·Again and again through the history of crvili
zation whole countries, continents even have
been swept by rapidly spreading bacterial or
virus borne diseases some deadly, some crip
sling some less destructive The Black Death
of the Middle Ages the Great Plague of 1665
the cholera epidemics of the nineteenth
century the more modern scourges of influ
enza in its various forms and poliomyelitis
are but a few of the best known
This book tells the story of the ravages
caused by these diseases in the past of the
origin spread and effects of epidemics, and
the attempts more or less successful to com
bat them It discusses immunity and immuni
zation the steps taken in recent times through
the growth of public health services and gen
eral medical knowledge to prevent and fore
stall the recurrence of such scourges such as
leprosy smallpox and tuberculosis and the
possibility of their return in the future
For a complete list of books arailable
please unite to Penguin Books
u hose address can be found on the
back of the title page

·PELICAY BOOKS
A 456
EPIDEMIC DISEASES
A JI GALE

·USA
Penguo Books Ltd Harmond worth M ddles
Pengu Books Inc. 3390 lpper MIR d Balkmore I1 M
AVI BALIA PSU a Books Pty Ltd 762 Wh tehon Rod
M tcham. V ctona
First p b bied 1950
Cops gbe o MSIB G1 958
Md. dpd a Great Brital
by Spottiswood Bella fyne & Cold
London and Ow hester

·CONTENTS 7 List of Figures Foreword 9 Preface II Introduction 13 19 25 51 66 79 84 1 An Examination of Sources 2 Plague 3 Influenza - The Sweating Sickness 4 Leprosy - The Great Poe (Syphilis) - Smallpor 5 Asiatic Cholera 6 Continued Fevers Typhus - Enteric (Typhoid Paratyphoid and Food Poisoning) 7 Sumner Diarrhoea of Infants 8 Throat Dutempers Scarlet Fever - Diphtheria 9 Measles and Whooping Cough 10 Epidemic Diseases of the Central Nervous System Cerebrospinal Fever - Anterior Poliomyelitis - Encephalius Lethargica 11 Malaria and Yellow Feser 12 Tuberculosis 13 The Relative Importance of the Different Diseases at Different Times 88 98 107 119 13 131 149 Appendix Bill of Mortality for 1665 Bibliography Index 153 157

·P Books Lid Harmondsworth M ddlese
Pergu a Books Inc. $300 Cuppe Agull Road B lumore It M
AOITRALIA Pengun Boots Puy Lad 962 Wb tehorse Ro
M tcham Vtoria
Fint p bu hed 1939
Copyright © MOB Gale 959
Blad nd pe ted in Ore Bntalo
by Spottinwood Ball tyne & Co Ltd
London and Co hester

·LIST OF FIGURES 30 31 3 93 39 48 J5 7 1 Annual deaths from plague recorded in the London Bulls of Mortality between 1563 and 1666 2 Deaths from plague and other causes returned in the Bills of Mortality for 1665-6 From Bell Y G The Great Plagu n London t 1605 London (John Lane The Bodley Head) 1924 3 Chart showing trend of plague in London from west to cast. Based on the Bulls of Mortality for 1665 From The Great Plague in London in 1665 4. Map of London showing areas affected by the plague in 1665 and destroyed by fire in 1666 Based on a map in The Great Plague of London in 1669 5 Plague in East Anglia 1906-18 6 Deaths from influenza in England and Wales per 100 000 of population 1840-1955 7 (a) Deaths from smallpox in London 1629-1837 Com piled from the Bills of Mortality 7 (b) Deaths from smallpox an England and Wales in the period from the beginning of registration to 1905 8 Decline of typhus enteric and pyrexia showing num ber of deaths per million of the population in England and Wales 1871-1940 9 Recent history of typhoid and paratyphoid 1938-55 10 Infant mortality rates from diarrhoca and other causes in England and Wales 1870-1952 11 Deaths from scarlet fever and dsphtheria per million living under fifteen years of age 1856-1954 12 Notifications of scarlet fever and diphtheria in England and Wales per 100 000 of the population 1911-55 13 Declinc of mortality in England and Wales from diph theria measles and whooping cough 1911-55 14 Deaths of children in England and Wales under fifteen from measles and whooping cough per million of the population 1851-1955 15 Notifications of cases of measles and whooping-cough in England and Wales per 100 000 of the population 1940-55 16 Notifications of epidemic diseases of the central nervous system in England and Wales per 100 000 of the popu laton 1913-55 75 81 85 97 94 gr 101 102 108

·No text on this page.

·FOREIVORD
This book on pestilence through the ages was al
most completed when Arthur Gale died so prema
turely in 1996 I was asked by Mrs Gale to edit the
volume a task which I gladly accepted and which
has given me great personal pleasure
The work has not proved easy as although con
versant with much of the book since its conception
1 bad little knowledge of the sources to which
Arthur Gale had turned to compile this fund of
knowledge.
I should like to express my thanks to Professor
Bruce Perry for much helpful advice and for writ
ing the preface to this work Also to John Lane
The Bodley Head Ltd for permission to include
certain plates and diagrams contained in a book
by Walter G Bell PSA, PRAS entitled The
Great Plague of London in 1665 and published by The
Bodley Head
ER HAROREAVES

·125
126
LIST OF FIGURES
17 Comparatnc mortality index showing trend of respura
tory tuberculosis in England and Wales 1891-1954
(193821)
18 Comparative mortality index for respiratory tubes
culosis in England and Wales 1905-55
19 Respiratory tuberculosis Notifications and deaths in
England and Wales 1932-55 Based on the Joint Tuber
culosis Council Report May 1955 p 4
20 Deaths from diarrhoea pneumonia bronchitu whoop
ing-cough and measles of chudren under fivc in Eng
land and Wales 1911-14
21 Death rates (all causes) of children in different age
groups in England and Wales 1911-55
126
145

·PREFACE When Dr Arthur Gale died in October 1956 he left the nearly completed manuscript of this book which repre sents an expression of the main guding interest of his professional life The changes in the epidemuology of the common infectious diseases had interested him for many years Always keenly laterested in the welfare of children he was from 1933 to 1947 one of the medical officers to the Board of Education Some of his researches during this time formed the basis of his Mulroy Lectures to the Royal College of Physicians in 1914 on A Century of Changes in the Mortality and Incidence of the Principal Infections of Childhood His increasing interest in epi demiology lead in 1947 to his transfer to the Ministry of Health There he became a member of the epidemiological team and was thus enabled to continue his studies on the epidemiological features of acute anterior poliomyelitis In 1950 he was invited by the University of Bristol to accept the combined posts of Director of Medi cal Post Graduate Studies and Lecturer in Epidemiology The former post brought bim into contact with consult ants and practitioners throughout the West Country and this enabled him with their help to continue his re scarches He was particularly intngued by the way in which epidemics of anterior poliomyelitis widely separ ated in time struck the same villages in the south west, and he spent much time and thought in attempting to solve this problem. This book written in simple and non technical terms introduces to the layman the fascinating history of the common infectious diseases in this country After Dr Cales death the manuscript has been com pleted and in a few places brought up to date by one of his great friends Dr E R Hargreaves Deputy Medical Officer for the County of Cornwall It is largely due to Dr Hargrcaves s enthusiasm and devoted care in prepar ing the manuscript that the book is now published it forms a most fitting memorial to Dz Gale s life work. BRUCE PERRY MD PRC.P

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·INTRODUCTION There are many books on the history of medicine and several on the history of public health but the only book which deals systematically with the history of epidemic dis cases in this country is Creighton s great work of scholar ship The History of Epidemus in Britain published in two Volumes in 1894 Creighton s book is an inexhaustible store of information but it is not the kind of book which anyone would read unless he had a special interest in the subject Greenwood s Egidemics and Croud Diseases is the nearest ap proach to a history for the general reader but the first part of it is concerned with the development of epidemiological theory from the time of Hippocrates and the second treats of individual diseases as examples to allustrate epidemio logical principles Thus Greenwood s book is in some ways more comprehensive than this one and in others less He ranges the world for his examples but he does not include all the cpidemic diseases which have at some time been important in Britain in an address to the National Book League Trevelyan once said Besides the contemplation and study of the past for its own sake there remains the second great value of history namely the light it throws on the present There can be little doubt about the intrinsic interest of the history of epidemic diseases but there may be some about the value of this study for the light at throws upon the present because many of the diseases to be discussed have vanished from the English scenic or have become trivial However infantile paralysis as still with us we can never be quite sure what influenza may do and several of the other diseases cause a great deal of sickness even if they no longer kill as they used to do The chief criterion for the inclusion of a disease has been that it has at some time been epidemic in the dictionary sense of being prevalent at one time and not at another Some descases which are certainly epidemic for exampic

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·INTRODUCTION epidemic process is fundamentally the same as that which the gardener secs when his strawberry plants or his rasp berry canes proceed to die off from a virus infection Animals including man have a highly complex mechan 1sm for protecting themselves against attack by micro-organ isms and producing immunity and the following scheme gives some idea of how this works (Innate Immunity Passive Acquired Active Not very much is known about innate immunity but it obviously exists because some micro-organisms have power to produce disease in many different kinds of animals whereas others affect only one kind It seems possible that there may be genetic differences between individual human beings which determine to some extent their susceptibility to different diseases but we have little exact knowledge about this Acquired immunity is dependent on the fact that the in troduction of the parasite into the host results in the pro duction of protective substances The substances in the para site which provoke this response are known as antigens and the substances produced by the host are called antibodies The details of anugen-antibody reactions in special cases are extremely complicated, and a large proportion of the time of bacteriologists is spent in working out such details but for our purpose it is sufficient to know that antigen provokes the production of antibody that a single micro-organ um may incorporate a number of different antigens and that variations in the antigenic structure of some microorganisms frequently occur both under natural conditions and in the laboratory We speak of immunity as being active when the host has itself manufactured antibodies as a result of invasion by a parasite and we speak of it as passive when some other host has done the manufacturing and the ready made antibodies are transferred from the host to the one we wish to protect Active immunity may occur naturally as a result of infection or be produced artificially by the administration of some ·EPIDEMIC DISEASES chicken pox and mumps, have perforce been omited be cause they have led such blameless lives from the point of Vicw of causing scrious damage that they have little recorded history All the diseases to be discussed are believed to be duc to micro organisms and although my aim has been to write a book which shall be intelligibic to the general reader, it 1$ hardly possible to asord the use of some technical terms in Writing about them Each chapter begins with a short summary of modern knowledge about the disease or discases to be ducussed but the following general remarks may help the non technical reader to understand these summaries Most of the microorganisms which cause important epidemic discases in human berags in Britain belong to two main classes (1) the bac teria or (2) the viruses The bacteria belong to a world in which the unit of measurement is the micron se one thous andth of a millimetre - written Ih They are visible directly under the highest power of an ordinary microscope The viruses belong to a world in which the unit of measurcinent w only one thousandth of 14 - Written i mybut they vary in size more than the bacteria the largest of them being about 300 mu in length or diameter whereas the smallest are about 10-20mu The largest viruses may be just visible under the highest power of an ordinary microscope but most of them can be made vassble only in photographs taken with an electron microscope Bacteria can multiply outside the body and are habitually grown in enormous numbers in or on various substances in thousands of bacteriological laboratones throughout the world Vuruses though they can suryne outside the animal body cannot multiply except Mithun lving cells and so in laboratories they have to be grown cther in fertile living eggs or in a lying culture of anual tissue This u obviously a more difficult and Imitag technique than that of the culture of bacteria in a culture medium composed of broth or agar or some surnalar sub stanec All animal discase due to sucro-organisms may be regarded as the reaction of a host to a parasite the animal being the host and the microorganwin the parante The ·INTRODUCTION Another factor which has profoundly affected the history of these cpidemic diseases 23 that of the mechanism of their transmission from one host to another The mechanism of infection is sometimes a complicated one involving animal and insect intermediaries as vectors Thus the incidence of discase in man may be determined not only by the preval ence of the parasite and man s susceptibility to it but also by the ecology of the intermediate host or hosts On this func of thought there w a theory that the disappearance of plague from Europe towards the end of the seventeenth century was largely due to the replacement of the black rat by the brown and thus explanation is often quoted in history books There is however one great difficulty in accepting the theory and this will be discussed later Finally we have to consider changes in the parasite There are numerous examples of diseases which have undoubtedly changed their behaviour in a way which suggests that the causal organım has changed Sometimes the change has been a sudden one for example when influenza caused such devastation in 1918-19 or when mild smallpox first ap peared and sometimes there has been a gradual change as ex cmplified by thc history of scarlet fever We know little about these changes in nature but we know that in the laboratory bacteria and viruses may change their virulence consider ably Generally speaking if a bactenal culture is kept going in a laboratory for some time the organism tends to lose virulence whereas if it is pas ed through a series of animals the bacteria tend to gain virulence Some of the recent work of Burnet* on the changes in influenza virus when grown in the laboratory in fertile hen s eggs is most intriguing from the epidemiological point of view We must remember that all bactenological knowledge is historically new Before about 1880 the only way of classify ing diseases was by their signs and symptoms and classifica tion founded on the identification of the micro organism came late and did not always coincide with the older classı fication For this reason many chapters begin with a description of the history of some rather vague groups of diseases FM Burnet 1944.

·EPIDEMIC DISEASES form of protective vaccinc, a vaccine being a suspension complete or part mcro-organisms, alive or dead, the sus pension thus containing antigens which, when inoculated, will stimulate the production of antibodies in the susceptible person Passive immunity may occur naturally, when antı bodies pass from the mother to her unborn child, or at may be produced artificially by the administration of blood scrum to an animal wuch hrs no antibody from one which has Passive immunify tends to be a temporary affair and in this book the words immunization and immunity may be taken to imply the active process unless the passive one u specific ally mentioned practice there are great differences between the cfficacy of different vacanes Bacterologists are always striving to find anugens which are harmless in themselves but will produce a large amount of antibody against the particular micro-organum concerned and they have had to use many different methods to protect against different discasa Some sumes the antigen 13 a harmless (or almost harmlesa) 11:45 of lying virus for example the vaccinc used to protect against smallpox sometimes it is an extract made from virulent bacteria made harmless by the addition of a chem tcal for example diphthersa prophylactic somctmc stes & suspension of killed bacteria, for example whooping-cough vaccine In the study of individual diseases we shall find one diphtherta whose history scems to have been affected profoundly by artificial immunization one smallpax in which the part played by immunization is difficult to RSSES and many whose history has so far been unaffected We have to remember that the process of natural immunization goes on all the time Sometime it is obvious a3 in a community of young children which suffers an epidemic of measles and then remains free from the disease unul there are enough unimmunized recrut to provide fuel for another cpıdemic Sometimes it 15 lets obvious because the prevence of some Inscro-organisms in a communsty may produce a great dca! of inmunity without producing much overt disease in thes respect the history of the disease » an uperfect reflection of the reaction between the community and its paraules 16 ·I AN EXAMINATION OF SOURCES It is necessary to begin with a rather protracted examina tion of sources because in medicine perhaps more than in any other subject ideas and nomenclature have changed enormously even in the last seventy years and almost out of recognition between 1348 and 1950 For the earliest period from 1348 to the reign of Henry VIII(1509-47) we depend for information chiefly on monas uc hustones state documents and for the Black Death on the rolls of manor courts There are also many fragmentary references to epidemics in letters of the time Medical books begin to be useful in the Tudor Period and become continu ously more so from the time of the great physicians of the Commonwealth and Restoration - Sydenham Willis and Morton In the Tudor Period also there were the beginnings of statistical records in the London Bills of Mortality (see Appendıx P 149) and the parish registers As these will be mentioned frequently when the history of individual discases 13 discussed a little more may be said about them The London Bills of Mortality began probably in 1532 and the first of them which is extant tells how many syns the 17th day of November until the 23rd day of the same month is dead within the city and freedom young and old these many following of the plague and other diseases This Bill accounts for only sixty six deaths and is almost certainly incomplete In the next thirty years the Bills were issued ir regularly probably only when plague was epidemic but between 1563 and 1592 the regular series began It is not clear how the first Bills were compiled but carly in their history they became the responsibility of the Company of Parish Clerks This Company was granted a royal charter in the thirteenth century and its function was connected with ·EPIDEMIO DISEASES for example the continued ſevers, and then branch out into a description of the ducasts which probably made up that group The modern classification did not always have to wait for the discovery of the causal organism, becausc clin ical different sation was proceeding apace before the discovery of bacteria but bacterology has nevertheless produced a revoluuon in modes of thought about communicable diseases It is much casier to write the history of a discase which has characteristic signs and symptoms such as plague, than or ose which has indefinite signs and symptoms such as in fluenza But many descases can be identified in the ancient records from the combined study of their clinical and cps demiological characteristics ·AN EXAMINATION OF SOURCES first the physicians made no use of the Bills and indeed they probably held them in contempt because they were based on the diagnoses of ignorant women It was left to a business man called John Graunt* (1620-74) to make the first serious study of the despused Bills His Observations on the Bills of Mortality are generally regarded as the first important con tribution to the study of vital statistics ever made and his handling of the extremely inadequate material at hus disposal was masterly He knew that he was on much safer ground in making deductions from total numbers of deaths than in using information about deaths from individual causes and some of the principles he adopted in analysing the Bills are still of first rate importance to anyone who tries to draw con clusions from figures of deaths by cause These principles seem simple but it is surprising how often they have been and sull are forgotten When Graunt found that deaths from a certain cause seemed to be increasing in the Bills over a period of years he was always careful to scrutinize the figures of deaths from nearly related causes to make sure that deaths from the cause he was examining really had increased and that the increase was not an artefact due to a change in classification or nomenclature In plague years he found that It was not only deaths from plague which increased but also those from many other causes and he suspected that deaths from plague were being concealed because of the inconveni ence which a death from plague in a house might cause to the other inmates Perhaps some of the discrepancies were due not to deliberate concealment but to genuine mistakes for a similar phenomenon is seen today in years of epidemic influenza This seems very simple and obvious but two examples may be given to show that the importance of scrutinizing sources was and is sometimes overlooked When examining the Bulls of a later period William Heberden the youngert concluded that deaths from dysentery had declined marked ly He assumed that guping of the guts in the Bills was synonymous with dysentery In fact it was what we call infantile diarrhoea and the deaths from it had merely to * John Graunt 1662 t Wilhan Heberdea 1819 1 ·EPIDEANIC DISEASES church music When a rich citizen died the whole company might be engaged to sing at hus funeral and thus at acquired the apparently incongruous function of registenng berths and deaths By 15Br the procedure had become formal In csery parish two discrete matrons were selected to be searchers They were sworn before the Dean of Arches at the Church of St Mary le Bow to search the body of es ery such person asskall happen to die in the same parish and to reportsseekly to the parish clerk The parish clerk had to make a weekly report to the warden of the parish clerks who sent it to the mayor who sent it to the munister of state The purpose of the Bills was to warn the great ones of the court and of the crty when plague was about so that they might depart I good time for the purer air of the countryside In 1625 the Company obtained a decree of Star Chamber permitting them to set up a special prinung press for the sue of weekly and annual Bills At mbt of burials fromx plague and from all other causes and numbers of chras tenings were returned In 629 causes of death other than plague wert dutinguished and the totals of deaths from all causes were separated by sex In 3727 the ages of those dying were given and in thu form the Bills continued untd 1849 eleven years after the establishment of the General Register Office had made them absolete In 1955 the weekly return of the Registrar General still includes & memento of the Bulls for Table III of the report is a rcrum of the deaths by 45€ sex and cause registered in London during the weck For places outside London the sources of information about births deaths and sometimes causes of death are the parish registers These Tiere kept wich different degrees of cart in different places from the reign of Elizabeth One of the inaccuracies of the Bills of Mortality and of the parish registers is that they did not include the deaths of Dissenters There are then two main streams of information about the incidence and mortality of disease from the middle of the seventeenth century One is medical Sterature which was contributed largely by the fashionable physicians in Lon don and makes httle use of figures and the other u the in complete information in the Pills and parish regissers At ·AV EXAMINATION OF SOURCES typhoid fever Deaths from diphtheria were included under scarlatina or possibly under one of the other headings for diseases of the throat unul 1887 and typhoid was included with typhus unul 1869 Statistics of the incidence of diseases came much later than those of deaths For some large cities the number of notifications of certain infectious diseases has been collected since 1898 but for the whole country the series began in 1911 and from time to time new diseases were added For example poliomyelius was added in 1912 encephalıtıs lethargica in 1918 measles and whooping cough in 1940 The great physicians of the Commonnealth and Restora uon of whom Sydenham is the outstanding example made important contributions to the clinical differenuation of discases and so some contribution to the study of their pre valence and fatality at different times It must be remem bered however that for the most part they practised in London and among the well to-do classes so that they probably knew little about the diseases of the poor which bulkcd so large in the Bills and even less about the discases of the countryside In the eighteenth century the founding of volun tary hospitals and of public dupensaries brought medical men of distinction into much closer contact with the poor of the cities and some of their writings are valuable to the student of the history of diseases Towards the end of the eighteenth century fever hospitals began to be established and their records are a useful supplement to the statistics which the office of the Registrar General began to collect in 1837 One of the results of the sanitary reforms of the period 1848-60 was the establishment of local and central departments of health The first medical officer of the cen tral department was Sir John Simon * who carly set about the task of collecting and analysing information about the incidence and fatality of epidemic diseases in different parts of the country An early example of the sort of inquiry he promoted was that of Dr EH Greenhowt into deaths by cause in different districts of England and Wales From 1858 * Sir Jhn Sicon 1856 FH Greenhow 23 ·EPIDEBIC DISEASES be transferred to the heading convulsions The second es ample is rather different but also illustrates the importance of knowing one s sources It is taken from an arude by Bradford Hill In the course of a single committee meeung I have heard a dis tinguished surgeon reject as quite valueless the death certificates obtained in a follow up of patients with cancer and yet express the greatest interest in the cancer mortality data by site of growth publushed by the Registrar General He apparently saw no inconsist cncy in the attitude towards material obtained frora precisely the same sources and such an attitude is by no means rare Up to 1839 the Bills of parish registers were the only con tinuous records of births and deaths but in certain places quite good records were kept for restricted periods For Carlisle for example there are records of deaths by age and cause for the years 1779-87 (omitting the year 1780) In 1750 Dr Thomas Short published his New obserations atural, Moral, Ciurl, Political and lfedual, on City Toun and Country Bills of Mortality As the title suggests this is a discursive book but it does contain many abstracts of the registers of parishes for a long penod of years In 1801 the first decennial census was taken so that for the first time reasonably accurate and comprehensive figures of population became available In July 1837 national regus tration of births and deaths began and in 1839 Samuel Farr was appointed to be compiler of abstracts at the new General Register Office For the first time comprehensive though at first incomplete information about fatal diseases became available for the country as a whole In his nomenclature of fatal diseases for statistical purposes Farr divided them into two main groups (1) Epidemic endemic and con tagious diseases (2) Sporadic diseases We are concerned with those diseases in group I and Farr s list is much more intelligible to the modern reader than are the names used in the Bills The changes in nomenclature since Tarr s time have been esolutionary rather than resolutionary There are two important omissions from Farr s isst diphtheria and • A Bradford Ill, 1947 22 ·AN EXAMINATION OF SOURCES typhoid fever Deaths from diphtheria were included under scarlatına or possibly under one of the other headings for diseases of the throat until 188, and typhoid was included with typhus unul 1869 Statistics of the incidence of diseases camc much later than those of deaths for some large cities the number of notifications of certain infectious diseases has been collected since 1898 but for the whole country the series began in 1911 and from time to time new diseases were added For example poliomyelitis was added in 1912 encephalitis lethargica in 1918 measles and whooping cough in 1940 The great physicians of the Commonwealth and Restora tion, of whom Sydenham is the outstanding example, made important contributions to the clinical differenuation of discases and so some contribution to the study of their pre valence and fatahty at different times It must be remem bered however that for the most part they practised in London and among the well to do classes so that they probably knew little about the diseases of the poor which bulked so large in the Bills and even less about the diseases of the countryside In the eighteenth century the founding of volun tary hospitals and of public dispensaries brought medical men of distinction into much closer contact with the poor of the cities and some of their writings are valuable to the student of the history of diseases Towards the end of the eighteenth century fever hospitals began to be established and their records are a useful supplement to the statistics which the office of the Registrar General began to collect in 1837 One of the results of the sanitary reforms of the period 1848-60 was the establishment of local and central departments of health The first medical officer of the cen tral department was Sir John Simon * who carly set about the task of collecting and analysing information about the incidence and fatality of epidemic diseases in different parts of the country An early example of the sort of inquiry he promoted was that of Dr E H Greenhowt into deaths by cause in different districts of England and Wales From 1858 • Sir John Supon 1856 TEH Greenhow ·EPIDEMIG DISEASES to 1872 Simon was medical officer to the Privy Council, and during that period he promoted inquiries into the prevalence and distribution of cpidemic discases which have served as models for the many official reports since wntten His reports and those of his successors are necessarily the chief source from which the history of diseases in the last hundred years has been written ·2 PLAGUE PLAQUE is duc to a bacıllus (Pasteurella pestis) which can cause ducase in man and in many animals among whuch rodents and particularly rats are the most important. The commonest form of the human disease is bubonic plague which begins as an epizoouc or glandular infection among rats and reaches man through the bites of rat fieas which have descrted their normal host after its death Occasionally plague occurs in man as a deadly form of pneumonia and this form can spread directly from man to man through the air There have been three pandemics of plague in the last 1 500 years The first was that which came with the corn ships from Egypt and Byzantium in the reign of Justinian in 542-3 the sccond was the Black Death which reached England in 1348 and the third began in 1894 We do not know whether the Justinian plague reached England as the chronicles of the time are not sufficiently precise to make adentification of pestilences possible The Black Death is sin gled out by Trevelyan* as the unique disaster of English social history and after it plague persisted in England for three hundred years The latest pandemic affected England not at all in a dramatic sense but certain events probably associated with it are of great interest to the epidemiologist The Black Death has been taken as the starting point of this book because it is one of the outstanding events of world history and because it 13 the first epidemic in Britain of a disease which we can identify with certainty Nothing is known for certain of the remote place of origin of the Black Death but it seems fairly well established tha the immediate source of infection for Europe was the Crimea GM Trevelyas 1943 ·EPIDEMIC DISEASES to 1872 Simon was medical officer to the Privy Counal and duning that penod he promoted inquiries into the prevalence and distribution of epidemic discases which have served as models for the many official reports since written His reports and those of his successors are necessarily the chief source from which the history of diseases in the last hundred years has been written ·PLAGUE ians have concluded that probably a quarter and possibly one-third of the inhabitants of England died of plague in the yeans 1348-9 Some idea of the prevading sense of desola tion and despair is contained in the following quotation from the chronicle of an Irish friar (quoted by Creighton) And I Frar John Clyn of the Order of Frars Minor and of the convent of Kilkenny wrote in this book those notable things which happened in my time which I saw with my eyes or which I learned from persons worthy of credit. And last things worthy of remem brance should perush with time and fall away from the memory of those who are to come after us I seeing these many evils and the whole world lying as it were in the wicked one among the dead waiting for death toll it came as I have truly heard and cxamined so have I reduced these things to writing and lest the wnting should perish with the writer and the work fail together with the workman I leave parchment for continung the work of haply any man sursive and any of the race of Adam escape this pestdence and continue the work which I have commenced Most of the contemporary monastic chronicles are how ever interrupted in 1348-9 and if there is an entry under the year 1349 it consists merely of the words magna mortal itas One can only imagine that one chronicler was prevent ed by death from continuing his task and another could find no words to describe so terrible a calamity The characteristic which distinguished the Black Death from later outbreaks of plague was more its universal distri bution than its high mortality in individual places It caused devastation in remote places and in the towns whereas carly in its subsequent history plague became a disease parucularly of the towns and of the poorer inhabitants of them London was much larger than any other town probably having a population of about forty thousand compared with the six or seven thousand of Bristol or Norwich Much of our in formation about plaguc after the Black Death u contained in state docunents concerning the movements of the court letters of ambassadors and the like For these reasons Lon don occupies a prominent place in the history of outbreaks after the Black Death The identification of these outbreaks 13 C Cre ghton 1894 ·FPIDEMIC DISEASES The cycwitnesses account given by de Mussis and summar azed by Creighton* 15 a cons incing one The substance of this story u that the Italian merthants who were then settled in considerable nutnbers at the various termini or entrepôts of the overland trade from China and Central Asia by the more northern route were harassed by the Tartar hordes that they had stood a siege in Tana on the Don but had been doren out of it and had sought refuge for themselves and their merchand isc within the wall of Caffa a small fortified post on the Crimean Straits (of hertch) built by Genoesc not long before that Caffa was besieged in due course by the Tartar barbarians that the in vestment lasted nearly three years that the merchants and others crowded into the narrow space within the walls were put to great straits and could hardly breathe being only partially relieved by the arrival of a ship with supplies that the plaguc broke out among the besieging Tartar host and daily destroyed thousands that the Tartars throw the pestilent dead bodies inside the walls by their engines of siege so that the infection took hold of those within the fort that the Tartars dispersed in panic and spread the infection all over the shores of the Euxine Caspian and Levant that such of the Italian traders as were able de Mussis himself with thema escaped from Caffa in a shup and that the infection appeared in Genoa in its most deadly form a day or two after the arrual of the ship although none of those on board were suffering from the plague Plaguc probably arrived in England at Weymouth (then Melcombe) at the beginning of August 1348 It is said to have spread rapidly through Dorset Deion, and Somerset and to havercached Bristol sometimein August From Bristol it came to Gloucester from Gloucester to Oxford and from Oxford to London, which it reached by : November The Eastern Counties and the north, which suffered very scverc ly, were attacked rather later - probably in the spring and summer of 1349 By the winter of 1319 the Black Death was oser but epidemic plague was established in England and was destined to recur in many lesser but still great epidemics until its final disappearance in 1663-6 It is, of course impossible to arrive at any exact figure of the total mortality from the Black Death but by piecing together scraps of information from all kinds of sources histor • C. Creighton 1894 26 ·PLAGUE The great plague of 1665 is thanks to Defoe* and Pepyst almost as well known an event in Engluh hustory as the Black Death It is difficult to compare its mortality with that of previous outbreaks because we do not know for certain the number of deaths or the population Creightont how ever gives the following table of comparison between the mortalities from plaguc in London (including the liberties and out parishes) in 1603 1625 and 1665 Year Estimated Total Number Largest Worst week population number of deaths number of deaths from of deaths plague in a week 1603 250 000 42 940 33 347 9 385 25 Aug -1 Sept 1625 320 000 63 001 41 313 5205 11 Aug -18 Aug 1665 460 000 97 306 68 596 12 Sept.-19 Sept 8297 In the County of London today with a population of ncarly 31 million the usual number of deaths in a week in winter is round about 1 000 Although Defoc was only about six years old in 1665 and we do not know whether he was in London he used the best contemporary authorities in compılıng his Journal of the Plague Tear He wrote it in 1722 when plague had acquired a par ticular news value because of the epidemic in Marseille and Provence which was the last great outbreak in western Europe Pepys makes frequent references to plaguc, some of which are worth quoting because they show how the calam ity affected a distinguished civil servant June 7th 1065 This day much against my will I did in Drury Lanc see two or three houses marked with a red cross on the doors and Lord have mercy on us wait there which was a sad sight to me being the first of the kind that to my remembrance I ever saw It put me into an el conception of myself and to my smell so that I was forced to buy some roll tobacco to smell and to chaw which took away the apprehension June 29th Up and by water to White Hall where the court full of waggons and people ready to go out of town DD foc 1722 Is Pepys 1825 C. Crc ghton 1894 ·EPIDEMIC DISEASES not always casy, because the word pestis was sometimes used in a generic sense and was not confined to bubonic plague After the Black Death there were probably four or five considerable outbreaks of plague before the end of the four teenth century They occurred in 1361, 1368-9, 1375 and 1390-1 There is also some record of a severe epidemic in 1381-2 which may or may not have been plague In the fifteenth century the first great outburst was in 1406-7, and there were major cpidemics in London in 1464 1479 and 1500 Between these major outbreaks however there are many records of lesser ones which were sufficiently important to justify the prorogation of Parliament (for example in 1433 and 1437) The story of plague in the sixteenth century is very like that in the fifteenth Except for a period of quiescence in the reigns of Edward VI (1547-53) and Mary (1553-8) the discase was ncarly always present in London and there were great outbursts in 1500 1513 1563 1569 and 1593 The first extant Bull of Mortality is assigned with probability to the year 1532 and from 1563 one can begin to construct a continuous of incomplete picture of the annual mortalities from the disease in London Figure 2 shows the number of deaths from plague in the London Bills from 1563 to 1666 In spite of their defects the Bulls give some adea of the relativc importance of plague to Londoners In the four non plague years 1597-1600 the Bills showed an aver age of about 4 250 burials and 4 500 baptisms cach year in other words an excess of births over deaths of 1,000 for the four years In 1603 plague was credited with 33 347 deaths in London (other years over 10,000) When these figures are considered in relauon to one another it is casy to sec why those of our ancestors who were in a position to do so moved hastily to the country when plague was about In this period also there are many accounts of plague in the provinces associated particularly with the movements of ar mics in the Civl War An example is the outbreak in Bristol in 1645 at the time of the siege of Prince Rupert s army by that of Fairfax It 13 said that there were 3 000 deaths in the city 23 ·PLAOUF the deaths returned in the weekly Bills from January 1605 to March 1666 Both the total number of deaths and the number of deaths from plague are shown and it is obvious that whereas at the beginning of the year some five hundred deaths were returned every week at the height of the epi demuc in August and September over 8 000 a week werc returned for all causes and about 7 000 from plague. It appears therefore that there may have been some 500 more deaths from plagucinaweek than were shown in the returns The quotation from Pepys s diary supports this view 8000 All deaths Death att buted to plug • Xoc Each & tundvate o rise or fall of mortalty 600C 5000 4000 3000 2000 1000 Jur. Feb Mar Apr My TV A Sept Oct N Det jan DMW 1665 1666 2 Deaths from plague and other causes returned it the Bulls of Afortality for 11965-6 Figure 3 shows how the plague spread from west to cast The position of the parishes (St Giles Cripplegate and Stepney) is indicated in Figure 4 which also shows how the City itself escaped relatively lightly when compared with the Liberties and Out parishes At this time the City was still the home of the prosperous merchants and the poor lived for the most part in the maze of alleys and courts outside the walls The standard of housing was worse here than in the City itself The hughest mortality of all was in the populous 31 ·EPIDEMIC DISEASES July rock An unpleasing thing to be at Court, everybody being fearful one of another August 30th Mct with Hadley our clerke for says he there died 9 this week tho I have returned but 6 which is a very uI pracuct and makes me think it is so in other places and therefore the plague much greater than people take it to be 695% 33 000 41 300 17 000 10 600 10 400 Thi Years of high prey lence 65 70 75 80 85 90 95 1600 05 10 15 25 30 35 40 45 50 55 60 65 : Anual deaths from plague rrounded on the London B Ils of Worlukty dekarn 1563 and 1685 The last extract is an interesting commentary on the changes in the structure of society since Pepys's time It is difficult to imagine a casual conversation in Whitchall today between the registrar for the Cory of llestminster and the permanent secretary of the Admiralty in the course of which the registrar mentioned to the permanent secretary that he had just falsified his weekly retum to the Regutrar General! Although statistical information about the plague of 166, us admittedly inaccurate it does enable us to form a reason ably clear picture of the main facts about its inadence and spread Figures 1-5 illustrate the main facts Figure 2 shows 30

