Journal of the Royal Society of Medicine Supplement No.

17 Volume 82 1989 3

Session 1: Malaria in Britain - Past and Present

History of malaria in England

M J Dobson MA DPhil Department of Community Medicine and General Practice, University of Oxford,
Medical School, John Radcliffe Hospital, Headington, Oxford OX3 9DU

Keywords: malaria; marsh fevers; England; medical history; Anopheles atroparvus mosquito

Malaria has long been one of the most debilitating especiallie nere the sea coastes ... and other lowe
diseases of mankind. Over the centuries malaria has places about the creeks which gave me a most cruell
accounted for innumerable deaths and has shaped the quarterne fever". In the 17th century Thomas
course of human history in regions far beyond its Sydenham wrote that 'if one spends two or three days
present geographical distributionl-3. in a locality of marshes and lakes, the blood is in the
The history of malaria in England has recently first instance impressed with a certain spirituous
attracted the attention of a number of scholars but miasma, which produces quartan ague.. ... Daniel
few studies have examined the true extent and impact Defoe related a story of Essex marshmen taking their
of malaria on English society in the pastl4-7. This brides from the uplands but losing them soon
paper summarizes the findings of a large historical afterwards as they succumbed to the ague fever:
survey of patterns of disease and mortality in 'the reason, as a merry fellow told me, who said he had had
England8-'0. It is based on a wealth of literary and about a dozen and a half wives (though I found afterwards
quantitative sources and pieces together clinical, he fibbed a little) was this: that they, being bred in the
demographic and geographical evidence to form parts marshes themselves and seasoned to the place, did pretty
of a fascinating epidemiological puzzle. From the well with it, but that they always went up into the hilly
complete set of evidence there appears no doubt that country or, to speak their own language, into the uplands
malaria was once indigenous to the coastal and for a wife. That when they took the young lasses out of the
estuarine marshes of England, that its prevalence was wholesome and fresh air they were healthy, fresh and clear
sharply controlled by the distribution and habits of and well: but when they came out of their native air into
the English Anopheles atroparvus mosquito and that the marshes among the fogs and damps, there they presently
within its geographical bounds malaria had a changed their complexion, got an ague or two, and seldom
profound effect on the marshland populations of this held it above half a year or a year at the most . . . .
country for several hundreds of years. And an anonymous poem by a Fenman read:
As early as the 16th century the English marsh-
lands were singled out for their extreme unhealthiness 'The moory soil, the watry atmosphere
With damp, unhealthy moisture chills the air.
(Figure 1). Residents and visitors described the 'marsh Thick, stinking fogs, and noxious vapours fall,
fevers' of these districts, variously calling them Agues and coughs are epidemicall;
'agues', 'tertian fevers', 'quartan fevers' or 'inter- Hence every face presented to our view
mittent fevers' and attributing them to the noxious Looks of a pallid or a sallow hue'4.
vapours of the stagnant marshes. The topographer,
John Norden, visited Essex in the 1590s but was Even by the early 19th century, Edward Hasted
unable to 'comende the healthfulness of it: And writing of the north Kent marshes, could still describe
'the severe agues which the inhabitants are very rarely
without, whose complexions from those distempers become
of a dingy yellow colour, and if they survive, are generally
afflicted with them till summer, and often for several years,
so that it is not unusual to see a poor man, his wife, and
whole family of five or six children, hovering over their fire
in their hovel, shaking with an ague all at the same time"5.
Hasted's vivid description reminds us of the
illustration by Thomas Rowlandson which forms
Figure 2.
Many documents describing tertian and quartan
fevers in early modern England have been examined
and this set ofclinical and epidemiological information -
EnpgAih Channel
albeit limited by modern standards - does tend to
confirmn that marshland ague was, indeed, plasmodium
malaria8. The alternating hot and cold fits and the
Figure 1. Parishes in Essex, Kent and Sussex described as periodicity of the fever according to type were
'unhealthy' or 'healthy' by 18th-century topographers. notable features of the disease. Many observed the
Parishes along the North Sea coast of Essex, the Thames, characteristic enlargement ofthe spleen, the anaemic
Medway and Stour estuaries, and the low-lying coastal and lethargic condition of the patient, and the relapse
marshes of Kent and Sussex are deemed very 'unhealthy' and several months after the primary attack. The expres-
constantly subject to 'agues' sion 'ague-cake' was often used to describe the
 _l;|(*vn.fXSti,ze .':/p4;rtvuJ.Zf,S}w{iy:e-<t !_r,sJ5oUn.X:WE^ils.e;
4 Journal of the Royal Society of Medicine Supplement No. 17 Volume 82 1989

I-I
;/w//*/< > /f i3tt ws rrw f-t>> *\ { { ]4* t *|* l< \t 5 R wttFl + < *Rr fJ-ft'

