden in 1891-96 death was not certified by a doctor in 49 per cent of all infant deaths, whereas in the higher age-groups this was the case in only 2 per cent of all deaths. 26 The situation was especially unsatisfactory in rural areas with a lower doctor-patient ratio. 27 2) Causes of death were registered in a terminology far removed from modern diagnosis. The use of a completely different classification system, often describing final symptoms (convulsions) or the period in life when death set in ('teeth' as a cause of death does not refer to an actual cause of death, but rather indicates that death occurred while the infant was getting his teeth), 28 rather than the actual sense of death in a modern sense, makes translation into present-day terminology at times impossible Yet, it has to be stated that in contrast to the 999 official causes of death in modern death registration, we have only to deal with a relatively small number of causes for the period under consideration. The most important of these diseases were the classic acute and chronic infections, so that a diagnosis was definitely not as taxing as it might be today, with the predominance of cardio-vascular disease and cancer. A careful analysis of the historical cause-of-death data is therefore both feasible and legitimate, and provides valuable information The predominant causes of death among infants were gastro-intestinal diseases and weakness of life (Lebenschwache),29 often linked with Abzehnmg (emaciation, atrophy), which most likely was a result of an illness of the digestive system (Table 2) 30 In Upper Bavaria and Swabia around the middle of the nineteenth century (1867/69), for instance, one quarter of all infants died of diarrhoea, atrophy and Fraisen (an associated condition). Thus, digestive diseases comprised up to 70 per cent of the whole disease panorama. 31 With substantially lower rates, diseases of the respiratory system followed in second 23 P n n z i n g , 'Kindersterblichkeit', p 634, F P n n z i n g , Handbuch der mediziinscheti Statistik (Jena, 1906) 1st edn , p p 3 2 3 - 5 24 Maier, 'Sterbhchken', p 193 25 F Prmzing, Handbuch (1906), p 322 26 Schlossmann, 'Studien', p 178 27 W u r z b u r g , 'Saughngssterbhchkeit', p 49, P n n z i n g , Handbuch (1906), p 323 28 Schlossmann, 'Studien', p 179 29 C o n t e m p o r a r y experts considered convulsions, emaciation, atrophy, and teeth as causes of death following sickness of digestive disease, and consequently subsumed those diseases under the digestive disease g r o u p See Prmzing. ' E n t w i c k l u n g ' , 577-635 H J Kintner confirmed this view applying regression analysis on cause-specific infant mortality rates for various G e r m a n administrative areas See H J Kintner, 'Classifying Causes o f Death during the Late Nineteenth and Early T w e n t i e t h Centuries T h e Case of G e r m a n Infant Mortality', Historical Methods, 19, 2 (1986), 4 5 - 5 4 30 C Flugge, 'Die Aufgaben u n d Leistungen der Milchstenhsierung gegenuber den D a r m krankheiten der Saughnge', Zettschrtft jiir Hygiene und Infectionskrankheiten, 17 (1894), 272-342, p

275, Wurzburg, 'Saughngssterbhchkeit', pp 48-52, Pnnzing, 'Kindersterblichkeit', pp 636-7 31 Mayr, 'Sterbhchken', p 218

Jorgi P. Vogele

408

TABLE 2 Causes of death among infants (per 10,000 births) in ten large German towns and in Prussia

Cause of death

Towns

Prussia

Difference Towns-Prussia

1877 1885 1900 1907 /10

1877 1885 1900 1907

1877 1885 1900 1907

607 701 609 Weakness of life 0 1 1 Smallpox 2 4 6 Scarlet fever 32 30 17 Measles/Rubella 9 20 Diphthena/Croup 25 33 31 39 Whooping cough 0 1 2 Typhoid fever 0 14 Dysentery 3 1257 1156 1114 Digestive diseases* 21 10 8 Scrofula 44 29 Tuberculosis 30 84 77 96 Brain and nerves Respiratory 215 240 270 diseases+ Influenza 0 23 3 Other communicable 7 2 diseases 0 Violence 6 3 6 Other causes 183 166 133 All causes

373 0 1 24 8 36 0 0 620 0 38 76

399 441 461 1 0 0 19 10 25 39 19 33 79 28 81 76 71 93 2 1 4 6 2 10 972 1000 1126 8 13 6 19 19 20 57 66 76

353 6 19 11 45 0 405 23 42

208 260 148 0 0 1 -8 -19 -15 -9 13 -16 -61 -54 -19 -54 -45 -38 -1 -2 -1 _2 4 -3 285 156 -12 2 2 8 25 10 10 27 11 20

20 —5 5 -3 -9 0 215 15 34

107 _

45 0

144 -

234 3

64 -

96 -

163 -

189 3

151 _

31 11 214

3 216

3 184

3 150

7 4 576

3 -44

0 -23 -23

24 7 -367

2000 2040 2125 1683

502

382

237

-15

2502 2422 2362 1668

* including cholera nostras, diarrhoea, convulsions (Prussia 1907 excluding convulsions) + including bronchitis, catarrh of the lungs, pneumonia, pleurisy, other diseases of the lungs Sources. Preufjischc Statistik, Mittheilungen des Statishschen Bureaus der Stadt Dresden, Jahresbericht des stattstischen Amtes der Stadt Dresden, Statistisches Jahrbuch fur die Stadt Dresden, Statistik des Hamburgtschen Staates, Statistik des Deutschen Reuhs, Mittheilungen des statistischen Bureaus der Stadt Leipzig, Statistisches Jahrbuch der Stadt Leipzig, Mitteilungen des stat Bureaus der Stadt Munchen, Mittetlungen des stat Amtes der Stadt Munchen

place. In third place were diseases of the brain and nerves. 32 Whereas in Prussia, when compared to the urban sample, mortality from the classic infectious diseases of childhood was clearly higher (scarlet fever, measles and rubella, diphtheria and croup, whooping cough), it was especially the gastrointestinal disease complex that was responsible for the higher urban overall mortality, followed by weakness, and diseases of the respiratory system (Table 2). The frequency of digestive diseases increased with urban size: in Prussia in 1880, 91.6 out of 1,000 live births died of diarrhoea and dysentery in towns with a population exceeding 100,000 inhabitants, 45.8 in towns between 20,000 and 100,000 inhabitants, 19.1 in towns below 20,000 inhabitants, and 8.3 in rural communities. 33 Until 1900 the reduction of high infant mortality levels in urban areas was principally brought about by a decrease in gastrointestinal diseases, although the massive decline of this cause of death occurred 32 Diseases of the nervous system might also, at least partially, have included intestinal diseases See Kmtner, 'Historical Methods', p 46 33 Wurzburg, 'Saughngssterbhchkeit', p 56.

