1 For a study of eighteenth-century mortality in Sweden, see Imhof, A. E. and Lindskog, B. I., ‘Dödsorsakerna i Sydsverige 1749–1773’, Sydsvenska medicinhistoriska sällskapets årsskrift (1973), 120–43.Google Scholar For the nineteenth century, see Fridlizius, G., ‘The mortality decline in the first phase of the demographic transition: Swedish experiences’, in Bengtsson, T., Fridlizius, G. and Ohlsson, R. eds., Pre-industrial population change (Stockholm, 1984).Google Scholar

2 Historisk statistik för Sverige, Vol. 1: Befolkning, 1720–1967 (2nd edn; Stockholm, 1969), 91–7.Google Scholar

3 Omran, A., ‘The epidemiologic transition: a theory of the epidemiology of population change’, The Milbank Memorial Quarterly XLIX: 4, Part 1 (1971), 509–38.CrossRefGoogle Scholar

4 E. Hofsten and H. Lundström observed unusually high mortality rates for children aged one to fifteen years in Sweden, especially for the period 1850–1870. See Hofsten, E. and Lundström, H., Swedish population history: main trends 1750–1970 (Urval 8, Skriftserie utgiven av Statistiska centralbyrån; Stockholm, 1976), 47.Google Scholar

5 Arvidsson, S.-O., De svenska koleraepidemierna. En epidemiografisk studie (Stockholm, 1972)Google Scholar; Bidrag till Sveriges officiella statistik. A. Befolkningsstatistik (hereafter BiSOS. A).

6 Nelson, M. C., Bitter bread: the famine in Norrbotten 1867–1868 (Acta Universitatis Upsaliensis, Studia Historica Upsaliensia, 153; Uppsala, 1988), 97.Google Scholar

7 For a survey of mortality in Sweden as a result of the great influenza pandemic, see Åman, Maragreta, Spanska sjukan. Den svenska epidemin 1981–1920 och dess internationella bakgrund (Acta Universitatis Upsaliensia, Studia Historica Upsaliensis, 160; Uppsala, 1990), 42–78.Google Scholar

8 There are numerous studies of the decline of infant mortality in Sweden. See, for example, Lithell, U.-B., Breast-feeding and reproduction: studies in marital fertility and infant mortality in 19th-century Finland and Sweden (Acta Universitatis Upsaliensis, Studia Historica Upsaliensia, 120; Uppsala, 1981)Google Scholar; Brändström, A., ‘De kärlekslösa mödrana’. Spädbarnsdödligheten i Sverige under 1800-talet med särskild hänsyn till Nedertorneå (Acta Universitatis Umensis, Umeå Studies in the Humanities, 62; Umeå, 1984).Google Scholar

9 Hofsten, and Lundström, , Swedish population history, 47.Google Scholar

10 Nelson, M. C. and Rogers, J., ‘Sweden and the epidemiologic transition. Some regional implications’, in Swedish mortality crises in historical perspective (Meddelande från familjehistoriska projektet, 11; Uppsala, forthcoming).Google Scholar

11 Historisk statistik för Sverige, 93, 97.Google Scholar

12 Ibid., 45–6.

13 See, for example, Edvinsson, Sören, Den osunda staden. Sociala skillnader i dödlighet i 1800-talets Sundsvall (Report from the Demographic Data Base, Umeå University, 7; Stockholm, 1992), 52.Google Scholar

14 For a concise summary of the history of diphtheria, see McGrew, R. E. with McGrew, M. P., Encyclopedia of medical history (London, 1985), 93–8CrossRefGoogle Scholar, and Wærn, J., Om difterin och strypsjukans uppträdande i Sverige (Stockholm, 1885), 8.Google Scholar It has been questioned whether the seventeenth-century North American epidemic really was diphtheria in Matossian, M. E., Poisons of the past: molds, epidemics, and history (New Haven, Conn., 1989), 107–12.Google Scholar Matossian's argument is that the disease is actually a case of poisoning caused by mouldy grain and that ergotism was not recognized in pre-industrial society. In Sweden, however, such poisoning was not only known among the peasantry, it was also one of the sickness categories in the eighteenth-century statistics, where it was most commonly known as dragsjuka. See, for example, Lagerkranz, G., Svenska sjukdomsnamn i gångna tider (Eskilstuna, 1983), 77–8.Google Scholar

15 Aurivillius, S., Dissertatio medico, de Angina infantum im patria recentioribus annis observata (Upsala, 1764).Google Scholar

16 Rosenstein, N. Rosén von, Underrättelse om Barns Sjukdomar och Deras Bote = Medel (Tredje Uplagan, något tillökt och förbättrad; Stockholm, 1771), Chapter 25.Google Scholar He described not only the existing literature of that day, but also a number of eighteenth-century clinical studies.

