Defeating the Ministers of Death

by David Isaacs

  CHAPTER 2

  Smallpox, the speckled monster

  The story of smallpox, one of the first diseases to be recognised by humans, is remarkable in many ways. It includes war crimes, tragedy and triumph. The introduction of smallpox devastated whole populations in Central and South America and in Australia. When it did not kill, smallpox often left a terrible legacy of facial scarring and blindness. Smallpox continued to kill millions of people every year until a half-century ago: a mere drop in the ocean of time. Within a few short years, smallpox was defeated and disappeared. The global eradication of the scourge that was smallpox is one of the greatest ever achievements of medicine, a triumph of science and public health policy.

  Historical claims about smallpox are difficult to verify. Although the clinical features of the disease are reasonably characteristic, there are other infections that can mimic it, including chickenpox. Thus, although it is often claimed that Egyptian mummies had facial lesions resembling smallpox – including the mummy of Ramses V, who died in 1157 BC – it is by no means certain that Ramses really had smallpox, or that it killed him.

  There are descriptions of a disease with all the characteristics of smallpox in the ancient Indian medical texts Charaka Samhita and Sushruta Samhita, which were compiled in the first century BC at the latest. The first reliable description of smallpox was in China in the fourth century AD, although there is historical evidence to suggest the disease may have been imported to China as early as the third century BC.

  The horror of smallpox was that it spread through a community like wildfire, causing devastating disease. A healthy child or young adult suddenly developed severe headache, back pain, fever, nausea and vomiting, and rapidly became so weak they could hardly move. After two or three days, small red spots appeared on their face and spread rapidly to the rest of the body. The spots became enlarged, raised and blistered. Then the unfortunate victim usually died within days. People who survived were often left permanently disfigured by deep facial scars. No wonder smallpox was called ‘the speckled monster’. It could also cause corneal ulceration, which rendered up to a third of all survivors totally blind.

  In about 165 AD, the Roman Empire was hit by a terrifying epidemic. An army campaigning in Mesopotamia contracted a disease that it brought back to Italy. It is often called the Plague of Galen, after the Greek physician who described the epidemic. Galen treated the infected soldiers in the army camp at Aquileia in northern Italy. According to his description, the soldiers were covered with blisters that later turned into a black rash, and the blisters fell off leaving scars. Many of the soldiers had fever, bloody stools and diarrhoea, features characteristic of what we now recognise as a haemorrhagic form of smallpox. If the stools turned black, the soldier died. The epidemic killed over 6 million people; some historians assert that it was one of the more important factors leading to the decline of the Roman Empire.

  Smallpox subsequently spread throughout Europe, transmitted by trade and wars, including the Crusades, and was widespread by the Middle Ages. Elizabeth I of England was imprisoned for a year by her half-sister Queen Mary, accused of supporting Protestant rebels. She succeeded Mary to the throne in 1588, aged 25. Four years later, she developed what seemed to be a bad cold. However, it rapidly progressed to a high fever, with muscle pain, malaise and headache, and she became so sick she was unable to speak.

  The young queen had smallpox. Her councillors surrounded her bed, thinking she was dying. After four hours she regained consciousness and instructed her councillors, in the event of her death, to appoint a personal favourite, Lord Robert Dudley, Earl of Leicester, as Protector of the Realm (which came with a massive income of £20,000 a year). The councillors vacillated, suspecting that Dudley was a secret lover. But Bishop Quadra later wrote to the King of Spain: ‘The Queen protested at the time that although she loved and had always loved Lord Robert dearly, as God was her witness, nothing improper had ever passed between them.’ They must have believed her, because Elizabeth became known as both the Virgin Queen and Good Queen Bess, and reigned successfully until her death at age 69.

  Elizabeth gave Dr Burcot, who tended her during her illness, a valuable land grant and a pair of golden spurs that had belonged to her grandfather Henry VII. But according to a later historian, she said that thenceforth she ‘wished never to be reminded of her illness’.