Urban Infant Mortality in Imperial Germany

409

Coefficient of variation 0.75

0,5

1895 Year •"*• Crude death rate "T Infant mortality ~*~ Tuberculosis —Digestive diseases

FIG 2. Urban variations in mortality in German towns 1877-1913

after the turn of the century. This is also evident in Prussia, although the pronounced increase in mortality from 'other causes' may be the result of changes in cause-of-death registration (referring especially to convulsions),34 so that a direct comparison is difficult, if not impossible. The digestive diseases were also mainly responsible for the wide inter-city variations. Expressed as a coefficient of variation, i.e. standard deviation of the variable divided by the mean, Figure 2 demonstrates this using a sample of 19 towns with over 15,000 inhabitants.35 Variations in mortality from digestive diseases (for all age-groups) and infant mortality declined from the beginning of the 1890s to a lower level, whereas differences in mortality from tuberculosis (for all age-groups) between the towns even increased. With this in mind, attention must be focused on changes in the urban environment, particularly during the late-nineteenth century, because of their potential impact on the decrease in digestive diseases. In this context, the analysis will now focus on the influence of the birth rate on infant mortality, the legitimacy status of infants, the role of feeding practices, as well as the affects of sanitary reforms and of rising living standards on mortality change.

34

'Preufien ErlaB, betr die N e u b e a r b e i t u n g des Verzeichmsses der K r a n k h e n e n u n d T o d e s u r sachen', Veroffenthchungeti des Kaiserlichen Gesundhettsamtes, 28 (1904), 645-51, Preufiische Statisttk 189 (1905), p 6 See also Kintner, 'Historical M e t h o d s ' , p 47 35 Source Veroffentlichutigeii des Kaiserhchen Cesundheitsamles (Beilagen), (1878-1914)

410

Jorg P. Vogele Determinants of Infant Mortality

Change

Infant mortality and birth rates

The modern secular fertility decline in Germany started in urban areas, and especially in the larger towns. The specific interrelationship between birth rates and infant mortality, however, is still far from clear, both with respect to the degree of relationship and the direction of the influences.36 A decline in infant mortality may lead to more extended birth intervals, either by a more or less conscious limitation of reproduction behaviour, through birth control, or by lactation-amenorrhoea during the period of breastfeeding. In this sense, intensive breastfeeding reduces not only infant mortality, but also fertility.37 A smaller number of children again might have a positive influence on the survival chances of infants, in that greater spacing between births might lead to more intensive care of already existing children. For Germany at the end of the nineteenth century, a strong statistical association between the birth rate and infant mortality can be established in some areas. 38 In Bavaria during the period 1871 to 1910, for example, the coefficient of correlation between the birth rate and infant mortality was up to 0.7777 (sig=0.000, n=40), 3 9 i.e. a high birth rate coincided with high infant mortality, or as expressed by a contemporary commentator, 'mass births provoke mass deaths of infants, and these again provoke mass births'. 40 In the urban milieu there was no direct association.41 A reduced birth rate did not obviously lead to a decline in infant mortality. Nor is there any direct verification of the plausible argument that a decline in infant mortality brought about lower birth rates. A correlation between the birth rate and infant mortality in nineteen German towns over 15,000 inhabitants (among them the ten largest) suggests a figure of only 0.3657 between 1877 and 1913 (sig. =0.000; n=691). 42 Using fertility rates for the ten largest towns in selected years, the analysis provides a similarly low coefficient.43 This is at least partly the result of regional particularities. In the Rhineland high birth rates were accompanied by low infant mortality rates 44 the towns of this region, among them, Diisseldorf, registered the highest birth rate in the sample, far above the average for all 36 J K n o d e l , The Decline of Fertility in Germany, 1871-1939 (Princeton, 1974), p p 1 4 8 - 8 7 , Knodel, 'Town and Country', pp 344—51, Woods, Watterson and Woodward, 'Causes', pp 121-6 37 J. K n o d e l , Demographic Behavior in the Past A Study of Fourteen German Village Populations in the Eighteenth and Nineteenth Centuries ( C a m b r i d g e , 1988), p p 393—405 38 Mayr, 'Sterbhchkeit', p 230 39 Source F Burgdorfer, 'Geburtenhaufigkeit und Saughngssterbhchkeit mit besonderer Berucksichtigung der bayenschen Verhaltmsse, Allgememes Statistisches Archiv, 7 (1914), 63-154, pp 102-3 40 G Mayr quoted after F Burgdorfer, 'Geburtenhaufigkeit und Saughngssterbhchkeit mit besonderer Berucksichtigung der bayenschen Verhaltmsse', Allgememes Statistiches Archiv, 7 (1914), 63-154, p 97 41 C Ballod, Die mittlere Lebensdauer m Stadt und Land (Leipzig, 1899), p p 4 1 - 2 42 M i s s i n g values = 12 Source Veroffentlichungen des Kaiserhchen Gesundheitsamtes (Beilagen), (1878-1914) 43 R = 0 3694, sig (two-tailed) = 0 045 Selected years and sources see Table 2 44 Pnnzing, 'Kindersterbhchkeit', p 640

Urban Infant Mortality in Imperial Germany

411

Death rate (per 100 births) 40

1875

1880

1885

1890

1895

"""Hamburg —Frankfurt

1900

1905

1910

1915

Dusseldorf "•" Berlin

FIG 3 Infant mortality in selected German towns 1877-1913

towns over 15,000 inhabitants, together with low infant mortality rates. Furthermore, they were frontrunners in the general overall decline in infant mortality after the turn of the century (Figure 3) (see fn. 42) Legitimacy status of infants Illegitimate infants traditionally had an especially slim chance of survival, as the lack of care went along with a disadvantaged economic situation. Correspondingly, the mortality rates of illegitimate infants significantly exceeded those of the legitimate (Table 3). In Prussia the respective death rate for legitimate and illegitimate infants was as follows: 19.4 and 35.3 (per 100 births) in 1875-80, 19.4 and 35.4 in 1881-90, 19.0 and 35.5 in 1891-1900; and finally 16.8 and 30.8 in 1901-10 45 As the proportion of illegitimate infants remained fairly stable in the period under investigation, 46 its potential impact has to be taken into account merely in regional or local comparisons. Again there were vast local and regional variations, with a traditionally high proportion of illegitimate infants in the eastern and south-eastern parts of Germany and a low proportion in the western parts. In areas with low overall illegitimacy, the level was higher in the urban than in the rural sector; otherwise, the reverse was true. 47 For example, the Regierungsbezirk Dusseldorf 45