17 Wærn, , Om difterin och strypsjukan.Google Scholar

18 Almquist, E., ‘Hygieniska studier i kyrkoarkiven’, Eira 8 (1884), 673–92.Google Scholar

19 Cf. Edvinsson, S., Den osunda staden.Google Scholar

20 For a discussion of popular terms, see Tillhagen, C.-H., Folklig läkekonst (Stockholm, 1962), 154Google Scholar, and Lagerkranz, , Svenska sjukdomsnamn, 20, 36, 76.Google Scholar Cf. BiSOS. A, 1902, Tab. 23 and BiSOS. A, 1903, Tab. 23. Such labels as halsröta and elakartad halssjuka were also widespread at all levels.

21 See, for example, Bidrag till Sveriges Officiella Statistik. K.I. Helso- och sjukvård (hereafter BiSOS. K.I.), 1862, 33; 1863, 24; 1864, 23. Cf. Hygiea XXVI (1864), 415–16.Google Scholar

22 Wærn, , Om difterin och strypsjukan, 12–20.Google Scholar

23 From 1830 to 1860, when listing the causes of death was not compulsory, there is only very sketchy information. The more virulent diphtheria's entry into the country more or less coincided with the formation of the new Bureau of Statistics (Statistiska centralbyrån) and the collection of more detailed cause of death material.

24 Almquist, E., ‘Om difterins uppträdande i Sverige och några lärdomar hemtade ur sjukdomens historia’, Eira 8 (1884), 541, 572.Google Scholar

25 BiSOS. K.I., 1861, appendices.Google Scholar

26 There was yet another epidemic in the early 1940s which received a great deal of attention from the medical community.

27 Bergman, R. (‘De epidemiska sjukdomarna och deras bekämpande’, in Kock, Wolfram ed., Medicinalväsendet i Sverige (Stockholm, 1963))Google Scholar defines epidemic diseases in terms of those included in the official reports.

28 Bergman, (‘De epidemiska sjukdomarna’, 329–80)Google Scholar does not specifically state his sources, but indicates that the morbidity statistics were ‘cases officially reported’. This would indicate that he has probably used the figures reported to the National Health Board by the district and town physicians. These figures are clearly gross underestimates, especially at the beginning of the period, and may also have varied greatly in degree of accuracy over time. The mortality figures, on the other hand, appear to have been derived from a different source, the officially reported causes of death.

29 Smith, F. B., The people's health 1830–1910 (London, 1990), 149.Google Scholar

30 Preston, S. H. and Haines, M. R., Fatal years: child mortality in late nineteenth century America (Princeton, N.J., 1991).CrossRefGoogle Scholar

31 BiSOS. K.I. The first volume was actually published in 1861, but provided a retrospective summary of the state of health in Sweden for the previous decade.

32 Almquist, , ‘Hygieniska studier’, 677–8.Google Scholar

33 Some of the points in the debate in the 1860s are discussed in Nelson, M. C., ‘The year the children died: a study of the diphtheria epidemic in Råneå parish, Sweden, 1863–1865’, in Rogers, J., ed., Death: the public and private spheres (Meddelande från Familjehistoriska projektet, 6; Uppsala, 1986), 66–70.Google Scholar

34 Nelson, , ‘The year the children died’, 69–70.Google Scholar

35 See, for example, Edvinsson, , Den osunda staden, 9.Google Scholar

36 Riksarkivet, Stockholm (hereafter RA), MSP-25, Sundsvall (Microfilm of RA, Sundhetskollegiums arkiv (hereafter SKA), Årsberättelser från provinsialläkare (hereafter PLR), 1862, Sundsvall).