Figure 2. 'Ague and Fever'. Etching by Thomas Rowlandson, after a design by JDunthorne (1 788), describing the characteristic
stages of malaria beginning with a fit of shivering and succeeded by dry heat and finally copious sweating (published with
kind permission of Wellcome Institute Library, London)

prominent spleen of a malaria victim. It was noted, endemic English forms rather than the more fatal
too, that the marsh fever was non-contagious and was P. falciparum5.
confined to low-lying, slightly salty estuarine and And yet, one of the most striking findings of this
marshy environments. It displayed two seasonal study has been the extent to which malaria affected
peaks - the primary attacks occurring in the autumn its marshland victims. Few other areas of the English
and the relapses the following spring. Its highest countryside were subject to such extreme levels of
fatality rates were amongst children and strangers sickness, suffering and death. Mortality rates for over
or the non-immunes while those repeatedly attacked 500 marshland and non-marshland southeast England
by the disease were left in a permanent cachetic state. parishes have been measured and compared using
Physicians also realized that the marsh fever, unlike 17th and 18th century English parish registers and
most other acute fevers, would yield to large doses of techniques of historical demography. On every count,
cinchona bark though they noticed that the bark could the marshland populations recorded the highest adult
not completely eradicate the disease once the patient and child mortality rates. Average crude death rates
stopped taking it. This bark had been brought back were as high as 60, 70 or 80 per 1000 - levels which
from Peru by the Spanish in the 17th century and was could be two to three times those of neighbouring non-
later to be the source of the alkaloid quinine. marshland parishes (Figure 3). Life expectancy at
Observers like Robert Willan who 'took the trouble birth was little more than 30 years for the sickly
to compare minutely' the marsh agues with other marshland residents and nearly half of all recorded
English fevers (such as typhus, relapsing fever, deaths occurred at age 10 years or below. Burial
typhoid and influenza) were convinced that their patterns from year to year occurred at age 10 years
clinical and epidemiological characteristics were as or below. Burial patterns from year to year and season
different as their 'exciting causes'"6 but when com- to season were also extremely volatile in the marshes
paring the English marsh fever with the notorious and there was a very close correspondence between
tropical fever they astutely noticed that 'whether on fluctuations in summer temperatures and the level
the marshy coasts of Essex and Kent, or the more of mortality in the autumn and following spring. The
dreadful banks of the Gambia and Niger, it is not hottest summers were always followed by the
improbable that the fever so destructive to European unhealthiest and most mortal times in the marsh-
life is of one character'7. English malaria was thought lands. The parish registers contain little information
to cause fewer direct fatalities than its tropical on cause of death but from time to time the vicar
counterpart and almost always 'when marsh-malaria scribbled in the burial record that the deceased died
destroys life' in the English climate 'it is by from 'fatigue' or was just 'worn out'. If the vivax
secondary, not by primary effects'"8. It seems likely form of malaria did not kill its victims outright, then
that Plasmodium vivax and P. malariae were the it certainly had a profound indirect effect on the
 Journal of the Royal Society of Medicine Supplement No. 17 Volume 82 1989 5

Vicar does not reside in parish

because air is unhealthy

X
+ +

Sea

J I North Sea
:+

0 5 mls

0 1 0 km

Figure 4. Vicars in 18th century Essex refused to live in the

coastal marsh parishes because the air was 'unhealthy' and
'much subject to marsh agues'

rendered incapable to reside in the cure and the

physicians assuring me that I must withor leave it
or die.' The incumbent ofNorthfleet, Kent, complained
that 'the Thames having a very foul shore in this
parish ... I soon found myself attacked by many so

repeated agues that my physicians told me I must

...

not pretend to reside there .' while the curate from

. .