S Engel and H Behrendt, 'Saughngsfursorge', in A Gottstein, A Schlossmann and L Teleky, eds , Handbuch der Sozialen Hygiene, Vol 1 (Berlin, 1927), 28-194, p 40 46 F Prinzing, 'Ehehche und unehehche Fruchtbarkeit u n d Aufwuchsziffern in Stadt u n d Land in PreuBen', Deutsche mediziiusche Wochenschnft, 13 (1918), 3 5 1 - 4 , p 353 47

Knodel, 'Town and Country', p 370

412

Jorg P. Vogele

TABLE 3 Infant mortality in the large towns of Prussia (more than 200,000 inhabitants), 1875-1910 (per 100 births)

Berlin Breslau Charlottenburg Cologne Dortmund Dusseldorf Duisburg Essen Frankfurt a M Hannover Kiel Komgsberg Magdeburg Neukolln Stettin

Legitimate

Illegitimate

1875-80 1881-90 1891-00 1901-10

1875-80 1881-90 1891-00 1901-10

27 7 27 9 29 1 236 18 2 19 9 18 8 18 4 16 3 16 4 15 7 24 9 23 8 25 6

24 7 27 4 26 9 24 8 16 9 19 9 19 3 17 7 16 2 17 1 16 7 25 5 24 5 _ 27 0

20 5 24 5 18.8 23.2 17 7 19 7 19 7 17 0 13 8 17 0 16 6 23 6 23 8 25 7 29 7

16 7 21 0 12 8 18 8 15 8 16 0 16 4 14 4 12 3 13 6 14 7 17 1 20 4 17 6 23 8

47 7 45 1 55 9 28 2 35 4 36 1 29 5 41 5 31 9 28 8 28 4 52 0 37 9 42 5

42 5 43 4 48 2 32 0 38 3 39 9 31 3 42 8 31 0 27 0 29 8 48 8 45 1 445

38 1 38 0 39 9 36 8 38 5 39 8 45 1 41 0 31 4 30 2 32 1 43 2 43 4 53 0 47 6

26 3 30 3 26 2 31 9 43 3 31 7 37 5 37 2 28 2 24 7 27 5 33 5 32 3 37 4 37 8

Source Taschenbuch des Statistischen Amis der Stadt Dusseldorf 5 vermehrte Auflage (Dusseldorf, 1913), p 23

registered a substantially lower proportion of illegitimate births when compared to Prussia. In the Regterungsbezirk only 3.41 per cent of all live births were illegitimate, in the Rhemprouinz 3.78, and in the whole of Prussia 8.38. 48 In the city of Dusseldorf, however, the rate was considerably higher than in the surrounding areas, in 1909 there were 8.8 per cent illegitimate infants in the city, 4.0 in the Regiemngsbezirk, 4.2 in the Rheinprovinz, 7.8 in Prussia and 9.0 in the German Empire. 49 However, it remains difficult to estimate the extent to which this risk group had reduced chances of survival. In areas with a high proportion of illegitimate infants they were most likely to be socially accepted to a larger degree and correspondingly found better living conditions than in areas with a low proportion. Despite the substantially higher mortality rates of illegitimate infants, the impact of the legitimacy composition of births on the level of the overall infant mortality rate remained rather limited. For example, in 1905 there were 8,912 infants born in Dusseldorf, among them 8,679 live births. 50 Of the latter, 7,995 (92.1 per cent) were legitimate and 684 (7.9 per cent) illegitimate. The total number of infant deaths during this year amounted to 1,658, of which 1,414 were legitimate and 244 illegitimate births Legitimate and illegitimate infant mortality was 17.7 and 35 7 respectively; on the whole there 48 Cewerbestatistik von Preussen, 3 Teil D e r R e g i e r u n g s b e z i r k Dusseldorf, 2 B a n d (Iserlohn, 1865), p 9 7 49 Source Taschenbuch des Statistischen Amts der Stadt Dusseldorf 3 v e r m e h r t e Auflage (Dusseldorf, 1911), p 17 50 Source Jahresbencht des Statistischen Amts der Stadt Dusseldorffiir 1905, p p 3 - 5

Urban Infant Mortality in Imperial Germany

413

were 19.1 infant deaths per 100 births. Assuming identical death rates, but a twice as high proportion of illegitimate births, the overall infant mortality rates would have risen merely by about 1.4 per cent, from 19.1 to 20.5. 51 Infant mortality and feeding practices

Feeding practices had a more obvious impact on the survival chances of infants. Different mortality levels from digestive diseases were determined to a large extent by regional variations in infant feeding methods. Artificial feeding was associated with high infant mortality, and extensive breastfeeding with low infant death rates. Breastfeeding minimizes the chances both of malnutrition and the acquisition of infectious diseases. Breast milk is not only considered to be nutritionally ideal, it is also clean and transmits immunities from the mother to the child. On the other hand, artificial food promotes bacterial infection, especially when prepared with milk, water, or, as was customary in some areas, with food pre-chewed by an adult. Processing and storing usually did not meet the requirements of hygiene. Furthermore, during the nineteenth century, artificial food often could not sufficiently supply proteins and vitamins. A substantial survival advantage of breastfed infants over artificially nourished infants, particularly in the first months of life,52 has been noted for historical populations as well as for contemporary less developed countries. 53 In Sweden at the beginning of the nineteenth century, for example, low infant mortality rates were linked with legislative coercion to breastfed infants.54 High infant mortality rates in the eastern and south-eastern parts of Germany, on the other hand, were associated with the fact that breastfeeding was relatively uncommon in these regions. The potential impact of breastfeeding on the survival chances of infants becomes obvious, if a homogenous social group is analysed, in this case 628 women, who gave birth in the Cologne maternity asylum (Wochnerinnen-Asyl). Only poor married women were admitted, and the municipal welfare committee had to confirm their indigence. Among this group, in 1900-01 infant mortality fluctuated between 8 deaths per 100, when breastfeeding was practised for over three months, and 37 for infants who were not breastfed at all or only for a period shorter than three months. 55 The wide spatial variation in mortality from diseases of the digestive system, however, cannot be attributed solely to differences in infant feeding practices, but must also reflect the role of local environmental factors. Feeding practices, for example, cannot explain the extensive mortality differences in the western towns of Germany, where deaths from intestinal diseases per 51 52