  Elizabeth’s survival when so many around her were dying from smallpox was attributed to divine intervention. Gold medals were produced to celebrate her recovery. They showed her face as unblemished. Queen Elizabeth may have been lucky enough to avoid disfiguring facial scars. She herself said she never had wrinkles because of the smallpox. But she was not renowned for her lack of vanity and was also well aware that her reputation as a beauty carried political power. Paintings show she always wore many layers of make-up. She also showed disdain to anyone scarred by smallpox, including a suitor, the Duke of Alençon – whom she refused point-blank to marry – and one of her ladiesin-waiting, Lady Mary Sidney.

  In nursing Elizabeth back to health, Lady Mary Sidney caught smallpox from her queen and was left permanently scarred. Sir Henry Sidney wrote about his wife: ‘When I went to Newhaven I lefte her a full faire Ladye in myne eye at least the fayerest, and when I retorned I found her as fowle a ladie as the smale pox could make her.’ Not much sympathy there.

  Early in the 17th century, the first references to smallpox started to appear in English poetry. In 1616, the year William Shakespeare died, Ben Jonson published An Epigram to the Smallpox, in which he wrote:

  Envious and foule Disease, could there not be

  One beauty in an Age, and free from thee?

  The English historian Lord Macaulay later wrote of this era that ‘small pox was always present’. He described how smallpox disfigured both children and adults, ‘turning the babe into a changeling at which the mother shuddered and making the eyes and cheeks of the betrothed maiden objects of horror to the lover’. Note the reference to the eyes as well as to facial scarring. In the 17th and 18th centuries smallpox was the leading cause of blindness in Europe.

  Turlough O’Carolan (the O’ is optional) was born in 1670. His father was a blacksmith from County Meath, Ireland, and worked for landed gentry, the MacDermott Roe family. The lady of the house was fond of O’Carolan and organised his education. O’Carolan was a promising young poet, but at the age of 18 he contracted smallpox, which destroyed his eyes and left him blind. The worthy Mrs MacDermott Roe sent O’Carolan to a blind school, where he was apprenticed to a harpist, Mr Cruise.

  From age 21, O’Carolan became a famous itinerant musician, travelling all over Ireland on horseback with a guide, singing songs he had composed and accompanying himself on the harp. Almost all his songs were written in the Irish language. He became one of Ireland’s most famous composers.

  Recently I heard one of Turlough O’Carolan’s compositions being played on a classical radio station. If your taste veers more towards pub music, you might well hear a Turlough O’Carolan song being performed by a band in an Irish pub.

  In London in the 18th and early 19th centuries, the infant mortality rate from smallpox was 30 to 40% – one in every three babies died from smallpox before they were a year old – and in Berlin during the late 1800s a catastrophic 98% of infant smallpox victims died. In late 18th century Glasgow, half of all children died before 10 years of age, and 40% of those deaths were due to smallpox. Yet, as we have seen, adults could also die from the disease. At the end of the 18th century, the average life expectancy in France was only 32 years, largely due to smallpox.

  Smallpox was unknown in the New World until it was introduced by the Spanish and Portuguese conquistadors and decimated the local population, contributing significantly to the demise of both the Aztec and Inca empires. Smallpox was introduced to the east coast of North America by early settlers, and spread rapidly through the local Native American population. The slave trade also influenced the spread of smallpox in the Ameri
cas, since many African slaves came from smallpox-affected areas.

  The most severe form of smallpox, variola major, persisted in Europe and the Americas until the end of the 19th century. Variola major killed 20 to 30% of those infected, but could be even more deadly when it first spread to an island or country whose population had never been exposed to the virus and had no immunity. Such an epidemic is sometimes called a ‘virgin soil’ outbreak.

  Two stories exemplify this island effect. In 1724, a smallpox epidemic on the island of St Kilda in Scotland’s Outer Hebrides killed all but four of the men, leaving too few to bury all the islanders who had died. The second example relates to remote, sparsely populated Easter Island in the Pacific, whose Polynesian inhabitants built massive and impressive Moai stone statues. The introduction of smallpox by European sailors wiped out almost the entire population, which fell from about 3000 in 1774, when Captain Cook first landed there, to just over 100 a century later.