·worly be dry
Libertla boundary
Boundary of red troved by fire
Areas most elected by plague
WWW
PLAQUE
4 Afap flod showing areas affected by the plague in 1065 and dest oyed by fire in 1606

·FPIDEMIC DISEASES
suburbs of Cripplegate Whitechapel, Stepney, St Martin
in the Fields St Giles in the Fields, Southwark, and test
minster Further references will be made to this point when
the possible effects of the Great Fire of 1666 are considered
800
• St Giles in the Fields
Cripplegate
Stepney
700
600
500
400
300
200
100
May June July Aug Sept Oct Νον Dec
3 Chart showing irmd of plague in London from uzyst to cast Dased on the D IL
of Afortably for 1005
On the whole the plague of 1665-6 affected London far
more than the provinces but certain provincial towns had
senere outbreaks notably Yarmouth (Rosember 1664) the
castern counties generally (in 1865-6) and many coast towns
in hent particularly naval stations (in 1666) There was
plague also at Derby and in Derbyshure and the story of
the outbreak at the little isolated sllage of ryam in the Peak
32

·PLAGUE beginning of January 1666 the plague was confined to two houses Four died in January cight in February six in March tunc in April and only three in May On 2 June another burial occurred and then there was another pause But in a week or more the epidemuc broke out with renewed power three having been bured on the 12th June thrce on the 15th one on the 16th three on the 17th and so on until the total for Junc reached nineteen The wealthier villagers at the west end had taken the alarm before and had mostly fled in the spring those who stayed kept within their houses or at least did not cross the stream Now that the infection was revived in the hot weather of June the rector 5 wife also proposed flight but on her husband s refusal she resolved to remain with him and to send her two children to a rela tive in Yorkshire At the same time the villagers in general were instinctively moved to escape from the tainted spot but Mompesson used his authority to prevent them and a boundary line was drawn round the village about half a mile in curcuit and marked by various familiar objects be yond which no one was to go Mompesson s motive appears to have been to prevent the spread of the infection to the country around and tus parishioners submitted passively After the end of June the villagers would have found it dilli cult to escape owing to the terror which the very name of their village caused in all the country round Some of them quitted their cottages and took up their abode in shelters built along the side of a rocky glen within the cordon. The Earl of Devonshire then at Chatsworth promised Mompesson that the village should not be left without supplies and people from the villages near brought their market produce to certain stated points on the boundary where the Eyam people came to fetch it the money paid being dropped into water Thus shut up in their narrow valley the villagers perushed helplessly like a stricken flock of sheep By the end of June ceremonual burials came to an end the church and the churchyard were closed the dead were carried out wrapped in sheets by one of the villagers noted for hus herculcan strength and laid on shallow graves in the meadows or on the hillsides In July the deaths mounted up to five or su 35 ·EPIDEMIC DISEASES District has become a part of Engluh history akın to the stories of the charge of the Light Brigade or the wreck of the Barkenhead The plague of Lyam is indeed the most famous of all English outbreaks Eyam was a village of some three hundred and fifty inhabitants standingamong meadows around which the hills towered It had no resident doctor, but it had two ministers The one was the rector the Rev William Mompes son a young man of twenty seven, with a wife and two chu dren who had been settled in Eyam only a year and did not like it the other was the former sector the Rev Thomas Stanley who had been cjected for nonconformity in 2662 and had remained to carry on his minustrauons as a Dussen ter among such of his old fock as adhered to him The wealther houscholders resided at the western and higher end of the village on the other side of a brook which crossed under the road as we shall see they escaped the infection almosi, sf nos altogether The annual village wake had been held in August 1665 with more than the usual concourse of people from villages near On 2 or 3 September a boxar rived from London to the village tailor who lived in a smak house at the western end of the churchyard it contained old clothes which someone in London is supposed to have bought for hum cheap and some tailors patterns of cloth. Thus bor 13 assumed to have been opened by one Cecorge Vicars a scrvant who was certainly the first victim of plague He found the contents to be damp and hung them up at the fire to dry He was quickly seized with violent sickness became delingus dacloped buboes in his neck and groun a plague token on hus brcast the third day, and died in a wretched state on 2 September His body whuch said to have become putnd sery soon was buned in the church yard on the 7th Acarly a fortnight passed before another case occurred that of a youth supposed to have been the tailors san who was boned on 22 September Before the goth four morchad died and in the course of October twenty two more MeTC buned of plague The desihe in November declined to seren and in December they were nane That was now snow on the ground with hard frost and at the 34 ·PLAGUE vanous theories which have been put forward to explain the disappearance of plague from England Perhaps the first chronologically is that the Great Fire of 1666 destroyed the seeds of infection so thoroughly that the discascnever appeared again Defoc ascribed thus theory to certain quacking philosophers There is a modem anant of this suggestion put forward after the discovery ofthe mech anum of infection which postulates that after the fire there was much rebuilding in brick and stone where wood and plaster had been before and that the new brick and stone houses offered a much less favourable breeding ground for rats than did the old The insuperablc objection to the thcory us that it is too parochial Even if we confinc our viewpoint to London we find that the arca destroyed by fire was a mere fraction of the whole (Figure 4) and was the part least affected by plague Plague began and throve not in the compara tively prosperous City but in the rat nidden wooden hovels of the poor in the Liberties and Out parishics These were hardly touched by the fire of 1666 If we survey the story of plague in western Europe as a whole we find that except for a serious outbreak in Marseille and Provence in 1720-2 it had disappeared everywhere by about 1700 Creightont himself suggested that the disappearance of plague was due to a great increase in the use of coffins for burial which presented the contamination of the soul by plague infected bodies This idea like many of Creighton s explanations as opposed to his purely historical wnting seems to have been peculiar to humself It need not perhaps be taken very seriously A theory put forward in many books notably in Trevelyan s great Social History * us that plague disappeared because the brown rat displaced the black. The black ratus morcdomestic ated than the brown and is a better clunber At the present day it u found in shups and in high buildings particularly in ports but elsewhere it has been wholly replaced by the brown rat Both types of rat are susceptible to plague and both harbour fleas which will attack man when their normal • D Defoc 1722 fC. Creighton 1894 GV Trevelyan, 1947 37 ·EPIDEMIC DISEASES on some days and the total for the month to fifty seven la August the dead numbered seventy-eight among them the rector : wfe on the 25th after a walk with her husband through the meadows during which she is said to have made che ominous remark that the air smelled sweet? September added twenty four to the total, and there were now only about forty five left alive in the place of these fifteen died up to 11 October when the mortalty ceased Some of the sururvors had passed through an attack of the plague among them the rector 3 man whose buboes suppurated fompct son himself who had an issue open in his leg all the time escaped the infection as well as his mard servant When the sickness had ceased Mompesson set about burn ing the infected articles in the empty cottages Three years after in 1669 he was presented to the better living of Esk ring in Notts but on arriving to enter on his daties he was refused admission by the vsllagers and had to take up his residence in a temporary hut in Raifford Park until such time as the prejudices of his new parishioners had been over come Between September 1665 and October 1666 259 in habitants died of plague at Eyam and only thirty three weTC left alue Mompesson s action has often been criticized yet although the cost was terrible his action certainly saved the surrounding villages from plague Creighton* writes the obituary of plague in Britain in the following sords Plague had been the grand infective ducast of Britain from the year of the Black Death 1348-9 for more than three centuries down to 666 The last of plague 1x Scotland was so 3617-3 in the west and north west of England about 16,0 in Wales probably in 2636-8 in Irciand in 1650 and in all other parts of the king dom * 1666 the absoluse last of its provincial prevalence hasong been at Peterborough in the first months of 1667 while tho or three deaths continued to occur aracally in London down to 16,3 There w an interesting but undramatic postscript to that obrruary but first it u desirable to say something of the • Creighton 3834 ·PLAGUE for us to consider events which are comparatively recent history and probably associated with the pandemir of plague whuch first became apparent at Hong Kong in 1893-4 and, like the carlier pandemics spread over most of the inhabited world though with different results from those of its pre decessors + Infected rats found x infected hares found Woodbr og Ipswch Hadie gh Orwell B 7 Felixstowe JA WCH FR Stour $ Plagus : Earl A glua 1906-18 A Felon confirmed cases 1970 (all dud) > Trimley 8 suspected cas 1909-10 (s ded) c Shotley & suspected cases 1906-7 (6 died) confirmed case 1977 (died) D Erwarton ? co firmed cos s 1918 (both dd) So far as us known plague never occurred in Britain be tween the late seventeenth century and the beginning of the twentieth In 1900 and 190t there were a few cases in Glas gow and in 1901 probably eleven in I iverpool and one in Cardiff All these occurred in large ports and although it was not always possible to trace the source of infection it seems reasonable to suppose that they were directly associ ated with rats from ships An incident which occurred in 1910 us of more interest in that it implied a much deeper and more lasting penetration 39 ·EPIDEMIC DISEASES host is dead Thus this theory depends essentially on the difference in the social habits of the two species - the black rat lives closer to man than does the brown The great difficulty about accepting the rat theory is that of chronology Plague to all intents and purposes disappeared from England in 1666 and from the whole of western Europe at about the same time with the single exception of the epidemic in the south of France about 1720 The earliest date gren for the arrival of the brown rat in England 1689 us a legendary one for the rat is said to have amved in the shup which brought William III from Holland In fact the brown rat probably arrived considerably later – in 1728 or 1729 according to Pennant • As late as 1783 Swaine a rat catcher (quoted by Barrett Hamilton and Hintont), said that the black rat was the common one in London Middle sex and Buckinghamshure but that elsewhere in the Home Counties the brown had ousted it. It would be reasonable to expect a long interval of freedom from plague in London after the great outburst of 1665-6, but to fit the rat theory one must postulate an interval of a hundred years Other theories of the disappearance of plague are more vague Lustont in his Milroy Lectures put forward the dea that epidemic diseases are a reflection of states of cıvılıza tion He pointed out that many of the diseases whuch we now regard as tropical diseases for example, plague and malaria were once serious problems in Britain He ascnbed the disappearance of plague to a gradual rise in the state of civil ization It is difficult to prove or disprove thus theory but it is doubtful whether the general state of civilization of the poor in large cities particularly in London was much higher in 1765 than in 1665 The deaths from other dicases of poverty, for example typhus rose rather than ſell and thus was the age of cheap gin drawn 30 vividly by Hogarth in Gin Lanc The conclusion must be that we do not really know why plague disappeared so suddenly when it did and it remains • T Pennant 1776-7 GEJ Barrett Hamulton and M A Clinton 1910-21 11 Glen Luton 1924 38 ·PLAGUE Western States of the United States there were for example sex human cases in New Mexico in 1949 but there has never been a larger scale epidemic. Although for the reasons already given we cannot ascribe the disappearance of plague from western Europe to a rising standard of avilization it does seem reasonable to attribute Its recent failure to spread to the changes in standards of uving since the seventrenth century ·EPIDEMIC DISEASES of infection in the winter of 1910-11 there occurred four cases of an extremely virulent type of pneumonia in the hide village of Freston (see Figure 5) Three of these cases were in one family, and the fourth was that of a neighbour who had nursed the mother during her illness All four patients died The family doctor was puzzled by the virulence of the disease and called in a consultant physician and a pathologut from Ipswich Specimens of sputum and blood were ex amined and Pasteurella pestus was found this incident was the starting point of an exhaustive inquiry by Dr Bulstrode and other medical officers of the Local Government Board In the light of the events at Freston certain happenings of the years immediately preceding took on a new signific ance It was found that in the winter 1906-7 eight cases of plague Itke illness with six deaths had occurred at Shotley (see Figure 5) and in 1909-10 eight cases with five deaths at Irumley It was naturally difficult to find out a grcat deal about these so long after the event, but there is a strong presumpoon that they were cases of plague The head keepers of two estates near Freston reported that from 1906 onwards rats had been dying in large numbers and similar observa tions relating to dead rats and rabbits were made on both sides of the River Ortxell After the cases at Freston a widespread scarch was made for infected rodents and the results of the search are indic ated on the map The search was kept up for several years and infected rodents were occasionally found even as late as 1918 There were three more cases of human plaguc in the district one in a scaman at Shotley naval barracks in 1911 and twoat Erwarton (see Figure 5) Ncarlyall the human cases occurred in poor homes with an abundance of ficas There seems to be little doubt thercfore that rodent plague was well established in this part of Suffolk from 1906 to 1918 and yet only thenty three human cases were reported in the whole perio There can be little doubt that the spread of plague is very unlikely in a community with standards of living similar to those in an English rural district There is other cyidence for this belief for plagucu now establushed in the wild rodent populations of no fewer than fifteen of the 40 ·INFLUENZA TIE SWEATINO SICKNPS3 or preferably pandemics of a disease with symptoms mainly connected with the respiratory tract with an acute otiset, a very high attack rate and on the whole a low case mor tality Some of these characteristics are very variable For cxample in some cpidemics the respiratory symptoms may be very obvious whilst in others they may be almost absent In some notably that of 1918-19 the total mortality has been enormous though even in that pandemic it must be remembered that the number of cases far exceeded the num ber of deaths In some communities in 1918-19 almost every member was attacked so that the pandemic did satisfy the critenon of a relatively low case fatality From the historical point of view the discovery of the Virus of influenza by Wilson Smith Andrewes and Landlow in 1933 us recent and does not help in the identification of the epidemics of the past For the identification of these we have to rely on a blend of clinical and epidemiological des cription and must often be in doubt as to whether the discase was or was not influenza Some descriptions are however, extremely lifelike and it may be permissible to quote a par ticularly good one out of its strict chronological order Thus was written by Willis* and relates to an epidemic in 1658 About the end of April suddenly a Dustemper arose as if sent by some blast of the stars which laid hold on very many together that in sorsac towns in the space of a week above a thousand people fell sıck together The particular symptom of this discase and which first invaded the sick was a troublesome cough with great spit ting also a catarth fallın down on the palat throat and nostrils also it was accompanied with a feaverish destemper joyned with heat and thirst want of appetite a spontaneous weanness and a gnevous pain in the back and limbs which feaver however was more remiss 1A some that they could go abroad and follow their affairs in the time of their sickness but complaining in the meantime of want of strength and of langushing a loathing of food a cough and a catarth But in some a very hot destemper plainly appeared that being thrown into bed they were troubled wib burning thirst waking hoarseness and coughing almost continual sometimes there came upon thus a bleed ng at the nose and in some a bloody spittle and frequently a bloody flux such as were indued with an infin *Tillis 1657 43 ·3 INFLUENZA - THE SWEATING SICKNESS 1 INFLUENZA is caused by a virus first described by Wilson Smith Andresses and Laidlow* in 1933 The demonstration of the existence of the influenza virus by the British workers mentioned abovc opened a new chapter in the study of the disease and since then an immense amount of work has been done Thus work on viruses is highly technical and complex and any brief description must neces sarıly be an over suplification Brsefly there are two im portant influenza viruses A and B Virus A is the one usually found in major epidemics whereas B tends to occur in more localized outbreaks-in camps schools and the like The virus discovered in 1933 was A but since then many other strains of A which differ from the original and from cach other have been isolated There is a general belief among those who work with influenza viruses that 1 succession of changes is occurring in them Strains of A isolated in different parts of the world at about the same time tend to resemble one another more than those isolated a few years carlier Even in non epidemic years some deaths arc attributed to influenza but in such ycars a virus can rarely be isolated In order to explain this Andrewes has suggested that there may be a basic influenza virus which is not detectable by the labora tory tests at present available but wuch can cause illness and occasionally death In an cpidemic year this virus be comes changed in some way, acquires the power of spread and can be detected by laboratory tests It is relata cly casy to write about plaguc because the clinical features of the disease are sufficiently characteristic to enable one to identify cpidemus far back into antiquity With influenza the position is sery different all that onc can do is to search the records for examples of epidemics • Smith CH Andrews and PP Laudlow 1933 42 ·INFLUENZA THE SWEATING SICKNESS 1528 and 1551, and then all references to the discasc ceased so far as Lngland was concerned Creighton quotes many contemporary references to the Sweating Sichness and it seems to bercasonablywell established that the disease usually occurred in the summer and autumn, attacking the rich rather than the poor often having a high mortality ratr among young adults and killing very quickly There seems to be no mention of respiratory symptoms in the contemporary accounts It is hard to recognize similarucs between these contemporary descriptions and influenza as we know it and the only disease of modern times which seems to have a like ness to the English Sucat is the disease described in France and known as the Iicardy Sweat There is an interesting short article on Sweating Sickness by Michael Fostert in the Memorial volume dederated to Osler on the occasion of his gmenticth birthday Foster was inspired to investigate the subject because he had seen a case of Picardy Sweat while scrving in France in the First World War He points out that there is a marhed similarity between the symptoms descnbrd by Calus - profuse sweating palpitation epigastric paw and fear of immunent death - and those described by the French writers on the Picardy Sweat The chief difference between the chnical descriptions is that the French writers describe a mzitary rash which is not mentioned in the Tudor records Th re seems to be little doubt that the Picardy Sweat 1s not the same discase as influenza but whether it is the samnc disease as the r'nglish Sweat is more doubtful On the whole the clinical evidence is against the identification of either the Lnglish Sweat or the Ficardy Sweat with in Auenza "The relatively short space of time (1485-1551) dur ing which epidemics of the Lngluh Sweat were occurring is roughly the same as that in which epidemics of rapira tory discases began to be reported following the pandemic of what was probably influenza in 2510 which has already been mentioned there were epidemues of acute respiratory descases which spread over Europe in 1580-2 In the first half of the seventeenth century there were few such outbreaks but in 1638 occurred the epidemic descnbed + Cre ghts 1834 ta Foster 1919 45 ·EPIDEMIC DISEASES body or men of a more declining age that were taken with thu disease not a few died of it but the more strong and almost all of an healthful constitution recovered those who falling sick of this discase and died for the most part dıcd by reason of the strength being leisurely wasted and a serous heap more and more gathered together in the breast with the feaver being increased, and a difficulty of breath like those sick of an hectic carer Con cerning this discase we are to enquire what procatartıc cause it had that it should arise in the middle of the Spring suddenly and that the third part of makind almost should be distempered with the same in the space of a month then the signs and symptoms being carefully collated the formal reason of thus disease also rls Crisis and way of cure ought to be assigned Anyone reading that description today must feel convinced that Willis saw an epidemic of influenza According to Thompson* the first identifiable epidemic of influenza in England was in 1510 The clinical descrip tion is similar to that of Willis alrcady quoted, but is shorter Something is said of its origin in Malta and of its spread The epidemic spread rapidly and insolved the whole of Europe According to Creightont there is no contemporary evidence of this epidemic in English writings, but certain foreign writers stated that England was affected One of the most intriguing epidemiological problems of these early years is that of the identity of the disease known as the Sweating Sichness or English Sweat Was it influenza or was it not? The main facts about it as given by Creightont are as follows It appeared suddenly in 148, either just be fore or soon after the battle of Bosworth (22 August 1485) It was raging in London at the end of September and in October ind tivo mayors and four aldermen died of it There u no very detailed account of the clinical course of the discase in this epidemic but it scems to has been rapidly fatal - sometimes within six hours ofonset The sweating from which the disease took its nime was a prominent symptom The best known description of the disease is that of John Cajus and relates to the last epidemic - that of 1551 Between 1485 and 1551, there were five cpidernics, in 1485 1508 1517 • T Thompson 18 C. Creaghton 1078 John Caius 1552 ·INFLUENZA - THE SWEATING SICKNESS Office and although the collection of information about deaths by cause was then very imperfect it is perhaps worth mentioning that in the year 181 16.9 dcaths from in fluenza were registered and 220 of thesc occurred in London The next explosion was in 1847-8 and in those two years some 15 000 deaths were ascribed to this cause From then to 18&the deaths registered every year exceeded 1 000 but from 1861 to 1889 they were insignificant, and Greenwood" in his sustimary of the history of influenza in the Ministry of Health report on the epidemic of 1918 says In 18an thus country had been free from pandemic influenza for more years than in any previous cpoch since the middle of the seventeenth century The pandemic of 1889-97 was the beginning of a new chapter in the history of the disease not only in England and Wales but also in Europe and North America and probably throughout the world Since 1889 influenza has been an appreciable cause of death in many years both before and after the greatest pandemic of all time - that of 1918-19 There are conflicting statements as to the origin of the pandernıc of 1889-92 but it seems to be established that Russia was affected in the early winter of 1889 Clemowt writing in the Lancet of 1894 produces reasonably convincing evidence of spread from western Siberia at the end of September to European Russia but the spread was extremely rapid and the disease appeared in St Petersburg (now Lenin grad) in October By the end of December, most of con tinental Europe nas affected and by the middle of Decem bor infuenza was reported in New York and Boston. A few cases began to be reported in London carly in December but the epidemic reached its height there about 11 January and was declining rapidly by 8 February A problem wiuch is always discussed during a pandemic or influenza 13 whether the epidemic begins in one country and spreads to others or whether it begins in several centres at about the same time In 1889-90 the disease was known in western Europe as Russian influenza , but whether the pandemic really had its ongin there must be regarded as LI Grecawood D Ciemnow 1896 47 ·EPIDEMIC DISEASES by Willis in the passage quoted carlier in this chapter From 166. to +686 Sydenham* was writing tus account of the seasons and reigning diseases of London and he makes many references to outbreaks of respiratory disease which may or may not have been epidemies of influenza As has been said in the previous chapter Sydenham s field of vision was some what limited as he sas a fashionable physician practising in London and so did not knoty much of what was happeruang elsewhere in the country or even perhaps in the poorer parts or London stself One observation of Sydenhams has been of particular interest to epidemiologuis of a later age this refers to the epidemic of 1685 in which Sydenham says that symptoms of disease of the neri ous system were particularly prevalent It is not easy to decide what disease Sydenham was describing but it may have been meningococcal tacnun gates or possibly encephalitis lethargica The chief difficulty in interpreting the writings of the great chocians of the Restoration is in deciding how wide spread were the cpidemics which they described and its in fact extremciy difficult to make any estimate of the scale of cpidemics until much later when national statistics began in 1837 Some attempt seems to have been made to estimate the extent of an epidemic of ufluenza in 1982 when the Royal College of Physicians by public advertisement asked for information from the physicians of Great Britain about the extent of the epidemic of influcnza then occurring They collected information from all over the country and ucre able en establish that the discasc started at Newcastle at the end of April 1782 and appeared m London beseca 12 and 18 May and in the Eastern Counties about the middle of May This seems to have been the first attempt to collect information on a nauonal scale Throughout the cighteenth and early nineteenth centuries there were many outbreaks of influenza but it is not possible to determine whether these were panderruc on the scale of those which occurred later There is little doubt that in 1837-41 there was a widespread prevalence ofinfluenza za Europe and England was certainly affected These were the carly years of the General Register •T Sydenh23 16+ 46 ·4 LEPROSY - THE GREAT POX (SYPHILIS) - SMALLPOX To the modern reader leprosy syphilis and smallpox may seem to have little in common but in medieval times there was much confusion between diseases in which unpleasant lesions of the skin were found and the term leprosy in par ticular was probably used to describe a multitude of skin conditions Leprosy is caused by a bacıllus which under the microscope looks like the tubercle bacillus The bacillus was discovered by Hansen* in 1871 Contrary to popular belief leprosy is not readily communicated from one person to another and those who contract the disease are people who have lived with lepers for many years The only reason for mentioning it in this book is the possible confusion with syphilis in medieval times Syphilis is caused by a spiral organism discovered by Schaudınn in 1905 and is com municated by intimate contact nearly always by sexual intercourse Smallpox is caused by a virus which is large as viruses go having a diameter of about 300 mg Smallpox us one of the most infectious diseases known and it has even been suspected that the virus could be carried by the wind from a smallpox hospital to infect persons at a considerable distance from the building LEPROSY AND SYPHILIS It may be well to consider leprosy first as there is little to per said about nd from the chronological point of view e lascaso tant only at the beginning of the period Pareightont considers that truc leprosy land in medieval times Hc quotes Inglicus of which the date is un characterstic signs and symp bows falling bare and getting C. Craghton 1891 ·EPIDEMIC DISEASES be but the temptation to speculate a little is irrestsuble Is at likely that a pandemic on the scale of that of 1918-19 may occur again and if so will the new drugs which have been discovered since then be so effeciate that the death rate will be negugible, at any rate among those in youth and early middle age? It seems probable that there will be pandemic in the future as there have been in the past and, although we shall be able to learn much more about them now that we can study the causative virus ze is unlikely that we shall be able to do a great deal to present their spread it may be possible to prepare effective vaccines but it will not be casy to prepare thero quckly enough and on a sufficiently large scale to protect whole populations It 19 more difficult to make even a griess at the probable effecuveness of the new drugs such as penicillin Probably none of those known at present is effective against the ! fluenza virus itself but we do not know whether it was the influenza virus which killed so many people in the prime of life in 1918-19 or whether the worst damage was done by secondary bacterial invaders The omens arc favourable of secondary infection did the damage and less favourabic of the virus itself did There 4 one small piece of statistical evidence recently put forward by Logan* which guesground for a little optimism He showed that in the most recent out break of 1955 the proportion of the total number of death among persons over fifty five was no less than 88 per cent - higher than in 1933 (59 per cent) and far higher than in 1918 (14 per cent) All this a lowever pure speculation and all that the epidemiologist can do is to keep a weather cye open for the danger signals which heralded the pan demic of 5918 - an outbreak in the summer with a sudden ago shult of mortality from old people to younger ones • WPD Logan se 14 H Bradley 1937 ·LEPROSY THE GREAT POX - SMALLPOX Cordoba At about the time of the occupation of Naples from February to May 1495 the disease became widely dus seminated in thcarmy and in Italy generally and from there It spread all over l'urope reaching Scotland by 1497 and London at least as early as 1503 The other school believes just as passionately that syphilis had occurred in Europe from time immemorial but that up to the end of the fifteenth and beginning of the sixteenth Centures it had bren a less acute and fatal illness and had been confused with leprosy and many other skin discases For some unknown reason there was at this time a pandemic of an extremely arute and fatal form of the discase which probably began in France and Spain and spread rapidly over the whole of Europe The change of type lasted somtwenty or thurty years and then the diserse reverted to the more chronic form of today The first original English writer on the Morbus Galhcus or Morbus Neapolitanus as he called it was William Clowes who published his treatise in 1579 He was surgeon to St Bartholomew & Hospital and had treated many cases with inunctions of mercury His descriptions suggest that the descasc had by then lost the terrible severity of the original cpidemic type The origin of the European pandemic remains a mystery and quite apart from the controversy over historical details the alternauve explanations both present serious difficulties to the epidemiologist On the one hand it is difficult to believe that the discase could have travelled so far and so fast from a single place and on the other it is difficult to explain the sudden change of type if one accepts the view that syphilis had been endemic in Europe for centuries SMALLPOS As cpidemic diseases leprosy and syphilis disappeared from the scene long ago but smallpox had a long innings and we have not seen the last of it even now The early history of smallpox in England is obscure In the medicval penod Coghton 1 (1891) P 419 52 ·EPIDEUG DISEASES knotted with uncsen tubcrosities the nose and other features becoming thick coarse and lump; the face losing its mobility or play of expression the raucous voice the loss of sensibility in the hands and the ultimate break up or maufragrum of the leprout growths into foul running sores It seems likely that true leprosy was declining at the end of the fourteenth century and had disappeared by the fifteenth The great interest of Cresghton s chapter on the subject lies rather in the references to skin conditions buch were almost certainly not leprosy at all and which may have been syphilus Creigh ton quotes a whole series of references from the beginning of the fourteenth century onwards to the vencrcal origin of leprosy and mentions an edict of Eduard III to the mayor and sherifls of London in 1346 instructing them to donc out lepers from the Crty One of the main reasons guon is that lepers communicate their discase by carnal intercourse with women in sicws and other secret place Some of the clinical descriptions gn en sound remarkably like the lesions of secondary syphus Whatever the lesions of the skin which were called leprosy really were there is no doubt that in the last years of the fifteenth century there was an extraordinary pandemic of syphilis in Europe Ifat were nol for this syphilis could have had no place in this book for since then st has been an endemic and not an epidemue disease Many thousands or words have been written by medical historians about the ongin of the pandestic of syphilus The controsers began carly in the sixteenth century and u still unsettled One school believes passionately that syphilis was brought back from America by sarlors who accompanied Columbus on hus second voyage and their story runs roughly as follows Columbus left Seville on 4 August 1492 landed on Haiti and returned to Palos 500 miles from Bucclona on 15 March 1493 Many of the forty four who seturned with Columbus were infected with syphlis and Iery soon after their return an cp depuc of an extremely cute and fatal form of the discase broke out in Barcelona In 1491 Charles Vill of France was prepanng for an invasion of Italy and in hos army was a body of Spans! mercennes under Conzalo de 52 ·- LEPROSY THE GREAT POX SMALL POX Cordoba At about the time of the occupation of Naples from February to May 1495 the disease became widely dis seminated in the army and in Italy generally and from there It spread all over Europe reaching Scotland by 1497 and London at least as early as 1503 The other school believes just as passionately that syphilus had occurred in Europe from time immemorial but that up to the end of the fifteenth and beginning of the sixteenth centuries it had been a less acute and fatal illness and had been confused with leprosy and many other skin diseases For some unknown reason there was at this time a pandemic of an extremely acute and fatal form of the disease which probably began in France and Spain and spread rapidly over the whole of Europe The change of type lasted some twenty or thirty years and then the disease reverted to the more chronic form of today The first original English writer on the Morbus Gallicus or Morbus Neapolitanus as he called it was William Clowes who published his treatise in 1579 He was surgeon to St Bartholomew Hospital and had treated many cases with inunctions of mercury His descriptions suggest that the discasc had by then lost the terrible severity of the original cpidemic type The origin of the European pandemic remains a mystery and quite apart from the controversy over historical details the alternative explanations both present serious difficulties to the epidemiologist On the one hand it 13 difficult to believe that the disease could have travelled so far and so fast from a single place and on the other it is difficult to explain the sudden change of type of one accepts the view that syphilis had been endemic in Europe for centuries SMALLPOS As epidemic diseases leprosy and syphilis disappeared from the scene long ago but smallpox had a long innings and we have not seen the last of it even now The carly history of smallpox in England is obscure In thc medieval period • C Creighton I (1891) P 419.

