How deadly was smallpox? Rethinking a familiar statistic

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A familiar figure appears repeatedly in textbooks and scholarship alike: that smallpox killed 20–30 percent of those infected. It is a striking statistic—but how reliable is it? Eric Schneider and Romola Davenport have revisited this question.

In 1707, as smallpox spread across Iceland, one observer described a haunting scene: farms stood silent, livestock wandered unattended, and “the healthy could not tend to the sick.” Entire households had fallen ill at once. Some who might have survived, he wrote, died simply because no one was left to care for them. All told some 25% of the population of Iceland died from smallpox in this epidemic. This epidemic shows that smallpox could be very lethal, but was this typical?

In our latest research, we examine smallpox case fatality rates in two eighteenth-century case studies: Iceland in 1707–09 and Sweden in 1776–1800. This allows us to understand how the lethality of smallpox varied in different epidemiological contexts, before the impact of vaccination.

A disease of childhood

In Sweden and many other parts of Europe before vaccination, smallpox was endemic. In such settings, it circulated continuously and was primarily a disease of childhood. By adulthood, most individuals had already been infected and acquired lifelong immunity.

Using detailed mortality data from Sweden between 1776 and 1800, we show that adult deaths from smallpox were extremely rare. This observation creates a puzzle. Given the number of reported smallpox deaths, if smallpox really killed 20–30 percent of those infected, a large proportion of the population should have remained susceptible into adulthood, but they did not.

By modelling mortality and immunity together, we estimate that the most plausible case fatality rate in this endemic context was much lower: around 8–10 percent. A very different picture emerges when smallpox struck as an epidemic disease.

When epidemics overwhelm society

The photo shows how sparse the population of Iceland was even in the capital city Reykjavik in the 1860s. (Sigfús Eymundsson 1837 – 1911, via Wikimedia Commons)

In Iceland, where the population was too small to sustain endemic transmission, outbreaks occurred only intermittently. When they did, they affected both children and adults. The epidemic of 1707–09 was particularly devastating, killing over a quarter of the population. By combining census and mortality data with estimates of infection rates, we calculate that the case fatality rate in this epidemic may have been as high as 43–55 percent.

Such figures are far above the familiar 20–30 percent. But they are not easily explained by biology alone. For historians of medicine, the most revealing aspect of our work lies in its emphasis on care. In endemic settings, infections were spread out over time. Households continued to function, and the sick could be nursed. In Iceland, by contrast, entire households fell ill at once. There were too few healthy people to care for the sick, prepare food or even tend livestock. Under these conditions, mortality rose sharply, not simply because the disease was virulent, but because the social systems that sustained life had broken down.

Beyond a single number

These findings challenge the idea that diseases have fixed case fatality rates that can be applied across time and place. Instead, they highlight the importance of context, especially the organisation of households, the availability of care and the scale of outbreaks.

They also have wider implications. High mortality in past smallpox epidemics, including those in the Americas, may reflect not only immunological vulnerability but also the social disruption caused by widespread infection.

Smallpox, in this light, was not simply a biological phenomenon. Its deadliness depended on the societies it struck. For historians, this serves as a reminder that disease outcomes are shaped as much by social conditions as by pathogens themselves.

Eric Schneider is Professor of Economic History at the LSE. His research focuses on the history of child health and the causes of the health transition. https://www.ericbschneider.com/

Romola Davenport is a research professor in the Cambridge Group for the History of Population and Social Structure, University of Cambridge. Her research addresses the demographic impacts of early public health interventions. https://www.geog.cam.ac.uk/people/davenport/

Their open-access paper is available at Schneider, E. B., & Davenport, R. J. (2026). What is the case fatality rate of smallpox? Population Studies, (ahead-of-print), 1–15. https://doi.org/10.1080/00324728.2026.2620692

Reconstructing an Early Modern Panacea

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For nearly two millennia, Theriac—a panacea developed in antiquity—was produced and praised across Europe. By the 19th century, it was dismissed as quackery. Today it has been reconstructed and will soon be tested. Danuta Raj explains.

