‘Opening Up the Body’ is a Wellcome-funded project to conserve the Post Mortem Examinations and Case Books of St George’s Hospital, 1841-1946. Our Archive team have been cataloguing and digitising records dating from 1841-1921. This post was written by Project Archivist Alexandra Foulds, with contributions from Project Archivist Natasha Shillingford and Archivist Juulia Ahvensalmi.
In December 2020 we decided to do an advent calendar on social media in which we would use every day to highlight a disease or condition that could be found in our post mortem casebooks. Calling it #MorbidAdvent, throughout the month we covered:
- Rabies
- von Recklinghausens disease
- Tuberculosis, consumption, or phthisis
- Scurvy
- Influenza
- Glanders
- Rock fever
- Whooping cough or pertussis
- Burns (from clothes catching fire)
- Tetanus
- Rickets
- Hysteria
- Malaria
- Elephantiasis
- Cholera
- Diphtheria
- Measles
- Typhoid fever
- Lead poisoning
- Plague
- Syphilis
- Chorea
- Leprosy
- Smallpox or variola
When we started, we assumed that these were conditions that had been relegated to history but the morbid nature of all these diseases was brought into stark relief with the realisation that none of the diseases apart from smallpox (thanks to the efforts of Edward Jenner) have actually been eradicated.
Vaccinations are, of course, of particular interest and relevance at the moment, and there are vaccines for many of the diseases we examined, including tuberculosis, rabies, influenza, whooping cough, tetanus, diphtheria, measles and smallpox. Others, such as malaria or leprosy can be treated with various medications.
Despite this, many of the diseases remain common outside of the Western world. 10 million people were diagnosed with tuberculosis in 2019, predominantly in South-East Asia, Africa, and the Western Pacific, resulting in 1.5 million deaths. There were an estimated 229 million cases of malaria in 2019, the majority of them in sub-Saharan Africa: children are particularly vulnerable to the disease. Diphtheria, despite mass immunisations in the UK in the 1940s, is still common in Africa, India and Indonesia, with a 5-10% death rate affecting mainly children. Measles, which has an alarmingly high R number of 12 to 18, similarly caused over 140,000 deaths in 2018, mostly in children under 5 years old. Cholera outbreaks remain common in Africa, South America and Asia. In 2008-2009 an outbreak in Zimbabwe killed 4200 people and in 2010-2011 another in Haiti caused 6631 deaths. In all of these places, a lack of access to health care, poor water quality and poor sanitation allow for contagious diseases to take hold and spread.
As these diseases have not been eradicated they frequently resurface in the United Kingdom. There are still around 12 new cases of leprosy diagnosed each year in the UK and the World Health Organisation states that in 2018 there were 208, with 619 new cases of leprosy diagnosed worldwide. This is approximately one every two minutes. In 2019 the notification rate for TB in the UK was 8.4 per 100,000 of the population. Even smallpox has the potential to return, as it did in 1978, as it is retained in laboratories.
It is not only contagious diseases that can have resurgences. Rickets, for example, which is caused by a vitamin D deficiency, despite mostly disappearing in the UK in the 1950s with mass programs of cod liver oil for children, has recently experienced a comeback that has been attributed to children spending more time indoors and the use of sun creams whenever they are outside.
The post mortem record of Ethel Almond who had rickets and then contracted tubercular meningitis (PM/1888/314). Archives and Special Collections, St George’s, University of London
Patients at St George’s Hospital
When we started the advent calendar we knew that the period covered by our post mortem casebooks (1841-1946) was punctuated by numerous outbreaks, epidemics and global pandemics of various contagious diseases. The most notable of these that affected the UK included:
Cholera: 1831-1832, 1838-1839, 1848-1849, 1853-1854, 1866-1867
Influenza: 1830-1831, 1833, 1836-1837, 1847-1848, 1857-1858, 1889-1890 (Russian/Asiatic Flu), 1918-1920 (Spanish Flu)
Smallpox: Large epidemics in 1837-1838 and 1870-1874 (after the Franco-Prussian War). 1901-1902 was the last outbreak in London. (England was declared rid of smallpox in 1939).
Scarlet fever: 1892-1893. Particularly common at the beginning and ends of the nineteenth century.
Diphtheria: 1850-1860
While trying to find cases of these diseases in the post mortem casebooks, however, we were struck by the fact that there were far fewer cases than we had expected, even in years when there were epidemics. This was despite many contagious diseases being more easily caught by people with malnourishment, a condition from which it is likely that many of the patients at St George’s would have suffered. St George’s Hospital’s nineteenth-century position at Hyde Park Corner meant that many of its patients came from Westminster and Pimlico, both of which were very impoverished, working-class areas of London at this time. Wealthier patients in nearby St James’s, Belgravia and Mayfair would have been more likely to have been treated by visiting physicians (some of whom would have also worked at St George’s) in their own homes. Hospitals had been created in the UK in the eighteenth century to serve the ‘deserving’ working class poor and were considered, at least until the late nineteenth century, to be dirty and sources of contagion, so people tended to stay away if they could. The extremely poor who were unable to support themselves, considered to be ‘undeserving’, would have been treated in workhouse hospitals.