See also Kintner, 'Determinants', pp 55-6

J. Knodel and H Kintner, ' T h e Impact of Breastfeeding Patterns o n the B i o m e t n c Analysis of Infant Mortality', Demography, 14, 4 (1977), 3 9 1 - 4 0 9 53 P n n z i n g , Handbuch (1906), p p 2 9 0 - 4 , Knodel and Kintner, 'Impact o f Breastfeeding' 54 Selter, ' D i e N o t h w e n d i g k e i t der Mutterbrust fur die E r n a h r u n g d e r Saughnge', Centralblalt fir allgememe Cesundheitspftege, 21 (1902), 3 7 7 - 9 2 , p. 389 55 Dietrich, 'Saughngsernahrung u n d W o c h n e n n n e n - A s y l e ' , Centralblatt fir allgememe Gesundheuspfiege, 21 (1902), 4 6 - 5 3 , p 48

414

Jbrg P. Vbgele

10,000 ranged from 29.15 in Frankfurt, over 58.15 in Dusseldorf, to 78.88 in Cologne during 1877, although infant feeding patterns were essentially similar. Infant mortality in Cologne was actually higher than in the non-breastfeeding area of Breslau, although both towns had similar birth rates. Here environmental factors might have played a more important role. Furthermore, the decline in urban infant mortality went along with a decline in breastfeeding practices in the large towns of Germany.56 For example in Berlin, in 1885 55.5 per cent of all infants were exclusively breastfed, 4.0 per cent additionally fed with animal milk, and 33.9 per cent solely raised on animal milk. In 1900 only 31.4 per cent were breastfed, 0.7 per cent supplied with additional animal milk, whereas 54.8 per cent relied on animal milk.57 In the traditional nonbreastfeeding areas the percentage of infants nourished solely artificially was even higher. According to material from the Munich children's hospital, the number of infants never breastfed was 78.3 per cent in 1861-69, rising even higher in the following decades to 82 3 (1870-78) and 86.4 (1879-86).58 In view of decreasing breastfeeding in the last quarter of the nineteenth century, environmental improvement must have played a more important role in determining the decline in infant mortality. Improved conditions of hygiene not only restricted outbreaks of severe typhoid fever that still occurred in the 1880s and early 1890s, but also the nutritional adequacy of artificial food was improved, thereby reducing the survival advantage of breastfed infants over those artificially nourished.59 Infant mortality and sanitary reform

Sanitary reform focused on infrastructural measures that were intended to improve the hygienic conditions of the urban environment. Particular emphasis was placed on improved water supply and sewerage systems, but also selectively included disinfection, control of food and especially municipal milk supply 60 Illness and disease were no longer regarded as natural and therefore a matter of destiny, but rather as something that could be positively influenced by improving environmental conditions. Specific measures were carried out in an increasingly systematic manner during the last decades of the nineteenth and the early twentieth century. At the turn of the century public health 56 Selter, ' N o t h w e n d i g k e i t ' , pp 3 8 2 - 5 , M Hohlfeld, ' U e b e r den U m f a n g der natiirhchen Saughngsernahrung in Leipzig', Deutsche Medizimsche Wochenschnft, 31 (1905), 1391-4, p 1392, P n n z i n g , Handbuch (1906), p 294, H J Kintner, 'Trends and Regional Differences in Breastfeeding in G e r m a n y from 1871 t o 1937', Journal of Family History (1985), 163-82, p p 169-72 H N e u m a n n , ' U b e r die Haufigkeit des Stillens', Deutsche Mediamsche Wochenschnft, 28 (1902), p 795 58 F Biiller, 'Ursachen u n d Folgen des Nichtstillens in der Bevolkerung M u n c h e n s ' , Jahrbuch fur Kmderheilkunde, 16 (1887), 3 1 3 - 4 0 , p 320, T Eschench, ' D i e Ursachen u n d Folgen des Nichtstillens bei der B e v o l k e r u n g M u n c h e n s ' , Munchener Mediamsche Wochenschnft, 34 (1887), 233-5, 256—9, p 233, H Seidlmayer, Geburtenzahl, Saughngssterblichkeit und Sttllung in Munchen w den letzten 50Jahren (Munich, 1937), p 29 59 J D W r a y , ' M a t e r n a l Nutrition. Breast-Feeding and Infant S u r v i v a l , in W H Mosley. ed , Human Nutrition and Reproduction ( N e w Y o r k , 1978), 197-230, pp 2 1 3 - 1 9 60 T Weyl, 'Assamerung', in T Weyl, ed . Soziale Hygiene Handbuch der Hygiene, 4 Supplement-Band (Jena. 1904), 1-27, p 1

Urban Infant Mortality in Imperial Germany

415

measures had become a fixed component of municipal budgets. Munich, for example, spent 16.3 per cent of its 1894 budget on public health issues.61 A major factor affecting the urban environment during the second half of the nineteenth century was the installation and expansion of central water supply and sewerage systems. Following the pioneering example of Britain, sanitary reforms spread in Germany during the last decades of the nineteenth century, with major building activity for central water supply systems being undertaken in the large towns particularly in the 1870s and 1880s; by 1900 all the large towns had a central water supply. The expansion of sewerage systems followed the construction of water-works at a delayed interval; the main period of construction occurred around the turn of the century. The level and trend of the death rate from typhoid fever is often considered to be a classic test for assessing the health-impact of these reforms. 62 In view of the declining frequency of breastfeeding in urban areas, the supply of clean water was especially important. Artificial food was to a large extent prepared with water, and animal milk was also often diluted. This implies that the potential effect of these infrastructural public health measures should also be measurable in relation to the subsequent development of death rates from digestive diseases as well as infant mortality. The limitations and successes of infrastructural measures can be demonstrated using the example of Hamburg. The city had an early central water supply (1842), yet failed to install a filter plant. This deficiency crucially contributed to the devastating effect of the infamous cholera epidemic of 1892 which caused 8,616 deaths Hamburg was the only large German city to be affected by this epidemic. 63 Figure 3 reveals that infant mortality reached a maximum during this year. After the installation of a filter plant in the following year not only did the risk of dying from cholera and typhoid fever decrease,64 but also deaths from digestive diseases were reduced, increasing the survival chances of infants (Figures 3 and 4). 65 Recent research indicates that sanitary reform had an impact on urban infant mortality. 66 In general, however, the quantitative and qualitative state of central water supply and urban sewerage systems left much to be desired. 67 In the nineteenth century 61 K Singer, Die Abmmderung der Sterblichkeitsziffer Munchens Em Beitrag zur Frage hygiemscher und sozialpolitischer Maassnahmen aufdie Cesundheit der Stadte (Munich, 1985), p 19 62 R O t t o , R Spree and J Vogele 'Seuchen u n d Seuchenbekampfung in deutschen Stadten w a h r e n d des 19 u n d friihen 20 J a h r h u n d e r t s . Stand u n d Desiderate der Forschung', Medtzmhistonsches Journal, 25 (1990), 286-304, p p 297-301 63 SeeR Evans,DeathinHamburg Society andPoliticsintheCholeraYearsl830-l910(Ox(or&,\9%l) 64 J Vogele, ' T h e U r b a n Mortality Decline in G e r m a n y , 1870-1913 S o m e Preliminary R e sults', in G Kearns, W R Lee, M C Nelson and J Rogers, eds , Improving the Public Health Essays in Medical History (Liverpool, forthcoming) 65 Source Verojfentlichungen des Kaiserlichen Cesundheitsamtes (Beilagen), (1878—1914) 66 J C . Brown, 'Public Health Reform and the Decline in Urban Mortality T h e Case of Germany, 1876-1912', in G Kearns, W R Lee, M C Nelson and J Rogers, eds , Improving the Public Health Essays in Medical History (Liverpool, forthcoming), Stockel, 'Saughngssterbhchkeit', 2 3 0 - 1 , J Vogele, 'Sanitare Reformen und der Wandel der Sterbhchkeitsverhaltmsse in deutschen Stadten, 1870-1913', VSWC, 80 (1993) H 3, 345-65 67 Vogele, 'Urban Mortality'