37 Arvidsson has noted the irony of the fact that miasma theories enjoyed their heyday just at the point when the new medical breakthroughs came (Arvidsson, S.-O., ‘Epidemiologiska teorier under 1800-talets kolera epidemier’, Nordisk medicinhistorisk årsbok (1971)).Google Scholar

38 Wærn, , Om difterins och strypsjukan; Almquist, ‘Om difterins uppträdande’, 533–4, 568–75.Google Scholar

39 Almquist, , ‘Hygieniska studier’.Google Scholar

40 Almquist, , ‘Om difterins uppträdande’.Google Scholar

41 See, for example, Helsovännen (1895), 21–4Google Scholar; (1895), 55–8Google Scholar; (1895), 81–5.Google Scholar The tide began to turn somewhat later in the year as more positive information appeared. See Helsovännen (1895), 222–5.Google Scholar

42 For detailed discussions of the adoption of serum treatment in Berlin, Paris and London and its implications, see Weindling, P., ‘From isolation to therapy: children's hospitals and diphtheria in fin de siècle Paris, London, and Berlin’, in Cooter, R. ed., In the name of the child: health and welfare, 1880–1940 (London, 1992), 124–45Google Scholar; Weindling, P., ‘From medical research to clinical practice: serum therapy for diphtheria in the 1890's’, in Pickstone, J. V. ed., Medical innovations in historical perspective (New York, 1992), 72–83.CrossRefGoogle Scholar

43 Lundblad, L. J., Om angina diphtherica (Uppsala, 1877), 10–19.Google Scholar

44 Wawrinsky, R., Om förebyggandet of epidemier genom anordning af isoleringslokaler (Stockholm, 1901), III.Google Scholar

45 Ibid., 4–8

46 Ibid., 46–59.

47 RA, Medicinalstyrelsens arkiv (hereafter MSA), PLR, E5A: 35 (1895), Göteborg stad.Google Scholar

48 For a discussion of the spread of popular information on health and the fight against specific diseases at this time, see Johannisson, K., ‘Folkhälsa. Del svenska projektet -från 1900 till 2:a världskriget’, Lychnos (1991), 156–61.Google Scholar Attempts at spreading information concerning disease and its treatment were not uncommon earlier. For example, the chapter on diphtheria named below in Rosén von Rosenstein, Underrättelse am Barns Sjukdomar was first published in a popular almanac. See, for example, Ericsson, G., ‘The Academy in the daily life of Sweden’, in Frängsmyr, T. ed., Science in Sweden: the Royal Swedish Academy of Sciences 1739–1989 (Canton, Mass. 1989), 73–4.Google Scholar

49 Selldén, H., Om difteri och strypsjuka enligt egna erfarenheter (Hälsovännens flygskrifter, 29; Stockholm, 1897).Google Scholar

50 The country was divided into medical districts which were served by a government-appointed district physician. These districts might comprise a number of parishes and take several days to cross in the sparsely populated regions of the north.

51 Kearns, G., Lee, W. R. and Rogers, J., ‘The interaction of political and economic factors in the management of urban public health’, in Nelson, M. C. and Rogers, J. eds., Urbanisation and the epidemiologic transition (Meddelande från Familjehistoriska projektet, 9; Uppsala, 1989).Google Scholar Other clerical personnel also had medical roles; for example, after 1816 a sexton was also required to be a certified smallpox vaccinator (Nelson, M. C. and Rogers, J., ‘The right to die? Anti-vaccination activity and the 1874 smallpox epidemic in Stockholm’, Social History of Medicine 5: 3 (1992), 369–88).CrossRefGoogle ScholarPubMed For a discussion of the role of the parish council in health matters, see Bergström, Carin, Lantprästen. Prästens funktion i del agrara samhället 1720, 1800. Oland-Frösåkers kontrakt av ärkesliftet (Nordiska muséets Handlingar, 110; Stockholm, 1991, 91, 103–5).Google Scholar For an example of the type of textbook used for instructing future clergymen, see Leffler, S. P., Något om prest-medicin (Upsala, 1810).Google Scholar

52 Although cholera did not strike Sweden until 1834, in Sweden as elsewhere in Europe precautions were taken to provide protection from the disease in 1831. The epidemics which caused the greatest death tolls from cholera were in 1834, 1857 and 1866. For a study of the earliest cholera epidemic, see, Zacke, B., Kolera epidemien i Stockholm 1834 (Mongrafier utgivna av Stockholms Kommunalförvaltning 32; Stockholm, 1971).Google Scholar For a comparative study of nineteenth-century cholera outbreaks in Sweden, see Arvidsson, , De svenska koleraepidemiera.Google Scholar

