On November 11–14 1993, Indiana University hosted a conference on the ‘History of Registration of Causes of Death’, with funding from the US National Institute on Aging and the National Institute of Child Health and Human Development. The conference brought together historians of medicine and historically-oriented demographers and epidemiologists to discuss the origins of the recording of causes of death and the possible uses of these documents in demographic and epidemiological research. Demographers and epidemiologists would like to use long-run series of causes of death to examine the effects of social and economic conditions, the availability of health care, and specific risk factors on mortality. Many important questions (such as the effects of early health experiences on old-age morbidity and mortality) are best studied with data on changes over long periods of time. However, it is very difficult to construct a consistent series of deaths by cause over time because advances in medical theory and practice have led to significant changes in the classification of diseases. For example, it is unclear whether the prevalence of heart disease was increasing, decreasing, or constant before 1940, because heart disease was often classified under other categories.

The essays in this special number of Continuity and Change offer a range of insights on the historical circumstances in which cause-of-death registration emerged. They help us to see the ways in which medical theory, medical practitioners, and their increasingly influential professional organizations shaped the conceptualization of reporting of causes of death. Günter Risse's ‘Causes of death as a historical problem’ serves as an overview of the problems that social historians of medicine find underlying any continuous history of mortality experience. Above all, he argues, medical historians react as historians, wary of Whiggish confidence in state records without attention to the ideologies governing their creation.

PROBLEM NUMBER 1: THE SHIFTING ECOLOGY OF DISEASE

We all know that human disease is a constant and natural expression of conflicting forces and agents. As biological phenomena, diseases are never static. Influenced by physical and social agents, sickness shifts constantly in specific ecological settings. In infectious diseases, for example, constant readjustments within changing physical environments occur between pathogenic agents such as micro-organisms and viruses and their human hosts. As do other complex organisms, humans display a series of adaptive mechanisms which can both prevent or create illness; a lifetime of such encounters categorized as ‘wear and tear’ phenomena leads to distinctions between chronological and physiological age that are useful in assessing susceptibility to disease and life expectancy.

To understand the broad contours of human disease and periodic epidemiological changes in various parts of the globe – what physicians have called the ‘ebb and flow’ of disease – many historians therefore subscribe to the idea of a shifting ecology of disease. This dynamic concept presupposes complex interactions between both biological and non-biological factors which are ultimately responsible for different and changing patterns of sickness in time and space, exemplified, at least superficially, by McNeill's popular book Plagues and peoples. By highlighting the interconnectedness of various possible factors, including those which could ultimately cause death, the ecological model is quite useful to both historians and demographers.

In early-nineteenth-century medical literature, one finds an elegant symmetry between causes of disease and causes of death: both were sufficient causes of particular events. However, as I will argue, by the end of the century physicians no longer sought sufficient causes of individual disease episodes – instead almost all of medical research was organized around the quest for necessary causes that were shared by all the episodes of each particular disease. Such causes carried great practical and theoretical advantages: they enabled physicians to control and to explain disease phenomena.

One might wonder why there has been no parallel change in our thinking about causes of death; to this very day, causes of death are sufficient causes of particular events. In principle there is no apparent reason why we could not identify necessary causes for classes of deaths – indeed, we sometimes do so. But, in the case of death, such causes hold little interest. Because of how they are used, sufficient causes for individual deaths are more interesting and more important to us than are necessary causes of deaths. Thus, the change in thinking about causes of disease – the change that destroyed the symmetry between causes of disease and causes of death – may not reflect simply progress within a fixed system of medical goals and values, but a profound change in the social role of physicians.

In nineteenth-century Canada, a Census was conducted every ten years, beginning in 1851. Historians have tried to use the information in the local, provincial, and national Censuses to determine the rate of mortality and causes of death. The mortality statistics are thought to be reliable after 1921, but practical as well as conceptual problems interfere with attempts to establish retrospective mortality patterns using the nineteenth-century Census. In this paper, I will review the problems with this source on mortality. I will then compare the Census data with that derived from a study of a physician's daybooks, focusing on four specific areas of discrepancy and the possible reasons for the differences. Finally, I will suggest that the combined use of both types of sources may challenge some durable assumptions and could help to establish more reliable estimates of mortality patterns.