416

Jbrg P. Vogele Death rate (per 10,000 living) 600

'i 'i 'i ' i ' i ' i 1 i ' i ' i

500

A f

i \

' 300

a

1

A 15.000 inh

FIG 4. Mortality from acute digestive diseases in German towns 1877-1913

they were still generally restricted to the large towns. Numerous outbreaks of typhoid fever in these places reflected the persistent risk of using drinking water. Correspondingly, the average death rate from acute digestive diseases remained at a permanent high level in towns over 15,000 inhabitants during the last decades of the nineteenth century (Figure 4). Sanitary reforms also included the establishment of municipal milk depots. For Britain it has been argued that the substantial fall in infant mortality after the turn of the century could be attributed mainly to the improved provision of pasteurized milk, the introduction and popularization of dried milk as an infant food, as well as the widespread use of condensed or evaporated milk 68 Recent studies are more sceptical about the impact of municipal milk supply on the decline of infant mortality in Britain As breastfeeding remained widespread, the health of weaned infants was more dependent on relative poverty, the mother's education and her participation in the labour force, on overcrowded housing, environmental conditions, and a general decline in fertility.69 Others suggest that consumption of often qualitatively poor milk contributed to ill-health,70 particularly because of its impact on infant deaths from tuberculosis and digestive diseases. 68 M W Beaver, 'Population, Infant Mortality and Milk', Population Studies, 27 (1973), 24354, D Dwork, War is Good for Babies and Other Young Children A History of the Infant and Child Welfare Movement w England, 1898-1918 (London/New York, 1987) Woods, Watterson, and Woodward, 'Causes', pp 116-20 70 P J Atkins, 'White Poison' The Social Consequences of Milk Consumption in London, 1850-1939', Sofia/ History of Medicine, 5 (1992), 207-28, p 227

Urban Infant Mortality in Imperial Germany

417

In view of the decline in breastfeeding in German towns and in areas where breastfeeding was already only practised to a minor extent, sanitary reformers regarded the quality of milk as a matter of supreme importance in the battle to combat the highly feared summer diarrhoea. However, whereas the towns spent substantial sums of money on central water supply and sewerage systems, backed by official arguments concerning diseases such as cholera and typhoid, the supply and distribution of municipal milk only began with some delay and hesitation. As contemporary doctors complained, high infant mortality rates were regarded as somewhat inevitable,71 even though some of the main reasons for these high rates were already known. Contemporaries indicated that differences in infant mortality between urban and rural areas could be attributed to higher mortality in towns during the hot summer months. 72 This was substantially supported by the prevalence of digestive diseases in the cause-of-death panorama. Indeed, the hot period of the year claimed numerous victims among infants. In Berlin in 1885, for example, more than 45 per cent of all infant deaths occurred in June, July, and August. 73 Increasingly fewer experts attributed this to urban housing conditions. 74 Instead, the case for adequate infant nutrition became more and more the focus of attention. The term children's milk (Kindermilch) was created, 75 and the supply of animal milk was considered to be a municipal task of the highest priority. In Germany the sale of pasteurized or sterilized milk commenced in the late 1880s with the invention of the so-called Soxhlet apparatus (1886), by which milk was heated within the bottle. Complete sterilization, however, was expensive, and therefore rarely applied in practice. Heating the milk to or beyond its boiling point, of course, caused the loss of a considerable amount of vitamins. Pasteurization of milk, discovered in the 1860s by Louis Pasteur, remained controversial, since it was taken as the cause for various infant diseases, for example infant scurvy (Sauglmgsskorbut). It was therefore suggested that pasteurized milk should only be used in the hot summer months, with the special treatment of milk regarded as superfluous in the cooler periods of the year. 76 Milk was not among the subjects dealt with in the nutrition laws (Nahrungsmittelgesetz), and in 1900 only three towns (Berlin, Dresden, and Munich) had special regulations concerning children's milk. In general, the quality of milk remained dubious. Partly sterilized milk was sold in green or brown bottles in order to make visual quality control impossible for the consumer. 77 71 Pfaffenholz, 'Wichtige Aufgaben der offenthchen und pnvaten Wohlfahrtspflege auf dem Gebiet der kunsthchen Ernahrung der Saughnge', Centralblatt fir allgemeitie Gesundheitspflege, 21 (1902), 393-416, p p 4 0 2 - 3 72 Schlossmann, 'Studien', p 137 73 W u r z b u r g , 'Saughngssterbhchkeit', p 74 74 For an overview see C Flugge, Groflstadtwohnungen und Kleinhaussiedluiigen m ihrer Emwirkung auf die Volksgesutidhat (Jena, 1916) Pfaffenholz, 'Saughngs-Sterblichkeic und Kindermilch', Centralblatt fir allgemeitie Gesundheitspflete, 21 (1902), 183-200, p 183 L Spiegel, 'Kommunale Milchversorgung', Schriften des Verems fir Socialpolitik, 128 (1908), 219-43, p 231 77 Flugge, 'Aufgaben', p 321