In recent years, historical reconstruction has emerged as an innovative approach in research, bridging traditional historiography with hands-on practices from craftsmanship and the sciences. This interdisciplinary method allows scholars to re-examine and reinterpret primary sources through ‘practice’ and direct experience. By engaging with the material culture of the past—smelling, touching, and even tasting—researchers gain insights into historical realities that might otherwise remain obscure.

Making Theriac

Historical reconstructions, especially those involving the recreation of ancient medicines, are truly fascinating. They expose researchers to sensory factors not usually included in texts: pungent smells, unusual textures and sometimes, let’s be honest, less-than-pleasant tastes. These experiences are often far from what we’re accustomed to, so first encounters can be… surprising, to say the least!

Today, Theriac is making a return in academic circles, no longer as a highly valued medicine but rather as a model for investigating historical medical and apothecary practices. Thanks to collaborations between historians and pharmacists, ancient formulations emerge again after centuries of oblivion.

Guldenius recipe for Theriac

Our historical-pharmaceutical team comprises four people from three universities. We call ourselves The Pracademics. The recipe we worked on has its own intriguing history. In 1630, in Toruń, Poland, amidst plague outbreaks, an apothecary named Paul Guldenius prepared a batch of Theriac to help the citizens survive the epidemic. He was granted official permission by authorities in Wittenberg, the best-known approval centre for that part of Europe. The recipe was preserved in municipal documents, allowing us, centuries later, to attempt a reconstruction of an authentically used version.

Making Theriac

Our first step was translating the recipe to stay as true as possible to the original craft. Then came the small task of gathering 71 ingredients from Europe, Africa, and Asia. Some, like St John’s wort or ginger, are still valued in medicine today. Others are so obsolete that obtaining them became an adventure in itself. Let’s just say that ordering obscure materials from the far corners of the internet led to my credit card details being stolen. Twice.

The preparation took a week of grinding and two days of mixing. We even used historical utensils from the pharmacy museum because no contemporary laboratory equipment quite fit the bill. Adjusting a 17th century recipe to a 21st century setting was truly challenging but immensely enjoyable. It’s great fun to watch when a text, previously seen as straightforward, turns out to be problematic. What exactly does “reasonably sticky” mean in practical terms?

At the end, we were rewarded with a blackish, sticky residue with a tar-like smell, matching descriptions of freshly prepared Theriac. Prepared in early spring 2024, our Theriac is currently maturing and will be ready in early 2025. Once matured, the Theriac will be subjected to laboratory analyses, which will tell even more about this intriguing medicine.

The 2024 conference, “Historical Reconstructions: Touching the Past” in Wrocław, Poland. (text in English) provided an exciting platform for interdisciplinary discussion. We plan to make this event regular, so if you’re intrigued by delving hands-on into history, stay tuned for the next edition!

Danuta Raj is a pharmacist working on historical reconstructions, and—more conventionally—phytochemistry of medicinal plants. Other team members include Jakub Węglorz, Katarzyna Pękacka-Falkowska, both historians, and Maciej Włodarczyk, a pharmacist.

Further reading

  1. Raj D., Pękacka-Falkowska K., Włodarczyk M., Węglorz J.; The real Theriac – panacea, poisonous drug or quackery?, J. Ethnopharmacol., 2021, Vol. 281, nr 114535; DOI: https://doi.org/10.1016/j.jep.2021.114535
  2. Ahnfelt N. O., Fors H., Wendin K.; Making and taking theriac: an experimental and sensory approach to the history of medicine. BJHS Themes, 2022, Vol. 7, 1-24; DOI: 10.1017/bjt.2022.6
  3. Di Gennaro Splendore B., The State Drug. Theriac, Pharmacy, and Politics in Early Modern Italy (Cambridge: Harvard University Press, 2025)

Emil Kraepelin, the little known guru of British psychiatry

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Emil Kraepelin (1856-1926) is one of the psychiatrists who have shaped world psychiatry. His views have had more lasting influence on psychiatry than Freud, yet he is little known by the public, explains Peter Carpenter. 