·EPIDEMIC DISEASES there are scattered references to pockes but it is not cer tain whether these refer to splulus smallpor or passebly cven to other skin diseases For some my sterous reason the champions of vaccination of a later age seem to have felt that it was necessary to their argument to show that smal pox was a common and deadly disease in the Middle Ages whereas the opponents of vaccination tended to attnbute these references to other diseases and to consider that small por was a new discase in the England of the Tudors What cver one may think of Creighton s vicivs on the value of vaccination one cannot help respecting him as a historian and hus general account of the history of smallpos tarne more conviction than does that of his opponents It u dili cult to improve on Creighton s own summary The history of smallpox in Brilasa u that of a ducase romung gradually into prominence and hardly attaining a leading place unul the reign of James I In this respect st is unlike plague and sweating sackness both of which burst upon the country in their full strength just as both made thear last skow w cpidemso whach were as severe as any in their hustory In a later passage he says It would be a not incorrect summary of the incidence of smallpox I Brain to say that it first let the ncher classes then it in ihr villages then it left the provincial towns to contro iuclf in the cap.cal at the same tune it was leaving the age of infancy and childhood Of course I did none of these things absolutely but the movesicat in any one of those directions has been as obvious at in any other Measles and scarlauna have not shown the same tendency to change or dimut their nedence Smalipox say have surprises in store for us but as an exosc infection is peculiar behaviour may not unreasonably be taken to mean that it w dying out- dying as in the death of some indinduals gradually from the Extrcntcs to the beart. That was written in 1894 and Creighton nas com inced that vacanation was ineffective in preventing smallpox Iles argument that the chief determining factor in the history of Amallpox has been the natural history of the discase seir unaffected by vaccination is onc for which there a much ·LEPROSY - TRE GREAT POT SMALLPOX to be sand but in the following pages we shall have to con sider the ather side of the argument and also to describe some of the surprises which smallpox had in store 1894 The number of deathy recorded cach year in the London Bils from 1729 to the beginning of death registration (1837) 33 shown in Figure ya "These can of course bic regarded. 30 1000 1621 50 80 70 1 TOO TO 29 30 358 X 800 1800 10 * * 7(a) Deatre som smallpox » London 169 1837 Compiled form the Bills fortalty only as a very rough guide to the actual number of deaths and it must also be remembered that over the long period London was growing enormously and that the movement of population from the City into the surrounding Lilycrocs and Out parishes was begmning from time to ime the arca covered by the Bells was extended but St Pancras St Mary lebone Chelsea and Kensington were never included in them The Balls are a particularly maccurate guide at the end of the period and there is a sery marked discrepancy between the figure given in them for the year 1837 - 217 - and the number of deaths actually registered in the period July-31 December 1837 - 762 In spite of the inaccuracies of the Bulls Creighton considers that they may be taken as showing on the whole fairly the proportion of deaths from smallpox to those from other causes and the cars of its greatest outburst Tigure 3b shows the annual deach rates in England and Wales from smallpor from the first full year of registration (1838) to 1905 The epidemic of 1900-5 42s the last considerable outbreak of major smallpox in Britain and after at the annual death rates reached a very low figure The end of major smallpox as a native disease was less 5.5 ·EPIDEMIC DISEASES sudden than that of plaguc but it is probably true to say that since the time of the First World War major smallpox has been exoue It impossible to prove this thesis because it has not always been possible to trace the source of the many small outbreaks but it seems plausible The trend of smallpox from igr 1 to 1955 as shown in the table below of notifications and deaths recorded in each year Year Cases Deaths Sear Cases Deaths III Year Cases Deaths ** 23 9 16 1995 19 9 19!! 1912 *913 *914 1955 1936 1987 3958 919 1920 3923 5922 295 123 Its 64 go 149 7 63 294 363 3'5 973 + 35 26 9 12 3 18 1 2 Minor Smallpox 1923 2465 19 3765 5365 1926 10146 1927 14767 1928 19470 1929 1097 1930 17839 2337 5664 1932 2009 1933 fgs 1934 179 1935 1936 $937 1938 3939 1940 1941 194% 7 53 39 28 9 3 2 6 1944 16 3 90 5 27 1945 5 1946 56 1947 78 1948 1949 19 1950 1952 $7 193% 935 1993 1934 *93 20 1 8 If one compares thc three columns of tius table it is im mediately obvious that smallpor had indeed onc grcat #us prie in store when Cresghton wrait of it as a dying disease in 1894 In the summer of 1919 there was a small outbreak of smallpox in Norfolk and Suffolk in which the disease had quite different cluical characteristica from those usually associated with amallpox It was far mulder than that expert enced in former yeant and was very rarely fatal. In 1920 there was another outbreak of the minor smallpox in Lancashure with 83 known cases and sot a single death Throughout 56

·LEPROSY - THE GREAT POT
SMALLPOT
1000
750
250
Rates too as to be show often O
Nallgur wvalabit
1905
180
fan2 Compulsory
Kutation but not
torted
1148
Compulsory
und
forced
fee
7) Deaths frem malipax e England and it ales the dead from the
ens eft grisor k 1905

