‘Opening Up the Body’ is a Wellcome-funded project to conserve the Post Mortem Examinations and Case Books of St George’s Hospital, 1841-1946. Our Archive team have been cataloguing and digitising records dating from 1841-1921.This blogpost was written by Archivist Juulia Ahvensalmi.
‘It is difficult to imagine a more favourable opportunity than the one recently afforded us here, of investigating the laws of an epidemic disease such as the one we have just experienced’Thomas Jones, ‘On the Recent Outbreak of Smallpox at St George’s Hospital’ (1870)
‘Contact tracing’ has in the past year become a phrase that is surely now familiar to us all. As a concept, however, it’s nothing new. In this blogpost, we’ll take a look at how St George’s reacted to a smallpox epidemic at the hospital.
In November 1870, smallpox cases started spreading within St George’s hospital. The infected patients had all been admitted for other causes, and had all been in the hospital for a long time – somewhere between two weeks and four months. It seemed clear the disease was being somehow transmitted among the patients, but as the cases occurred in different wards and floors with no direct contact between the patients, the route of transmission was a mystery.
Generally, patients with infectious diseases were sent to specialised hospitals to prevent the spread in more general hospitals. Two of these so-called fever hospitals were the Fountain Hospital and the Grove Hospital, which stood side by side on the site now occupied by St George’s in Tooting. The Fountain Hospital was established by the Metropolitan Asylums Board (MAB) in 1893 in response to a scarlet fever epidemic, and later became a mental hospital for children. The Grove Fever Hospital opened in 1899; in 1954 it became the Tooting branch of St George’s. The last remaining buildings are now being demolished.
Tracing the epidemic
Sarah M., 23, was admitted into St George’s hospital on 28 Sep 1870 for ‘syphilitic laryngitis’. For several weeks, she was given potassium iodide. The first smallpox eruptions appeared nearly two months after her initial admission, and were first thought to be a side effect of her medication. When her condition became apparent, she was quarantined in a separate room in the basement of the hospital, her bed and bedlinen were disinfected, and she was moved back to the workhouse she had come from only a few days later (which sounds like not very effective quarantine practice, but we’ll come back to that later).
Thomas Jones, MD, wrote an article on the outbreak in St George’s Hospital and Medical School Annual Reports, which consisted not only of reports of specifically relating to St George’s (despite the name), but also of articles by the staff of St George’s and external contributors. These were printed and widely distributed, and have been digitised by HathiTrust from copies held at Harvard University and University of Michigan: we are very grateful for this, especially now when our access to our own physical archives remains sporadic! Jones had only gained his MD earlier that year from St George’s, and was working at the hospital as resident medical officer and anaesthetist.
The article details the cases of the infected patients, with remarks on whether the patient in question had been vaccinated:
‘CASE XV. Mary H., æt. 12, admitted December 12, Drummond Ward. Suffering from knocked-knees. Smallpox eruption, very modified, appeared on January 9th. Discharged convalescent, January 31st. Vaccinated in infancy; vaccine cicatrices of excelled quality.’
‘Case XIX. Florence B., æt.19, admitted December 14th, Crayle Ward. Eczema. Smallpox eruption, which was distinct, appeared on January 14th. Was re-vaccinated on the same day. The attack was rather severe. There was no trace of the re-vaccination on the seventh day. Was vaccinated in infancy; one vaccine mark of bad quality. Has made a good recovery.’
There were altogether 27 cases, of which 20 were cases of transmission within the hospital, whose symptoms appeared between 25 Nov and 15 Jan. In addition, there were three patients who were admitted with smallpox between 12 Jan and 8 Feb, and four who showed symptoms only after having been discharged from the hospital initially.
Of these 27, six died. They were all said to have been suffering from various underlying conditions, including softening of the spinal cord, heart disease, pyelitis and congested lungs; one was recovering from an operation and one, a 23-year old probationer nurse at St George’s called Christiana S. in the article, was said to be ‘of a delicate constitution’ and in ‘a weak state of health’. Three of these six had been vaccinated.
The death of Christiana S., or Christina Stewart, was recorded in the St George’s post mortem books, although there are no case notes as no post mortem was performed – not uncommon when it came to hospital staff. Her cause of death is recorded as ‘Variola’, another name for smallpox.
One of the unfortunate people who died was James Jennings. His occupation in his post mortem notes was recorded as ‘pork butcher’, and he had been suffering from a feeling of tightness around his abdomen and increasing weakness in his legs for some time; he was also partially paralysed on his hands and legs:
‘He walked to the train on day of admission but says that while in the carriage he felt a sudden sensation of coldness all over, & on reaching London found that he had entirely lost power in the legs’
His treatment included potassium iodide and belladonna. The rash appearing on his skin was initially attributed to the belladonna he had been receiving, rather than smallpox. He died 8 Jan 1871, a couple of days after the appearance of the pustules signifying a smallpox infection, ‘in spite of wine, which was freely administered’. The post mortem found no evidence that he had been vaccinated against smallpox.
The other deaths recorded include that of Ellen Collier, a milliner (whose body was not examined) and David Edwards, a groom, who became delirious and died after being moved to the temporary smallpox ward which had been set up on the top floor of the hospital.
