Smallpox and Cholera with Particular Reference to S.W. England
By: Dr John Sell
For a long time, it was thought that smallpox was one of the most devastating diseases of mankind for over 5,000 years, the earliest known cases being in Egypt or India. More recently doubt has been cast on the antiquity of the disease, some thinking it did not appear until the early 16th century A.D. The Antonine plague of 165 – 180 A.D., which broke out in the Roman army during the Marcomannic Wars, was thought to have been smallpox but this is now contested and Measles has been promoted as an alternative diagnosis. In the 16th century, Europeans inadvertently carried the disease to the Americas where the indigenous populations had no innate resistance and mortality among them was so high that by the late 1700s, their populations were less than 10% of pre-colonization levels.
In more recent times it is estimated to have killed between 300 and 500 million people worldwide in the last 100 years of its existence. It is a viral infection caused by the Variola major virus. Symptoms begin with fever and vomiting up to three weeks after exposure, leading to ulceration of the mouth and the characteristic skin rash which starts with blisters with a central dent, then scab over and eventually fall off leaving scars that can be very disfiguring. The mortality rate is 30% but usually higher in infants.
During the course of history, six European monarchs, including Louis XV of France, Queen Mary II of Britain, wife of King William III and Ulrika Eleanora, Queen of Sweden, have succumbed to smallpox, one as recently as 1967. Queen Elizabeth I survived smallpox but, like many, carried the scars for the rest of her life.
The U.K. was by no means immune. Decade by decade between 1629 and 1830 in London the effect of smallpox grew to become responsible for 9 – 10% of total deaths by the second half of the 18th century. After vaccination took off, the smallpox death rate gradually returned to what it was in the mid-1600s.
Progress towards eradication began as far back as the 1500s in China where the technique of inoculation was developed. This involved scratching the skin of the arm with a small blade loaded with pus from a smallpox blister. It was a relatively dangerous business as it could result in a fatal infection rather than the desired object of a mild infection followed by immunity, and even more alarmingly, if the subject of the inoculation was not kept in quarantine for an appropriate time they could infect those around them with the possibility of starting an epidemic.
Nevertheless, inoculation was popular in the far and Middle East and in the early 18th century a redoubtable woman called Lady Mary Wortley Montagu, wife of the British ambassador to Constantinople, who had lost a brother and nephew to smallpox, and survived it herself, had her son and daughter both successfully inoculated. As a result, inoculation achieved a moderate vogue and was, in 1754, even endorsed by the College of Physicians. But the problem of contagion from inoculated subjects still persisted and its popularity soon waned.
A major step forward came in 1796 when Dr Edward Jenner, of Berkeley in Gloucestershire, who had been the favourite pupil of the famous surgeon, John Hunter, and remained a lifelong friend, decided to put their old much discussed hypotheses to the test. Having noted that milkmaids seldom caught smallpox if they had had the much milder disease Cowpox, he followed his old mentor’s advice of “Don’t think, try it,” and so with as much record keeping and caution as he could manage, vaccinated a young boy, James Phipps, with Cowpox pus from a milkmaid called Sarah Nelmes. Several weeks later he inoculated him with smallpox pus, and he did not develop the disease. After numerous more successful vaccinations, two years later he published what was to become one of the most influential publications of all time, his Inquiry into the Cause and Effect of the Variolae Vacciniae. Like many new medical innovations, it sparked heated controversy in the profession and the nation. Opinions were polarised, many critical and dismissive but many approving. One such was Dr Richard Reece, M.D. author of the widely consulted, Medical Guide for the Use of the Clergy, Heads of Families, and Practitioners in Medicine and Surgery, who wrote in his 1813 edition in its section “Of the Cowpox”:
This disease was first introduced by Dr Jenner as a preventive of smallpox contagion…..Cowpox, like all other discoveries in medicine, has met with the opposition of those professional characters who, from motives of lucre and jealousy, act as enemies to their own species…..In consequence of the late recommendation of the Cowpox by the legislature, I resolved to embrace every opportunity to put it to the test of experience. For this purpose I inoculated with smallpox matter about 30 children whom I had vaccinated within the last 10 years, the whole of whom resisted it. The result of these and other experiments has induced me to recommend vaccination.
Would that all medical practitioners were as assiduous in determining the truth before making sweeping pronouncements! (My words).
Eventually, after much debate and argument in medical circles, and the press, vaccination was adopted as the procedure of choice to prevent smallpox in the population. But it took a long time and several acts of Parliament to ensure that vaccination was widely practised. There was an unusually large epidemic in London in 1837-38 which spread to Europe. Following this, Parliament passed the Vaccination Act 1840 which made vaccination free and banned variolation. A second act was passed in 1853 which made vaccination available to babies in the first 4 months of life. When this was not adopted widely enough, a third act in 1867 brought in harsher penalties for non-compliance.