·EPIDEMIC DISEASES the late twenties and early thirties this form of smallpos spread widely ia the midlands and north at first but in southern England and in Wales later Throughout the years of prevalence of minor smallpox there was occasional impor tation of major smallpos which was just as virulent as it had ever been In 1931 minor smallpox begin to die out and in the year 1935 only one non fatal case of smallpox was reported for the whole country There was 1 small re crudescence in 1938 in which year 9 cases were of minor and 9 cases of major sinallpox with three deaths In the war y cars importations of smallpox became less frequent and in 1941 and 1943 no cases were reported but in 1946 there ssere no fewer than 15 known importations which gave rise to 56 cases with 14 deaths Towards the end of 1951 minor small pox appeared again after an interval of 13 years It went unrecognized unul carly in 1952 when 1:4 cases without deaths were reported in and around Rochdale Lancashire. It is not certain how outbreaks of minor smallpox begin but there is strong presumptive evidence that the virus us um ported in consignments of raw cotton The present position of smallpox in England may be sum marized as follows Occasional small outbreaks of major smallpor occur which can usually be traced to a vaccinated traveller retuming from the East who des clops a modified attack which goes unrecognized unti severe secondary cases appcar Minorsmallpor appears at long intervals and usually in one of the cotton towns of Lancashire It tends to spread more widely than major probably because mild cases are unrecognized particularly in the carly stages of an out break Vaccina (the lesions produced by vaccination) munor smallpox and major smallpox are due to infection sith a virus or viruses which can be grown in fertile eggiand photo graphed under the clectron microscope Whether all three discases are due to variants of one virus or to different viruses a most difficult question to answer and one may perhaps aroid it by saying 'It all depends what you mean by different and by suminanzing the likericsscs and differ ences In the laboratory material obtained from all three 59 ·LEPROSY - THE GREAT POT SWALLPOX discaso behar es in much the same way though there are slight differences between the appearances produced in the ferul egg by material from vaccinia and those produced by material from major or minor smallpor An attack of one discase produces strong inamumty against the other two As kuman diseases the three are very different Vaccia as ordinarily produced by inoculation of glycerinated lymph u nearly always a trivial affair of a small itching spot at the ate of inoculatson Very rarely howeser the sash is general ized and the illness severe Minor smallpor varies a good deal in severity but is generally speaking shghtly more un pleasant than chicken por whereas major smallpor u onc of the most deadly infectious discases knows with a mor kality of the order of twenty five per cent or more in the unvaccinated One of the raost difficult tasks which confronts the histor tan of smallpox is to forta a just estimate of the part played by snaculation and vaccination in contributing to the decline of the discase Thc laserature on the subject us enormous and much has been written both by those who regard it as heresy to question for one moment the part played by vaccination and on the other kand by those who regard vaccination 29 an invention of the devil It w important to distinguish be tween vaccination as a means of protecting an individual agamsi small pot and vaccination as a public health measure designed to protect a community against epidemics of the descase There can be no doubt at all that vaccinauon re peated at intervals of five years or 50 will almost certainly protect an individual from smallpox The problem us how ever to decsde how far the lumited amount of inoculanon and vaccination which has been practised in England at different times kas determined the trends of morbidity and mortality of the disease Inoculation with materiaiderived from the pocks ofpatients suffering from muld attacks of smallpox had been practused from very carly times It was introduced into England about 1720 largely owing to the efforts of Lady Mary Wortley Montagu 1hroughout the eighteenth century snoculatson was practised usth varying frequency and varying success 5Q ·EPIDEMIC DISEASES Sometimes the patient had a mild attack and sometimes be had a severe or even fatal ont The procedure was however too chaney to become very popular and with the introduc uon of vaccination in the early part of the nineteenth cen tury it gradually fell into disuse Inoculauon is made a criminal offence in 1840 In 1798 Edward Jenner published his famous Inquiry into the Causes and Effects of the Vanolar Vaccinae Hus argument rested on two propositions (1) that those who had suffered from naturally acquired cowpordid notget smallpor (a) that cowpor could be carried from armn to arm and would prom tect all those who had been cowpored agaisut smallpox. In support of his first proposton kc cred some tienty instance of persons who had had cowpox and had subsequendy been given an inoculation of matter from a patient with smallpox without any ill effect The intervals between the attacks of cowpor and the test inoculations of smallpor varied from fifty three years to nine months in every case the rest in oculation failed to produce smallpor. In support ofhis second proposition Jenner cated his experiment of inoculaung * child with matter from a darymard who had contracied natural cowpox and other children with matter from a cow suffering from the disease He did not apply the rest of small pox inoculation to all thesc thuldren but to only threc of them According to modern standards these experiments of Jenners were rather than but they did arouse a great deal of attenuon sa London and in particular they stimulated Dr Woodville* of the Smallpox and Inoculation flospital to undertake a clinical trual of the method Dr Woodville > ex periments are of particular interest as it seems possible that some of the vaccine lymph which is in use today may have had its ulumate ancestry in them Unfortunately if is diffi cult to interpret the experients Hoodville got his cowpox lymph from a cow sn a dairy in Gray's Inn Lane where 900 cows were kept of which sornic four fifths were attacked Hic loculated seven persons with this material and subsequently inoculated these seven with smallpox maller at varying in tervals Three of them were inoculated after an interval of .Ltloodvibe 5792 ·LEPROSY - THE GREAT POY SMALLPOY only five days The subsequent history of Woodville serpen ments 19 most confusing because from the original seen he inoculated a whole series of other persons with matter from the local cowpor lesions and atvarying inter als afterwards gave inoculations of material from cases of smallpor In all he inoculated 200 persons in his first series and another 300 later Some of them had generalized eruptions and a few were very ill Anyone reading Woodville sown account now must be loſt with a strong suspicion that some of Woodville: patients had attacks of modified smallpox He expressed hus conclusions as follows Here I enabled to state a number of cases of variolous inoculation equal to those given above and reduced to a sislar tabular form the comparative magnitude of the two diseases iasght be estatuared wich colerable precision. It is evident haweser that the matter of the vaccine ducase has generally produced much fewer pustules and le« indisposinon than that of the smallpox for 11 appears from the preceding statement that about tso-fifths of all the per sons Doculated for the Vanolae Vaccusac had no pustules and that Io not more than a fourth part of them was there experienced any perceptible disorder of the constitution But it must be acknow Ledgeel that in several instances the cowpox has proved a very amere discase In three or four cases out of five hundred ibe patient has been in considerable danger and one child as I have already observed actually died under the effects of the discase Now : be admitted that at an average one of he hundred will die of the inoculated cowpor I confess I should not be disposed to introduce thu ducase into the Inoculation Hospital because out of the last five thousand cases of variojous un xulation the number of deaths has not ckcorded the proportion of one in sex hundred But I am unclined to think that if the matter of the cowpox used for the purpose of noculation were only taken from those in whom the disease appeared is a very suild form the result would be rore favou able than in the statement here given It is impossible to trace all the ramifications of the early hastory of vaccine lysuph and it is difficult to interpret even so good an account of experiments as that of Woodville One can only make a guess at what happened in London after 1799 The most plausible guess seems to me to be that the bringing together of cowbox and smallpox visu did in some ·EPIDEMIC DISEASES Sometimes the patient had a muld attack and sometimes hc had a severe or even fatal ont The procedure was however, coo chancy to become very popular, and with the introduc tion of vaccination in the early part of the nineteenth cen tury at gradually fell into disuse Inoculation was made a criminal offence in 1840 In 1798 Edward Jeaner published his famous inquiry into the Causes and Effects of the lartolae Vaccinat Hus argument rested on tuo propositions (1) that shose who had suffered from naturally acquired cowpor did not get smallpor (2) that cowpox could be carried from arm to arm and would prom tect all those who had been cowpoxed against smallpox In support of his first proposition he cuted some twenty instances of persons who had had cowpox and had subsequently been given an inoculation of matter from a patient with smallpox without any ill effect The intervals between the attacks of cowpox and the test inoculations of smallpox varied from fifty three years to oune months In cvery case the test in oculation failed to produce smallpox Insupportofhis second proposition Jenner crted his experiment of inoculaung a child with matter from a dairymard who had contracted natural cowpor and other children with matter from a cow suffering from the descase He did not apply the test of small pox snoculation to all these children but to only three of them According to modern standards these experiments of Jenners were rather thun but they did arouse a great deal of attention in London and in particular they sumulated Dr Woodville* of the Smallpor and Inoculation Hospital to undertake a clinical trial of the method Dr Voodville s ex periments are of particular interest as if secms possible that some of the vaccinc lymph wuch as K izse today may have had its ultimate ancestry in thern Unfortunately t u diffi cult to interpret the experiments Woodville got his cowpox lymph from a cow in a dairy in Grays Inn Lane where 200 Cows ytre kept of wbuch some four fifths were attacked He inoculated seven persons with the material and subsequently inoculated these seven with smallpor matter at varying in tervals Three of them were inoculated after an interval of * Moodnite 1999 60 ·LEPROSY THE GREAT POY - SMALLPOT only five days the subsequent history of loodville a expen ments is most confusing because from the original seen he inoculated a whole series of other persons with matter from the local cowpor lesions and at iarying intervals afterwards gate inoculators of material from cases of smallpox In all he inoculated 200 persons in his first series and another 300 Later Some of them had generalized crupuons and a few were very ill Anyont reading bloodville s own account now must be left with a strong suspicion that some of Bloodvilles patients had attacks of modified smallpor Hc erpressed faus conclusions as follows Were I enabled to state a nurober of cases of sanoious inoculation equal to those given above and reduced to a similar tabular form the comparatie magnitude of the two descases might be estimated wsch tolerablc precision. It is evident, however that the matter of the vaccine discase tuas generally produced much fewer pustules and less indesposition than that of the smallpox for is appears from the preceding statement that about two-fifths of all the per Hona inoculated for the Varvolar Vaccinac had na putules and that in not more than a fourth part of them was there reperienced any perceptible disorder of the constitution But I must be acknow ledged that in several instances the cowpox has proved a very Kere disease Ia threcor four cases out of five hundred the patient has been in corderable danger and one chuld as I have already obrned actually died under the effects of the disease Now aſ a be admitted that at an average one of five hundred will dse of the boculated cowpex I confess I should not be disposed to introduce this discure into the Inoculation Hospital because out of the last fire thousand cases of varolous inoculation the ruraber of deaths has not exceeded the proportion of one in six hundred But I am inclined to think that the matter of the coupox wwed for the purpose of inokulation were only taken from those in whom the dutast apptared in a very mid form the result would be more favourable than in the stateraent here given It w impossible to trace all the ramifications of the early hustory of vaccine fyraph and st is difficult to interpret een so good an account of experiments as that of Woodville One can only make a guess at what happcaed in London after 1799 The most plausible guess seems to me to be that the bringing together of cowpox and smallpox vtru did in some ·EPIDEMIC DISEASES way produce a modificd smallpox virus which by an eros pirical process of selection (see Woodville s last sentence) og the part of the vaccinators gradually became safer and safer The virus was kept going by arm to arm vaccination right up to 1881 when glycerinated calf lymph began to be susbon stituted for it Arm to arm vaccination was not finally prou hubited till 1898 Modern work on viruses lends some support to the theory in that in the laboratory the vaccsma virus resembles the smallpox Virus rather more than the cowpps virus though the cowpox virus has a simlar antigenic structure Whatever may be the true origin of the vaccina virus at is reasonably certain that in the early years of the nincteenth century vaccination became recognized more and more as an effective method of preventing smallpox and even more as an effective method of prevenang death from smallpox The trend of deaths in London during the carly years of the ruineteenth century (sce Figure 7a) suggests that some potent factor was at work which tended to disunish the number of deaths It is true that there were substantial outbreaks of smallpox later in the century particularly in 1873-2, and Grocawood* considered that the decline in the number of dcaths in London was not a valid argument in favour of vaccinationasa publichealth measure Creighton alsopointed out that the returns of the parish clerks in the early sunan teenth century were partscularly inaccurate He forbore to point out however that the total number of deaths returned cach year did not fall as did those from smallpox The argu ment that vaccination had a good deal to do with the decline of deaths as of course an argument post hoc ergo propler hoc but the alternause explanation that smallpox suddenly changed in type at just about the time vaccination was in troduced scems more difficult to substanisate The year 1838 was the first full year of segistration of deaths in England and Wales and with all their failings the statistics avadable from that car onwards are incom parably more reliable and comprehensave than the cariser ones The early years of registration correspond with the last LH Greeswood 1935 62 ·LEPROSY THE GREAT POX SMALLPOX great epidemic 1837-40 whuch showed smallpor in its old colours (Creighton) It is not possible to compare the num bers of deaths reported in this cpidemic with those recorded in the Bulls because the area included in London as a registration area was much larger than the area included in the Bells There had also been great changes in population since the eighteenth century It is however of some interest to note that the number of deaths from smallpox registered in London in 1838 (3 817) was only a little larger than the number (3 548) recorded in the Bills in 1796 This suggests a considerable reduction in mortality From 18.30 to 1870 there was a fair amount of smallpox in England and Wales but il was a mere shadow of its cighteenth century self and began to change from a disease which killed children almost exclusively to one which caused deaths among older people also in the eighteenth century some 80 per cent of the deaths were those of children under five and nearly the whole of the remaining 20 per cent of children between five and ten but in the registration period the age distribution changed at first gradually and then much more rapidly in the epidemic of 1871-2 In the period 1851-60 the deaths of children under five were 62 per cent of the total in 1861-70 54 per cent and in 1871-80 only 30 per cent Another new characteristic of smallpox in the nineteenth century was its tendency to remain an important disease in London when it was dying out in the provinces Smallpox deathIs per millsong (Creighton (1894) Vol II P 617) 1847-9 1850-4 1855-9 1860-4 1865-9 1870-4 1875-9 1880-4 London 460 300 237 281 276 65+ 292 244 271 192 175 17* 48 34 It is not possible to give exact estimates of the amount of vaccination carried out at any of these penods but informa tion became more accurate throughout the second half of the century as the machinery of public health administra tion improved Greenwood* considered that the amount of vaccination practised in London in the first twenty five years LH Greenwood IP 239 Provinces 274 339 ·5 ASIATIC CHOLERA CHOLERA IS an acute infectious discase due to a microorganiso the cholera vibrio (discovered by Koch in 1883) which grows sn the aimentary canal The disease is char acterized by violent purging muscular cramps and rapid collapse Infecton is usually waterkomne The Indian or Asiatic cholera wbuch first showed siself on British sol in one or more houses on the Quay at Sunderland in the month of October 1831 was a new discase la a more real sense thao anything in this country since the sweating sickness of 1485 * Cholera is only a name to us in Britain pow, and unless some major disaster which dislocaies samstary services over takes us at scems likely to remain so Its hustory is lowever full of interest for scucral rather unconnected reasons The menace of cholera was one of the most potent factors 102 securing the sanitary reforrns which have made our towns places so different from what they were at the beginning of the runeteenth century Cholera has occurred in India be fore the beginning of the nineteenth century but for some mysterious reason it began about the year 1817 to spread from its stative haunts not rapidly but inexorably The first stage of thus first pandemic lasted until 1823 when the descasc reached the confines of European Russia Between 1826 and 1838 xt spread to practically the whole of the world between lautude 41 S and 65° N Thus it showed a power of disper son almost equal to that of plague or influenza From the English point of view perhaps the most interesting specula tron $ why this had nezer happened before England had carried on an extensive trade with India for over 200 ycars and throughout thu period London at least must have been just as favourable an environment for an epidemic of cholen * Creighton Vol 11 p 793. 66 ·ASIATIC CIIOLERA as it was in 1832 Perhaps a partial explanation is that as cholera has a relatrely short incubation period, it could not survive the long sca voyage froin India durmg which an epidemic on shipboard would have burned itself out The chief explanation seems to be however that in 1817 this disease of India acquired a new dynamism which carried it round the world Conditions in all the large towns were at this time very favourable to the spread of cholera Much of the drinking water came from wells in the towns themselves which were in close proximity to cesspools Even when piped water supplies existed the water was often taken from rivers grossly polluted by human sewage In London for example some of the water companies between which there was intense competition derived their supplies direct from the Thames near Westminster No one realized that the drinking of pol luted water was dangerous and indeed even at the end of the century there were still a few diehards like Creighton who refused to believe that drinking water was an important vehnle of infection Considering how favourable the condi tions were cholera spread rather slowly In Sunderland with a population of about 18 000 about 400 people were attacked in October-December 1831 and some 200 died By January 1832 the disease had gained a footingin Newcastle Gateshead North Shields and Houghton le Spring Thc places on Tyneside which were most severely attacked were the low lying ones near the river chicfly in habited by poor industrial workers It was not untul April 1832 that the infection began to show itself obviously in other parts of England A few suspicious cases occurred at Rotherhuthe in the London Dock area in February and there was a gradual increase until mid June when the disease became more severe and affected parishes like St Giles in the Fields in the west end of London In all there were some 11 000 cases with 5 °75 deaths in London in 1832 The most disastrous outbreak in the whole country was at Balston in the Black Country in August 1832 The population was about 15 000 and in August and September there were some 3 568 cases with 742 deaths In this first epidemic it ·EPIDEMIC DISEASES 18 estimated that there were about 22 000 deaths in England and Wales which had at the time a population of about 14 000 000 England svas almost free of cholera from 1832 to the second epidemic of 1818ng but in January 1838 there was an explosive outbreak of cholera like discase in the Coventry House of industry with 55 deaths The severity of the discase suggests that this was true Asiatic cholera The second epidemic began in Scotland in October 1898 but did not really reach England unul the end of that car In December there was a terrible outbreak in a large institu tion for pauper children at Tooting The school contained about 1 000 children of whom 300 had the disease and 280 died in the Spring of 1849 there was little cholera but in June the epidemuc began in real carnest Once again the Black Country was severely affected as at had been in 1832 but the outbreaks in Hull and Merthyr Tydfil were even worse The epidemnic chiefly affected manufacturing towns and big ports and many agricultural countes escaped altogether or had a few unusipostant centres of infection In England and Wales 53 293 deaths from cholera were regis tered and this second epidemic was the most serious of all The thurd visitation was in 1853-4 and like that of 183r began on Tyneside Again industrial districts were affected chiefly but some which had been severely affected in one or more of the earlier epidemics escaped Liverpool which never escaped had a moderate epidemic Merthyr Tydfil had about a quarter of the deaths ctperenced in 1849 but Plymouth Hull Bristol Manchester Leeds and the towns of the Black Country were more or less free of the ducase This epidemic is notable chiefly because it was the occa sion of John Snow s* brilliant inquiry into the source of in fection in cholera Thus thurty ycars before the discovery of the cholera baallus he showed clearly that cholera was spread by water contaminated with excrement from cha sufferers It us difficult for us now to appreciate the fu] measure of Snows achievement since what he proved seems 30 obvious but we must remember that the climatcofopioion John Snow 1819 68 ·ASIATIC CHOLERA before the days of bacteriology was completely different from that at the present time Then and for many years after wards the mjasmatic theory of the origin of infectious diseases was the one which was most generally believed The theory was that soil polluted with excrement or refuse of any kind gave off an atmospheric miasma which was the cause of certain cpidemic diseases There was nothing specific about it and indeed it was commonly believed that one disease could change into another for example even after the clini cal destinction between typhoid and typhus had been made it was commonly believed that one could change into the other The miasmatic theory was that on which the early movement for sanitary reform was based In the early years Chadwick and Simon waged war on all filth indiscrimin ately and regarded a heap of manure as just as dangerous as a cesspool which was contaminating a well of drinking water Snow s hypothesis that the excreta of cholera patients contained some specific poison which was transferred to the healthy by drinking water and caused cholera in them was therefore a completely revolutionary one Perhaps Snows greatest contribution was however his use of the epidemiological method to solve the problem His inquiry of 1894 into the distribution of cases of cholera around the Broad Street Pump showed that those who had drunk the water from the pump suffered far more than those living in precisely the same conditions and geographical situation who had not drunk the water He also examined the purpp itself and showed how the well had been polluted by the evacuations from sick people near by At first the General Board of Health did not accept Snow's conclusions and in a report of 1854 a commuttee of inquiry into the incident of the Broad Street Pimp reported that We do not find it established that the water was contaminated in the manner alleged nor is there before us any sufficient evidence to show whether inhabit ants of the district drinking from the well suffered in proportion rrore than other inhabitants of the district who drank from other sources In spite of this official scepticism the theory that water was very important in the spread of cholera received additional confirmation from differences in the ·EPIDEMIC DISEASES incidence of the discase in different households in south Lon don There were two rival water companies supplying south London In 1849 both these companies took their supply direct from the grossly polluted Thames in the neighbour hood of Westminster but before 1854 company A had removed its source of supply to Thames Ditton higher up the river whereas company B retained its original source The pipes of these two companies often interlaced in the same street, so that there was no difference other than water supply, between most of the houses It was found that deaths from cholera were 57 1 per 1 000 houses supplied from the polluted source and 11 3 per 1,000 houses supplied from the purer source above Teddington Lock There had been no such difference in 1849 when the supplies of both com panies came from the grossly polluted source The last epidemic of cholera in England and Wales was in 1866 It was brought in by emigrants passing from Hull and Gnimsby to Liverpool on their way to America As al ways Liverpool had a severe epidemic with 2 122 deaths but the only other important centres were Swansea Neath Llanelly Merthyr Chester Northwich a group of townis on the Exe, Portsmouth and certain parts of east London The outbreak in London is of particular interest in that three quarters of the deaths occurred in Whitechapel Bethnal Green Poplar Stepney Mile End, St Georges in the East and Greenwich These districts were supplied by the East London Company from the Old Ford reservoir which was grossly polluted and from which water was supplied without filtration Sir John Simon said of the outbreak of 1866 in London The area of intense cholera was almost exactly the area of this particular water supply nearly if not absolutely filling it and scarcely if at all reaching beyond it By 1866 the main drainage scheme of the metropolis had been carried out and all the water companies supplying the western parts had moved their sources of supply much farther up nyer The history of cholera illustrates very well the difficulty of giving complete explanations of epidemiological phenomena The immediate causation of the English cpidemics has been fully explained because the decline of cholera fol 70 ·ASIATIC CHOLERA lowed so closely the sanitary reforms which safeguarded water supplies from gross pollution with human sewage The problem which is still unsolved is why the disease rela uvely suddenly acquired in the nineteenth century an im mense power of dispersion which it had apparently never shown before ·6 CONTINUED FEVERS TYPHUS - ENTERIC (TYPHOID PARATY PHOID AND FOOD POISONING) Typrus fever is caused by a member of a group of mucro organisms known as Rickettsia the organism lives normally in the body louse and the disease is transmitted by the bitc of this insect This mode of transmission was described by Nicolle Conor and Conseil in 1911 and five years later da Roche Lima* isolated the organism (Rickettsia Prou azeli) The disease is characterized by severe toxaema, a high temperature and a rash The enteric fevers are caused by a group of bacteria (B Ophosus -B para typhosus A and B) and as with typhus torte mia a high temperature and a rash are characteristic symptoms The bacteria gain entry through food or water and live in the large intestine in consequence enteritis often with blood in the motion is an added symptom The early histories of typhus and the enteric group of fevers are confused one with another because the clinical distinction between the two diseases was not finally settled in England untul Sir William Jenner s treatise which was published in 1893 The distinction between typhus and en teric fever in the Registrar General s returns of causes of death was first made in 1869 only a short time before typhus disappeared from the English scene In earlier times it was appreciated that the continued fevers as they arc called were of different types but it was thought that one could change into the other The descrip tive names for the two diseases varied from time to time but perhaps the most commonly used were those adopted by Huxham He described a slow nervous fever' which • I da Roche Lampa 1916 John Huxham 1755 72 ·CONTINUED FEVERS TYPHUS - ENTERIC was chuefly enteric and a putrid malignant fever which was chiefly typhus These were broad distinctions however and many other diseases were no doubt included under both headings Although it is not possible to give any comprehensive picture of the relative importance of typhus and enteric before the middle of the nineteenth century it is possible to make reasonably intelligent guesses and to identify cer tain famous outbreaks which were almost certainly typhus TYPHUS In the Tudor Period there are at least three accounts of outbreaks of gaol fever or typhus originating in the assize courts - the Black Assizes at Cambridge (1522) at Oxford (1577) and at Exeter (1586) At Oxford the Assizes met on 5 and 6 July 1577 and soon after the two Judge the Sheriff of the County tho Knights eight Squires and Justices of the Peace and many others who had attended the court fell ill and died The symptoms were an acute and rapidly fatal delirium but no mention is made of a rash The disease spread to Merton College and also in the town but was soon over We catch further glimpses of severe epidemics of typhus in the Civil War in both the royal and the parliamentary armies in 1643 the royal army was holding Reading and was besieged by Fairfax with an army of 15 000 foot and 3 000 horse The king and Prince Rupert failed to raise the siege but when Fairfax took the town he found it infected and his army suffered severely in the ensuing weeks so much so that he was unable to pursue his original plan of advanc ing on Oxford The royal army in Oxford was attacked a little later Willis * the great anatomist was a young man in Oxford at the time and he gives a clinical description of the disease which leaves little doubt that it was typhus The victims had an acute fever with delinum or stupor and a rash In 1644 there was a severe outbreak at Tiverton which had recently been occupied by both parliamentary and ·EPIDEMIC DISEASES royalıst troops According to the parish registers 10g of the 8,000 inhabitants were buned in the single month of October 1644 and the total number of burials during the year was 443 These dramatic outbreaks were associated with the misenes of war, as typhus has so often been in human his tory but there is little doubt that throughout the seven teenth cighteenth, and first half of the nineteenth centuries the disease was also a constant visitor to London in par ticular, and, less frequently to smaller towns Throughout the eighteenth century the annual number of deaths in the London Bills from Fevers was usually about 3 000 arc sometimes exceeded 7 000 On the whole these deaths slightly cxceeded those from smallpox and fluctuated rather less from year to year In 1750 there was a Black Assize at the Old Bailey as a result of which there died of fever the Lord Mayor a Justice of the Common Pleas a Baron of the Exchequer, and an Alderman together with many less important persons In the latter part of the cighteenth century the great growth of the manufacturing towns of the north produced conditions very favourable to the spread of typhus The poor lived in grossly overcrowded and insanıtary slums and starvation was never far away It seems possible that in London typhus may have been a little on the decline Lettson * who was one of the first fashionable physicians to visit the poor of London in their homes wrote in 1973 that in the airy parts of the city and in large open streets fevers of a putrid tendenry rarely arise In my practice I base attentively observed that at least forty eight out of fifty of these fevers have cristed in narrow courts and alleys Outbreaks of typhus in the nincteenth century were often asociated with the great Irish immigrations which followed the potato famines In England the bad years were 1847-8 and the areas chicfly affected were Lancashirc and Cheshire Luverpool being the town with highest incidence in the north western registration district of Cogland there were 9076 deaths in 1847 and 380 in 1848 In the latter half of the nineteenth century, typhus was declining rapidly It was • John C. Lettson 1774. 34 ·- CONTINUED FEVERS TYPHUS ENTERIC still important as a cause of death among the poor of the great industrial towns particularly in times of industrial distress but by 1870 it had practically disappeared from southern England and lingered on only in a few of the northern ports such as Liverpool and Sunderland in the twentieth century the disease has occurred only occasionally in ports as a result of importation from abroad Epidemic louse born typhus is perhaps the best example of a disease associated with the depths of human misery Typh eri Py ex wowower) 400 379 30 325 300 275 250 225 200 175 ISO 125 100 75 50 25 19 6 1931 1936 1930 1935 1940 1871 1876 leat 1896 1997 1996 1905 1906 1911 1916 1921 1975 1830 1885 1990 1895 1900 19 1910 1915 1920 1925 & Decl ne of typhus cleric and pyrers shownng number of de the per million of the population in Engl nd and Wales 1871-1940 Widespread starvation and infestation with body lice are necessary conditions for the genesis of epidemic typhus but when once an epidemic has started it can spread to the more prosperous members of the community as it did at the Black Assizes of the Middle Ages (Body lice are no respecters of persons ) Two modern instances may be quoted to illustrate some essential features of the epidemiology of typhus In the First World War the troops on the Western Front were nearly all infested with body lice and the louse borne disease called trench fever was common but the armies ·EPIDEMIC DISEASES bacteriologicalevidence offaecal pollution of the water supply was produced Aprimitive attempt was made to free the water mains frotti infection by the use of chlorine, which has since become so important a substance for the punficauon of water supplies At this time the water supply of Maidstone was derived from three main sources known as the l'arleigh Cossington and Boarley supplies The Farleigh supply was the most subject to human pollution and just before the epidemic started hop pickers had been camping near certain Springs which contributed to this supplv Most of the cases occurred in the area of the town which received the Farleigh supply and there was a number of cases in the County Asylum which also received this water The areas supplied from Cossington and Boarley had fewer cases chiefly in the later stages of the epidemic and the barracks and prison supplied frorn Boarley or a separate well, had no cases at all Public water supplies have often been the source of severe outbreaks of typhoid and the most recent large scale cpi demic due to this cause was that at Croydon between October 1937 and February 1938 In this period there were 310 cases and 43 deaths in a limited area of Croydon In all probability the outbreak was due to the infection of a deep well at Addington by a workman a chronic carrier, who was engaged on repair work there in October 1937 While the work was going on untreated water from the well was pumped into the public supply The cases nearly all oc curred among consumers of the high level supply to which the Addington well was one of the two contributory sources The Croydon outbreak illustrates very well how a single error in the technique of safeguarding the purity of water supplies may be fatal Water bome outbreaks of typhoid have been perhaps the largest and most explosive of any, but milk borne out brcaks are not far behind and that at Bournemouth and Poole in August and September 1936 is a good modern example In this epidemic there were 518 cases scattered throughout Bournemouth Poole and Christchurch The water supplies of the three towns were separate and inquiry ·CONTINUED FEVERS TYPHUS ENTERIC showed that all those taken ill in the first wave had drunk raw milk retailed by one firm and distributed by twelve roundsmen Immediate steps were taken to pasteurize this supply whilst attempts were made to trace the outbreak to its source Nothing suspicious was found at the headquarters of the rctailing firm but at one of the small holdings (A) among the thirty seven scattered farms which supplied the retailer it was found that the farmer s wife had been taken ill on 10 August A diagnosis of typhoid fever was not made unul 31 August At first this appeared to be the source case but this hypothesis did not quite fit the facts because twenty ninc cases had occurred in the three towns before the farmers wife became ill The small holding occupied by famıly A was part of what had originally been a farm and two cot tages In all there were five families living there A already mentioned B in the cottage next door and C D and E in the onginal farmhouse There had been a fatal case of typhoid fever in family B in 1934 These families were all supplied from a well wluch seemed reasonably satisfactory but a stream ran past them which aroused suspicion Care ful exploration of the stream above the cottages revealed that about halfa mile above them there was a four inch pipe discharging opaque fluid resembling sewage It was found that this came from a large house with some sixteen occu pants the effluent from this house discharged into a small impervious tank and the overflow from this discharged via the four inch pipe into the stream Bacteriological examina tions of the effluent for the presence of typhoid bacıllus in September and early October proved negative but on 16 and 24 October thus organism was present in large numbers but was not found in the stream above the point of entry of the effluent One occupant of the house who stayed there at intervals and had been staying there in 1934 when the single fatal case occurred in family B was found to be a chroruc intermittent typhoid carrier The carrier was ing in the house throughout the summer of 1936 up to to August when he went away and he did not return until 28 September This story has been told at some length be cause it is an interesting example of epidemiologicaldetective ·EPIDEMIC DISEASES ascribed to these diseases have become so sinall that rates are misleading for that reason also Paratyphoid not only is a milder disease than typhoid with a much lower mortality but also tends to differ from at epidemiologically Some of the big outbreaks of para typhoid have been like the classical milk borne epidemics of typhoid but others have been more akin to outbreaks of food poisoning due to one or other of the very many other organisms belonging to the group These organisms are widely distributed in the animal world and have variable pathogenicity for man They tend to cause gastro-enteritis of much more sudden onset and shorter duration than ty phoid In this respect, the organisms of the paratyphoid group are intermediate between typhio and the food poison ing group in that sometimes they produce a long drawn out illness known as food poisoning Outbreaks of 'food poisoning have probably always oc curred but it seems probable that their frequency may have increased as the scale of manufacture and distribution of cooked meat and other ready cooled foods has grown in the modern world meat pies manufactured in say London may be consumed by hundreds of different people scattered all over southern England at more or less the same time Fortunately food poisoning of this kind is rarely fatal but it can occur in widespread outbreaks of sudden onset Another important vehicle of infection during and since the last war has been artificial cream In the early days of the manufac ture of this product methods of manufacture were crude and as the material was a good culture medium and the product was eaten without being cooked all the conditions necessary for widespread human infection were present in the year 1952 117 outbreaks of food poisoning affecting more than one family and probably due to bactenal organisms were reported The epidemiology of infections with any organism of the intestinal group has some obvious links but from the his toncal aspect it is perhaps the differences rather than the similarities which are interesting Cholera had a short history as an inportant epidemic disease in England and at B2 ·CONTINUED FEVERS TYPHUS - ENTERIC would appear that in a country of western civilization a profound breakdown of sanitary arrangements would be necessary before cholera could become a serious menace again Epidemics of typhoid fever are a possible punishment for carelessness in the enforcement of precautions for the protection of water and milk supplics and outbreaks of in fecuon with food poisoning organisms can occur as a result of some quite minor error of technique in the manufacture of a variety of food products ·EPIDEMIC DISEASES definitive heading of convulsions' A comparison of the weekly returns taken from Creighton for tuo very hot summers one at the beginning (1670) and one at the end (1718) of the penod, illustrates this point Weck ending Con Gnping vulsions in guts All Con Gaping AN Week causes vulsions in guts causes ending 160 2 Aug 160 653 12 Aug 653 16 1718 49 113 4,0 9 38 485 n26 34 16 1 289 555 339 23 645 19 23 47 222 629 256 25 693 26 30 42 250 629 265 28 668 2 Sept 6 Sept. 31 253 617 245 27 725 9 13 24 239 586 221 26 20 98 225 575 213 27 639 23 27 7 150 474 182 24 632 30 Creighton considers that, in London diarrhoca of infants was probably at its worst in the period 1720-40 the era of cheap gin In any case there can be no doubt that in cycry hot summer for at least 300 years before 1g11 there was an chormous mortality among infants from diarrhoca At the beginning of the cra of comprehenske statistics from 1837 onward, at became obvious that the great manu facturing towns of the north suffered even more severely in cpidemics of summer diarrhoea than did London The towns where many women were employed in industry were par ticularly bad The only real change which occurred in the ninetcenth century was that mortality fell slightly don whereas in the great manufacturing towns it tended to Tise a stle In the year 1911 no less than 31,900 deaths among in fants under a year were ascribed to diarrhoca and enteritis, and in 1956 only 319 were reported Besides this enormous decline in the absolute number of deaths there has been a change in the seasonal distribution In 1911 nearly all deaths from diarrhoea and enteritis in infants occurred in the late summer and carly autumn whereas nowadays the deaths from this cause are much more esenly distributed throughout in Lon the year 86 ·SUMBER DIARRHOEA OF INFANTS Nowadays fatal diarrhoca tends to occur in outbreaks in institutions where a number of young babies are congre gated A great deal of work has been done on the bacteriology of these outbreaks and the general conclusion scems to be that they are generally but not always due to particular kinds of bacillus coli The subject is a difficult one because other kinds of bacillus coli are normal and harmless in habitants of the human intestine It seems almost as though a disease which nowoccurs only as an occasional 1fdangerous visitor in institutions was formerly a nation wide scourge in every hot summer It is interesting to speculate on possible explanations for this one whuch has been suggested is that the decline in summer diarrhoea may have been associated with the decline in the use of horses This theory involves the assumption that the disease was largely fly borne and that the disappearance of the heaps of manure a splendid breeding ground for flies from our cities so reduced the fly population that the great summer epidemics ccased Per haps all one can say is that the theory seems plausible but cannot now be proved or disproved Death rates are impersonal things and it may be helpful to summarize the history of fatal diarrhoea in infants under one year in England and Wales by giving total numbers of deaths in some representative hot summers Year Deaths frorn diarrhoca Deaths from all causes Ratio between deaths from diarrhoea and deaths from all causes 31 goo 11 705 114 600 1911 1921 1933 1949 70 250 36 960 136 16 1 TO I 12 3 558 1963 33 882 Thus the number of deaths in 1911 from diarrhoea alone was 8 000 more than the deaths from all causes in 1949 Moreover the proportion of infantile deaths caused by diarrhoea has decreased from 1 in 36 in 1911 to 1 in 12 in 1949 ·EPIDEMIC DISEASES may have been describing diphthersa as well Huxhama : deseriphon also seems to refer to severe scarlet fes er rather than to diphtheria Both Fothergill and Huxham made frequent reference to a skin rash and Huxham speaks of generalized dropsy At the end of the eighteenth century Willan* gave remarkably good and complete description of scarlet fever m hu book on cutaneous diseases He described three types 1 Scarlauna simplex with a rash and no sore throat 2 Scarlatna anginosa with a rash and a sore throat which might be very severe 3 Scarlatina maligna which was a very severe form of scarlatına anginosa with sloughing of the soft tissues of the throat and mouth and profound totaemia He pointed out that cases of very different degrees of seventy could occur in the same household and that the sore throat occurred without the rash He states that the severe form of the disease was the leading cpidemic disease in London in 1786 from 1804 to $836 Batemant kept records of the diseases of London based on fis experience as physician to the Public Dispensary and consulting physician to the Fever Insututson in London In Autumn 1807 and agai in 1808 he wrote that scarlatina was generally mild presenting the eruption with a slight sore throat In the autumn of 1814 he wrote as fallows The scarlatina has been in all cases accompansed by sore throat se the adults indeed in <wa or three families the throar as x usual was the only sat of the discasc as the rash did not appear on the skin. Under the cool treatment which however us often uzperfectly accomplished in the close and crowded apastments of the poor these cases havt unforttely done well Bateman also mentions dropsy following scarlet lever In the light of our modern knowledge of streptococcal sore throat 25 sec77 clear that bad epsdemos occurred in the cighteenth century that there were quite long inter als betucen them and that sometimes in the early years of the • Rap 1798-1803 Thomas Batman 1819 ·SCARLET FEVER DIPHTIERIA nineteenth century - probably about 1803 - the disease became milder though it was still common NINETEENTH AND TWENTIETH CENTURIES The mild phase of scarlet fever lasted until about 1830 but from then on the disease began to increase in severity again and in the first two and a half years (1836-9) of registration the number of deaths attributed to this cause was consider able In 1840 the number of deaths nearly doubled and for 2500 2000 Scarlet feve Disa herua 1500 1000 500 2 924 736 50 735 NOW 10% 6h 4 X 001 KOMS ro 7 0 MS MO 175 mm 11 Deaths from scarlet fever and d phslena per mill on lag under fifteen pears of age 1855-1954 a generation after scarlet fever was the leading cause of death amongst the infectious diseases of childhood Creigh ton says of this period The enormous number of deaths from scarlatına during some thirty or forty years in the middle of the nineteenth century will appear in history as one of the most rernarkable things in our cpidemiology The year of highest mortality was 1863 when the death rate of children under fifteen was 3 966 per million living In 1863 there were just over 30 000 deaths from scarlet fever and in 1953 there were 27 ·EPIDEMIC DISEASES Figure it shows the trend of death rates from scarlet lever of chldren under fifteen from the tune when scarlet ferer and diphtheria were separated in the statistical returns to the present The marked decline of mortality began in the quinquennum 1866-70 and has continued pretty steadily cver since No satisfactory explanauon of this dechne has ever been offered but it may be due to a diminution of virulence of the haemolytic streptococcus as a similar (all has occurred in other streptococcal diseases such as erysi pelas and puerperal fever and has also affected acute sheu matism which is usually an sadirect result of streptococcal infection It seems unlikely that advances in medical treat ment have had much to do with this decline because the change set in long before the sulpha drugs and penicillin were discovered It is perhaps a little troncal yer deserving of thought that penicillm whach us so potent a remedy for streptococcal diseases should have been discovered after the streptococcus had lost much of ats virulence Epidemiolon gists with a taste for tastory have often sounded a note of warning about the possible future trends of streptocoxcal diseases They have pointed out that scarlet fever vaned a great deal in severity before the middle of the nineteenth century and that it may again become a deadly disease. Against these gloomy forebodings may be set the fact that the decline in severity has gone on steadily for nearly a cen tury and that we now have drugs which will kill the strep tococa without hurting the pauent DIPHTHERIA EARLY HISTORY Some examples of outbreaks of severe sore throat occurring in the eighteenth century have been given already Most of the accounts quoted have suggested that the discasc des cribed was scarlet lever rather than diphtheria but there are others in which the description is more like diphtheria than scarlet fever In 1750 John Starr of Liskeard en Corriwall described an outbreak of severt sore throat in which the prominent sym 92 ·SCARLET FEVER DIPHTHERIA toms and suns were agonized breathing and an inflamma tion of the throat with the formation of membran. In onc case that of a child the father pulled from the child s mouth a complete membrancous cast of the wind pipe Although Huxham s* descriptions of the disease in Ply mouth about 1751 seem to refer to severe scarlet fever he also mentions membrane in the wind pipe which suggests diphtheria rather than scarlet fever All one can say about this difficult early perod is that the evidence seems to sug gest that severe scarlet fever was a more prevalent disease than diphtheria but that diphtheria did occur It seems certain that diphtheria was not an important descasc in England in the first half of the nineteenth century though there were probably small outbreaks eg Ashford (kent) 1817 Liſton (Devon) 1852 In France however it was important and the modern description of the disease was given by Bretonneau of Tours in 1821 in a paper to the Academy MODERN HISTORY The modern history of diphtheria in England begins with the wave of prevalence which started about 1855 Simon st srcond report to the Privy Council for the year 1809 has a section of 160 pages about it He says that the disease was almost unknown to British doctors until 1895 but in the four years since then it had become widespread As is usual when an epidemic disease which has been rare becomes common importation from abroad was blamed and at first diphtheria was known as the Boulogne sore throat If it was indeed imported it seems to have spread far and fast In 1855-6 epidemics were reported from places so widely scattered as Launceston (Cornwall) Spalding (Lincoln shire) Thame (Oxfordshire) Billericay (Essex) Ash (kent) and many other places In 1859 the 9 587 deaths ascribed to the disease were scattered throughout England and Wales At first diphtheria was overshadowed by scarlet fever as a cause of death among children but in the quinquennium • J Huxham 1735 Sr John Smon 1860 ·EPIDEMIC DISEASES 1886-go it took the lead (see Figure 11) and remained a leading cause of death in chưdren up to 1941 When epidemic diphtheria first appeared it tended to affect rural areas more than urban, but in the second half of the nineteenth century and the first forty years of the twentieth there was a gradual change so that in the decen nium 1871-8o the rural areas had a death rate only slightly higher than that of the urban and by 1939 the County Boroughs had a substantially higher rate than the Rural Districts In the early years of the twentieth century diph theria tended to kill children under school age more than SOY 400 Scarlet lever Duphtherla - 300 200 1001 1911 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 5 4 49 51 99 55 22 Nonfications of sca let fever and diphtheria in England and I ales per 100 ooo of the population 1911-55 older children but here again there was a gradual change and in 1938 diphtheria was the chief cause of death among children aged 5-9 The trend of mortality among children is shown in Figure 11 After the first outburst in the sixties the death rate remained more or less stable at about 800 per million living until about 1900 then there was a slow fall to about 300 in 1921-5 and thereafter a period of stability until 1940 Antitoxin was first used in treatment in England in 1895 and it seems reasonable to suppose that the reduction in mortalıty between 1896-1900 and 1921-5 was chiefly duc to the improvement the treatment of the cstablished disease More efficient treatment saved many lives but it had no effect on incidence and the graph of annual noti fications (Figure 12) showed fluctuations but no consistent downward trend The diphtheria bacillus itself loves chiefly 94 ·SCARLET FEVER DIPHTHPRIA in the throat and nose of the host causing a local inflamma tion but it also produces a powerful poison (town) which circulates in the hosts blood and causes the more serious symptoms and signs of diphtheria The antitoxin which us so effecuve in the treatment of established disease is an agent for passive immunization and can be used to secure temporary protection against catching the descase It is made by the active immunization of horses and the serum from the immunized horse which us rich in anubodies is injected into the person to be protected Passive immuniza tion is only temporary and clearly some safe method of producing the active immunization of man was always Iikely to be far more effective in controlling the discase than passive immunization Bacteriologists recognized this quite carly and in 1913 the first effective diphtheria prophylactic was produced Unfortunately this was not absolutely safe and it was not unul 1923 that an effective and safe anugen for the protection of man was produced In the late twenties and the thirties a certain amount of active immunization of children was done in Britain but was insufficient to in fluence diphtheria as a disease of the community In other countries however notably in the United States and Canada a great deal was done and it became clear that active immunization of large numbers of children could reduce the incidence of and mortality from diphtheria in the commu raty In 1940 the Ministry of Health inspưed by Sir William Janneson its chief medical officer embarked on a campaign to popularize the immunization of all children against diph theria The mortality from diphtheria from 1911 to 1955 us shown in Figure 13 in which it is compared with those of measles and whooping-cough In 1941 an extremely rapid decline of both incidence and mortality of diphthena began and has continued until the present time In a dozen years diphtheria has become a very rate disease so much so that a generation of doctors us growing up who have never seen a patient suffering from it. The recent history of diphtheria in the countnes of Western Europe has been quite different Virulent diphtheria came with the German armies and in the occupied countries ·EPIDEMIC DISEASES there was a stccp rise in the death rate from diphtheria during the years of the Second World War In Holland for example the death rate rose from o 9 per 100 000 living in 1939 to 46 per 100 000 in 1945 Since then it has declined In 1945 there were 4 270 deaths and in 1952 only 173 1000 Diphtheria M.asles Whoop ng-cough 100- 10- 1911 15 16-20 21 25 26-30 31 35 36-40 41-45 46-50 51 55 13 Declens of mortality w England and I ales from diphthena measles and whooping-cough 1911-55 Memories are short and there is no doubt that it is now very much more difficult to persuade parents to have their children immunized than it was in 1941 This is a disturbing state of affairs but the wholesale immunization of children has had one unexpected result which makes it a little less disturbing than it might at first sight appear to be In thcory there is no reason why immunization against the toxın or the diphthena bacillus should have any cffect on the popu lation of diphtheria bacilli One might reasonably expect 96 ·SCARLET FET ER DIPATHIERIA that the number of healthy human carriers would increase as the number of cases of overt disease diminished There is some evidence however that in fact the population of diph theria bacallı has declined pari passu with the decline of the disease Small epidemics of diphtheria do however still occur and are particularly dangerous because the discase now so uncommon that it is often some time before a correct diagnosis is made Diphtheria is the most convincing example of a discasc which can be controlled by artificial active immunizaton and any reasonable person must be convinced that in England the hard work of public health officers has been the most important factor in determining its Virtual disappearance in the last twelve years Their achievement has been considerable In 1941 there were 50 000 notified cases with 1 622 deaths and in 1956 there were 37 cases with 6 deaths ·9 MEASLES AND WHOOPING COUGH Measles and whooping cough are not particularly alike in their symptoms but they have other affinities which justify their sharing of a chapter Perhaps the most obvious of these is that nearly all of us have at some time in our lives had both diseases and it seems likely that most of our ancestors had much the same experience from the notifica tion returns it would appear that measles is about three times as common as whooping cough but whooping cough is more difficult to diagnose because thecharacteristic whoop is not a constant symptom, and so the returns are less com plete than are those of measles Both diseases still have their dangers for young children though they have become much less dangerous in the twentieth century In both the com plications rather than the original diseases cause death and disability Measles is caused by a virus but little is known of its size or shape It has been cultivated in tissue from a chick em bryo and several species of monkey can be infected with it In contrast with some other viruses for example that of influenza, the virus of measles appears to have remained stable for hundreds of years When a susceptible person 13 exposed to infection he almost invariably develops measles and the resulting immunity is nearly always complete and long lasting Because so many people have had an attack of mcasles serum prepared from an ordinary blood bank is rich in antibodies and this property has been used to modify the attack in weakly children after a known exposure to infection Nowadays the usual procedure is to give an injection of y globulin (that fraction of the serum protein which contains the antibodies) to the exposed child about five days after exposure The object is to produce a modified attack which will save the weakly child from a severe but will at the same time produce lasting immunity 98 ·WEASLES AND WHOOPING COUCH Whooping-cough is caused by a small bacillus discoi cred by Bordet and Gengou* in 1906 An attack of the discase usually produces lasting immunity but second attacks are not quite so rare as are those of measies Many attempts have been made to produce a safe and effective vaccine to protect against whooping-cough, and modern vaccines will produce immunity in a good proportion of children On the whole the bacterology of these two diseases is not mportant to an understanding of their hustory The diag Dosis depends and always has depended chiefly on signs and symptoms and these are sufficiently characteristic to cnable us to trace their history reasonably well M[casles is a febrile illaess which starts like a severe cold and has a blotchy rash which comes out on the third or fourth day In whooping cough the characteristic is the cough which becomes more and more paroxysmal cach paroxysm ending with the char acteristic crowing inspiration or whoop MEASLES EARLY HISTORY The name mezıls seems to have been used first by John of Gaddesden (1280-1361) who applied it both to measles and to certain leprous lesions in the Arabic writings vanolac (smallpox) and morbilli (measles) are an inseparable pair and the same is true of smallpox and maczıls in the writings of Tudor umnes At that time measles was generally thought to be a mild form of smallpox though the severe form of haemorrhagic smallpox was also confused with it Probably by 1620 when the Parish Clerks first returned measles under a separate heading in the Bills the distinction between smallpox and measles was reasonably well understood In the first series of London Bills from 1629 to 166o the deaths vary from only 2 in 1630 to 153 in 1656 In the next senes the numbers of deaths became greater 311 in 1664 and 295 in 1670 The epidemic of 1670 is notable because it gare Sydenhamt hus opportunity and his clinical description would seein quite at home in a modern textbook There was J Bordet and O Geng u 1906 T Sydenhan 16 6 ·EPIDEMIC DISEASES another bad epideruic in 1674 with 795 deaths in the BILL and then a long interval of low mortality until 1705-6 whic ncarly 800 deaths were retumed for the two years in the early period the bad cpidemus apparently came at home intervals In the aghceenth century epidemus in Londo became more frequent and by the middle of it werT OCCHI ring every other year or every three years but not with the biennial regularity which was so prominent a feature measles in London in the nineteenth century and the earl years of the twentieth In the carly years of the nineteenth century smallpa began to decline as a common cause of death in children and measles and whooping-cough became more prominent though it is difficult to say whether the number of death incrcased absolutely or only relatively In this period 200 mediately before the latroduction of universal registrato of births and deaths the Bills are notoriously incomplete In the first four complete years of registrauon 1838-42 the common infectious discases of childhood had the following mcan annual death rates per million living at all ages Scarlet fever 797 Measley 539 Whooping-cough 504 Diphtheria had not yet been separated from scarlet fever but as we have already seen it seems unlikely that it was an important cause of death at this time Scarlet fever was just beginning to assume the promnence which became obvious in the sixties and seventies and measles and whooping cough had rates about the same as they had us the second hall of the century MODERN STORY The trend of the death rate of children under fifteen (roma 1851 to 1955 13 shown in Figure 4 At the begioning of th period measles had a slightly higher rate than that of whooping-cough but the rate for measles began to decline later and even in the early years of the First Horld War 11 was very nearly the same as it had been in 1871- Sun 100 ·MEASLES AND WHOOPING COUCII 1915 in which year there was a bad cpidemic there has been a rapid fall in mortality In 1915 16,445 dcaths resulted from measles and in 1955 only 176 in spite of the fact that there were nearly half a million notifications (the discase was not notifiable in 1915) There is no evidence that the incidence of measles has decreased at all It has been generally notifiablc only since 1940 and the annual notification rates since then are shown 15001 Measles Whoopie cough 1000 1 500 651 1656 16 1866 187 188 1836 183 % 6 %! 