Am J Epidemiol 2003; 157:856-857.
Copyright © 2003 by Johns
Hopkins Bloomberg School of Public Health
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The First Epidemiology Textbook, Revisited
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The city of Liverpool, England, has contributed much to the development of epidemiology and public health. The city was the first (in 1847) in the United Kingdom to have a Medical Officer of Health, William Henry Duncan, for whom both the annual Duncan Memorial Lecture and the Duncan Society (dedicated to the advancement of public health) are named. In 1931, one of Duncan’s successors, Clare Oswald Stallybrass, authored the earliest known epidemiology textbook, The Principles of Epidemiology and the Process of Infection (1). At 696 pages (649 pages of text, the rest indices), the book addressed its subject matter in considerable depth. What do we know of the author and his textbook?
Information regarding Stallybrass is difficult to obtain on this side of the Atlantic. A search using Yahoo! disclosed little information. The first printing of The Principles of Epidemiology and the Process of Infection gives minimal biographic information. Library catalogs cite 1881 as Stallybrass’ birth year, but no year of death is given. An earlier book lists two positions: Assistant Medical Officer of Health for Liverpool and lecturer in "public health subjects, etc." at the University of Liverpool (2). This earlier book, which focused on occupational medicine, discussed its subject with considerable facility, including insightful discussions of both pneumoconioses and cancer. Stallybrass’ last book, the 12th edition of the 1923 one, extended its scope to encompass all of public health, comparable to the current reference texts (3–5).
Intended for the Medical Officer of Health, the 16 chapters of Stallybrass’ book focus on infectious diseases. In the book’s preface, epidemiology is defined as "the science of infective diseases—their prime causes, propagation, and prevention. More especially it deals with their epidemic manifestations" (1, p. v). This focus was chosen because "[since] infective diseases still cause more than half of the deaths, and probably an ever higher proportion of the illnesses of men, it is hoped that a work treating of infection will pose of interest to others besides those officially engaged in preventive medicine" (1, p. v). The preface noted the eclectic nature of epidemiologic inquiry: "[T]he basis of the science is the knowledge of the process of infection of the individual, and of the responses to infection of the individual and of the herd. So clinical medicine, pathology, bacteriology and immunology all bring grist to the epidemiologist’s mill" (1, p. v).
One might think that epidemiologists of this era, before noninfectious diseases became a focus of epidemiologic activity, were concerned about infectious diseases because noninfectious diseases were less prevalent. However, in 1923 Stallybrass recognized noninfectious diseases as amenable to epidemiologic consideration: "A very marked increase in the incidence of cancer has been an almost accompaniment of the rise of modern industry. This increase is still continuing and is remarkably regular" (2, p. 409). Stallybrass then summarized a 1922 report by Collis and Greenwood on the use of mortality rates as a proxy for hygienic condition: "The rise in cancer incidence is greater than can be accounted for by more accurate diagnosis, and is much greater than can be explained by any increase in the expectation of life... Cancer is less frequent in rural than in urban communities... due to the incidence of cancer at earlier ages in the towns... Apart from the special liability of females to cancer of the breast and generative organs, cancer is everywhere more frequent in males than in females... Cancer becomes progressively more prevalent in urban populations in the northern hemisphere the further these are removed from the equator" (2, p. 409; 6). The discussion concluded, "[T]he cause of the great increase of cancer is to be found in some feature of industrial and urban life. A consideration of the various forms of industrial cancer throws much light on the etiology of cancer" (2, p. 409). Cancer was clearly of concern in preventive medicine even in the 1920s. Perhaps it was not considered to be in the domain of the epidemiologist because it was more properly the province of the occupational physician. Such an explanation does not preclude noninfectious diseases from statistical-epidemiologic inquiry, yet it accounts for the inattention to noninfectious diseases by epidemiologists of this era.
Some chapters (chapters 1 and 8) had been published previously. The first chapter, a history of the concept of contagion, is accurate and insightful. The second chapter discusses epidemiologic principles, focusing on the specificity of disease and the use of Koch’s postulates. Several concepts commonly taught in present-day introductory courses, such as the influence of age, gender, and season on disease incidence, are considered. Three factors are cited as key in the spread of disease: the host, the environment, and the reservoir. Interestingly, the concept of herd immunity is introduced. (Stallybrass asserts it developed in 1909.) Chapter 3 considers statistical methods, including age adjustment, indirect standardization, and proportionate mortality, as well as correlation and regression.
In chapter 4, the characteristics of agents are considered, such as toxicity and lethality. Chapters 5–7 discuss host factors, such as immunity and factors affecting susceptibility. Herd immunity is described in chapter 8 (previously published). In chapters 9–15, agent transmission is discussed, with a focus on the different routes used by various agents. The final chapter concentrates on prophylaxis and disease prevention, including the many means then understood to interrupt agent transmission.
Of what significance was Stallybrass’ book? This is a difficult question, insofar as most of its likely users are now deceased. In 1990, the late Morton L. Levin, a major figure in the development of modern cancer epidemiology, informed me that he used Stallybrass as a textbook during Wade Hampton Frost’s introductory course in the 1930s (Morton L. Levin, personal communication, 1990) (7). This is my only knowledge of a major figure in epidemiology using this textbook.
Stallybrass is less well known than his contemporary, Major Greenwood, who was epidemiology chair at the London School of Hygiene and Tropical Medicine and author of Epidemics and Crowd-Diseases: An Introduction to the Study of Epidemiology (8, 9). Greenwood established the English tradition of randomized clinical trials that found fruition in Bradford Hill’s 1948 streptomycin trial and continues in the activities of Peto and Rory-Collins, among others (10, 11). (Greenwood began his statistical epidemiology career in the laboratory of Lord Hill, Bradford Hill’s father—a major English physiologist.) Greenwood’s position afforded more visibility than might accrue to a Liverpool medical officer. This difference should not, however, diminish the impact of Stallybrass’ text or deny him due recognition as the author of the first epidemiology textbook.
REFERENCES
- Stallybrass CO. The principles of epidemiology and the process of infection. London, United Kingdom: G Routledge and Son Ltd, 1931.
- Hope EW, Hanna W, Stallybrass CO. Industrial hygiene and medicine. London, United Kingdom: Balliere Tindall, 1923.
- Frazer WM, Stallybrass CO. Text-book of public health. Baltimore, MD: Williams and Wilkins, 1948.
- Detels R, ed. Oxford textbook of public health. 4th ed. New York, NY: Oxford University Press, 2002.
- Wallace RB, ed. Maxcy-Rosenau-Last public health and preventive medicine. 14th ed. Stamford, CT: Appleton and Lange, 1998.
- Collis C, Greenwood M. The use of death-rates as a measure of hygienic conditions. (Medical Research Council special report, series no. 60). London, United Kingdom: HMSO, 1922.
- Kluger R. Ashes to ashes. New York, NY: Alfred A Knopf, 1996.
- Winkelstein W Jr. From the editor: the first epidemiology textbook? (Editorial). Am J Epidemiol 2002;156:684.
[Free Full Text] - Greenwood M. Epidemics and crowd-diseases: an introduction to the study of epidemiology. London, United Kingdom: Williams and Norgate Ltd, 1935.
- Matthews JR. Major Greenwood versus Almroth Wright: contrasting visions of "scientific" medicine in Edwardian Britain. Bull Hist Med 1995;69:30–43.[Web of Science][Medline]
- Marks HM. The progress of experiment: science and therapeutic reform in the United States, 1900–1990. Cambridge, United Kingdom: Cambridge University Press, 2000.
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