In 1870 – 75, a smallpox pandemic called the “Great Pandemic” swept across Europe, including Britain, claiming more than 500,000 lives. It originated from the Franco-Prussian War of 1870 – 71 where French P.O.Ws infected the German civilian population, leading it to spread across Europe. In England, thanks to compulsory vaccination, the death rate was only a third of that in Prussia, Belgium and Austria, being 1,000 per 1m. in 1871 and reducing to 250 per 1 m. in 1873-4.
After the Great Pandemic, many countries introduced compulsory vaccination, or stricter penalties where already compulsory. Austria and Belgium were exceptions and despite having among the highest infection rates did not apply compulsion.
Opposition to vaccination was quite common in the U.K., much of it based on ignorance or misinformation, as we have seen in Britain with Covid vaccination. In the early years of the 19th century, the Royal Cornwall Gazette carried several articles by prominent Cornish physicians including Drs Borlase and Isaac Head of Helston in 1802 and Dr C. Carlyon of Bodmin in 1812 to try to encourage the population to embrace vaccination, i.e. the safer preventive, instead of the much more dangerous technique of inoculation i.e. the use of “raw” smallpox pus. But as time went on it became apparent that things were not quite as black and white as it had been hoped, as a letter to the Royal Cornwall Gazette from Dr John C. Sleman of St Austell in July 1830, illustrates.
Dr Sleman states that between 1820 and 1830 he personally saw over a thousand cases of mild smallpox after the inoculation technique, and there were no fatalities and over an extended period, no reinfections. On the other hand, he says, he has seen many cases of natural smallpox in vaccinated children and adults, as many as one in three, with a significant death rate. His work included cases seen in a local Smallpox Hospital. What seemed to be emerging was that vaccination with Cowpox gave a high degree of protection against smallpox for 10 to 12 years but that after that it wained dramatically, and re-vaccination of children was not effective, but revaccination of adults usually gave good and long-lasting protection. As a result of these observations, the vaccination policy was reconsidered to advise vaccination of infants soon after birth and revaccination after puberty. This approach gave very long protection but was not nationally introduced quickly enough to avoid another national epidemic in 1837-38. All this was summarised in an article in the Falmouth Express and Colonial Journal on 23rd February 1839 which had been taken from The Lancet of 26th January 1839. Slowness of government legislation meant that the Vaccination Act, making vaccination free and banning variolation was not passed until 1840 and availability to the newborn was not strictly legal until 1853.
Low take-up of vaccination remained a national problem for several more decades and although Britain escaped the full force of the Great Pandemic which swept across Europe in 1870 – 75 we did not escape entirely. But gradually vaccination against smallpox became almost a mark of passage as those of us from the wartime and post-war N.H.S. generations will remember.
On the brighter side, smallpox was officially declared by the World Health Organisation to be eradicated across the world in 1980 and there have been very few occurrences since then.
Another infectious disease which has caused devastating pandemics is cholera which first appeared in European literature in 1642 in the Dutch physician, Jakob de Bondt’s book, De Medicina Indorum, The Medicine of the Indies. Cholera is a Greek word meaning bile or gall, in Old English, gealla. The ancients were rather confused about the physiology of bile and anything that was yellow was called cholera or choleric. The yellow diarrhoea of early stage cholera was therefore called cholera, but this did not distinguish it from the many other intestinal disorders that caused yellow diarrhoea. It soon became clear that what we now call cholera was a much more severe disease capable of killing many people very quickly and so the name cholera morbus was used from the 1830s to differentiate true cholera from Asiatic cholera, or common diarrhoea. By 1817, cholera morbus had spread by trade routes to Russia and thence on to the rest of Europe and from there to the U.S.A.
Cholera is an infection of the small intestine which causes watery diarrhoea (rice water stools) and vomiting ranging from quite mild to life-threatening without rapid, adequate treatment. The cause of death is severe dehydration and electrolyte imbalance. Cholera is caused by a bacterium called Vibrio cholerae, of which there are numerous different strains, some causing more severe disease than others. The seventh pandemic in 1961 which arose in Indonesia featured a new strain, the El tor strain, which still persists in developing countries today.
Cholera is spread through faecal contamination of food and water from infected persons. Prior to the mid-nineteenth century, this was not realised, the miasma theory of disease i.e. bad or noxious air, propounded by Hippocrates in the 4th century B.C. being still widely accepted, but the famous English doctor, John Snow, curtailed an outbreak in the Broad Street district of Soho in 1854 by removing the handle of the pump used by most of the inhabitants to draw water.
There have been seven cholera pandemics between 1817 and 1961 covering most of the globe and killing millions of people.
Due to the great growth in trade and travel, cholera became widespread in the nineteenth century and has killed tens of millions of people. Currently, it affects 3 – 5 million people worldwide and causes 30 – 130,000 deaths per year, especially in Africa and S.E. Asia.