418

Jorg P. Vogele

Municipal milk was increasingly based on an imported supply, as cattlebreeding in the towns declined rapidly. In the early years the supply and preparation of milk was completely in the hands of private enterprises and free tradesmen. By the late-nineteenth century, by contrast, many municipalities had established their own management system dealing with milk supply and distribution. 78 In the first decade of the twentieth century, however, only a handful of towns had established municipal milk depots. Yet, many other towns also recognized the importance of regulating milk supply and insisted on certain standards. As a consequence quality improved In Diisseldorf, for example, in 1895, 60 out of the 265 official examinations of milk were unsatisfactory, in 1906 only 125 out of 3,743 failed to pass the test. 79 Police ordinances (Pohzeiverordnungen) by 1901 included regulations about the quality and the importation of milk from outside the town. Merchants who wanted to sell milk had to register at the police station. Each consignment of milk had to be sealed before being imported, and its origin clearly identified, so that in the case of irregularities the responsible merchants could be easily found. 80 Bacteriological examination, however, remained difficult and was hardly feasible in practice,81 given the expense involved. It was for this reason that the amount of specially treated and controlled milk for children available in the towns remained very limited, often amounting to only 500 litres in a town of 100,000 inhabitants. 82 Sold at a price of 50-60 Pfennige per litre this type of milk was only an option for well-established circles of the population. Elements of the food industry clearly were, at least at times, not in favour of municipal milk supply and promoted their own artificial products. There were reports from Bonn in 1902 that families, immediately following a child's birth, received a brochure signed by a paediatrician, promoting the use of powdered infant food, the so-called children's flour (Kindermehl).83 Contemporaries were convinced of the success of municipal milk supply in terms of improving the state of health of infants and young children. However, demographic data confirms the generally poor state of municipal milk provision. An adequate and widespread milk supply should have contributed to a decline in mortality from tuberculosis and digestive diseases among infants, as well as weakening the climatic structure of infant mortality by reducing the extent of its seasonal fluctuation In the German towns, however, the death rates from tuberculosis among infants actually increased from 29 (per 10,000 births) in 1877 to 44 in 1900 and then declined only slightly to 38 by 1907 (Table 2), although it fell in the age-groups from 5 years onwards. Death rates from digestive diseases, on the other hand, showed a strong decline at the beginning of the twentieth century when assessed from average 78

Spiegel, 'Milchversorgung', p 232 F Schrakamp, 'Gesundheitswesen', in T Weyl, ed , Die Assamenmg der Stadte in Emzeldarstellungen, Vol 2 2 Die Assamerung von Dusseldorf (Leipzig, 1908), 8 3 - 1 1 9 , p 110 80 Schrakamp, 'Gesundheitswesen', p 110-13 81 Pfaffenholz, 'Aufgaben', p 400 82 Pfaffenholz, 'Aufgaben', p 404, Spiegel, 'Milchversorgung', p 229 83 Cramer, Contribution to the discussion following Pfaffenholz, 'Aufgaben', p 419 79

Urban Infant Mortality in Imperial Germany

419

figures for all towns with a population exceeding 15,000 inhabitants (Figure 4) and in the ten largest towns (Table 2). However, climatic dependency remained; the cold summer of 1902 was accompanied by low infant mortality, 84 but the hot summer of 1911 registered high infant mortality rates. 85 Seasonal fluctuations persisted, with a pronounced summer peak (Figure 5), 86 and affected most powerfully artificially fed infants. 87 Excellent long sources in Hamburg show that summer infant mortality was even higher in the twentieth century, when compared with the preceding hundred years (Figure 6). 88 In Berlin, the summer peak reached its pinnacle in 1885, yet in 1900 it was still much higher than in the period 1850-74, and did not disappear completely until 1926-28. 89 A similar development can be observed in Munich, where the summer peak did not vanish until the second decade of the twentieth century, 90 in part as a result of increased breastfeeding,91 Whereas urban infant death rates were already below the corresponding rural figures after 1900, higher urban infant mortality in the hot summer months remained a common feature. Figure 7 shows the actual infant mortality rates in urban and rural areas of Prussia at the beginning of the twentieth century. 92 Demographic evidence, therefore, confirms the view that a qualitatively satisfactory milk supply reaching a substantial portion of the population, and especially the poor, had still not been developed by the first decade of the twentieth century. Contemporary attempts to provide adequate infant food, however, demonstrate increasing concern about high infant mortality rates. Declining birth rates raised fears about the nation's future in economic and military respects, and led to a concentration of forces in the battle against high infant mortality. 84 See Figure 1, Spiegel, 'Milchversorgung', p 225; W Kruse, ' W a s lehren u n s die letzten Jahrzehnte u n d der heisse S o m r a e r 1911 uber die Saughngssterbhchkeit u n d lhre Bekampfung', Centralblatt fur allgememe Cesundheitspflege, 31 (1912), 175-201, p 179 85 Kruse, ' W a s lehren u n s ' , p p 175-201, Seidlmayer, Geburteiizahl, p 20 A m o r e elaborate statistical test, h o w e v e r , is difficult to achieve due t o inadequate source material S o m e information about climatic conditions in the t o w n s of the sample is only available for a selection of these t o w n s for a small n u m b e r of years from the Statisttsches Jahrbuch Deutscher Stadle, 1 (1890) o n w a r d s Correlating average annual air temperature with annual overall mortality, infant mortality and death rates from various diseases in the years 1888-96 leaves us with a rather weak association T h e relatively strongest, and surprisingly negative correlation is achieved with mortality from digestive diseases (r = - 0 5200, sig = 0 000, n = 67), followed b y infant mortality (r = - 0 4375, sig = 0 000, n = 67) A correlation using temperature m a x i m a leaves an even weaker relation For the period 1907-11 correlations are weaker Here the strongest interrelationship is between annual average temperature and deaths from tuberculosis of the lungs (r = - 0 5212, sig = 0 000, n = 49) 86 Source H Silberglen, 'Kindersterblichkeit in europaischen Grossstadten', Huitieme Congres International D'Hygiene El De De'mographte, T o m e VII (Budapest, 1896), 4 4 3 - 5 6 , p 454 87 A E Imhof, 'Unterschiedhche Saughngssterbhchkeit', p 352 ^Sources Statistisches Handbuch fur den Hamburgischen Staat (1920), p 48, p 70; Die Cesundheitsverhallmsse Hamburgs im neunzehntenjahrhundert Den arztlichen Thetlnehmern der li Versammhmg Deutscher Naturforscher und Arzlegewtdmel von dem Medicinal-Collegium ( H a m b u r g , 1901), p 108, p 114 89 Imhof, 'Saughngssterblichkeit', p 352 90 R Hecker, 'Studien uber Sterbhchkeit, Todesursachen u n d E r n a h r u n g M u n c h e n e r Saughnge', Archw fur Hygiene, 93 (1923), 2 8 0 - 9 4 , p 287 1 Seidlmayer, Ceburtenzahl, p 22, p 31 92 Source W Kruse, 'Was lehren u n s die letzten Jahrzehnte u n d d e r heisse S o m m e r 1911 uber die Saughngssterbhchkeit und lhre Bekampfung', Centralblatt fur allgememe Cesundheitspflege, 31 (1912), 175-201, p 178