53 Zacke, , Kolera epidemien i Stockholm, 18–33.Google Scholar

54 ‘K. Förordning d. 30 Dec. 1857, ang. hvad till förekommande och hämmande af farsoter och smittosamma sjukdomar bland rikets innevånare iakttagas bör’, in Wistrand, A. H. ed., Författningar angående medicinalväsendet i Sverige, Vol I (Stockholm, 1860).Google Scholar

55 These included first of all, cholera and yellow fever. Others specifically mentioned included dysentery, typhus and typhoid, smallpox, scarlet fever, measles, various forms of ergotism and various diseases afflicting the lungs, such as tuberculosis. Diphtheria was not listed.

56 ‘K. Förordn. d. 19 Mars 1875, ang. åtgärder mot införande och utbredning af smittosamma sjukdomar bland rikets invånare (S. F. S. N:o 21)’, in Kullberg, A. ed., Författningar m.m. angående medicinal väsendet i Sverige, Vol. 2 (Stockholm, 1877).Google Scholar

57 ‘Råd och anvisningar, meddelade af K. Sundh.-koll. d. 10 Nov. 1875 med anledning af K. Förordn. d. 19 Mars 1875, ang. åtgärder mot införande och utbredning af smittosamma sjukdomar bland rikets invånare’, in Kullberg, , Författningar, 538–47.Google Scholar

58 Rogers, J. and Nelson, M. C., ‘Cleaning up the cities: the first comprehensive public health law in Sweden’, The Scandinavian Journal of History (in press).Google Scholar

59 ‘K. Br. d. 28 Jan 1898 till Med.-Styr:n (N:o 32) ang. åtgärder till förekommande af spetelskesjukdomens spridning’, in Pontin, D. M. ed., Författningar mm. angående Medicinalväsendet i Sverige. Omfattande år 1898 (Stockholm, 1900)Google Scholar; ‘K. kung. d. 30 Dec. 1911, ang. andrad lydelse af §§20 och 24, mom. 1 i nåd. förordningen angående åtgärder mot införande och utbredning of smittosamma sjukdomar bland rikets invånare d. 19 mars 1875’, in Petersson, H. ed., Författningar mm. angående Medicinalväsendet i Sverige. Omfattande år 1911 (Stockholm, 1913).Google Scholar

60 ‘Kongl. Medicinalstyrelsens cirkulär, d. 29 Dec. 1890, till läkare i riket med anledning af den för dem utfärde nya instruktionen den 31 Okt. 1890’, in Pontin, D. M. ed., Författningar angående Medicinalväsendet i Sverige. Omfattande år 1890 (Stockholm, 1891).Google Scholar The diseases to be included were cholera, smallpox, typhus, typhoid, scarlet fever, diphtheria, dysentery and ‘others’.

61 ‘K. Br. d. 24 April 1885 till Med.-styr:n, ang. verkställande af helsovårdsinspektioner i städer och andra större samhällen’ and ‘K. Br. d. 24 Juli 1885 till Med.-styr:n ang. verkställande af helsovårdsinspektioner m. m.’, in Pontin, D. M. ed., Författningar angående Medicinalväsendet i Sverige. Omfattande år 1885 (Stockholm, 1886).Google Scholar

62 ‘Med,-styr:ns cirkulär d. 19 Febr. 1886 till Helsovårdsnämnderna i riket i anledning af de sanitära inspektioner, sorn under år 1885 blifvit förrättade inom en del städer och andra orter, der gällande Helsovårdsstadgas föreskrifter beträffande stad jemväl skola i tillämpliga delar iakttagas’, in Pontin, D. M. ed., Författningar angående Medicinalväsendet i Sverige. Omfattande år 1886 (Stockholm, 1887).Google Scholar

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64 Arvidsson, , De svenska koleraepidemierna.Google Scholar

65 Duffy, J., A history of public health in New York City: 1866–1966 (New York, 1974), 155.Google Scholar

66 Rogers, and Nelson, , ‘Cleaning up the cities’.Google Scholar

67 For a new study of the health conditions in the city, see Edvinsson, Den osunda staden. Sundsvall, which had a population exceeding 2,800 in 1850, had more than doubled in size by 1870, and by 1900 had reached nearly 15,000.