Recognition of the importance of clean water and efficient sewage disposal gradually became more widespread and, aided by the developing germ theory of disease between the 1850s and 80s due to the work of people like Pasteur in Paris and Koch in Berlin, led to an enormous growth in the provision of clean water and efficient sewage disposal. In places that acted on these discoveries and improved their local water and sewage systems, cholera outbreaks diminished greatly. St Ives was relatively late in inaugurating an adequate fresh water and sewerage system and it wasn’t until 1895 that work on a comprehensive scheme was begun.
In Cornwall, there were many outbreaks of cholera during the 19th century and most of the large and mid-sized towns lost people to the disease. The local papers reported the situation and local medical men made their recommendations for treatments and prevention which ranged from the sensible to the ridiculous. Dr T. Hingston M.D. of Truro wrote to the Royal Cornwall Gazette on 22nd September 1832 at great length recommending common sense measures like cleanliness of person and home, good ventilation, regular exercise, and temperance of habit, but completely failed to mention the importance of clean water and efficient sewage disposal because the medical profession as a whole was still ignorant of the vital importance of these in avoiding the disease.
1832 appears to have been a particularly bad year for Cornwall. In St Ives, the local Methodist chapels held prayer meetings for the sick and deliverance from the scourge. During the latter half of the year, Penzance, Newlyn, Mousehole, Hayle, and St Ives were all badly affected. In some places, new ground had to be found for the increased number of burials. By the autumn of that year, the outbreak seems to have been abating, as the following excerpts from the Royal Cornwall Gazette show, R.C.G. 22nd September 1832:
This pestilential disease raged with great violence in Newlyn claiming 30 – 40 victims. Much praise is due to the medical gentlemen of Penzance for zeal and skill at risk of their own lives. Real accommodation from the Lord of the Manor of Mousehole and Mr Halse who granted a meadow for internments, the old ground being full.
In Penzance, only one death – of a person imprudently visiting Penzance to visit a sick brother.
And the R.C.G. of 28th September continues the theme: “Cholera at Hayle”. To the editor R.C.G. from St Erth Board of Health, Foundry 26.9.1832:
Amid general alarm which prevails from cholera having appeared at Hayle, I beg leave to state for the information of your readers, that so far as this parish is concerned, the last death was on the 9th inst., and through divine mercy we have had but one case since (in the person of a woman attacked at St Ives) who has since recovered: so far, therefore, we may reasonably infer that the disease has disappeared from within the precincts of St Erth, Thomas Rawlings (Sec to Board).
Around the time that Local Authorities were improving their sanitation, the doctors began work on an injectable cholera vaccine. Louis Pasteur was the first in this area, but his attempts were shown to be ineffective. In 1884 a Spanish physician, Jaume I Clua produced a live vaccine isolated from cholera patients in Marseilles and tried it in over 30,000 people in Valencia during an epidemic. Although having partial success in preventing disease, its mode of administration and side effects led to its rejection by the medical profession. A few years later, in 1892, Waldemar Haffkine, developed an effective vaccine with less severe side effects and tested it in 40,000 people in Calcutta between 1893 – 6. It is accepted as the first effective human cholera vaccine. This was a little later superseded by Wilhelm Kolle’s heat-treated vaccine in 1896 which was easier to prepare and was put to large-scale use in Japan in 1902.
This injectable vaccine remained the main preventive treatment until the development of an oral vaccine in the 1990s. This is now the treatment of choice for people in cholera-infected countries and for travellers. There are two main brands on the market, Dukoral and Vaxchora. Both use inactivated strains of Vibrio cholerae, while one has the addition of part of a cholera toxin as well. Both are licensed for use in humans of 2 years upwards. Two or three doses of either give up to two years of protection in adults but only six months in children aged 2 – 5 years, so quite frequent repeat doses are necessary for continuing protection.
Lest anyone should think that cholera is a disease of the past, very recently I received a request from UNICEF asking if I would make a donation to help combat a recent “Deadly Surge” in cholera in countries ranging from Syria to Africa and the Caribbean particularly affecting children and claiming that over one billion people are currently at risk. UNICEF’s aim is to greatly increase supplies of vaccines, water purification tablets and rehydration salts.
‘Plagues, Pandemics and Epidemics Through History’ is a four-part series written by Dr John Sell. ‘Introduction and the Black Death with Particular Reference to S.W. England’ is Part 1 in the series.
World Health Organisation online article
Wikipedia online article
Centres for Disease Control and Prevention online
The Reluctant Surgeon (biography of the surgeon John Hunter) by John Kobler pub. Heinemann
The Medical Guide for the use of Clergy, Heads of Families, and Practitioners in medicine and surgery. Dr R. Reece, M.D. pub. 1813 Longman
Royal Cornwall Gazettes for 1802,1812,1832,1839
Falmouth Express and Colonial Journal 1839
Cholera – vibrio cholerae infection, Centre for Disease Control and Prevention online.
Cholera – World Health Organisation online
Cholera – Wikipedia online
Royal Cornwall Gazette 1832 various articles.
Featured image: 16th-century Aztec drawing of smallpox victims (Wikimedia Commons)