Kraepelin arguably is the most significant figure in the development of the ideas of British psychiatry. The impending centenary of his death has prompted a two-day conference at the Royal Society of Medicine in London: After Kraepelin: Ambitions, Images, Practices and the History of Psychiatry 1926-2026 on 6-7 March.

Bearded older man in oval format

Emil Kraepelin

His comparative obscurity is probably because he was a German by birth, spent his entire life within Germany and wrote in German. He left others to translate. But he wrote at a time when British psychiatry was looking for evidence to develop the profession. His great work Compendium der Psychiatrie: Zum Gebrauche für Studirende und Aerzte (Compendium of Psychiatry: For the Use of Students and Physicians) was first printed in 1883, and he wrote nine editions of the work during his life.

He first stressed the biological basis of mental illness and the need to collect observations over time. He started the advance from concepts of mental illness from classifications that still depended on 18th century and earlier ideas that named mental conditions by how they presented in the here and now. A patient, therefore, could have series of names given to their condition over a period of ill-health. As part of this, in his 1893 edition he separated major affective disorders – mania and melancholia – from dementia praecox (later called schizophrenia) – rather than grouping them on whether they were violent or inactive when seen.

With his detailed case records and search for physical causes, Kraepelin turned psychiatry and the treatment of mental illness from a philosophical argument into a science and psychiatrists from quacks to doctors. His ideas were practically useful to psychiatrists dealing with major mental illness, and whilst Freud later held the public’s imagination, Kraepelin (and his views of the biological basis of major mental illness) continued and determined much of modern psychiatric thinking and treatment.

Kraepelin actively rejected the ideas of Freud on childhood experiences being a cause of illness. He studied speech in dreams as a means of understanding psychotic speech. He campaigned for better treatment of the mentally ill but also supported the ideas of eugenicists and taught that homosexuality was a vice.

The conference After Kraepelin: Ambitions, images, Practices and the History of Psychiatry 1926-2026 has a programme that covers both his history and his ideas and how biological research and social and political changes have altered how his ideas are now seen. It will take place on 6-7 March and is open to all. Further details: https://www.rsm.ac.uk/events/psychiatry/2024-25/pyt02/.

Peter Carpenter is a retired psychiatrist, now co-chair of the history of psychiatry group in the Royal College of Psychiatrists and a fellow of the RSM.

The Royal Lancaster Infirmary Collecting Barrel 

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Soon after its opening in 1896, the general committee of the Royal Lancaster Infirmary (RLI) discovered that they needed an additional £4200 for essential items. Bryan Rhodes describes an object used to raise funds.

Late 19th century stone building

Royal Lancaster Infirmary original building https://commons.wikimedia.org/wiki/User:The_wub

Building work on the new Lancaster Infirmary began in 1893, and by 1896 this ‘state of the art’ new hospital was ready to be opened. The Duke and Duchess of York arrived in Lancaster for the official opening of the hospital in March 1896. The Duke, later crowned George V, opened the hospital using a golden key presented by the architects, Paley and Austin, on Tuesday 24 March, and announced that from that moment onwards, the infirmary would become the ‘Royal Lancaster Infirmary’, courtesy of his grandmother, Queen Victoria.

Despite various fundraising events and multiple donations at the opening ceremony, the general committee needed to raise the additional funds, and this collecting barrel was probably one method to do so.

Wooden collecting barrel with plaque dating from 1896

The RLI Collecting Barrel. Photo courtesy Bryan Rhodes

Object of the month

The barrel is the first in the series of ‘Object of the Month’ on the new website of the Lancaster Health and Medical Museum Collection and is one of the museums’ most recent donations, received in October 2024 from Mrs J. Parker

Mrs. Parker discovered the collecting barrel, measuring 22.5 cm long  (just under 9 inches), in the cellar of her late father’s house. Her father, Kenneth Townson, had moved to Lancaster in 1961 to work in the Bay View Hospital (the last name for the Lancaster workhouse hospital). By coincidence, I had arranged to meet her to collect the barrel in the Bay View Garden Centre café.

When the Bay View Hospital closed in 1962, Mr. Townson moved to the RLI where he worked until 1984 as the manager of the general office, close to the main entrance. We don’t know how the barrel came to be in his possession, but we are grateful to Mrs. Parker both for photos of her father and the barrel.