Fever hospitals
Trying to account for this low number of contagious diseases in our post mortem casebooks led us to find out about fever hospitals, or hospitals set up in the nineteenth century specifically to treat contagious diseases. Prior to this only a small amount of hospitals were willing to take contagious patients. A smallpox hospital had been created in Windmill Street off Tottenham Court Road in 1746, and patients with other contagious diseases could be sent to one of the Royal Hospitals or to Guy’s Hospital. As part of the nineteenth-century public health movement, 12 fever hospitals were created in London, starting with the Institution for the Care and Prevention of Contagious Fevers (later called the London Fever Hospital) at Grays Inn Lane in 1801. While the majority of these were on land, between 1883 and the end of the nineteenth century three of them were converted ships (the wooden warships the Atlas and the Endymion, and the iron paddle steamer Castalia), which were moored on the River Thames and used to treat smallpox patients. Patients who needed to be treated in a hospital were sent to one of these fever hospitals after being referred by a doctor, and were only treated in hospitals such as St George’s if their condition was not apparent when they were admitted. Once their condition was diagnosed, we can see from the medical notes in our post mortem casebooks that they were moved to separate wards. One of the fever hospitals, however, the Grove Fever Hospital which opened in 1899, was sited where St George’s Hospital is now in Tooting. Two of the ward blocks survive to this day.
Highlights of the advent calendar
A few of the conditions covered in the advent calendar proved to be particularly interesting and unusual, such as glanders, leprosy, and malaria.
Glanders
Glanders is an unusual disease in the Morbid Advent Calendar as it is a zoonotic disease. In other words, Glanders primarily occurs in horses, mules and donkeys but can be transmitted to humans by direct contact with an infected animal’s body fluid and tissues, and can enter the body through skin abrasions. The majority of patient’s in the post mortem volumes who contracted Glanders, were stablemen, horse keepers and grooms.
Despite the fact that the last confirmed case in Great Britain was in 1928, it still remains a very real threat, particularly as a biological weapon during war and has long been a threat to armies. It is believed that Glanders may have affected the horses of Marshall Tallard’s cavalry prior to the Battle of Blenheim in 1704 which helped the Duke of Marlborough to win the battle. It is also believed that during World War I, Russian horses on the Eastern Front were deliberately infected with Glanders by German agents. More recently, the Soviet Union allegedly used the germ that causes Glanders during the Soviet-Afghan War.
Unlike many of the diseases featured in the calendar, there is currently no vaccine for Glanders. The lack of a vaccine, the fact that the disease is not widely known and is therefore difficult to diagnose, the ability for the germs to be released into the air, water or food supply, and the germ’s resistance to common antibiotics makes the bacteria a significant bioterrorism threat.
Leprosy
The earliest possible account of a disease which is believed to be leprosy appears in an Egyptian papyrus document written around 1500 BC. The first account of the disease in Europe occurs in the records of Ancient Greece after the army of Alexander the Great returned from India.
Leprosy had entered England by the 4th century AD and was a common feature of life by 1050. However, it seemed unusual to find a case of leprosy in London in 1884, particularly as the last case of indigenous leprosy in the United Kingdom was diagnosed in 1798.
Further research uncovered that it wasn’t until 1873 that Dr Gerhard Henrik Armauer from Norway identified the germ that causes leprosy and proved that it was not a hereditary disease or a punishment by God, but an infection caused by bacteria. It is now curable with a multidrug therapy which was developed in the early 1980s.
Malaria
From ‘mal’aria’, or bad air, malaria was so named as it was thought to be caused by miasma. The connection between mosquitoes and malaria was not established until the 1890s; Patrick Manson, the first lecturer in tropical diseases at St George’s Hospital Medical School and the founder of the London School of Hygiene and Tropical Medicine, was instrumental in developing the so-called mosquito-malaria theory.
Far from being confined to hot, faraway countries (though the postmortems show that the majority of the cases were contracted by soldiers, seamen and colonial officers in India, the West Indies, China or the United States), the postmortem books reveal cases in places like Deptford, Hampshire and Eastbourne: it turns out that malaria was, in fact, a significant cause of death in Britain. In these cases, the diagnosis is often given as ‘ague’ or ‘marsh fever’. Decrease of marsh wetlands and increase in cattle as well as improvements in housing, drainage and ventilation (factors which affect also many other causes of death during this period) and water chlorination led to malaria gradually disappearing as an endemic disease in Britain (the last cases occurred in Stockwell in 1953).
Quinine, derived from the bark of cinchona tree, has been used to treat malaria since the 1600s, and the origins of gin & tonic is often said to be as an anti-malarial drug, though this is not strictly true. Quinine is still used to treat malaria, although there are now various other medications too.
What did we take away?
Finding out more about these diseases put the current Covid-19 pandemic in a new light. While it is easy to think of our current situation as exceptional, what our advent calendar made clear was that it is something that humans have experienced many times before and continue to endure in many parts of the world. While it might be easy to find this thought quite bleak, it helped us to feel more positive. Like all outbreaks of contagious disease, this too shall pass, and as our history and our experience over the last year shows, we have the ability to band together to make great medical advancements when we have the drive to do so. Current technology has enabled us to experience this pandemic in a global way that has never been seen before and hopefully this unity will continue as we try to vaccinate the world’s population. Perhaps this will carry forward and enable us tackle other diseases together, giving new impetus to strategies such as the World Health Organisation’s plan to cut new cases of TB by 90% and reduce deaths by 95% by 2035.
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