The two other deaths occurred outside the hospital, and are not recorded in the post mortems. Michael S., 48, had been discharged from the hospital 28 Dec; he had spent the following night at Vauxhall-bridge-road, before returning home to Fellday, Dorking. He died 12 Jan 1871, and was examined by a local doctor in Dorking. John T. was only three years old, and had had lithotomy performed on him. Whilst at the hospital, he developed a sore throat, which was assumed to be due to ‘hospital air’ and was sent home, where he died less than a week after the appearance of the smallpox pustules. He had not been vaccinated.
Prevention and tracing the origins of the epidemic
The measures taken at the hospital to mitigate the spread of the disease included isolation of the infected patients: after the first three cases, a convalescent ward on the top floor was set up as a smallpox unit. The ward had dedicated nurses, and no visitors were allowed: the medical officer in charge visited this ward after all his other rounds. Particular attention was also paid to disinfecting the hospital:
‘For the atmosphere of the whole Hospital has been so thoroughly impregnated with carbolic acid, from sheets steeped in it and hung before the door of each ward, and from the floors being washed with a weak solution of the acid, that it has positively been painful to some with very sensitive organs of smell.’
The initial assumption was that the disease had been brought in by visitors, as it was known that smallpox was circulating in the neighbourhood, having, according to the Medical Officer of Health report, been introduced by a governess returning from Paris. Visitors were therefore banned from the wards, unless there were special reasons, i.e. the patient they were visiting was very ill.
Jones set up to detect the origin of the disease. Assuming the incubation period to be 13×24 hours (or 14 days), from the infection to the appearance of an eruption, he managed to trace patient zero, or Case I, Sarah M., who had spent 11 weeks at the hospital.
On 10 Nov, however, she had been allowed to leave the hospital for a few hours to visit a friend, who was later ascertained to have smallpox. Sarah had, however, since been moved back to the workhouse (there is no note in the article of whether the workhouse also suffered from an outbreak, but it is hard to imagine it did not), and Cases II and III did not appear until three weeks later, on a different floor – so how was it possible that the disease continued to spread at the hospital? Moreover, the cases continued to spread even after the visitor ban and the ‘rigidly observed’ quarantine measures.
Did it spread through the air? This theory was dismissed as unlikely, since the cases were so spread over different floors and wards. All other theories were similarly dismissed, and after careful investigation, the only common factor between the cases appeared to be the days when bed-linen was changed.
The linen was changed on Mondays and Thursdays: the dirty linen was sent out to be washed on Thursdays and returned, clean, the following Thursday. One sheet was used on that day, and another clean sheet on the following Monday. This theory seemed to account for the majority of the cases, with a few exceptions, one of which included the hospital carpenter, who may instead have caught the disease through contact with one of the patients.
This led to Jones concluding that the disease was infectious even before any eruptions appeared, and thus any cases of fever during an epidemic should be closely monitored to enable early isolation and disinfection.
Linen was supposed to be washed in boiling water, but, whether or not that actually happened (and washing the linen for the hospital was not an easy or light task!) this, it was concluded, was ‘not sufficient to destroy the fever-poison’. Carbolic acid, however, appears to have worked, as the sheets of the patients known to be infected were steeped in carbolic acid before being sent to the laundry.
The main conclusion, however, was to do with vaccination, and in particular re-vaccination:
‘This outbreak … supplies us with farther evidence, if any were required, of the protective power of re-vaccination against smallpox’
Indeed, as the disease spread, it was decided that all the nurses and patients at the hospital should immediately be vaccinated. The vaccination programme was commenced on 13 January 1871, and by March, the measures taken appeared to have stopped the spread of the epidemic.
A follow-up article by obstetric assistant Richard Wilson examines how the vaccination programme was conducted. Three methods were used:
- Puncturing: ‘by grasping the arm (usually the left) with the left hand, drawing the skin tense, and then making from four to five punctures down to the cutis-vera with an arrow-headed lancet’;
- Abrasion or scratching, using an ‘ordinary bleeding-lancet’: ‘two or three small parallel scratches were made …. the lymph, if liquid, was then rubbed well in with the point of the lancet; if points were used, these were first moistened by the breath, and rubbed into the different scratches’; and
- Vesication, using ‘blistering fluid’ the night before the vaccination to make small blisters: ‘on the following day they were priced to allow the serum to exude, and then the lymph was applied to the raw surface’.
The scratching method appeared to be most effective, although it was prone to produce severe inflammation in the elderly or those with other health conditions.
The quality of the ‘vaccine marks’ or ‘cicatrices’ appears of particular interest, with ‘good marks’ equating, it was speculated, to stronger protection and increasing the likelihood of a mild form of the disease. ‘Bad’ marks were smooth and shiny, or hardly visible at all: the stronger and more visible the mark, it was thought, the stronger the protection. The vast majority of the staff and patients had already been vaccinated at some point in their lives, most of them in infancy.
Smallpox epidemics were common throughout the 19th century, despite Edward Jenner, a St George’s alumnus, having developed smallpox vaccination in 1796. He was not the first one to attempt to treat the disease, one of the deadliest in history. Mary Montagu introduced the idea of inoculation from Turkey to Britain in the early 1700s. Smallpox was not eradicated until 1973, and to date remains the only human disease to have been eradicated by vaccination.
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