Collecting barrels of this design were quite common in the late 1800s. Our example is beautifully coopered with narrow wooden staves and four brass hoops. At one end there is a small wooden door with a lock. The key for the lock is missing.

After collecting the barrel, I discovered that Mrs. Parker’s husband also has a connection to Lancaster’s medical history. He is a direct descendant of Agnes Oxley, who worked as one of two cleaners for the notorious Dr Buck Ruxton in September 1935. She was scheduled to clean his house and surgery the day after he murdered his common law wife and the housemaid and was surprised to have a very early visit from the doctor asking her not to come that day!

Bryan Rhodes is the chair of the Lancaster Health and Medical Museum Collection and guest editor of the 5th edition of Topics in the History of Medicine, to be published later this year by the British Society for the History of Medicine.  He is a retired orthopaedic surgeon.

Further Reading: ‘In Times of Need, The History of the Royal Lancaster Infirmary’  by J.G. Blacktop

 

 

Plague Houses and Pandemics – Some comparisons between 1665 and 2020

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Charles ll issued an edict in 1665 that every parish should identify a shed, a tent or a house to accommodate those identified with the plague. Alison Wall looks at the role of such isolation in times of pandemic.

19th century lithograph of old plague houses in bleak setting

Pest houses Tothill Fields, Westminster, London, lithograph 1840, Wellcome Collection

Plague, pest or pestilence houses – the terms can be used interchangeably – were buildings set apart as places to isolate those suffering plague and smallpox. It seems that there was often a favourable outcome and people survived.

There were five pest houses in London, accommodating about 600 sufferers, and there are houses still standing across the country, some Grade ll listed.

Was there a degree of restraint for those confined to the pest house? There may well have been if we look at Samuel Pepys’s comments, in his diary of 1665: “A mayde having run away was taken back to the pest house in the pest coach.”

What was the pest coach? It was a special sedan chair painted black, with black curtains, so it was clear what its function was.

Then and now, the most important difference between the 21st and the 17th centuries was the realisation in the 17th century it was wrong to admit plague and smallpox sufferers into the general hospitals or hospitiums, as they were initially called. The latter were there to serve the poor and suffering and give general shelter and care.

Charles II looked back in history and understood the importance of isolation and care in the pest houses. Sadly, our equivalent Nightingale hospitals were erected in a very reactive and uncoordinated fashion. In our time, how many people were admitted into the general hospitals with some acute or chronic condition, unrelated to Covid but caught Covid in hospital and died? Many health professionals also died in the early days of Covid.

Another, if less significant contrast, is that in the time of the Great Plague in 1665, thousands of stray cats and dogs were slaughtered, as people believed they carried dirt and fleas. The cat population could have helped reduce the numbers of black rats that were carrying the plague carrying fleas. Conversely, during the Covid lockdown many people homed cats and dogs for companionship.

The spread of Covid across the world has had a massive impact. The isolation that plague victims must have experienced – and sometimes tried to escape – has echoes in that endured during lockdown in the period of Covid. Isolation causes huge psychological and emotional impacts, with greater understanding of this post Covid.

Inevitably there will be future pandemics. We need to reflect and plan for the future, remembering the value of those parish pest houses.

Alison Wall is a retired nurse, midwife and health visitor. She is the author of “Plague Houses and Pandemics”. Before her retirement she worked in Camden and Islington as a public health strategist.

Woman in pink dress with figure in red cloak and plague masque.

Alison Ward with a figure wearing plague masque

References and further reading

  1. https://www.nationalarchives.gov.uk/education/resources/great-plague/
  2. Byrne, J. Encyclopedia of the Black Death. Bloomsbury. 2024. p.217
  3. https://onlinelibrary.wiley.com/doi/abs/10.1111/nuf.12001
  4. Latham, R.C. & Matthews, W. (ed) 1885. The Diary of Samuel Pepys, Vol. Vl. p.120
  5. Boyd, D. Plagues and Pandemics. Pen and Sword. 2021. p. 67