18 192 191 36 * * * BSS WO 845 1170 1873 890 895 DO 19 $0 OS 101 S 125 5 0 45 50 1955 14 Death of child en in England and Itales under fifteen ſon measles and whoopt g-coughs per milion of the population 1851-1955 in Figure 15 Incidence varies enormously in different years for example there were about 160 000 notifications in 1946 and about 600 000 in 1951 The reduction in mortality has therefore been entirely due to the fact that the discase has become less fatal than it used to be The reasons for the decline of the fatality of measles arc probably complex It began to fall many years before there were any really effective drugs for the treatment of the fatal complications Deaths from measles have always tended to ·EPIDEMIC DISEASES occur in young children particularly in those between I months and tho years old Those under six months have antibodies derived from their mother and so are less Sable to develop the disease than slightly older chuldren and chuldren over two have a stronger hold on kyſe than the tery young Anythung therefore, which will tend to postpone the age of attack will tend to make the disease less mortal It weems likely that much of the reduction from about 1gist) about 1935 was due to the reduction in the size of families partscularly of poor families Thus fatourable influence oper 4561 200 les Whooping ou *CKO *740 +1 + 0 ++ 46 +2 49 50 31 is Melicators of cares of measles ord hasping cough in England and I per 100 000 of the population 1975 ated in two ways The older children who go to school pick up infectious diseases there and bring them back to their younger brothers and sisters When there are many younger brothers and sisters in the population measles will tend to occur at an early age and wall tend to be more dangerous In addition to the danger of infection at an early age in the large family there is the obvious factor of poor feeding and all the other factors which make up the complex of poor social conditions The total effect of these influences on mortality from measles was examined in the Regudar Generals Decennal Supplement 1931, p 167 The mortal ity from mcasles of children aged one in social class V 130 102 ·MEASLES AND WHOOPING COUGI nearly twenty times that of children of the same age in social class 1 There is no convinang evidence in the national figures indicating that the sulpha drugs and peniallın have had much influence on mortality The decline has been a little steeper since about 1935 than it was before but not very markedly so Passive immunization with scrum or y globulin has never been used on a sufficient scale to haveany influence on national figures. In contrast to diphtheria measles is a disease in which changes in social conditions rather than advances in methods of prevention or treatment have been the important factor in determining the decline of mortality The decline of virut ence of the haemolytic streptococcus which was discussed in the chapter on scarlet fever has also had something to do with it because infections with bacmolytic streptococci used to be common and fatal complications of the disease WHOOPING COUCH Creighton* says that there is singularly little reference to whooping cough in carly medical writings and suggests that a possible reason may be that it was generally left to the maanagement of parents and nurses and also that it may have been thought of as a complication of other diseases rather than as a disease in its own night There is however a refer ence to the kink in a medieval prescription book The first medical description ofanepidemic was that given by Baillout of Paris in 1578 Sydenhamt mentions it under the name pertussis whuch we call hooping cough but always in as sociation with another disease in one instance with measles and in another with influenza There is one description written by a mother to her husband in 1661 which will arouse a little wave of sympathy in the heart of any modern parent who has nursed a child through the disease I am in a sad condition for my poor children who are all so trobled with the chancofe that I am afraid it will kill them There is many dye out in this town and many abroad that we hearc of I am fane to have a candell stand by me to goo • C. Craghton 1874 † Baillous of Parul 1578 T Sydenham 1676 ·EPIDEMIC DISEASES in too them when the fitt comes 'In a later letter follas much the worst They have such fits that it stopes theare wind and puts me to such fits and feares that I am not myselfc In a thurd letter the children are said to be better and the mother asks her husband to bring a paper of lozenges for them It seems clear that in the seventeenth century whooping cough as a common and distressing malady of children just as it is now, but as a cause of death it was overshadowed by other diseases, particularly by small pox and so did not attract much notice from doctors In the Bills of Mortality hooping cough and chincough' do not achieve a separate heading until 1701 and for fifteen years the deaths returned are only units in 1715 they rise to tens and by the end of the century are counted in hun dreds – in 1780 for example 573 deaths were ascribed to hooping cough It seems probable that in the early part of the century many deaths really due to whooping cough were returned under the indefinite heading of convulsions In the carly years of the nineteenth century measles and whooping cough together began to replace smallpox as the principal killing discase of young children in Glasgow, Robert Watt* demonstrated this by a painstaking examina tion of the Parish Registers and published his findings as an appendix to his Treatise on the History, Nature, and Treat ment of Chincough Although in most years smallpor killed fewer children than measles and whooping cough it sull surpassed them from time to time when it became epidemic In the first six months of registration in England and Wales the deaths from the principal causes of death among chil dren were as follows Convulsions 10 729 Smallpox Measles 4 732 Whooping-cough 3004 Scarlatina 2 550 An epidemic of smallpox was just beginning at this time but had not reached its full force in London In London in contrast with the rest of England and Wales the number * Robert tatt 1813 104 5 811 ·MEASLES AYD WHOOPINO COUCHI of deaths frora measles and from whooping-cough separately greatly exceeded the number of deaths from smallpox The trend of mortality from whooping cough in children under Sficen from 1851 to 1955 as shown in Figure 14 From r851 to 188a at altered little and was rather higher than that of measles but u began to declnc rather tarlier than did the death rate of measles and ss the quinquennum 1886-90 # fell below that of measles and remained below until the quinquennium 1931-5 Since then now onc disease and now the other has been the more important the scla tave importance depending chicfly on incidence Of latc years the death rasc of whooping-cough has been consistently higher than that of measles but in 1955 2t was the same that 24 per million lying under 15 Tht actual mutaber of deaths attributed to measles in 1955 was 576 and to whooping-cough 88 but a higher proportion of the deaths from whooping cough occurred in infants under a year old The same influences which have led to the decline of mortality from measles have sesulted in the decline of mor tality from whooping cough As we have seen mortality from whooping cough began to fall rather carker than that of measles and it may be that thus is due to the fact that whooping-cough tends to have its highest mortality at a rather younger age than measles in 1931 mortality from whooping cough of babies one ycar old was very much sugher in children of social class V is the RG slowest social grade) The difference was nearly but not quite as great as in the case of measles It would be interesting to be able to trace the history of the case fatality (deaths and notifications) of these tno discases furthes back than 1980 but unfortunately they were not generally noufable belore then In 1940 one in every seventy cases of whooping cough died in 195.) only one death occurred for every Func hundred cases The recent history of death rates for whoop ing cough and measles (Figure 14) shows that the trend in recent years has been similar for both diseases. The fall has been particularly steep since 1947 and thus inay have been due to the more effective treatment of complicauons by penicillm and other antibiotics There u no sign in the 105 ·EPIDEMIC DISEASES for regarding these fevers as any one of a number of other diseases with typhus perhaps the most probable On the whole, therefore it is an interesting but unproft able exercise to spend much time on the early history of the epidemic diseases of the central nervous system, and in the study of individual diseases the starting point will be the first modern description From time to time there has been confusion between the three diseases, and indeed between them and other diseases 301 Men ngococcal mening is on Poliomyelitis Encephalt s letha gca 20 1 TO Anne 1910 1920 1930 1940 19 0 1955 16 Norfuations of epidemic diseases of the central nervous sv tomt in Englad and Wales per roo ooo of the population 1913-55 For example when widespread cpidemics of poliomyelitis began in 1910 and 191 they were at first mistaken for epidemics of cerebrospinal fever and when encephalius lethargica appeared in 1918 it was mistaken for a severe form of food poisoning known as botulism which also affects the central nervous system Clear cut cases of these diseases are not difficult to distinguish one from another but there are many atypical cases in which it is difficult to make an exact diagnosis For these reasons statistics are in cvitably incact They do however give a general picture 108 ·THE CENTRAL NERVOUS SYSTEM of swedence and mortality which reasonably accurate (Figure 56) In all three diseases the number of persons who become infected with the causal organum far exceeds the number who develop obvious disease The bacterologists have shown that this a true of cerebrospinal (ever and poliomyelitis but 45 the organism which causes encephaltus lethargica has never been duectly demonstrated the theory that healthy carners are important rests only on analogy with the other discases Healthy carriers and patients with muld and atypical disease are of course important reservoirs of infec tion in many epidemse diseases but they are particularly important in the epidemic diseases of the central ners ous system CEREBROSPINAL FEVER Cerebrospinal fever (sposted fever meningococcal mersin gitus) u an acute inflammation of the membrancous cover ings of the brain caused by a bean shaped organism which is usually found in pairs within the cells in the cerebrospinal fluid The meningococcus was discovered by Wechselbaum ta 1887 but the descasc had been distinguished clinically long before though it may have been confused with meras gotes due to other organums The mam symptoms and signs are intense headache vomiting high temperature and suffness of the neck so severe that the head becomes bent backwards by the spasm of the muscles and as held in that position These are signs and symptoms of any form of acute meningitis and the final diagnosu depends on examunation of the cerebrospinal flud It so happetas konever that epidemics of very acute meningitis are always due to the meningococcus and we can assume that those described before bactenological confirmation was possible were cere brospinal fever The meningococcus as found in the secre trons from the nose of perfectly healthy people parucularly s time of epidemic and it seems that the disease cerebrospsal ſeves us a rart manfestation of infecuon with the meningococcus A. Meschselbaum 1887 1og ·EPIDEMIC DISEASES for regarding these fevers as any one of a number of other diseases with typhus perhaps the most probable On the whole therefore, it is an interesting but unprofit able exercise to spend much time on the early history of the epidemic diseases of the central nervous system and in the study of individual diseases the starting point will be the first modern description From time to time there has been confusion between the three diseases and indeed between them and other discases 301 Men ngococcal me i gits Polomyelts E cephalt s letharga . + 202 11 10 A 1940 1910 1920 1930 1950 1955 16 Not fications of epidem e diseases of the central nertous system in England and I cles per 100 000 of the population, 1913-55 For example when widespread cpidemics of poliomyelitis began in 1910 and 1991 they were at first mistaken for epidemics of cerebrospinal fever and when encephalitus lethargica appeared in 1918 it was mistaken for a sciere form of food poisoning known as botulism which also affects the central nervous system Clear-cut cases of these diseases are not difficult to distinguish one from another but there are many atypical c35cs in which it is difficult to make an exact diagnosis for these reasons statistics are in cvitably inexact They do however give a general picture 108 ·THE CENTRAL NERVOUS SYSTEM and there was a rapid falling off in subsequent years so that by 1922 annual notifications had reverted to the usual en demic leve] In this cpidemuc the proportion of cases was greater in the services than in the civilian populauon and the disease was commones among recruits than among Seasoned troops Glover and others showed that in over crowded barrackswfiere casesof cerebrospinal fevts occurred the appearance of obnous cases of discase was preceded by a rise in the number of healthy carriers of the menungan coccus Sometimes as many as 60 per cent of the troops in a barracks marght be harbouring meningococci in the nose and throat whercas the incidence of obvious disease was under 1 per cent Between the World Wars the level of incidence remained fairly constant except for a period of activity in the years 1935-3 but in the first winter (1939-40) of the Second World War there was a recrudescence of activity very like that of the first but on a larger scale in the year 1940 notifications were 11 185 for cwvilians and 1 586 for non cinthians The chief differences between the cpidemics of the two World Wars were that in the first it was the services such werechiefly affected whicreasin abe second it was the civilian population and in the second War the fataluy of the disease was much less than it had been because the sulpha drugo whuch had come into general use about 1938 were effective in treatment It is impossible to be quite sure that the cpu demic of 2940-3 was much larger than that of 1915-18 because it is likely that ascertainment was more complete in the latcr period The difference between the number of cases in the two cpidemics is howeser considerablc and is probably too big to be accounted for purely by better diag nos In the epidemic of 1914-18 there were about 10 700 cases in England and Wales whereas in that of 1939443 there were about 34 700 but in the earlser epidemic 4 136 deaths were among civilians whereas in the later one the number of deaths was 6 g16 representing a much lower case fatality 20 per cent against 39 per cent in recent years wher meningococcal infections have been endemic rather ·EPIDEMIC DISEASES The first identifiable description of an epidemic was given by Viesseux* and related to an epidemic at Geneva in 1805 though as has been said, it is not certain whether or no some of the 'nervous' fevers described by the physicians of the Restoration period may have been cerebrospinal feser In the early stages of its history it was noticed that the disease tended to be associated with troops living in over crowded barracks There were several examples of this among the French garrisons in the Napoleonic wars Herscht writing in 1886 divided the history of the disease in the world as a whole into four periods (1) 1805-30, (2) 1837-50 (3) 1854-75 (4) 1876-86 but apart from two rather doubt ful small epidemics in England one on Dartmoor in 1807, and one at Sunderland in 1830 it did not affect that country until 1865 and even then not very much In writing about this period Simon medical officer of the Privy Council, describes cerebrospinal fever as a disease whuch we in England had hitherto hardly heard named and which on the continent had but recently been identified He went on to say that there had been about 1,000 deaths from it in Danzig in three or four months From 1865 onwards cases began to be reported in the medical press and from time to time localized outbreaks occurred in widely scattered places Some of these carly out breaks were confused with outbreaks of poliomyelitis which was also on the increase in the early years of the twentieth century The distinguishing features of the two diseases were at this time well known to neurologists but not so well known to doctors in general In 1912 cerebrospinal fever and poliomyelitis became notifiable all over the country, and from 1914 to 1918 there was an epidemic of cerebrospinal fever which was much larger and more widespread than anything which had gone before This epidemic of the First World War, which began in the winter of 1914-15 was associated with outbreaks in army camps particularly those on Salisbury Plain where the first contingent of Canadian troops was quartered The largest number of cases occurred in the first ycar (winter 1914-15) * M Viesseux 1805 A. Hirsch 1833-6 ITO ·ILLE. CENTRAL NERVOUS SYSTEM ducise to monkeys and from that time until recently the only method for the detection of most strains of virus was by the inoculation of monkeys Recently Enders' and his co3leagues have succeeded in growing poliomyelitus viruscs in cultures of living tissues a technique which enormously enlarge the scope of the laboratory investigation of the disease These viruses have variable cffects on different people They can produce anything from a severe and rapidly fatal allness to a carner state with no symptoms at all and st is generally bebered that the paralysis which is the distinctive feature of the ducast w a comparatively rare result of infec tion that the so-called non paralytic cascs far outnumber the paralytse and that the healthy camers outnumber the non paralytic cascs There is however sorte controversy as to the relative proporuons of paralytic and non paralytic cases and of healthy carriers which occur in human popula trons during epidemics Some believe that nearly everyone becomes infected at some time in his or her life whereas others believe that the distnbution of the virus as restricted to those in close contact with known cases Why some develop paralysis when they become infected with the virus whereas others develop a mild febrle illness or no illness at all is unknown although some people have acquired im munsty from single or repeated exposures to infections which have beers insufficient to produce discase In terms of whole populations this factor of silent immunization has been pur forward as the explanation for the relative freedom of popu lacions living under primutive conditions from dramatic epi demcs of polsomychitis The theory is that such populations are so lo speak, salted and so acquire immunity at an carly age In England and indeed throughout the world authentic records of epidemics of poliomyelius are historically very recent In England there is a record by Badhamt of four cases among children in the small town of Yorksop Notting hamshire in the late summer and autumn of 1834 and after that there is a long interval in which no groups of cases nert J F Enders 1953 13 Badham 1837 ng ·EPIDEMIC DISEASES than epidemic there have been about 1 300 cases a star with about 300 deaths but these national figures g1 c a rather gloomy picture of the normal fatality of the disease because the deaths usually occur in the atypical cases where the interval between onset and death us only a few hours Treatment with sulpha drugs and penicillin 5 cfcctue of Started carly enough and in some hospitals the case mor tality is now very low The general epidemiological picture of cerebrospinal [ever is that of a disease which has been ondersc in England (or at least a hundred years There have been two cpidemic periods associated with the two World Wars and one lesses epidemic period between them The last epidemic produced the largest number of cases, but the discasc was less fatal than in prevzous ones because new and successful methods of trcatment had been discovered These have now been improved still more and if a diagnosis is made quickly and treatment is started at once parents usually recover No one knows why epidemics occur but it looks as though one of the most important factors is the suddrn aggregation of young adults in overcrowded barracks which occurs at the beginning of a war Possibly the importation of unfamiliar strains of meningococcus by troops from abroad may be important but there is not much evidence of this ANTERIOR POLIOMYELITIS (INFANTILE PARALYSIS) The popular name infantile paralysis no longer gives a truc picture of the usual age incidence of this descasc and so the scientific name anterior poliomyelitis shortened to polo myelitis or cren polo has come so generally into use that It secinus best to call the discase poliomyelses throughout thus section Poliomyelitus 25 an acute infection due to one of the smallest known viruses or rather to a group of viruses of three main types The presence of a sus was dezronsirated by Landsteiner and Popper* in 1903 by transmission of the • E. Popper 1902 I12 ·THE CENTRAL NERVOUS SYSTEM ducase to monkeys and from that time until recently the only method for the detection of most strains of virus was by the inoculation of monkeys Recently Enders* and his colleagucs have succeeded in growing poliomyelitis viruses in cultures of living tissues a technique which enormously chlarges the scope of the laboratory investigation of the disease. These varuses have variable effects on different people They can produce anything from a severe and rapidly fatal illness to a carrier state with no symptoms at all and st is generally believed that the paralysu which is the distinctive feature of the ducase us a comparaincly rare result of inſec tson that the so-called non paralytic cases far outnumber the paralytic and that the healthy carriers outnumber the non paralytic cases There is however some controversy as to the relative proportions of paralytic and non paralytic cases and of healthy carriers which accur in human popula tsons during epideme Some believe that nearly everyone becomes infected at some time in his or her lule whereas others believe that the distribution of the virus is restricted to those in close contact with knows cases Why some develop paralytus when they become infected with the virus whereas others develop a mld febrle illness or no ellness at all is unknown although some people have acquired im riunity from single or repeated exposure to snfections which have been insufficient to produce discase In terms of whole populations this factor of silent immunuzation has been pur forward as the explanation for the relative freedom of popu lations living under primitive conditions from dramatic epi demics of poliomycius The theory is that such populations are so to speak, salted and so acquire immunity at an carly age. In England and indeed throughout the world authenuc records of cpidemics of poliomyelitis arc historically very recent In England there u a record by Badhamt of four cases among children m the small town of Worksop Notting hamshire in the late summer and autumn of 1834 and after that there is a long interval in which no groups of cases were *JF Enders 1953 t Badhana 1834 113 ·EPIDEMIC DISEASES than epidemic there have been about : 300 cases a year with about 300 deaths, but these national figures give a rather gloomy picture of the normal fatality of the discase because the deaths usually occur in the atypical cases where the interval between onset and death is only a few hours. Treatment with sulpha drugs and perucillin us effective started early enough and in some hospitals the case-mor tality is now very low The general epidemiological picture ofcerebrospinal lever is that of a disease which has been cademic in England for at least a hundred years There have been two epidemic periods associated with the two World Wars and one lesser cpidemic penod between them The last epidemic produced the largest number of cases but the disease was less fatal than in previous ones because new and successful methods of treatment had been discovered These have now been improved still more and if a dsagnosis is made quxckly and treatment is started at once patients usually recover No one knows why epidemues occur but it looks as though one of the most important factors is the sudden aggregation of young adults in overcrowded barracks which occurs as the beginning of a war Possibly the importation of unfamiliar strains of meningococcus by troops from abroad may be important but there is not much evidence of this ANTERIOR POLIOMYELITIS (INFANTILE PARALY8Y8) The popular name infanule paralysis no longer gives a truc pucture of the usual age incidence of this discase and so the scientific name anterior poliomyelitzs shortened to polomyelitis or even polio has come so generally into use that at sccms best to call the disease poliomyelitis throughout thus section Polomyelitis u an acute infection duc to one of the smallest known vinuscs or rather to a group of viruses of three main types The presence of a virus was demonstrated by Landstener and Popper* in 1908 by transmission of the * E Popper 1908 ·THE CENTRAL NERVOUS SYSTEM certain other countries notably in North America and Scandinavia la the years of hugh prevalence epidemics were localized in the sense that some counties and cities had dramatic outbrcaks but in addition many other places experienced a slight increase in the number of cases There were a few exceptions to thus general pattern when only one or two districts had a sharp epidemic in a year while the country as a whole had a year of low incidence In the total number of cases notified rose suddenly to 7 776 as compared with the previous highest figure of 1,489 in 1938 But the general pattern of distribution in 1947 was not very different in type from that of previous years Once agam there were centres of epidemic dissemination with an in creased prevalence in many other places The change seems to have been quanutatne rather than qualitauve Since 1947 the general level of incidence has been much higher than ever before and even the years of low prevalence for example 1948 hase outstripped the years of highese Pre valcace before the Second World War From the historical point of view the most interesing feature about the geographical distribution of poliomyelitis the tendency for epidemucs to recur un certain places sometimes after many years The reasons why an epidermic in arca A in one year should extend into the adjacent arca Bin the next are not difficult to give but why area A should have an epidemuc in say glo and others in 1996 and 1938 not easy to explain it weren more difficult to see why when A has had an epidemic in 1910 B the arca moda ately adjacent should have one perhaps thenty years later And yet thus type of thing seems to have happened oftener than can be explaned by pure chance The problem has been examined in detail for the period between the wars by Professor Bradford Hull and the author has added a foot note covering the epidemic wave before the First World War Clearly recurrences in these periods art sore impresfive as evidence than recent experience because prevalence has been so widespread suoce 1917 that it would be possible to find snstances of recurrence almost anywhere in the A. Bradle dil 1947 515 ·BPIDEMIC DISEASES reported Throughout the nineteenth century single cases were often shown at medical meetings and knowledge of the disease gradually became more general but it was only in the last two decades of the century that groups of cases began to be reported in various parts of the world In the late summer of 18gr there was a group of cases of paralysu among children in and acar the town of Market Rasen in Lincolnshire This outbreak was descnbed by the medical officer of health in a report which is in the archives of the Local Government Board (now the Ministry of Health) At the time this was thought to be an outbreak of cerebrospinal ferer but there are good reasons for believing that seventeen children who fell ilt in the period June to October 1897 really had poliomyelitis All of them had some degree of paralysis but only two died This incident is of particular interest because if it was poliomyelits and not cerebrospinal fever this is the first authentic epidemuc in England In the ninetics there are several reports from neurologists of small groups of cases and in the first decade of the twentieth cen tury there are indicauons that the disease was on the in crease in big cities in 1908 there was an outbreak of eight cases in the village of Upminster Esser followed in 1909 by thirty seven cases in Bristol In the years immediately preceding the First World War and particularly in 1912 there was an epidemic wave which affected widely scattered areas in the country In 1910 for example the parts chsefly affected were Leicestershire and the north west coast (Carlisle eta and Barrow in Furness) whereas in 1991 a widespread prevalence was identified with particularly hugh incidence in parts of Devon and Cornwall East Anglia Westmorland Birmungham and in the West Ridmg of Yorkshire During the early years of the First World War httle was heard of poliomyelitis but in 1917 the reports of epidemics began again and thereafter up to 1946 the annual reports of the Chief Medical Officer of the Ministry of Health usualy sncluded a record of an epidemic somewhere in the country Between the World Wars two years 1926 and 1938 were outstanding but even in thesc the incidence was never on the scale of that experienced in 114 ·THE CENTRAL NERVOUS SYSTEM extensive trals of a vaccine prepared from virus killed by formalın have proved the value of the vacaine The method of control by actose immunization is although not giving complete protection the only one which seems likely to be effective because the spread of VIU 23 so often an unseen and therefore uncontrollable affair Unul 1947 England had been fortunate in us experience of epidemic poliorny clatus in comparison with the Scandin avian counines and with North America but since then the attack rates have been much higher than ever before and at present they show no sign of falling to the levels obtaining before 1947 LYCEPHALITIS LETHARCICA Frora the hustoncal point of view epidemic encephalitis lethargıca has so far been a rusic-days wonder Whether it was a discase entirely new to Englasd when it appeared in 1918 u uncertain but the epidemic which began then and petered out about 1930 was certainly unique in authentic hastoncal records After the epidemic period a few cases of cocephalstus lethargica were still notified every year but there u considerable doubt whether these were really cases of the same disease or whether they were other forms of encephalitis It us difficult to distinguish between different kands of encephalitus from signs and symptoms and the causal organism of encephalitis lethargica has never been demonstrated though in other parts of the world several asuses which cause cacephaltus have been discovered Encephalssss lethargica » assumed to be due to a virus because of its analogies with other forms of encephalitas due to viruses and because so larger organism has ever been found The chuel symptoms and signs noticed in the carly casts seen in London and in Sheffield in March and Apnl 1918 were lethargy with paralysis of cranial serves particularly of the nerves working the muscles of the cyes but the syraptoms of onset were varsable One of the most distressing fcatures of the disease was that permanent mental changes 117 ·EPIDEMIC DISEASES country It us however interesting that some of the places which were affected carly in 1947 had been the scene of considerable cpidemics in the past Poliomyelitis is no longer a disease of infants in England or indeed in any of the countnes of Western cuilization, We have somewhat meagre records of the age distribution of cases before 1944 but there can be no doubt that the proportion of older children and adults attacked in recent ycars has been much higher than it was in the early epi demics In 1947 about one third of all cases occurred among chldren under five about one third in children from five to fourteen and about one third in persons aged fifteen and over Children are still more suscepuble to the disease, but if adults do contract it they tend to have severe attacks In all parts of the world poliomyelitis tends to occur in the wartre months of the year but of recent years in England cases scem to have occurred more commonly kn the colder months than was previously normal, and there have been instances of definite winter epidemics in other To the student of preventive medicine polomyelius appears at first seght to be a thoroughly per crse discase The greatest cpidemics have occurred in countries with relately high scandards of living and the discase seems to be just as commos and as fatal among members of the higher social classes as among those of the lower It has een been sug gested from time to time that members of the higher social classes suffer more though this view rests on impressions rather than on definite evidence the usually accepted ex planation for this appareat perversity has already been mentioned it is that the population with relatively low hygienic standards becomes salted whereas that with high standards does not From time to time attempts have been made to protect individuals against poliomyelitis by passive or active im munization but in the monkey era of laboratory work they were completely unsuccessfu? Recently the introduc tions of methods for the culture of virus on living ussues revived interest in the problem of actist immunizatios and countrics ·II MALARIA AND YELLOW FEVER MALARIA and yellow fever are now generally regarded as tropical or at least hot country diseases but formerly neither discase was confined to the tropics Malaria had a wide distribution in marshy places throughout the world and was at one time quite important in England Yellow lever caused some devastating epidemics in the United States in the eighteenth century of which that in Philadel phia in 1793 15 a well known example Though it never became very important in England there was one little outbreak in 1865 which will be described because of its interest as an epidemiological freak MALARIA In the world as a whole malaria is still probably the most important communicable disease not so much from the aspect of the number of deaths it causes but because of the amount of chronic ill health which results In England indigenous malaria is now of no importance at all but occasionally a single case of the disease apparently con tracted in that country is reported in the medical press as a curiosity The disease is due to a group of protozoa and the different members of the group produce slightly different symptoms These protozoa have complicated life histories and are carried from the infected person to the uninfected by anopheline mosquitoes Laveran * a French army surgeon discovered the protozoa in the blood of infected patients in 1880 and Rosst demonstrated the truth which had long been suspected that the protozoa were carried by mos quitoes and that they completed a stage of their complicated C.A.L. Laveran 1880 | R. Ross 1923 119 ·EPIDEMIC DISEASES werc apt to occur and another permanent effect was a con dition resembling paralysts agitans In 1978 the disease was reported in fifty one widely separated districts in England and Wales The history of notifications as shown in Figure 16 The year 1924 was the year of hughest inadence with just over 5000 notifications and after that there was a gradual decline The duscase attacked people of all ages and of both sexes and was commoner in the great centres of populatson than in rural areas The first quarter of the year shossed the hughest number of notifications with a gradual falling of in the second and turd quarters whereas in the fourth inadence began to rise again In most instances there was Rattle evidence of case to case infection but there were strik ing exceptions to this rule notably an outbrcak in a home for girls at Derby in 1919 in włuch twelve cases with five deaths occurred among twenty two residents There appeared to be no conneuon between lability to attack and social conditions The epidemiological behaviour of encephaltis lcthargica and poliomyelitis exhibits many szularities The same unde distributon of cases with occasional dramatic localized out breaks is typical but the age duimbution and the scasonal distribution are quite different The epidemic foren of en cephalus lethargica has now disappeared from the records but no one can tell whether the story is ended or s to be continued ·MALARIA AND YELLOW FEVER Channel coast near Bridgwater Except in the Isle of Shep- Pey it was generally agreed that the amount of discasc had declined very much in the twenty years preceding 1860 By the beginning of the twentieth century indigenous malaria had practically disappeared from England but the two World Wars aroused fears of a possible recrudescence In both large numbers of infected service men arnved back in the country and mosquitoes which could carry the diseasc were not uncommon There was therefore a theo retical danger that the disease might become endemc in the marshy districts once again YELLOW FEVER Yellow fever ( Yellow Jack ) is caused by a virus camned by certain species of mosquito of which Aedes aegyptt is the most important An attack of the disease confers a long lasting imunity and in areas where the disease is endemic the native population has considerable herd unmunity An effec tive vaccine is now available for protection against the disease At the present time the disease is confined to the west coast of Africa and to parts of South America but in the seventeenth cighteenth and nineteenth centuries there were many serious epidemics in the ports of the eastern sea board of North America extending as far north as Halıfax Nova Scotia (epidemic in 1861) In Europe there were epidemics in Spain and Portugal in the eighteenth and nine teenth centuries but in England though ships have often arrived with cases aboard the disease has spread from a ship to the inhabitants of a port on only one occasion - in Swansea in 1865 This epidemiological curiosity is of suffi cient interest to deserve a detailed description The small barque Hecla left Cuba on 26 July 1865 On the voyage several of the crew of ten fell ill, and when she arrived at Swansca on 9 September one seaman was dying and two were convalescent The Hecla was moored next to a small vessel called the Eleanor and in the ensuing weeks twenty inhabitants of Swansea and three other members of the crew of the Eleanor developed yellow fever Fifteen of those 121 ·EPIDEMIC DISEASES life history within the body of the mosquito These funda mental discoveries have been enormously important from the point of view of control in tropical countries, and the applied science of malariology has grown up and is con cerned with the peculiarities of the different parasites the ecology of the various anopheline mosquitoes and the de vising of methods for their destruction From the parochial point of view it is however salutary to remember that these fundamental discoveries had nothing to do with the disappearance of indigenous malaria from England It had gone before the discoveries were made as a result of social change which was not directed specifically to the control of malaria The early history of malaria in England is lost in a con fusion of names Creighton* points out that originally the word ague, which later became the popular name for malana did not mean a paroxysmal or intermittent fever but inerely an acute one Sydenhamt frequently uses the term ague to describe various epidemics of febrile diseases but he makes only one reference to marsh agues This single reference is in his essay on hysteria where he interpolates the remark that the blood of a person who has spent two or three days in a locality of marshes and lakes is in the first Instance impressed with a certain spirituous miasma which produces quartan ague It is clear that Sydenham and hus contemporaries knew of the endemic ague of marshy districts, but did not regard it as of much importance in comparison with all the other acute fevers which came in epidemics all over England We have to wait until Sunon si tenure of office under the Privy Council for any serious attempt to estimate the pre valence of malaria in England In Simons sixth report (P 430) there is a section by Dr G Whatley on the prevalence of ague and other inalarious conditions in the marshy districts of England He found that the Isle of Sheppey was the chief focus of the disease, but that there was still some in the Fen country and in the marshy districts of the Bristol • Creighton 1894 † T Sydenham 1676 John Simon 1860 120 ·12 TUBERCULOSIS TUBERCULOSIS u different from the diseases considered so far in that st has never been epidemic in Britain in the sense of being much more prevalent at one time than at another It has however been an important cause of death throughout the period covered by this book and probably for much longer The disease is caused by Mycobacterium tuberculosis discovered by Robert Koch* (1843-1910) in 1882 and two types the human and the bovine cause disease in man Many different organs can be affected but disease of the lungs is by far the most common form and the easiest to trace in historical records Laennec (1781-1826) the French physician who invented the stethoscope recognized the essential unity of tuberculosis of different organs but the final proof of this unity did not come until Koch s discovery of the tubercle bacıllus and so earlier statistical records of forms of tuberculosis other than respiratory are particularly suspect because of difficulties of classification and confusion with other diseases In considering the early history of tuberculosis it is better to confine the discussion to disease of the lungs than to attempt a review of all forms of the disease PULMONARY TUBERCULOSIS EARLY HISTORY The earliest medical books by English physicians about pulmonary tuberculosis (consumption phthisis) were wat ten in the seventeenth century In thus century Christopher Bennett (1617-55) Thomas Willis (1621-75) Thomas Sy denhamn (1624-89), and Richard Morton (1639-98) all R koch 1882 123 ·EPIDEMIC DISEASES attacked died The three members of the crew of the Eleanor actually developed the disease at Llanclly The weather at thu time was extremely hot with temperatures of Bo to go F in the sun and 70 to 80 in the shade This unique experience has a little relevance to the present day since the aeroplane has brought the tropies to our door step and it is always a possibility that a person in the in cubation stage of yellow fever may arrive and develop the disease in England We must remember honever that the Swansea incident is unique and happened long before the part played by mosquitoes in carrying the discase was known Nowadays strict precauhons are taken against the importa tion of infected mosquitoes and there are also strict rules about the vaccination of travellers Perhaps the greatest safeguard is the fact that England seems to be a most un favourable soul for the propagauon of epidemics of yellow ſever In the days before much was known about the disease there must have been many undetected importatsons of Yellow Jack particularly from the West Indies and yet so far as we know the Swansea outbreak as the only occasion on which the disease spread to the native population and that to a very lirated extent ·TUBERCULOSIS causes The crude death rate for the quinquennial period 1838-42 was 3 880 per million There is a gap in the status tical record in the forties because the number of deaths by causc was not abstracted for the years 1843-6 The figures for the years 1851--5 suggest however that there was a slow fall in the death rate in the fortes In this quinquennium (1891-5) the total number of deaths averaged about 400 000 a year and those from tuberculosis of the lungs amounted to about st ooo a year The crude death rate for the years 1851 1856 181 e66 T 1876 1821 1886 1891 59 1901 1906 1911 1914 1921 1936 193 1936 1941 194 1951 +55 1B50 865 1870 187 $20 1895 1890 1895 1900 905 1910 1919 1920 1925 1970 1935 1940 945 1950 954 17 Compara! morlal by index showing trend of respiratory berculons England and Wale 1851–1954 (1938=1) 1851-5 was 2 851 per million. The trend of mortality from 1857 to 1954 is shown in Figure 17 This graph is derived from table sıx of the Registrar General s Statistical Redtem (Part I) 1954 In this table he gives comparative mortality indexes for quinquennial periods from 1851-5 to 1931-5 for the four year period 1936-9 immediately preceding the outbreak of the Second World War and subsequently for the quinquennual periods 1940-4 to 1950-4 The base year for all comparative mortality indexes is the year 1938 which is taken as unuty Thus mortality in 1851-5 was nearly sex times what it was in 1938 whereas in 1950-4 it was o 25 125 ·EPIDEMIC DISEASES either wrote whole books about the disease or desoled chapters cost in general text books Morton 3 book, Phthard logia published in 1688 was the most comprehensive and important of these contributions Much of the theoretical matter in these books is now out of date but the descrita tions of cases make it clear that the authors were in the mam writing about tuberculosis of the lungs as we know it today that the disease was common and that it was an Important cause of death The Bulls of Mortality confirm this, for in most years between fifteen and twenty per cent of all deaths in London were returned under the heading consumption In plague years parucularly in 1665 the proportion was much lower because the deaths from plague were so many Brownlee reviewed the evidence of the Bills for the whole penod 1629-1838 during which causes of death were des tinguished He came to the conclusion that there was an Increase in the death rate frora pulmonary tuberculosis an London in the eighteenth century which culminated about 1800 and that there was a slow fall in mortality from then on For the statistical period (1838 onwards) this fall is well authenticated but the statistics of the earlier perod are 100 doubtful to make it more than a probability for the country as a whole there are no statistics before 1838 but the growth of towns through immigration from the country districts was going on rapidly and these ticw aggregation of sus ceptable people must have been favourable soul for the spread of the disease The probability is therefore that the rise in mortality which affected London in the eighteenth century affected the industnal towns even more and probably reached its zenith rather later in ther than in London FROM 1838 TO THE PRESENT DAY The trend of mortality et all ages In the first five complete years of registratson the number of deaths assigned to tuberculosis of the lungs was about 60 000 a year out of a total of some 350 000 deaths from all J Brownlee 1916 ·TUBERCULOSIS times that of 1938 The advantage of using the comparative mortality index (CMI) rather than the crude death rate for a long term study is that the CMI makes allowance for the great changes in the age distribution of the popula tion which have taken place in the last hundred years The recent trend of annual mortality at all ages is shown in Figure 19 which overlaps the long term graph (Figure 18) The effect of the two World Wars is shown more clearly than in the long term graph and the prolongation to 1955 brings out the rapidity of the decline of mortality since 1917 The inde fell from 18 to 1o in the seventeen years 1921-38 and from o 93 to o 25 in the cight years 1947–55 In this last eight years the new druge streptomycin para aminosalicylic acid (PAS) and isoniazid (I NH) have come into general use and therc have been important advances in Surgical treatment Incidence Figure 19 serves as a link between the discussion of mortality and that of incidence The lower curve is virtually the same as the second half of that shown in Figure 18 but in construcung it the absolute numbers of deaths each year have been plotted instead of the comparative mortality indexes The total deaths fell from about 27 000 in 1932 to 20000 in 1947 and 5 837 in 1955 Notifications on the other hand have hardly fallen at all It may be that im proved methods of ascertainment particularly by mass radiography have had some effect in keeping up the num ber of notifications but even allowing for this possibility it seems probable that there has been no decline of incidence comparable to that of mortality Changes in the age and sex distribution of mortality Although mortality at all ages has been falling through out the statistical penod there have been differences in the rate of decline in different age groups For example the rate of mortality among young women which has always been higher than that of young men fell very little between about 1900 and 1932 Recently however the death rates 127