Aldington, Kent, summarized the general opinion: 'so

unhealthy a situation as to be absolutely unfit for any
curate'8. Visitors were wary of entering these un-
healthy tracts. The parish of Lower Halstow in Kent
was 'unhealthy to an extreme, the look of which the
1000 1650 1700 1750 1800 inhabitants carry in their countenances; indeed it
seems so enveloped among creeks, marshes and salts,
Figure 3. Annual burials in two Kent parishes in the 17th the look of which extends as far as the eye can see
and 18th centuries. Both communities had approximately 250
inhabitants but Newington, a marshland village in north that it seems a boundary beyond which the traveller
Kent, suffered a far higher toll ofmortality than Stelling, an dreads to hazard his future safety'"5. Even the land-
upland village on the North Downs owners avoided living on their farms leaving the care
of flocks and crops to local marshmen or 'lookers'.
demographic variables. Malaria acted as a great These folk were described as 'stupid, apathetic and
debilitator. It was a disease which the people of the fatalistic' seeking only a good reward from rich
marshes constantly had to live with and which they farmlands and illicit smuggling and caring little
often had to experience in combination with a host whether they lived or died. The parish of Wigborough
of other infections prevalent in England at this time Salcot, Essex, was described as 'an hospital being
(including smallpox, pulmonary infections and many little else than a rendezvous of poor and ignorant
other fevers). The marsh folk were generally in a wretched people'6. Some 'lookers' adopted strange
weakened state of health and eventually succumbed folk charms and remedies to try and suppress the
to their frequent and intense bouts of sickness. The debilitating effects of malaria. Stinking worms, bed
toll of energy and life which malaria imposed on bugs, herbal powders, alcohol and opium were all used
marshland communities was dramatic. As many a in various ways to ward offthe fever attacks. One lady
Kentish person was reminded: with malaria, kept tied round her neck a note given
to her by a wandering charlatan. When the minister
'He that will not live long, of the parish opened the note he found written the
Let him dwell at Murston, Tenham or Tong'.
words: 'Ague farewell, till we meet in Hell'. The
These regions, by their very nature, acquired a minister feared the lady had been visited by the Devil,
strange demographic and social structure. Men of he threw the note into the fire and subsequently
wealth and education avoided a residence in the witnessed her death from an ague attack'9.
marshes. Vicars, though frequently obliged to attend The medical and demographic sources provide a
the burials of their parishioners, rarely resided clear idea of the geographical distribution of malaria
permanently in their marshland parishes. When in England. Indeed, it appears that English malaria
questioned by their Bishop, many explained that they was unique in its geography. It was a disease endemic
had been forced away by the unhealthiness ofthe air in the marshlands but rarely contracted in other parts
and the prevalence of agues (Figure 4). The Vicar of of the country. Its prevalence was limited to a number
Ashledham, Essex, in 1723, wrote saying that he and of well-defined localities: the Fens, the Thames,
his family had been obliged to leave the parish 'being the coastal marshes of southeast England and,
so violently afflicted with the worst of agues and more marginally, the Somerset Levels, the Ribble
languishing long under it that our constitutions
so district of Lancashire, and the Holderness of
were almost broke and I brought low that I was
so Yorkshire (Figure 5). Its striking geography and
6 Journal of the Royal Society of Medicine Supplement No. 17 Volume 82 1989

the cause of extreme unhealthiness and high mortality.

Indeed, the marshlands experienced one of the
steepest declines in mortality of any rural area of
England and by the mid-18th century were seen to
equal the rest of the country in terms of their health.
The reasons for this change are undoubtedly complex
and this study concludes that many factors probably
worked together towards a reduction of both the
frequency and severity of malaria. Drainage may
have reduced the density of A. atroparvus in some
localities though today this species is still to be found
in abundance in marshy areas of England. Better
ventilated houses and separate dwelling quarters for
humans and animals may have led to the transference
of mosquitoes to cows and horses for their blood meals.
The wider use and cheaper availability of quinine in
the 19th century would certainly have helped to
control the disease and many marsh folk regularly
visited the parson or chemist for a supply of quinine
powders. The prevalence of several other infectious
diseases (notably smallpox) was declining in parts of
rural England during this period and the general
improvements in health status and standards of
living may have been critical factors explaining the
diminished severity of malaria.
Figure 5. The geographical distribution of indigenous malaria By the time Laveran, Manson, Ross and others
in early modern England elucidated the mosquito cycle in the late 19th
century24, malaria was no longer considered an im-
abrupt boundaries are the key to differentiating the portant cause of suffering in the English marshes.
true plasmodium malaria from the many other 'agues' Malaria's recession and eventual disappearance from
and 'fevers' which spread across all parts of early the English shores began before there was any real
modern England. understanding of the aetiology of the digease, in a
It is precisely in those marshland parishes that country where there had been little attempt at
the necessary ecological conditions for malaria eradication and in an environment which still
transmission are met. Five species of anopheline continues to harbour a vicious mosquito population .
mosquito capable of carrying the malaria parasite Today, indigenous malaria in England is not con-
are indigenous to Britain today (Anopheles claviger, sidered a hazard to health. But imported malaria and
A. atroparvus, A. plumbeus, A. messeae and A. jet-setting mosquitoes are posing a new threat to the
algeriensis). One species, A. atroparvus, breeds in British population26. In view of the topic of the next
sufficient numbers and in close association with paper in this symposium, it is perhaps pertinent to
humans to act as an efficient vector amongst human end this historical introduction with the warning of
populations20. And it is this species which is found John MacCulloch who first introduced the word
breeding in the slightly saline waters of our coastal 'malaria' (literally meaning 'bad air') into the English
marshes and is caught resting in the dwellings of literature in 1827:
marshland communities. The presence of the A. 'there is no work more wanted in medical statistics, than
atroparvus mosquito in the exact regions once subject a geography of malaria; a work which .. . seems of pressing
to 'marsh fevers' provides a crucial piece of evidence urgency from the increase of travelling as well as of
for this epidemiological investigation. migrating residents abroad, and from the mass of misery,
Malaria flourished in the coastal and estuarine added to the considerable mortality, which results from this
marshes of England for several centuries, its geo- ignorance 27
graphical limits determined by the natural habitats
of the A. atroparvus species of mosquito. There is MacCulloch's words echo the theme of these
clinical proof that a mild form of vivax malaria was proceedings.
still indigenous in parts ofKent during the early 20th
century. A patient from Romney Marsh found in 1910 References
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