Hopefully, we are coming to the end of the worldwide Covid-19 pandemic. In the UK by the beginning of August 2021 we have had 5,982,581 cases which tragically resulted in 130,086 deaths, or a mortality rate of 2.17%.
This is the story about the smallpox pandemic which hit Britain 150 years ago. The first state hospital to try to deal with the disease was built in Hampstead, near Haverstock Hill and Pond Street. The site is now covered by the Royal Free Hospital.
What is Smallpox?
Smallpox is a variola virus, worldwide killing a third of those it infected, and in the 20th Century alone an estimated 300 million people died from the disease. The initial symptoms of the painful disease included fever and vomiting. This was followed by formation of ulcers in the mouth and a skin rash over much of the body. Soon the skin rash turned into characteristic fluid-filled blisters. The cause of death from smallpox is not clear but involves multiple organ failure. Those who survived were often left badly scarred and in some cases blind. The disease is contagious and spread in droplets by coughing and sneezing.
The virus has a very long history of at least 3,000 years and its origin is unknown. The earliest evidence for the disease comes from the Egyptian Pharaoh Ramses V, who died in 1157 B.C. His mummified remains show the tell-tale pockmarks on his skin.
In 1796, Edward Jenner, a doctor in the small town of Berkeley in Gloucestershire, discovered that immunity to smallpox could be produced by inoculating a person with material from cowpox, which is a virus in the same family as variola. Jenner called the material used for inoculation ‘vaccine’ from vacca, which is Latin for cow. During the 19th century, the cowpox virus used for smallpox vaccination was replaced by the vaccinia virus. Vaccinia is in the same family as cowpox and variola but is genetically distinct from both.
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| A Gillray cartoon, 1802 |
A smallpox hospital was established at King’s Cross in 1746 and replaced in 1815 by the London Fever Hospital which had moved there from its original site in Gray’s Inn Lane. In 1848 a new hospital opened in Liverpool Road Islington. The original smallpox hospital moved to Highgate (where the Whittington Hospital is now) and remained until 1896, when it finally went to Clare Hall in Barnet.
The Vaccination Act
In 1853 a compulsory Act was passed requiring vaccination of all babies within three or four months after birth. This resulted in the deaths of children under five falling from 75% to 55% in a few years. However, there was inadequate administration of the vaccination laws in London. Anti-vaccination sentiment and a mobile population meant that a large minority of infants were not inoculated. Revaccination, which might have reinforced individual and group immunity, was unfunded and mostly neglected so smallpox became a disease of adults as well as of unvaccinated children.
In 1869 and 1870 smallpox was rife in Europe, and the number of deaths in London rose throughout 1870. In the last week of December, 110 people died with a total of 879 for the last quarter of the year. The numbers peaked in the first quarter of 1872 with 7,720 deaths in England and Wales. Subsequently the numbers declined to 277 in the last quarter of 1873.
Although the pandemic was severe, it was estimated the death rate was about one third of the pre-vaccination period. It was also the lowest in Europe where a smaller percentage of babies had been vaccinated. However, people who were vaccinated could still die. In a sample of 14,808 cases admitted to metropolitan hospitals up to 30 March 1872; 11,174 cases were reported as previously vaccinated with a mortality rate of 10.15%, and 3,634 unvaccinated had a mortality of 44.80%.
A total of 69,018 people died of smallpox from 1870 to 1874 in England and Wales. The 1871 census showed a population of 23.476 million. For comparison, the 2021 population of England and Wales is 56.223 million.
The Metropolitan Asylums Board
Following Gathorne Hardy’s Act of February 1867, the Metropolitan Asylums Board (MAB) was established in June to organise and provide health care for the poor of London. One of its responsibilities was the care and control of all infectious disease cases. To this end, MAB began a programme of building fever hospitals in Hampstead, Stockwell and Homerton.
In 1868, the MAB paid £16,000 for the Hampstead site of the eight-acre Old Bartram’s fields. However, progress was delayed by local opposition to the scheme led by Sir Rowland Hill, the pioneer of the penny postage scheme, who owned the adjacent property called Bartram House.
At the end of 1869, before the Stockwell and Homerton hospitals were ready, there was an outbreak of ‘relapsing fever’ in the east of London. This is a bacterial infection with symptoms of fever, headache, muscle aches, and nausea. It is transmitted by ticks or lice. To deal with this outbreak, the MAB erected temporary huts in the grounds of the London Fever Hospital, and at the Hampstead site. The facilities at Hampstead, designed by the Manchester firm of Pennington & Bridgen, consisted of timber and metal huts providing 90 beds, with the possibility of being enlarged to 180 beds.
It was built and staffed in one month. The site, which opened on 25 January 1870, was effectively England’s first state hospital. Nursing care was provided by the Anglican Sisters of St Margaret, from East Grinstead.