·FALL
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18 Comparatie ma tahty ind for respiratory sube rulon » England and
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126

·TUBERCULOSIS times that of 1938 The advantage of using the comparative mortality index (CMI) rather than the crude death rate for a long term study is that the CMI makes allowance for the great changes in the age distribution of the popula tron wluch have taken place in the last hundred years The recent trend of annual mortality at all ages is shown in Figure 19 which overlaps the long term graph (Figure 18) The effect of the two World Wars is shown more clearly than in the long term graph and the prolongation to 1955 brings out the rapidity of the decline of mortality since 1947 The inder fell from 18 to 1 o in the seventeen years 1921-38 and from 0 93 to 0 25 in the eight years 1947-95 In this last eight years the new drugs streptomycın para aminosalicylic acid (P A.S) and isoniazid (I NH) have come into general use and there have been important advances in surgical treatment Incidence Figure 19 serves as a link between the discussion of mortality and that of incidence The lower curve is virtually the same as the second half of that shown in Ligure 18, but in constructing it the absolute numbers of deaths each year have been plotted instead of the comparative mortality indexes Thc total deaths fell from about 27 000 in 1932 to 20 000 in 1947 and 5 837 in 195, Notifications on the other hand have hardly fallen at all It may be that im proved methods of ascertainment particularly by mass radiography have had somc effect in keeping up the num ber of notifications but even allowing for this possibility at seetns probable that there has bren no decline of incidence comparable to that of mortality Changes in the age and sex distribution of mortality Although mortality at all ages has tren falling through out the statistical period there have been differences in the rate of decline in different apr groups For example the rate of mortality among young women which has always been higher than that of your mon fill very little between about Jen and 11932 Premily, luswever the death rates 127