420

Jorg P. Vdgele Per cent

-°- Dusseldorf "T Cologne ^ Frankfurt/M * Berlin ^Breslau "0" Dresden A Leipzig & Munich

FIG. 5 Seasonal distribution of infant mortahty (%) 1889/93 Per cent

Quarter -°-1850 + 1 8 6 0 ^ 1 8 7 0 *

1880 X i 8 9 0 O 1900 A 1910 X"1911

FIG. 6 Seasonal distribution of infant mortality in Hamburg (%) Infant mortality and living standards

Many contemporaries in fact attributed high infant mortality rates primarily to the participation of women in the labour force. High female labour force participation was associated with an absence of breastfeeding and a general

Urban Infant Mortality in Imperial Germany

421

Death rate (per 100 births) 35

+Urban

FIG. 7

"• Rural

Seasonal distribution of infant mortality in Prussia, 1911 (per 100 births)

neglect of child care.93 The effects of female labour force participation on the health of infants, however, remain ambiguous and differ through time and space. Some contemporaries were already puzzled by the negative relation between female earnings and the infant mortality rate.94 For the sample of German towns there was no statistical correlation between the percentage of women not participating in the official labour market in 1907 and infant mortality rates (1901-13): r = -0.1106, sig (two-tailed) = 0.761.95 Presumably, improved health conditions increasingly reduced the differences in mortality between breastfed and artificially nourished infants. Against this background the working mother's wage, which bought a better standard of living for the family, might have become a more important factor in the survival chances of infants.96 After the turn of the century generally higher female wages for day labour reduced infant mortality in towns: there is a relatively strong statistical correlation between female wages and infant mortality (r = —0.6974, sig (two-tailed) = 0.025),97 indicating again that for families at the lowest end of the income distribution additional income outweighed the impact of reduced breastfeeding. The lack of correlation between 93 C D y h o u s e , 'Working-Class M o t h e r s and Infant Mortality in England, 1895-1914', Journal of Social History, 12 (1978), 2 4 8 - 6 7 , p p . 2 5 1 - 3 94 W o o d s , Watterson a n d W o o d w a r d , 'Causes', p 115 95 Sources Statistik des Deutschen Reichs, N F 207 (1907), Veroffentlichungen des Kaiserhchen Gesundheitsamtes (Beilagen), (1901-1914) 96 Dyhouse, 'Working-Class Mothers', pp 254-7 97 Sources Stalistisches Jahrbuch Deutscher Stadte, 19 (1913), p 826, Verojfemlichungen des Kaiserhchen Gesundheitsamtes (Beiiagen), (1901-1914) See also Brown, 'Public Health'

422

Jorg P. Vogele

female labour force participation and infant mortality, however, could well be the result of regional differences, which possibly disguised potential interrelations. Whereas in the highly industrialized western areas of Germany, differences in infant mortality rates between breastfed and artificially-fed infants increasingly vanished, they remained evident in the less industrialized eastern areas. Industrialization, therefore, reinforced contemporary regional differences.98 Towns of the sample belonging to traditionally nonbreastfeeding areas, i.e. Breslau, Munich, and Nuremberg, registered a high proportion of female labour force participation as well as high infant mortality rates. In these towns high female labour force participation could not counterbalance low living standards, so that the absence of breastfeeding had a stronger negative impact on the survival chances of infants than in the better-off more industrialized western areas In Eastern Prussia, for example, the growth of Junker estates based on grain monoculture led to a peasant class which needed to exploit the labour of its female members in order to subsist This resulted not only in high adult female mortality, but also in high infant mortality rates, caused by the inability of many mothers to breastfeed. In Western Prussia, on the other hand, land reforms in the early nineteenth century resulting in a wider distribution of peasant land ownership, greater crop variations and more livestock, brought about better health conditions." In southern Germany the impoverishment of the vast majority of the population as a consequence of the Thirty Years' War continued into the following periods. Regions which suffered most deeply from the Napoleonic Wars 1796 -1809 registered high infant mortality rates. Battles, troop movements, harvest failure, the requisition of cattle, as well as war contributions led to severe pauperization. 10° In addition, those regions based on agriculture were hit severely by the spread of potato-rot. Yet, even in periods of bad harvest and hunger crisis, corn was exported to neighbouring foreign countries. 101 Finally, a peasantry poor in purchasing power made the survival of small-scale traders in the towns difficult. All this and in particular the lack of cattle led to notorious infant feeding practices using a thick and sweetened meal-pap Dummies were often filled with mashed rusk and sugar Even poppy-seed extracts and opium were added as a sedative. As a result of this poor situation, Imhof claims that the local population developed a fatalistic mentality, particularly in Catholic areas, based on a deeply rooted 'system of wastage of human life'. 102 This, however, remains dubious in view of the fact that economic growth and industrialization from the late 1860s, the expansion of 98

Lee, 'Germany', p 156 W R Lee, 'Mortality Levels and Agrarian Reform in Early 19th Century Prussia Some Regional Evidence', in T Bengtsson, G Fndhzius and R Ohlsson, eds , Pre-Indiistnal Population Change The Mortality Decline and Short-Term Population Movements (Stockholm. 1984), 161-90. pp 168-72 100 Pnnzing, 'Entwicklung'. p 598 101 J Vogele, Getreidemarkte am Bodensee mi 19 Jahrhundert Strnkturen und Enlwicklungen (St Kathannen, 1989), p 37 102 Imhof, 'Saughngssterbhchkeit' 99