68 In a study of epidemic diseases in Malmö in 1855–1960, diphtheria reportedly was most severe in the 1870s, when more than 90 per cent of the 91 reported cases died. An epidemic with 502 cases in 1892 exhibited a case fatality rate of about 27 per cent. In recurring epidemics the numbers of cases reported remained about the same until the early 1930s, but mortality decreased from 16.5 per cent of all cases to about 4 per cent in 1928. See Petrén, Ebbe and Hellsten, Hans, ‘Epidemiska sjukdomar i Malmö under ett århundrade (1855–1960)’, Sydsvenska medicinhistoriska sällskapets årsskrift (1965), 10–31.Google Scholar

69 Demographic Data Base, Umeå University. This agrees well with the statistics produced by C. Lindman, who found that between 1876 and 1895 approximately 9 per cent of all diphtheria deaths in Gothenburg were among infants under the age of one year (Lindman, C., Dödligheten i första levnadsåret i Sveriges tjugo större städer 1876–1895 (Helsingborg, 1898), 122).Google Scholar

70 Demographic Data Base, Umeå University. However, a cautionary note is in order as rates have not been calculated on an age- or sex-specific basis.

71 Gezelius, K. J., ‘Göteborgs stads hälso- och sjukvård’, in Wimarson, N. ed., Göteborg. En översikt vid trehundraårsjubileet 1923 över stadens kommunala, kulturella och sociala förhållanden samt viktigaste näringsgrenar (Skrifter utgivna till Göteborgs stads trehundraårsjubileum genom jubileums utställnings publikationskommitté, XX; Gothenburg, 1923), 338–85.Google Scholar Gothenburg, Sweden's second city, had more than 26,000 inhabitants in 1850, 56, 288 in 1870 and 130, 619 by 1900.

72 RA, SKA, PLR, E5A:42 (1872)Google Scholar, Göteborg stad; RA, MSA, Hälsovårdsnåmndernas årsberättelser (hereafter HVNR), E5G:8 (1884), Göteborg.Google Scholar See the comment in note 70.

73 Such a map of diphtheria in 1898 is found in Göteborgs Helsovärdsnämnds årsberättelse (hereafter GHÅB) 1898, Appendix.

74 Sundsvalls Helsovårdsnämnds årsberättelse (hereafter SHÅB) 1895–1907Google Scholar; GHÅB, 1896–1897.Google Scholar

75 RA, MSA, PLR, E5A:14 (1884), Göteborg stad.Google Scholar

76 Residents were treated at no cost, while others paid a certain fee. During the years studied there was an unspecified number of paying patients (GHÅB, 1888–1897).Google Scholar

77 Edvinsson, , Den osunda staden, 110–12.Google Scholar

78 RA, MSA, PLR, E5A:35 (1895), Göteborg stad.Google Scholar

79 RA, MSA, PLR, E5A:37 (1896), Göteborg stad.Google Scholar

80 Gezelius, , ‘Göteborgs stads hälso-och sjukvård’, 371–4.Google Scholar

81 Edvinsson, , Den osunda staden, 110.Google Scholar

82 SHÅB, 1895–1907.Google Scholar See also, Edvinsson, , Den osunda staden, 110–11.Google Scholar

83 Bergman, , ‘De epidemiska sjukdomarna’, 373.Google Scholar

84 Utdrag ur Sundsvalls Helsovårdsnämnds arsberattelse for 1896.

85 GHÅB, 1895, 46–8.Google Scholar

86 GHÅB, 1894, 35, 36, 50.Google Scholar

87 See, for example, Hygiea XLVI (1884), 629–31.Google Scholar Cf. Hardy, Anne, ‘Tracheotomy versus intubation: surgical intervention in diphtheria in Europe and the United States, 1825–1930’, Bulletin of the History of Medicine 66 (1992), 536–59.Google ScholarPubMed

88 A cautionary note! There is little agreement among the sources on the reported number of diphtheria cases. Much further investigation is needed here in the evaluation of the sources.

89 RA; MSA; PLR, E5A:35 (1895), Göteborg stad.Google Scholar

90 Selldén, , Om difteri och strypsjuka.Google Scholar

91 For bacteriological testing, see for example SHÅB, 1895.Google Scholar