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126

·TUBERCULOSIS times that of 1938 The advantage of using the comparative mortality index (CMI) rather than the crude death rate for a long term study is that the CMI makes allonance for the great changes in the age distribution of the popula tion which have taken place in the last hundred years The recent trend of annual mortality at all ages is shown in Figure 19 which overlaps the long term graph (Figure 18) The effect of the two World Wars is shown morc clearly than in the long term graph and the prolongation to 1955 brings out the rapidity of the decline of mortality since 1947 The index fell from 18 to 10 in the seventeen years 1921–38 and from o93 to o 25 in the eight years 1947-55 In this last eight years the new drugs streptomycin para aminosalicylic acid (PAS) and isoniazid (IN Hhave come into general use and there have been important advances in surgical treatment Incidence Figure 19 serves as a link between the discussion of tortality and that of incidence The lower curve is virtually the same as the second half of that shown in Figure 18 but in constructing it the absolute numbers of deaths cach ycar have been plotted instead of the comparative mortality indexes The total deaths fell from about 27 000 in 1932 to 20 000 in 1947 and 5 837 in 1955 Noufications on the other hand have hardly fallen at all It may be that im proved methods of ascertainment particularly by mass radiography have had some effect in keeping up the num ber of notifications but even allowing for this possibility it seems probable that there has been no decline of incidence comparable to that of mortality Changes in the age and see distribution of mortality Although mortality at all ages has been falling through out the statistical period there have been differences in the rate of decline in different age groups For example the rate of mortality among young women which has always been higher than that of young men fell very little between about 1900 and 1932 Recently howes or the death rates ·EPIDEMIC DISEASES of young men and young women have been falling very quickly much more rapidly than those of middle agen! people and there has also been a lessening of the different between young men and young women Moders methods of treatment are hughly successful in young adults but less successful in the muddle aged Social Conditions including sccupation The Registrar General s studies of occupational mortality have always shown in tuberculosis a rising gradient from social class 1 (the professzonal classes) to socal class V (us skilled workers) in 1950 according to the analysis of the one per cent sample of the population the standardized mortality of men in social class V was 2 3 umes that of me 2 social class 1 Within the sub-classes mortality was high among members of the armed forces dock la ers and hewers getters of coal It was particularly low in agricultural workers The peculiar dangers of dust containing silicon have long been known, and in the supplement to the thirty fisch report of the Registrar General (years 1861-70) Farr drew attendon to the fact that steel gnnders ran a much greater risk from dust than did those breathung vegetable dusts such as mullers The recognition of this risk has led to a whole send of Acts of Parliament and regulations designed to protect workers in dusty industries and to ensure compensation for Those who do contract disease when working in a dusty atmosphere Though dusts do not themselves cause tuber culosis they may make the lungs more vulnerable to the effects of infection by tubercle bacallus PREVENTION OF TUBERCULOSIS There are three lines of attack up the prevestos of any infectious disease namely I Stamp out the reservou of infection 2 Discourage the vector 3 Protect the individual 23 ·EPIDEMIC DISEASES With tuberculosus all three methods are of value to us and although it is not yet possible to win complete success the amount of success which can be achieved depends on how well they are applied The reservoir of infection in tuberculosis is the so-called open case the patient who has tuberculosis of the lungs and is coughing up lie tubercle bacillus This reservoir may be further considered under two headings (a) The known reservoir of infectors ie the known cases of open pulmonary tuberculosis and treatment at chocs and hospitals in England and Wales the number of these cases in 1955 was estimated to be approximately 20 000 (b) The unknown reservoir of infectors ie unknown cases of open pulmonary tuberculosis still at large amongst the general public It is difficult to give an exact figure for this but if mass radiography experi ence is representative of the whole population there are about 75 000 unsuspected cases of respiratory tuberculosis in the community at any one tirne or onc in every 6oo of the population Where the patient is known and attending regularly for treatment, much can be done to prevent the spread of the disease It is not always possible even with modern drugs to render him not infectious but much can be done to minimize the ruk by instructing him in methods of personal hygiene and disposal of sputum The unknown infector patient is much more dangerous and the finding of such patients is perhaps the most import ant task in the preventive service of today Mass radiography surveys have proved of great value in this respect but there remains a small group of elderly bronchitics whom It is very difficult to persuade to attend Our last line of attack against tuberculosis protecting the individual has been much used in this country in recent years It consists of vaccinating the healthy person with a live but attenuated strain of tubercle bacillus known as the Bacille Calmette Guerin (BCG) 129 ·TUBERCULOSIS Thus vaccine was brought into experimental use as long ago a3 1924 but reccıyed a severe setback in 1930 in the Lubeck disaster where, owing to a mistake in culture chel dren were vaccinated by an actose virulent bacillus and 73 died of tuberculosis The vaccine u now manufactured in an isolated labora for completely separated from any other building and having its own staff The vaccint gives good protection for some five to seves years In England it is used 10 protect all children who have to be in a tuberculous household all nurses and staff of tuberculosis clinics and hospitals and fastly it ss given to school children of fourteen years of age to afford protection in these adolescent years as it is in the late teens when these children first go out into the world that tuberculosis 2 most likely to develop ·13 THE RELATIVE IMPORTANCE OF THE DIFFERENT DISEASES AT DIFFERENT TIMES The characters in this book are diseases and in order that we may see them in relation to one another at different periods of history it is interesung to analyse the deaths by cause in certain years when one or other disease has been at its zenith Thu is a rough and ready method of comparı son which introduces a little more precision into the story than the bare magna mortalitas of the chronicles of the Black Death As we progress through the centuries the picture becomes clearer and the year 1838 when the Bills of Mortality were replaced by proper registration is a most important landmark From then on the figures are far more accurate and comprehensive than they had ever been before 1665 The year ofthe Great Plague is the most convenient starting place because it marks the end of that penod lasting ncarly 300 years during which plague dominated the scene so much that other cpidemic diseases paled into insignificance beside it The complete Bul for 1665 (sce Appendix p 149) gives a total of 97 306 burials whereof of the plague 68 596 The heading wluch comes next numerically is that called ague and feaser with 5 257 burials It seems likely that some of the deaths really due to plague were returned under this heading since the number is considerably swollen in comparison with the figures of other years In 1664 for example there were 1, 453 burials in the Bills and 22,8 of them were ascribed to ague and leaver in the whole period of five years 1660-4 there were some 71 000 bunals noted in the Bulls - only about 2 000 more than the number 131 ·TUBERCULOSIS This vaccine was brought into experimental use as long ago as 1924, but received a severe setback in 1930 in the Lubeck disaster where owing to a mistake in culture chil dren were vaccinated by an active, virulent bacillus and 3 died of tuberculosis The vaccine is now manufactured in an isolated labora tory completely separated from any other building and having its own staff The vaccinc gives good protection for some five to seven years In England it is used to protect all children who have to live in a tuberculous household all nurses and staff of tuberculosis clinics and hospitals and, lastly it is given to school children of fourteen years of age to afford protection in these adolescent years as it is in the late teens when these children first go out into the world that tuberculosis 19 most likely to develop ·DIFFERENT DISEASES AT DIFFERENT TIMES in young children - rather than to an increase in the barth rate Edmonds * writing in the Lancel of 1835-6 made some simple calculations from the Bills of Mortality whuch show that there was a substantial fall in the mortality of young children in London and it seems reasonable to suppose that the fall was even greater in the far healthier countryside 1730-49 1759-69 1770-89 1990-1 Boy 1810-29 15 773 15370 17.474 19 320 23 896 Anoual baptismus (average) Annual deaths of children unders years old (average) Deaths per cent of bapusme 15757 9 685 9003 7979 7530 75 S2 41 32 The rise in the number of baptusitis may seem inconsistent with the statement that there was no great increase in the birth rate in this perod but it must be remembered that London differed from the country as a whole in that it grew not only by natural increase but by immigration from the rest of the country From the strictly medical point of view it is not easy to sec cxactly why the decline of the death rate began when it did There were no great discovenes in the fields of preven Con or of the treatment of discases There was however a little lightening of the shadow's Throughout the second half of the eighteenth century hospitals and dispensaries for the sick poor were being founded by chantable subscrip tions both in London and in the industrial areas which were growing so rapidly Distinguished physicians like Lettsom working at the General Dispensary 10 Aldersgatr Street Clerk of Newcastle Fergjar of Manchester and Cumc of Liverpool were beginning to penetrate into the slums and to write about the horrors which they found there In par ticular they wrote about the prevalence of epidemic typhus which was by this time almost unknown among the more prosperous citizens Social hustorians have laid stress on the T R. Edmonds, 1835 133 ·EPIDEMIC DISEASES ascribed to plague alone in 1665 Never since then has the mortality from an epidemic disease been so overwhelmung Small wonder that a disease which could cause as many deaths in a year as usually occurred in five years from all causes was an ever present shadow over the lives of our ancestors particularly those who lived in London! 1772-1814 The year 1772 is of particular interest because it was the year in which deaths from smallpox in the London Bulls reached their zenith of 3 992 (see Figure 7a) The position of smallpox was however nothing like that of plague in the seventeenth century because deaths from fever' probably chiefly typhus fever were not far behund being 3 207 in 1772 The total number of deaths in the year was 26 053 so that smallpox and fever between them accounted for 28 per cent of the tota The nom lature of discases in the Bills was in some respects archaic even for the eighteenth century, and thus makes it impossible to describe the trend of many diseases The number of deaths from both smallpox and fever almost certainly declined a little in the last thirty years and those from smallpox declined rapidly in the early part of the nineteenth century (see Figure 7b) On the other hand deaths attributed to mcasles and whooping cough increased though it is impossible to be sure whether this was a real increase or due to rather better reporting The whole period of the second half of the eighteenth century is of great general interest because it marked the beginning of the rapid growth of population which lasted throughout the nineteenth century and only began to slow down at the end of the first decade of the twentieth There was no census until 1801 and so carlier statistics of popula tion are to some extent controversial but between 1750 and 1801 (first census) the population of England and Wales probably increased from about 61 millions to about 9 millions and that of London from about 675 000 to about a million It is generally accepted that the increase was duc to a decline in the death rate - particularly the death rate 132 ·DIFFERENT DISEASES AT DIFFERPNT TIMES In the first half of the nineteenth century there were two main trends influencing social conditions the one favour able to the public health and the other unfavourable and the two cancelled one another The layourable factors were chiefly better feeding and more enlightened medicine the unfavourable factor the enormous and uncontrolled growth of the great industrial towns Social conditions in these new towns tended to be worse than those in London since many had no form of local government capable of ensuring even the most elementary standards of public hygiene So far as individual discases were concerned the number of smallpox deaths declined considerably in London (sec Figurr 7b) and probably elsewhere Deaths from fever declined in London and probably increased in the large ports and andustrial towns particularly in I iverpool which received many Irish immigrants Typhus was probably the most important ſever but there can be no doubt that there was typhoid too and in August 1826 Hewett (quoted by Creighton*) of St Georges Hospital published an account of ten fatal cases of a fever which was almost certainly typhoid The common infectious diseases of childhood began to occupy an important place in the London Bills of Mor tality and in the writings of medical men in other cities (cf Wattt in Glasgow) In 1831 there began the first epidemic of Asiatic cholera important enough in itself but even more important in its results because it was the fear of cholera which made people Tcalize how bad sanitary conditions were and so led to the eries of Public Health Acts of which that of 1848 was the first. The events which led up to the Act of 1848 arr not strictly relevant to the history of diseases but mention must be made of the establishment of the General Register Olhce in 1837 and of Chadwick a General Report on the Sanitary Con dilson of the Labouring Population of Great Britain of 1842 The General Register Office collected the facts about fc and death for the whole country and Chadwick s report drove C Creight 1 1894 TR Watt 1813 Sir E Chaduck 1837 ·CPIDEBIC DISEASES contribution which the doctors made to the reduction of the death rate but general social causes must have been important too Throughout the eighteenth century methods of farming were improving rapidly and the reforming land lords were producing food for the growing populations of the towns on land which had hitherto produced enough for the local inhabitants only The quality of food was improv ing because root crops made it possible for farmers to keep their anımals throughout the winter instcad of killing most of them in the autumn These fundamental changes must have improved the diet of the poor and any improvement would reduce the general mortality in particular that of typhus which is pre eminently a disease of famine By modern standards the diet of the poor of the aties was still appalling but we have to compare it with what went before and not with what came after Although the period of sanitary reform came considerably later in the second half of the nineteenth century, there were beginnings towards the end of the esghteenth The sheer discomfort of luring in cities with no proper drunage, water supply, or refuse disposal made clementary improvements essential but con scious efforts to improve the public health by sanitary measures were long delayed For example, up to 1815. was illegal to connect the drains from a house to a public sewer and the houses of the rich had cesspools under the basement Sanitation in the poorer quarters of cities was unspeakably crude Once again however we must make comparisons with what went before and say that there was a little improvement 1819-18 After 1815 the population continued to grow at a rapid rate but the rate of growth was already established and there does not appear to have been any outstanding alteration in the birth or death rates Once the death rate has fallen below the birth rate to any considerable degree a population will continue to grow without any further alteration of rates or even in tpite of a degree of adverse change *M C. Buer 1926 534 ·DIFFERENT DISEASES AT DIFFERENT TIMES stables the growth of cities had created but three names stand out Edwin Chadwick (1800-90) was the ruthless administrator William Farr the reflective student and re search worker while John Simon (1816-1904) comes some where between the two Chadwick s official life from his appointment as an Assistant Commissioner of the Poor Law in 1832 to his compulsory retirement from the General Board of Health in 1854 was relatively short, but his achievement was great and his contribution to the future of public health incalculable Farr was appointed compiler of abstracts to the General Register Office in 1839 and retired in 1879 Thus he was largely responsible for the analysis of the information about life and death in this country for the first forty years of general registration He supplied the ammunition which Chadwick and Simon used in their war against dirt and disease Simon was appointed Medical Officer of Health for the City of London in 1847 and from 1855 to 1876 served the various government de partments which were successively charged with the care of the public health Simon s period of office at the Privy Council (1858-7-) was his golden age In spite of the fact that the legal powers of the Privy Council were limited Simon promoted a number of inquiries into the incidence and mortality of diseases in different districts wluch had an enormous influence in promoting sanitary reform In the supplement to the thirty fifth Annual Report of the Registrar General (1861-70) Farr traced the march of an English generation through life and compared the mortality experience of the healthy districts with that of England as a whole and with that of Liverpool which was then the supreme example of an unhealthy district His table show ing the numbers of children dying under five years of age from various causes is an admirable summary of the relative importance of the principal epidemic diseases in the years 1861-70 The part of Farr s table which relates to epidemic diseases 13 reproduced on p 138 Appalling as the facts revealed in this table were they were not a complete picture There was another indefinite heading in the table - Brain Diseases which included a ·EPIDEMIC DISEASES them home to many influential people who had little adca of how the other half of the world Ined 1848-75 The yearımmediately following the first Public Health Act is an interesting one in which to take another look at the prevailing epidemic diseases of London because cholera u shown at its worst It must be remembered that the Registration Area was much larger than that of the Bills and that the information collected though still defective, was much more complete The Registration Area had a population of 360 000 and 68 755 deaths were registered in the year. Of these deaths 26 243 were ascnbed to the seven principal epidemic diseases Cholera 14 125 Diarrhoea 3 463 (chiefly deaths of infants) Typhus 2 482 (typhoid included with typhus) Whooping cough 2,349 Scarlatına 2 149 (including diphtheria*) Measles 1,151 Smallpox 521 26 243 Some of these figures were understated as deaths of in fants resulting from epidemic discases were often returned under indefinite causes such as convulsions The number of births was 72 612 and of deaths among children under five years of age 24 999 so that if we express the number of deaths under five as a percentagcofthe births as Edmondst did for earlier years (sce table on p 133) we arrive at the figure 34 - not very different from the figure for the years 1810-29 The period between the first Public Health Act of 1848 and the great consolidating Act of 1875 was one of intense activity in the field of preventive medicine Mfany men played important parts in the cleansing of the Augean * It is doubtful whether diphtheria was of any importance at to a time ITR Edmonds 1835 136 ·DIFFERENT DISEASES AT DIFFERENT TIMES stables the growth of cities had created but three names stand out. Cdwin Chadwick (1800-90) was the ruthless administrator Williarn Farr the reflective student and re search worker while John Simon (1816-1904) comes some where between the two Chadwicks official life from his appointment as an Assistant Commissioner of the Poor Law In 1832 to his compulsory retirement from the General Board of Health in 1854 was relatively short but his achievement was great and his contribution to the future of public health incalculable Fart was appointed compiler of abstracts to the General Register Office in 1839 and retired in 1879 Thus he was largely responsible for the analysis of the information about life and death in this country for the first forty years of general registration He supplied the ammunition which Chadwick and Simon used in their war against dirt and disease Simon was appointed Medical Officer of Health for the City of London in 1847 and from 1855 to 1876 served the various government de partments which were successively charged with the care of the public health Simon s period of office at the Privy Council (1858-72) was his golden age In spite of the fact that the legal powers of the Pnvy Council were limited Simon promoted a number of inquiries into the incidence and mortality of diseases in different districts which had an enormous influence in promoting sanitary reform In the supplement to the thirty fifth Annual Report of the Registrar General (1861-70) Farr traced the march of an Englısh generation through life and compared the mortality experience of the healthy districts with that of England as a whole and with that of Liverpool which was then the supreine example of an unhealthy dastrict His table show ing the numbers of children dying under five years of age from various causes is an admirable summary of the relative importance of the principal epidemic diseases in the years 1861-70 The part of Farr s table which relates to epidemic diseases is reproduced on p 138 Appalling as the facts revealed in this table were they were not a complete Picture There was another indefinite heading in the table - Brain Diseases - which included a 197 ·EPIDEMIC DISEASES them home to many influential people who had little idea of how the other half of the world lived 1848-75 The ycarımmediately following the first Public Health Act 19 an interesting one in which to take another look at the prevailing epidemic diseases of London because cholera 13 shown at its worst It must be remembered that the Regis tration Area was much larger than that of the Bills and that the information collected though still defective, was much more complete The Registration Area had a population of 2,360 000 and 68 755 deaths were registered in the scar. Of these deaths 26 243 were ascribed to the seven principal epidemic diseases Cholera 14 125 Diarrhoea 3 463 (chiefly deaths of infants) Typhus 2 482 (typhoid included with typhus) Whooping cough ? 349 Scarlatina 2,149 (including diphtheria*) Measles 1 154 Smallpor 521 26 243 Some of these figures were understated as deaths of in fants resulting from cpidemic discases were often returned under indefinite causes such as convulsions The number of births was 72 612 and of deaths among children under five years of age 24 999 so that if we express the number of deaths under fiveas a percentage of the births as Edmondst did for earlier years (sce table on p 133) we arrive at the figure 34 - not very different from the figure for the years 1810-29 The period between the first Public Health Act of 1848 and the great consolidating Act of 1875 was one of intense activity in the field of preventive medicine Many men played important parts in the cleansing of the Augcan It is doubtful whether d phư cria was of any mportance at th stime TR Edmonds 1835 136 ·DIFFERENT DISEASES AT DIFFERENT TIMES End of London where the new sewage system was not yet completed The last great outbreak of classical smallpox occurred in 1871-2 and in the two years there were 42 000 deaths in England and Wales nearly 10 000 of them in London 1875-1900 In1889-92 there was a pandemic of influenza which affected England chiefly in 1891-2 Ever since then influenza has been an important epidemic disease After 1872 the death rate of smallpox declined rapidly Scarlet fever was the most fatal of the common infectious dueases of childhood at the beginning of the period but at the end of the century measles and whooping-cough came almost cqual first, diphtheria second and scarlet fever last with a death rate less than half that of measles or of whoop ing-cough The death rate and probably the incidence of the enteric fevers (typhoid and paratyphoid) declined between 1871 and 18go and then remained constant unul 1900 The de chine was probably associated with the improvements which were being made in public water supplies These improve ments in the public health affected the mortality of adults and of older children more than they affected that of babies and infant mortality in the quinquennium 1895-1900 was even a little higher than in the decennium 1841--50 In this last quarter of the nineteenth century the new science of bactenology came into its own and discoveries of micro-organisms which cause disease were announced nearly every year At first the discovery of the mucroorganism which caused a disease seemed likely to lead to the effective control of that disease but soon it became cvident that control was not so easy The discovery of the existence of healthy carriers or organisms which could produce disease in others made it obvious that with some diseases the isolation of those who had obvious symptoms only would never prevent spread Studies of immunity which had their origin in Pasteur s work on chicken cholera anthrax and rabies were also Inn ·EPIDEMIC DISEASES large number of deaths of young children from one of the acute infectious discases In the Laverpool distnct there were 49 840 deaths under this headıng Thus in Liverpool ncarly half the children born died before the age of five, and even in the healthy districts just over one sixth died before that Table showing the number of deaths of children under five out of 1 000 000 children born alive (1) ja the healthy districts (?) in all England (3) in the Liverpool district (Based on the returns for the years 1861-70) 6 135 87 099 Healthy Distncts England Liscrpool Deaths from all causes 175 410 263 782 460 370 Smallpor 602 3 331 575 Measles 5257 11 507 25 514 Scarlauna 11 373 17 959 26 818 Diphthena 4 184 2,425 3 395 Whooping-cough 9 650 14 424 32 551 Typhus (with enteric and common fever) 2 807 5,401 9 297 Diarrhoca and dysentery 9 354 20 31 51 911 Cholera 399 I 129 4355 Other zymotic diseases 10 579 12 093 Total zymatic diseases 49 761 77 00g (NB Zymotic diseases was the term roughly equivalent to the modern term Acute Infectious Diseases ) age Farr does not give a detailed table for London but he gives a summary which shows that the figure for deaths from all causes was 304 518 Thus London came between Liverpool and the whole of England Figures for the decennial period provide a good idea of the general level of mortality from epidemic diseases but they do not show how disastrous were the effects of individual epidemics In 1863 and 1873 for example more than 30 000 dcaths were ascribed to scarlet fever and in London alone there were about 6 ooo deaths from this disease in 1869 and in 1870 The last epidemic of cholera was in 1865-6 It was smaller than its predecessors and affected chiefly the East 138

·DIFFERENT DISEASES AT DIFFERENT TIMES
60 000
50 000
40 000
30 000
20 000
10 000
Age 01274 01234 01234 01234 01234
Dia shoes
Pneumonia Bro chtis Whoop ng Measles
cough
90 Draws from diarrhoes pronor & bronctatus whoopins-tough and medias
of children under fex in England and Wale 1911-14 (age oes infants ſom
si hafi l bothday)

·EPIDEMIC DISEASES going on in this period and in 1890 von Behring* (1854- 1917) made an antitoun which was effective in the treat ment of diphthera 1900-1914 The decline in the death rate of diphtheria which beganın the carly part of the twentieth century was probably duc largely to the introduction of antitoxin (see Figure 13) The death rate of the entenc fevers which had remained constant from about 1885 to 1900 also began to fall about 1900 and it seems plausible to suppose that this second fall was associ ated with the greater precision which bacteriology brought to measures of control (see Figure 8) The greatest change in the trend of mortality in the carly twentieth century related however to infants The infant mortality rate had been almost constant at about 150 deaths per thousand live births from the beginning of registration (1838) to 1901 but since then it has declined steadily except for small setbacks in the two World Wars and in 1954 the rate was 25 4 There are many indefinite causes of death in infancy and it is therefore difficult to make valıd general izations about the causes of this decline but general im provements in social conditions and better carc of infants seem to have been more important than advances in methods of treatment The reduction in the size of families may have been important because a school child often brings infec tious discase into its home and many infections are more fatal to babies than they are to older children In the years immediately preceding the outbreak of the First World War the epidemic diseases which had been important causes of death among older children and adults had become relatively unimportant Typhus cholera and smallpox had virtually disappeared the entenc fevers were much less common and scarlet fever though probably as prevalent as ever, was less fatal Influenza was at this time more a nuisance than a serious cause of death Although the death rate of diphtheria had declined slowly, it was the . E von Behring and cricke 1892 140 ·DIFFERENT DISEASES AT DIFFERENT TIMES reported in the years 1911–13 In this period the disease chiefly attacked children under five and so its popular name of infanule paralysis was an appropriate one As a cause of death it was insignificant in comparison with the common infectious diseases and it was not even mentioned in the report from which the table on p 142 and Figure 20 were taken As a cause of crippling poliomyelius has been important ever since 1910 and it became relatively more prominent as tuberculosis of bones and joints declined 1914-18 In the winter of 1914-15 cerebrospinal feser appeared in certain army camps particularly in those on Salisbury Plain where the first contingent of Canadian troops was quartered In the First World War the disease affected the services morc than civilians and outbreaks were cominoner among recruits than among seasoned troops The outstanding cpi demic of the war years was however that of influenza which began in the early summer of 1918 and reached a climax in the autumn and winter An exact comparison with the great epidemics of earlier years is impossible but anyone who lived through it must remember that nearly everyone had the disease The number of deaths attributed to influenza in the two years 1918–19 was 157 000 but there is no doubt that many deaths really due to influenza were returned under other headings particularly that of pneu monia The deaths ascribed to pneumonia were much higher in these two years than in those preceding or following them Influenza killed at least three times as many people in England and Wales as did the worst epidemic of cholera in 1849 but between 1849 and 1918 the population had increased from about 17 millions to 37 millions The chief feature of the pandemic of 1918-19 was that all over the world the disease was more fatal to those in the prime of life than it had ever been before or has been since In March and April 1918 the first cases of encephalitis lethargica were reported in London and in Sheffield There had been an epidemic of the disease in Vienna in the war years but doctors in England only heard about it after the 143 ·EPIDEMIC DISEASES most important of the common infectious diseases as a cause of death in children of school age The epidemic diseases which affected young children par ticularly were still a serious public health problem and the Local Government Board prepared a series of reports on infant and child mortality in order to emphasize the need for improvements in the child health services One of these dealt with the causes of death among children under five in England and Wales in the four years 1911-14 In this age group there were four diseases or groups of diseases which were major causes of death bronchitis and pneumonia, summer diarrhoea, measles whooping cough There were important differences in mortality in different types of area and in the relative importance of the different diseases in different age groups The following table illustrates the first point and Figure 20 the second England Large Smaller Other Rural London and Wales towns towns towns districts Infant mortality ITO 122 113 104 90 108 Deaths of children under 5 per 1 000 births All causes 164 188 167 152 125 164 Measles 12 15 72 10 6 16 Whooping-cough 8 9 8 8 7 8 Bronchitis and Pneumonia 32 98 32 29 23 33 Diarrhoca 26 32 28 21 15 30 The figures in the London column may be compared with those of Edmonds in the table on page 133 Nearly half the deaths ascribed to summer diarrhoca occurred in one season of one of the four years the excep tionally hot summer of 1911 and so the above table gives an exaggerated impression of the general importance of summer diarrhoea The authors of the report could not know what the future trend of summer diarrhoea would be but in fact the last great epidemic was that of 1971 (see Figure 10) The earliest widespread epidemics of poliomyelitis were 142

·DIFFERENT DISEASES AT DIFFERENT TIMES
two diseases did not change cather and that the decline of
their death rates was entirely due to the fact that they
became less fatal Deaths from measles and whooping cough
are usually caused by complications rather than by the
100
Infant mortal ty
10
A
5-9
1910 15 20 25 30 35
45 50 55
21 De th ales (all causes) of hid en defent groups in E land and
Il els 1911-55 (on logaruhmic paper to fool tate come risors b tren the
raks of dedl not th d fferent a ég oros)