Urban Infant Mortality in Imperial Germany

423

the railway network, and numerous good harvests, led to a decline in infant mortality. Indeed, this decrease started even earlier than in the northern parts of Germany. 103 Germany's accelerated industrialization from the late 1860s and early 1870s' onwards brought about a rise in living standards. Between 1871 and 1913 real wages almost doubled and the average growth of the economy was significantly higher than in England. 104 This rise was distributed almost equally over this period, and may have had a substantial impact on the decline of mortality via improved nutrition. Although it is difficult to obtain direct evidence of this for the sample of towns, 1OD the congruence between rising real wages and falling death rates in towns and cities is impressive. As a supporting effect the growing world market in corn, which reduced prices, 106 provided better nutritional provision, independent of rising income. 107 Recent research has indeed indicated an improvement in diet during the nineteenth century, from which the lower classes increasingly benefited in the second half of the century 108 From the 1870/80s onwards the estimated actual calorific intake surpassed the recommended amount. 109 Despite this, infant mortality rates in Prussia did not decline among working class families before the end of the nineteenth century, with the consequence that class-specific differences in infant mortality levels increased.110 Only the twentieth century has brought about a decline in infant mortality among all social groups in Prussia. This clearly indicates that additional factors, such as cultural or mental aspects, might have played a strong part in determining levels and trends of urban infant mortality, ft also indicates that further research ought to refine the indicators under discussion As this, however, is hardly feasible in a macro103

Pnnzing, 'Entwicklung', p 599 KM -p j Orsagh, 'Lohne in Deutschland 1871-1913 Neue Literatur und weitere Ergebmsse', Zeitschnfi fur diegesamte Staatswissenschaft, 125 (1969), 476-83, p 483 Germany —1 3 per cent p a England —0 9 per cent More direct evidence could be obtained by analysing infant mortality according to parental occupation for the sample of towns, following R Spree's analysis of Prussian figures See Spree, Health and Social Class, pp 63-71, Spree, 'On Infant Mortality', See also Stockel, 'Saughngssterblichkeit', pp 240-9 Incorporating adequate material on occupational mortality for the sample of the ten largest towns would require an analysis of local data sources, which are scattered Furthermore, the number of records to be collated and analysed would by far surpass the scope of the present macro-level approach 106 Vogele, Getretdemarkte, p 39 107 R A Dickler, 'Labour Market Pressure Aspects o f Agricultural G r o w t h in the Eastern Region of Prussia, 1840-1914 A Case Study of Economic-Demographic Interrelations during the Demographic Transition', unpublished Ph D thesis, University of Pennsylvania (1975), pp 177-8 108 W Abdel, Stufen der Ernahrung Erne histonsche Skizze (Gottingen, 1981), H J Teuteberg, 'Studien zur Volksernahrung unter sozial- und wirtschaftsgeschichthchen Aspekten', in H J Teuteberg and G. Wiegelmann, eds , Der Wandel der Nahniiigsgewohnheiten unter dent Emflufi der Industnalisierung (Gottingen, 1972), 21-221, H J Teuteberg, 'Der Verzehr von Nahrungsmitteln in Deutschland pro Kopf und Jahr seit Beginn der Industnalisierung (1850-1975) Versuch emer quantitativen Langzeitanalyse', Archw fiir Soztalgeschuhte, 19 (1979), 331-88, H J Teuteberg and G Wiegelmann, Unsere taghche Kost Ceschichte und regtonale Pragung (Munster, 1986) 109 W G Hoffmann, Das Wachslum der deutschen Wirtschaft sen der Mute des 19 Jahrhunderts (Berlin, 1965), p 659 110 Spree, Health and Social Class, pp 63-71, Spree, 'On Infant Mortality'

424

Jorg P. Vogele

level approach, further analysis should be directed to the use of disaggregated micro-level data. Conclusion

The analysis indicates that in the long run the urban-industrial world has had a positive impact on health conditions. By creating health-preserving environmental conditions and through a rising standard of living, urban populations lost their earlier disadvantage in survival chances when compared to rural areas. This went so far that even traditional risk factors were largely eliminated. Despite a decrease in breastfeeding in towns, infant mortality rates started to decline earlier and more vehemently in urban areas in comparison to the national average. By implementing an increasing number of measures in the following decades, a health-preserving system was created, which counterbalanced traditional urban health risks, as well as those created by industrialization. These measures included, for example, the expansion of the health sector in general, municipal housing, statutory sickness insurance as well as increasing access to infant care (zugehende Saughngsfursorge). The impact of the last two factors, in particular, seems to have been underestimated. With respect to sickness insurance the focus has been on the medical treatment of the sick worker, neglecting a major objective of the scheme which was to provide financial support in case of sickness. Therefore, in the case of sickness of the main wage earner of the family, it was possible to maintain a standard of living for the whole family which prevented it from falling immediately into poverty. Thus, sickness insurance had a broader impact and could have substantially contributed to the decline in infant mortality. Health-securing measures, created in the period under investigation, formed the essential base for a health-preserving way of life. The role of the healthcare recipients, however, was of equal importance. The provision of satisfactory hygienic milk, for instance, was of little value, if the purchasers did not keep it cool, if they stored it in the warmest place in the house,''' and neither washed their hands before preparing the milk nor cleaned the bottles after use. In other words, the potential benefits of an improved health-related infrastructure remained underutilized in the absence of a corresponding improvement in personal hygiene. The evolution of a collectively rooted personal hygiene regime was therefore a prerequisite. This in turn was the result of an increase in rationalist conduct of life, which was based on the assumption that one could mould one's own destiny. Corresponding mentalities and norms of behaviour pervaded society from top to bottom. Within this process medicine increasingly took over educating and controlling tasks. As already mentioned, nineteenth-century doctors, for the most part, remained excluded from access to the sick infant. Medical guides and handbooks of infant care required a 111 F Soxhlet, 'Ueber Kindermilch und Saughngs-Ernahrung', Munchener Meduimsche Wochenschnft, 33 (1886), 253-6, 276-8, p 255

Urban Infant Mortality in Imperial Germany

425

certain level of education and therefore did not receive a wide circulation and distribution. Nineteenth-century breastfeeding campaigns remained without broad effect.112 With the beginning of the twentieth century, however, doctors realized the necessity of an active health-care approach to the population. From 1907 onwards they developed the so-called advancing infant care which enabled medical personnel to be in direct contact with mother and child through house-visits. 113 This made the doctors transmission vehicles for these new values, which successfully spread among working-class people and affected contemporary views on hygiene and health.

112

Stockel, 'Saughngssterbhchkeit', 252-6 Engel and Behrendt, 'Saughngsfursorge', pp 28-194, F Rott, 'Die drei Senkungspenoden der Saughngssterbhchkeit lm Deutschen Reiche', Gesundheitsfirsorge fir das Kmdesalter, 2 (1926/ 27), 491-508, F Rott, 'Gesundheitsfursorge fur das Kmdesalter', in M v Pfaundler and A Schlossmann, eds , Handbuch der Kttiderheilkunde Em Buchfar den praktischen Arzt, Vol. 1 (Berlin, 1931), 4th edn , 187-252 113