Even after the unification of Germany in 1871, political power continued to be fragmented. The Bismarckian constitution was superimposed on a collection of previously independent states: it acknowledged their continued existence as historical regions, granted them their own constitutions, state parliaments, and extensive legislative and executive powers. At a regional level, different perceptions of the appropriate role of the state continued to exist, with Prussian centralism contrasting with the laissez-faire amateurism of Bremen and Hamburg. The creation of centralized Reich (German Empire) agencies, such as the Imperial Health Office, failed to guarantee an effective implementation of German Empire decrees, and the administrative structure of individual states remained diverse. Indeed despite increasing pressure to create a uniform nation state and standardized administrative procedures, there were still 25 separate states in 1914. In relation to the structure of medical services and the formulation of medical policy, a significant degree of regional variation persisted into the twentieth century.

I. THE CREATION OF MODERN DEMOGRAPHIC STATISTICS

The existence of a specialized administrative organization depends on the political, economic, and social development of a country, and is indispensable for the availability of modern statistics. As more than one author has pointed out, quantitative assessments of its population reflect a government's capacity to rule. The first Spanish attempts to obtain such quantitative knowledge are found in the so-called Relaciones ordered by Philip II in the second half of the sixteenth century; they described both European and American territories of the Crown. These early attempts, however, lacked continuity.

As elsewhere in Europe in the middle of the nineteenth century, general dissatisfaction among Dutch doctors with their position in society and with overall levels of public health led to an active endeavour to raise their own status and to improve the level of public hygiene. For the most part these sanitary reformers or hygienists were inspired by the ‘Bodentheorie’ (literally ‘soil theory’) of the Munich hygienist Max von Pettenkofer, which postulated a specific relationship between chemical and biological processes in soil and air and in the human body, and by the Belgian statistician Adolphe Quetelet, according to whom statistics were an important means to social progress. The hygienists stressed the need for objective measures of health, including empirical research, standardization of data collection, and increased dissemination of data.

Although a national system of death registration had been functioning in the Netherlands for more than thirty years, there was no national registration of causes of death. Only local registration of causes existed and these were considered insufficient and inaccurate.

F. M. L. Thompson (ed.), The Cambridge social history of Britain, 1750–1950, Vol. I: Regions and communities; Vol. II: People and their environment; Vol. III: Social agencies and institutions. (Paperback edition, Cambridge: Cambridge University Press, 1993.) Pages xv+588; xv+373; xiii+492.

M. J. Daunton, Progress and poverty: an economic and social history of Britain 1700–1850. (Oxford: Oxford University Press, 1995.) Pages xvi+620.

Cormac Ó Gráda, Ireland: a new economic history, 1780–1939. (Oxford: Oxford University Press, 1994.) Pages xv+536.

What is social history and how should it be written? What are its ‘limits and divisions’ in the context of the ‘Britannic’ isles? F. M. L. Thompson, M. J. Daunton and Cormac Ó Gráda have provided important contributions, which will long survive the debate and reactions generated by their publications. These books are, in some respects, very different works, though they share a similar epistemological outlook based on ontological realism and empiricism. Together they offer a powerful and convincing alternative to the various versions of the ‘linguistic turn’ which has featured so prominently in the debate on social history in recent years.

The Cambridge social history (hereafter CSH) is a work of consolidation, a collective effort whose aim is ‘to communicate the fruits of…research…to the wider audience of students who are curious to know what the specialists have been doing and how their work fits into a general picture of the whole process of social change and development’. By contrast, Daunton and Ó Gráda have single-handedly produced inspiring analyses of crucial aspects of modern British and Irish history respectively. Daunton offers a nuanced discussion of the first industrial revolution. And, from a ‘new economic’ point of view, Ó Gráda reassesses the turning points in the making of contemporary Ireland, between the age of the American Revolution and the outbreak of World War II.