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| A Ward in the Hampstead Hospital, ILN October 1871 |
Hampstead closed after the relapsing fever epidemic subsided in May 1870, but then reopened on 1 December 1870 when there was a serious outbreak of smallpox in London. Hampstead was soon filled with cases from all over the Metropolis. Additional huts had to be built rapidly as patients were brought in and the site became very crowded. The rapidity with which the cases multiplied, and their high fatality are shown by the fact that within two months of opening 572 cases were admitted and 97 died, a mortality of 17 per cent. Between December 1870 to June 1871, 7,276 smallpox patients were treated in Hampstead.
Doctors, nurses, and workmen were in a race with the epidemic. By October 1871 about 24,000 patients had been treated at the four MAB fever and smallpox hospitals; Hampstead, Homerton and two in Stockwell.
On 14 November 1871, the Hampstead ratepayers, led by local MP Lord George Hamilton, sent a deputation to make their feelings known to James Stansfeld, President of Local Government Board. The residents felt so strongly about the matter that they offered to pay for the removal of the Hampstead Hospital to another location.
As a result of the residents’ campaign, a parliamentary select committee investigated the operation of the hospital during the 1871 epidemic. Its report, published in 1875, found that patients had communicated with people over the hospital walls, and that relatives and ambulance men often stopped for refreshment at The George pub on Haverstock Hill, close to the hospital gates. The committee concluded that the MAB had acted properly and that the problems were ones of individual carelessness and poor control of patients rather than to the presence of a smallpox hospital in the locality.
In his book ‘Contagion, Isolation, and Biopolitics in Victorian London’, Matthew Newsome Kerr (2018) outlines the complaints by patients in what the press called the ‘Hampstead Hospital Scandal’. These included the poor food and their alleged mistreatment including some cases of being tied to the bed, which were a result of the overcrowding at the peak of the smallpox pandemic.
A new outbreak of smallpox from 1876 to 1878 and the re-admission of cases to Hampstead led to a resurgence of complaints from local residents who believed that the disease was air-born. This was the widely-held ‘miasma theory’ of transmission from the ‘bad air’ of the undrained, filthy and stinking areas inhabited by the poor.
In January 1879, a legal suit was brought by Sir Rowland Hill against the MAB. After the eleven days’ trial the jury decided that the hospital was a nuisance, that the defendants during the 1871-72 epidemic did not use proper reasonable care with reference to the plaintiff’s rights or with respect to the ambulances. An appeal by the Board was unsuccessful, and for over three years from May 1879 to November 1882 the hospital remained closed.
Rowland Hill died in August 1879, and his son Pearson Hill took over the fight against the hospital. Legal wrangling continued until 1883 and with escalating costs for both the Board and the Hampstead ratepayers, the MAB finally made an out of court agreement limiting the number of smallpox patients in the hospital at any one time to 40 and moving the hospital’s entrance at Haverstock Hill to the opposite end of the site. As part of its settlement with the Hampstead ratepayers, the MAB purchased Bartram House, and a three-acre field for £13,000. The house was used as a nurses’ home.
In 1881 a Royal Commission was appointed to consider the wisdom of placing smallpox hospitals within the urban area. The outcome was that the Hampstead Smallpox Hospital ceased to admit smallpox patients in 1882 and was renamed the North-Western Fever Hospital, treating mainly cases of scarlet fever and diphtheria.
Following several influential reports and the legal cases, the MAB decided that from 1884 it should no longer treat smallpox in its urban hospitals. Instead, it resorted to hospital ships. At first it leased the ‘Dreadnought’, a seamen’s hospital ship moored at Greenwich. Then it acquired three other retired craft, the ‘Endymion’, ‘Atlas’ and ‘Castilia’, and moored them on the Long Reach of the Thames Estuary. The 1901–1903 smallpox epidemic led to extensive building nearby on the Dartford marshes of the Long Reach and Orchard hospitals, and then the large 940-bed Joyce Green Hospital, which opened in 1903.
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| The HMS Dreadnought hospital ship |
On joining the NHS in 1948 the Hampstead hospital became part of the Royal Free Hospital Group and was renamed the North-Western Hospital. The introduction of antibiotics meant fever cases significantly declined, and it became a general hospital. Infectious disease cases were taken instead to the Coppett’s Wood Hospital in Muswell Hill.
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| 1915 OS Map, showing the positions of the Hampstead General and the North Western Fever Hospitals |
The North-Western Hospital was demolished in 1973 and its site, together with that of Hampstead General Hospital, was used to build the new Royal Free Hospital. The 15-acre site contains the present Royal Free Hospital in Pond Street, which became fully operational in 1975.
The End of Smallpox
The World Health Organization led a global vaccination programme to wipe out smallpox and by the 1970s cases were rare. The last known fatal case in England was in 1978. The WHO announced the global end of smallpox in 1980, the only human infectious disease ever to be completely eradicated.
For more information see:
https://www.wikiwand.com/en/Smallpox
Stephen W Job has written an excellent account of the 1880s smallpox outbreaks in Hampstead and St Pancras in the Camden History Review 41 (2017).
The establishment of the first hospitals is given in Gwendoline Ayers (1971), ‘England’s First State Hospitals and the Metropolitan Asylums Board’, which can be downloaded from the Wellcome website.
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