·EPIDEMIC DISEASES end of the war and were at first puzzled by the bizarre symptoms and signs 1979-39 The influenza epidemic of 1891-2 was followed by a prolonged rise in the general level of mortality from the discase, and in the years following that of 1918-19 there was a further step-up The highest rate of the years between the World Wars was recorded in 1929 and after that there was a slow decline of the death rate both in cpidemic and in non epidemic years (see Figure 6) The death rate from the enteric fevers maintained the steady decline which had begun in 1900 Incidence, how ever after a steep fall between 1911 and 1920 shoned no consistent trend in the twenties in the thirties the general level of incidence was lower but was high in 1936 and 1937 chiefly because of the epidemics of typhoid fever in Bourne mouth (1936) and Croydon (1937) Summer diarrhoea of infants had almost disappeared by 1920 but there was a small rise in the infant mortality from this cause in the hot summer of 1921 There were interesting differences between the trends of mortality from the common infectious diseases of childhood At the beginning of the period the death rates of diphtheria measles and whooping cough among children under fifteen were not very different from one another That of scarlet fever was much lower By 1939 mortality from measles and whooping cough had declined so much that diphthena had becomnc easily the most important of the common infectious diseases particularly among children of school age Mortal ity from scarlet fever had declined still further and by 1939 the disease was of no importance as a cause of death From 1911 onu ards national statistics of notifications of diphtheria and scarlet fever were collected and these showed that there was no long term change in the trend of incidence of the two descases Measles and whooping cough were not made notifiable unul 1940 and so there are no national statistics of their incidence between the World Ivars It seems probable, however, that the long term trend of incidence of these 1.44 ·in 1947 DIFFERENT DISEASES AT DIFFERENT TIMES children was temporanly reversed The epidemic of cerebrospinal fever unlike that of the First World War affected the civilian population more than the services The disease was less fatal than it had been because the sulpha drugs were far more effective than any treatment which had been available before. In 1941 the comprehensive scheme for the immunization of children against diphtheria was inaugur ated and in the years since then the discase has almost disappeared The later war years were unesentful and the decline of the death rates of infants and children was even more rapid than it had been before the beginning of the war In 1946 there were no fewer than fifteen importations of severe smallpox and in this and the following year there was an increase in the number of cases to 56 in 1946 and 78 The most important event of 1947 was the sudden and unexplained increase in the prevalence of poliomyelitis At the end of June it became clear that the usual seasonal rise in notifications was much greater than in any previous year and in the week ended 5 July more notifications were received than there had been in the highest weck of 1938 The peak of the epidemic came in the week ended 6 September when 708 cases were notified compared with the previous record of 85 cases in a week in October 1938 In the whole year there were about four and a half times as many cases as in 1938 Since the end of June 1947 poliomyelitis had been the most prominent epidemic disease of England There have been good and bad years but the general level of incidence has been higher than it ever was before and so far there is no sign of a consistent downward trend Since 1948 the Chief Medical Officer of the Ministry of Health has included in his annual report a short section on the noteworthy outbreaks of epidemic diseases in each year A rough analysis of these is of interest in that it gives a general picture of the epidemic situation at the present time in the period there have been two small outbreaks of ty phoid fever and three of paratyphoid Outbreaks of food 147 ·EPIDEMIC DISEASES different age groups of childhood from igm to 1955 The most prominent peaks on the curves of age groups 1-4 and 5-9 are in 1918 and were due to influenza The lesser peaks are most obvious in the curve for age group 1-4 and were all associated with high prevalence of one or more of the acute infections For example, that of 1922 was due to high prevalence of whooping-cough and of measles and that of 1929 to epidemics of whooping cough and influenza In the last years of the war cerebrospinal fever declined and throughout the twenties incidence and mortality remained fairly constant In the carly thirties there was a further period of activity with a peak in the years 1931-2 There was no consistent decline in fatality like that of measles and whooping cough The prevalence of encepha htis lethargica rose to a peak in 1924 and then gradually declined Poliomyehtis occurred throughout the period but the outbreaks were usually scattered and the incidence was never on the same scale as that experienced in the sainc perod in the Scandinavian countries and in North America There were two years of particularly high incidence - 1926 and 1938 - and incidence in 1938 was higher than that in 1926 This discase was not important as a cause of death, but as other crippling diseases declined it became an im portant cause of permanent paralysis of limbs There are no comprehensive statistics of age incidence for the inter war years, but the figures for London suggest that after about 1930 there was a nse in the average age of attack, The chief trends in the inter war years were then, a further decline in the incidence of the enteric fevers a great decline in the fatality of measles whooping cough and scarlet fever, little change in the incidence or severity of cerebrospinal fever and poliomyelitis THE SECOND WORLD WAR AND AFTER In the years 1940 and 1941 there was a sharp rise in the notifications of paratyphoid fever and a small rise in the death rate from this disease In the same years cerebrospinal fever had the highest recorded prevalence since that of 1915 and the favourable trend of death rates of infants and 146 ·35 16 455 426 FO 94 66 APPENDIX A general Bill for this present year, ending the 19 of December 1665 according to the Report made to the KINGS most Excellent Majesty By the Company of Parish Clerks of London &c. Buried Pla Bunted Pla St Albans Woodstreet 200 121 St James Duka place 202 190 St Alhallowes Barking 514 330 St James Garlickhathe 189 118 St Athallowes Breadst St John Bapust 138 83 St Alhallowes Great St John Evangelist 9 St Alhallowes Horula 5 St John Zachane 85 54 St Athallowes Lesse 239 175 Sthatherine Coleman 299 213 St Alhall Lumbardste go 62 St Kathenne Crec-chu. 335 231 St Alhallowes Staining 185 112 St Lawrence lewne 48 St Alhallowes the Wal 300 356 St Lawrence Pountney 214 140 St Alphage 271115 St Leonard Eastchcape 42 27 St And ev Hubbard 71 25 St Leonard Fosterlanc 335 255 St Andrew Vndershaft 274 189 St Magnus Parish 103 60 St Andrew Wardrobe 476 308 St Margaret Lothbury 200 St Anne Aldersgate 282 97 St Margaret Moses 38 25 St Anne Blacke Fners 652 467 St Margar New Fishst 114 66 St Antholins Parush 38 33 St Margarct Pattons 24 St Austins Parish 43 St Mary Abcharch 99 54 St Bart! OL Exchange 73 51 St Mary Ald manbury 181 109 St Bennet Fynch 47 23 St Mary Aldermary 105 75 St Beanet Grace chur 57 41 St Mary le Bow 64 36 St Bennet Pauls Wharf 355 172 St Mary Bothaw 55 30 St Benr et Sherebog St Mary Colechurch 17 6 St Botolph B lungsgate 83 50 St Mary Hall 91 64 Christs Church 653 467 St Mary Mounthaw 56 37 St Christophers 60 St Mary Summerset St Clements Eastcheal 38 St Mary Sta ning 47 St Dons Back-church 78 27 St Mary Wool hurch 65 33 Se Dunstans East 265 550 St Mary Woolnoth 75 38 St Ed nunds Lumbard 70 St Martins Iremonger St Ethelbo ough St Martins Ludgate 196 128 St Fa ths 104 70 St Martins Organs 71 St Fosters 144 105 St Martins Outwitch bo 34 Si Gabr 1 Fen-church 39 St Martins Vintrey 417 349 St George Bot Iphlare 41 27 St Vattbew Fndaystr 14 6 St Gregones by Pauls 375 232 St Maudhns Aukstreet 44 StHuns 108 75 St Mudbous Oldfishstr 176 121 149 49 20 11 I 47 342 262 20 27 21 IL 36 195 106 TIO 69 22 ·EPIDEMIC DISEASES poisoning caused by one or other of the Salmonellae appear in every report and four were selected for special notice Severe smallpox occurred three times and mild smallpox once The other special reports concerned diphtheria and poliomyelitis It is a sign of the times that individual out breaks of diphtheria can be singled out for special notice As recently as 1941 the disease was so common that it would have been impossible for the Chief Medical Officer to select individual outbreaks The special reports on poliomyelitis relate to districts where prevalence was particularly high in a restricted area in the Isle of Wight in 1950 and at Guldford in 1952 These then are the diseases which have been of particular concern to the Ministry of Health in recent years Polomyelitis is the only one of them which has been epidemic in the country as a whole though outbreaks of food poison ing have been more common than they should be The other diseases may be described as rare specimens Fortun ately all of them cause relatively few deaths and all except poliomyelitis can be prevented The production of a vaccine against poliomyelitis gives promise that in the next few years it may be possible to stop the spread of this disease ·APPENDIX Lased sx tk Pesukus in die hand Liberties of Ratuunster Is herms of the Plague 12194 6703 9363 The Told of all the Chinese us The Total of all the Borrals this year Ihrreos of the Plague 9 306 68,96 5257 Jaundies SO 110 227 46 86 2 14 20 7 9 68,95 6 15 Druscases and Casualties thus my Abortve and Sulborne 617 H admouldshot Aged 1545 MovidGallen Ague and Feases Appoplex and Suddenly 116 Impostume Bedrid held by several accidents Blasted 5 Ringt E 198 Bleeding 16 Leprose Eloudy Flux Scowring & Lethargy Flux 785 L ergrowne Burnt and Scaldet 8 leagrom and Iſeadach Calenture Measles 3 Cancer Gangrene and Murthered and Shot Fistula 36 Overlad and Starved Canker and Thrush Palac 113 Chuldbrd 625 Maguc Chrisorms and Inf nts 1238 Plandet Cold and Cough Plurisc Collack and Winde Poysoned 13+ Consumpbon and Tistick Quinste Rickets Convulsson and Voth-t 2034 Distracted Rising of the Lights 5 Rupture Dropsic and Timpany Scurvy Drowned 50 Shingles and Swie pox Execut d Sores Ulcers broken and Fox and Soul Por 635 brused Lamba Found dead in streets Spleen fickts &c. Spotted Feave and French Post 86 Purples Fngtited 33 Stopp ng of the Stomack Gout and Scala 27 Stork and Sarangury Gner 46 Suriet Gaping a thre Guts 1288 Teeth and of Hangd & made away Vomiting thensel 7 Hend 157 ES 35 557 397 34 105 2 1478 25 B2 20 1929 332 1251 2614 5! I ·APPENDIX Buried Pla St Michael Bassishaw 253 164 St Michael Corncbull 104 52 St Mchael Crookedla 179 133 St Michael Queenchi 203 122 St Michael Querne 18 St Michael Royall 152 116 St Michael Woodstreet 122 62 St Mildred Breadstreet 59 26 St Mildred Poultrey 68 46 St Nicholas Acons 46 28 St Micholas Colcabby 1.5 91 St Micholas Olaues 90 62 St Olaves Hart strecte 237 160 Buried Pla St Olaves lewry 54 92 St Olaves Siluerstreet 250 137 St Pancras Soperlane 30 15 St Peters Cheape 61 35 St Peters Corne hall 136 76 St Peters Pauls Wharfe 114 86 St Peters Poore 79 47 St Stevens Colemanst 560 395 St Stevens Walbrooke 344 12 St Swithins 93 56 St Thomas Apostle 163 110 Tnnitie Parish 115 Buried or the 97 Parishes wrthin the walls 15207 Whereof of the Plague 9887 Buried Pla Buned Plt. St Andrew Holbome 3958 3103 St George Southwark 1613 + 60 St Bartholmcw Great 493 344 St Giles Cr gate 8069 4838 St Bartholmcw Lesse 193 239 St Olaves Southwark 4793 2785 St Bridget 2011 1427 St Saviours Southwark 4235 846 Badewell Precinct 230 179 St Sepulchres Pansh St Botolph Aldersgate 997 755 St Thomas Southwark 475 371 St Botolph Algate 4926 4051 Trinity Minones 168 123 St Botolph Bishopsgate 3464 2500 At the Pesthouse St Dunstans West 958 665 4509 2746 159 156 41351 28889 Buried to the 76 Parishes unthout the Halls I'hereof of the Plagus Buried Pla Burud PL St Giles in the Fields 4457 3216 St Magdalens Bermon 1943 1363 Hackney Parish 232 132 St Mary Newington 1272 1004 St Jarnes Clarkenwel 1863 1377 St Mary Ishington 696 392 St Katherines Tower 956 601 St Mary Whitechap 4766 3855 Lambeth Parish 798 537 Rednffe Parish St Leonards Shorditch -669 1949 304 210 Stepney Pansh 8598 6583 Bunted in the 11 out Parishes in Mfuddlesex and Surrey 2855+ Whereas of the Plagge 21420 Bured Pla Buried Pla St Clement Dancs 1969 1319 St Mary Sauoy 303 198 St Paul Covent Garden 408 261 St Margaret Westmin 4710 3742 St Martin in the Field 480.4 -883 Thereof at the Pesthouse 236 150 ·BIBLIOGRAPHY 1 BADHAN J London Vedical Gaustie 15 (1834) 215 2 BAILLOL << Panis 15,& Cated by Creighton see 17 3 BARELT HAMILTON G EH and HINTOY VL. H. C. History of Brisk Vammals London (Gurney & Jackson) 1910-21 4. BATEMAN Thomas Reports on the Diseases of London 1819 5 BZURING E. son and WERNICLE Disch Ned Ische 39 (1892) 873 6 BORDET J and Gencol o Ann Inst Pastew 20 (1906) 731 7 BRADLEY W I MASSEY LOGAN WPD SEMPLE A B BENJAMIN B GRIST NR and HOPL SIXPSON R. E Discussion - Influenza 1951 Proc Royal Society of Al ducine xliv (1951) 789-801 8 BROWNLLE J The History of the Birth and Death Rates in England and Wales taken as a whole from 1570 to the present tune Public Health (1916) 211-22 228-38 9 Buop W Typhmd Feer London 1873 10 Buzu, VL. C. Health Salth and Population in the Early Days of the Industrial Revolution London (Routledge) 1926 11 BULATRODE HT Report on Suspected Pacuronic and Bubonic Plague in East Suffolk and on the Prevalence of Plague In Rodents in Suffolk and Essex Reports and Papers on Suspected Cases of Human Plagut in East Suffolk and on an Epuno of Plague in Rodents (Great Britau Local Govern ment Board) Vol I (1911) 12 BURNET FM Principles of Animal Virolo. New York (Academic Press) 1964 13 CAIUS John 4 Boke of Counseill a gust de Dutrase called the Sleate or S.erating Suknesse London 1552 14 CHADWICK, Sir Edwin. Cerral Report on the Sarilan Condition of the Labowing Population of G eat Britain London (HM SO) 1837 15. CLEWOW F Lancet (20 January 1894) 16 Clowes William. A short and Profitable Treatise on the case of the Dusease Colled Viorbus Gallicus by Uncirons Londoa, 1579 17 CREICHION C A History of Epidemics in B ifau Cambndge University Press 1891 153

·APPENDIX
Males 5114
Christned
Females 4853
In all
9967
Wales 48569
Buned
Females 48737
In all 97306
of the Plague
68592
19009
Increased in the Burials in the 130 Parishes and at the Pest
house this year
Increased of the Plague in the 130 Parishes and at the Pest
house this year
68590

·BIBLIOGRAPHY 42 LOPPLER F Afill. Retchsgesundhalsamt 2 (1884) 421 43 MINISTRY OF HEALT! (a) Reports on Publu Health and Medual Subjects (HUSO) No 81 1937 (b) Prawal Report 1952 4 NICOLLE C. COLOR A. and CONSEIL E Amals of the Institut Paste 25 (1911) 97 43 OILER W Prozciples and Practice of Medicine 1920 46 PENNANT T British Zoology (4 vols ) London (White) 1776-7 47 PŁPY S Pepyss Dany 1825 Deciphered by the Rev John Smith 1659-1639 48 POPPER E Expor therap 2 (1908) 377 49. ROCHE LIMA H da Bel Alen Ischr 53 (1916) 567 50 ROLLESTON J D History of Acule Exanthemalous London (Heinemann) 1937 51 Ross R. Vemoirs urth a full accowl of the Great 1ſalaria Problem and its Solution London (J Murray) 1923 52 SIMON Sir John Report on the Last Tuo Cholera Epidemics of London as affected by the Consumption of Impure War 1856 Second Report (for 1859) by the Medical Officer of the Prey Council London 1860 53 SMITH W ANDREWES CH and LAIDLOW PP Lancet II (1933) 66 54 SNOW John. On the Afode of Commin cation of Cholera 1849 55 SYDENHAM T Observators Medicae - 3rd cd 1676 English translation by R G Latham 56 THOMPSON T Account of Varioloid Epidemic in Scotland 1820 Annals of Influenwa London (Sydenham Society) 1852 57 TREVELYAN GV English Social History 1942 58 V 1ESSEUX M Sur la maladie qui a régne à Genève au prin temps de 1805 7 Med Cher Pharm (Paris) 1805 59 WATT Robert A Treatise on the nature History and Treatment of Chincough to which is subjoined an Ingury into the Relatice Mortality of the Priple Diseases of Chlden Glasgow 1813 60 HZICHSELBAUM A Forische Afed 5 (1887) 573 61 WILLAN R Descript on and Treatment of Cutaneous Diseases 1798-1808 62 WILL18 Thomas Dust be Duge Hagae 1659 63 WOODVILLE Y Reports of a series of Inoculations for the la rola accunse of Coupor London Phillips) 1799 ·BIBLIOGRAPHY 18 DEFOE D Journal of the Place Year 1722 19 DICK G F and Dick G H Journal of American Aledical Assoc 82 (1934) 265 20 EDMONDS TR The Dimunution of the Mortality of Infants in England Lancet Vol I 1833 21 ENDERS JP Proc Soc Exp Bol New Tork 82 (19,3) 100 22 FARR W Annual Reports of the Registrar General 1861-70 23 FOSTER MG Sweating Sickness in Modern Times From Contributions to Medical and Biological Research Dedicated to Si lilliam Osler in honour of his setentieth birthday New York (Paul B Hoeber) 1919 24 FOTIIERCILL J An account of the Sore Throal Attended 2016 Ulcers London 1748 25 GOODALL Charles Bool on History of Infectious Diseases 1661 26 GRAUNT John Observations on Bills of Afortality 1f62 Quoted by Creighton (set 17) 27 GREENHOW E H Deaths by Cautes in Different Areas worked under Simon 28 GREENWOOD L H Epidemus and Croud Diseases Williams and Norgate 1935 29 HANSEN G H A Norsk Mag Lacquidensk 1874 30 HARRIS Walter Acule Diseases of Infants London 1689 31 HEBERDEN W The Mortality of London Med Trans Coll Physicians of London Vol 4 (1813) 103 32 HILL A Bradford Statistics in the Medical Curriculum BM Vol II (1947), 366 33 HIRSCH August Handbuch der historisch geographisch Pathologie 1881 English Translation by C Creighton 1833-6 34 Home F An Enquiry into the Nature Cause and Cure of the Croup Edinburgh 1765 35 HUXHAM John An Essay on Feters 1755 36 JENNER Edward An Inquiry into the Causes and Effects of Lartolae Vaccinde 1798 37 JENNER Sir William Lectures and Essays on Froers and Diph theria 787-79 London 1893 38 hocu R Bal Klin IVschr 19 (1882) 221 39 LAVERAN C.AL Un nous cau parasite trouvé dans le sang de plusieurs malades atteints de fièvre palustre Bull Sac Afed Hop (Paris) **11 (1830) 158-64 49 Lettsox Joha C Medral Memoirs of the General Depensary in London April 1773 to March 1774 41 LISTON Y Glen Vroy Lectures on the Plague B17 I (194) 900 950 997 151 ·BIBLIOGRAPIY 42 LOTFLEX F Vitt Reichsgesundheilsam 2 (1834) 42! 43 MINISTRY OF HEALTH (a) Reports on Public Health and Vedical Subjects (H VSO) No 86 1937 (b) Annual Report 1952 4 NICOLLE C. CONOR A and CONSEIL, E Annals of the Instatsat Paster 25 (1911) 97 45 Oster, W Principles and Practice of Medicine 1920 46 PENNANT T British Zoology (4 vols ) London (Whatr) 17767 47 PxPY S Pepys Diary 1825 Deciphered by the Rev J hn Smith 1659-1699 48 POPPER E Exper therap_2 (1908) 377 49 ROCHE LIKA H da Berl 3 lunsch 3 (19ır), 50 ROLLESTON J D History of Acute Exanthemalmur Imm (Heinemann) 1937 56 Ross R. Vemoirs with a full account of the Great Alalamal roblem and tis Solution London Murray) 1923 52 SIMON Sir John Report on the Last Two Colera 1/Kernice of London as affected by the Consum icon of Im w. Haler 18+ Second Report (for 1859) by the Medical Ofur ting Council London 1860 53 SMITH W ANDREWES CII and I Afrow 15 Lancet II (1933) 66 54 Snow John On the Afade of Communication of Colero 1949 55 SYDENHAM T Observations Aleduras - 3rd od 1696 Irwah translation by R G Latham 56 THOMPSON T Account of Larsoloud I'fuemec in Scotland 18,0 Annals of Influeng London (Sydent am i ty) of a 57 TREVELYAN G M English Social Ilutory 1914 58 Virseux M Sur la maladıc yn a stune antur au prin temps de 1805 I Afed Chu Pham (1 aru) 12, 53 WATT Robert A Treatise on the Nature Ilutory and Treatment of Chincough to slih u subjoined an Inquiry into the Relatie Afort lity of the Principle Diseases of CA Ideen Glasgow 1813 60 WEICHSELIAUM A Forlich Med 5 (1887) 573 61 WILLAN R Description and T calment of Culane us Diseases 1798-1808 62 WILLIS Thomas Diatribe Dune Elogae 1659 63 WOODVILLE M Rets of a Series of Inoculations for the I a solas aceinde or Coup London Phillips) 1799

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·INDEX Ague 120 131 112 143 147 fatal ty In Andrewes C H 42 43 146 symptoms 109 Anterior poliomy bus See Polic Chadwick Sr Edwin 69 135 137 myelitis Chicken pox 14 59 Isiatic cholera Se Cholera Chincofe See Whoop ng-cough Cholera 66-71 77 B2 f causes Bacille Calmette-Guerin (BCG) 68 decl ne 70 f 140 cp 129 demics 67 f 70 135 144 Badham J 113 fatality 136 138 history Baillou of Paris 103 66 f spread of 67 theories Barrett Hamilton EH 38 concerning 69 Baternan Thomas go Clemow D 47 Behring E. von, 140 Clowes Will am 53 Bennett, Christophe 133 Columbus 52 B Ils of Mortalıty the 1928 Corusurption S Tuberculosis 31 55f 63 74 84 ff 99 Convulsions 86 104 136 100 104 124 131 f 133 Cowpox 60 ff 135 136 Cr ghton C 13 26 27 29 36 Black Assuzes the 73 74 75 76 37 44f 51 53 54 ff 6 Black Death the 19 25 ff 37 49 63 64 66 67 84 ff 91 103 131 120 133 Bordet J 99 Croup S&D phth rua Botulism 108 Boulogne sore throat the see Da Roche Lima H 72 D phtheria Defoe Dan el 29 37 Bradfod H A 22 115 de Missas 26 B adley W H 50 . Diarrhoc 21 847 144 cp B onchitis 142 dem a 84 ff fatal ty 84 87 B ownlee J 124 136 138 143 144 Bubonic plague Se P1 guc Dck G F and G H 89 Budd llam 77 D phtheria 22 f 89 92 7 100 Buer MC. 134 103 106 148 ep dema 94 Bulstrode HT 40 fatal ty 91 96 136 133 Burnet FM17 140 f 144 h tory 93 F 95 f immunization 16 95 Cains John 44 45 96 f 147 symptoms 88 Cancer 22 Cer b ospinal fever 46 107 Dropsy 88 go 10g 114 cp demues Ilo Dysentery 21 198 92f ·INDEX Edmonds TR 133 136 142 Encephalitis lethargica 23 46 107 ff 117-18 causes 117 epidemics 117 143 history 108 143 prevalence 118 Influenza 13 17 18 21 0 103 140 epidemics 43 47 ff 139 143 144 fatality 48 f 50 146 sunulanty of Sweating Sickness with 44f symptoms viruses causing 4 49f 98 146 43 f Enders J F 113 English Sweat See Sweating S ck 238 Enteric 72 7663 epidemics 77 ff 80 82 fatality 138 spread 78 ff Enteritis 72 86 Eyam plague at 32 3+ ff Jameson Sir William 95 Jenner Edward 60 Jenner Sir William 72 Justinian Plaguc 27 49 hoch Robert 66 123 Farr Samuel 2 Farr William 128 137f Food poisoning 76 82-3 140 144 147f Foster M chael 45 Fothergill 89f Freston plague at 40 f Laennec René 123 Lardlow P P 42 43 Laveran CAL. It Leprosy 51 ff Lettson John C 74 Liston Glen 38 Loffler F 88 Logan WPD 50 General Register Office 20 23 46 137 Gengou O 99 Glbertus Anglicus 51 Goodall C 107 Graunt John 21 Great Firc the 37 Greenhow EH 23 Greenwood LH 13 47 62 63 Gryping in the guts 21 85 f 103 Malaria 39 119-21 Measles 16 23 57 93–103 106 132 decline in fatafity 101ff 106 146 cpidemics 99 fr 104 f fatality 99 ff 104 f 106 136 138 139 142 1441 history of 99 ff mmunity developed 98 102 prevalence 98 101 preven tion of 103 virus causing 98 Meningitis 109 Meningococcal meningitis Sce Cerebrosp nal fever Mezils See Measles Mompesson Rev William 34 fr Montagu Lady Mary Wortley 59 Morbus Gallicus (Vorbus Neapo- 1 tanus) 53 Morton l'ichard 19 123f Mumps 34 Hansen GHA 51 Harris Walter 8 Heberden William the younger 21f Hinton MAC 38 Hippocrates 13 Hirsch A. TIO Huxham John 72 Bgf 93 Industrial Resolution the 84 Infantile paralysis See Poliomyel tis Osler I 45 89 158 ·לבחוץ IND Paratyprod 76 807 139 140 on 16 54 53 A 144 146 147 cauerg 51 58 Parish registers 90 22 Smoth Vuilson 42 43 Pasteur Louis 159 Snow Juha 68 € 77 Pennant T38 Spotted fever Ses Lesebrospinal Pepy Samuel 29 ff fever Pertusas Se Whooping-cough Start John 92 Phthi Se Tuberculosaa Sutocr d arthoca su Darshoea Picardy Sweat 43 Sweaung Sckness (Engl "Sw at) Plague 18 20 21 25-41 14 441 54 baalus c# sing 29 Black Sydenham, T 19 23 46 B9 99 Death 25 ft 131 f in East 103 107 120 133 Anglia 40 f in Lyam 32 ff Syphlus 51 ff 54 epidemic 19 25 f 39 f Thompson T 4+ fatality 28 ff history of Trevelyan GM 19 35 37 25 f theor es for du.appcar Tuberculos s 123-30 143 bac! ance of 17 37 ff Ius causin 123 dec) ne Pneumonia 25 39 142 143 nf tatty 127 cond tons broncho-pneumonia 145 n which prevalent 128 Polion yelitis 13 23 109 1127 fatal ty 124f hutory ff 118 cpd mics 108 10 incide ce 127 f prevent on 124 f 1425 147 umuputy 128 ff from 123 126 prevalence Typhoid f ver 23 76 78-83 135 113 f 116 146 vaccine 117 136 139 140 141 147 148 virus causing 112 ! Typhus 13 72-6 135 140 Popper E 512 Black Asses 73 75 cund ROB R 119 t ons in which prevalet Royal Colicg of Phys fans 46 73 € 75 cp lem cs 73 Russ an offuenza 47 133 f f tality 38 74f 132 Sarlatına 33 54 89-92 104 136 138 inoculation 76 135 138 5 also S ari tſeve Viesseux M 110 Scarlet fever 17 89-92 93 W tt Robert 104 135 decline of 92 139 140 144 \ chselbaum A 10 146 cp demics 89 f 91 Whoop ng cougb 23 99 103-6 f tal ty 10 138 139 symp- 144 bacillus caus ng 99 toms 83 f go decline n fatal ty 105 146 Schaudiron 5t fatality 100 104f 132 136 Shaw en Bo Sh rt Thomas 22 138 139 142 145 symptoms Surnon Sir John 238 69 70 93 98 99 vaccine 16 106 Willan Rgo 12D 13 Wallus Thomas 19 43 f 46 73 Smallpox 17 51 53-65 99 107 123 cp dernies 5 f 147 1 Wood illc M 60 ff fatality 55 63 f 65 74 104 105 132 33 134 138 139 Y lowf er ( Yellow Jack) 119 history of 539 140 vaccin 12)-

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