  In 1763, during the so-called French and Indian War between British and French colonisers in North America, inhabitants of Fort Pitt (later Pittsburgh), Pennsylvania, fell ill with smallpox. British commander Field Marshal Jeffery Amherst wrote to Colonel Henry Bouquet: ‘Could it not be contrived to send the small pox among the disaffected tribes of Indians? We must on this occasion use every stratagem in our power to reduce them.’ Bouquet replied: ‘I will try to inoculate the Indians by means of Blankets that may fall in their hands, taking care however not to get the disease myself.’

  These British Army officers excused the ethically inexcusable by declaring that the enemy were savages who did not need to be treated like human beings. Bouquet wrote to Amherst: ‘that Vermine . . . have forfeited . . . all claim to the rights of humanity’. Amherst also wrote to Captain Simeon Ecuyer, encouraging him to send smallpox-infected blankets and handkerchiefs to the Native Americans surrounding Fort Pitt.

  These letters provide incontrovertible proof that British forces planned to deliberately infect the Native Americans. While it has proved difficult to obtain robust evidence that the British definitely did give them contaminated blankets, most historians believe that they did, and that smallpox provided an early example of the morally repugnant practice of biological warfare.

  In January 1788, the British First Fleet reached Australia, landing at Port Jackson in Sydney. The Port Jackson Aborigines were involved in resisting the European invasion. Just 15 months later, an outbreak of a disease characterised by rash and fever decimated the Aboriginal population. Based on the account of a French sailor who landed at Botany Bay soon after the start of the outbreak, Alan Moorehead wrote:

  Then a disaster happened. In April 1789 black bodies were suddenly seen to be floating in the harbour and washed up in the coves. Smallpox had struck . . . by May the disease had spread through all the harbour tribes. A few of the sick who were too feeble to protest were brought into Sydney for treatment but the majority, comprehending nothing of this mysterious enormity that had struck them down, quickly succumbed by their campfires.

  Lieutenant-Colonel David Collins, a fascinating man who later became Lieutenant Governor of New South Wales, Lieutenant Governor of Tasmania and a deputy judge and gave his name to St David’s Church in Hobart, wrote:

  The number that it swept off by their own accounts was incredible. The native who at that time resided in Sydney on going down to the harbour to look for his former comrades is described by those who witnessed his emotions as suffering the extreme of agony. He looked anxiously into the different coves they visited; not a vestige on the sand was to be found of human foot; the excavations in the rocks were filled with putrid bodies of those who had fallen victims to the disorder; not a living person was anywhere to be met with.

  Although some historians and physicians have raised the unlikely possibility that the disease was chickenpox, the severity of the epidemic described in historical accounts has convinced most experts that it was smallpox. Lieutenant Watkin Tench – who commanded five detachments of marines on the Charlotte, a First Fleet vessel – wrote that doctors who examined victims found that ‘pustules similar to those occasioned by the smallpox were thickly spread on the bodies’.

  Aboriginal people had lived in Australia for more than 60,000 years, and smallpox was unknown to them. This was indeed virgin soil. The total Aboriginal population of Australia then was about 500,000. Historians estimate that the outbreak killed tens of thousands of Aboriginal people, including 90% or more of the Aboriginal population living around Port Jackson and over half of those living between the Hawkesbury River and Port Hacking. Children died from starvation when there were no adults left alive to look after them. Smallpox spread among Aboriginal populations throughout New South Wales, as far south as Jervis Bay and to the tribes on the Western Plains across the Blue Mountains, killing an unknown number.

  The only case of smallpox among the immigrants was a seaman on the ship Supply, who died. Watkin Tench kept a journal in which he recorded that First Fleet surgeons brought with them bottles containing smallpox-infected material. In 1791 he wrote about the smallpox outbreak: ‘It is true that our surgeons had brought variolous matter in bottles, but to infer that it was produced from this cause, were a supposition so wild as to be unworthy of consideration.’

  Was the smallpox material intended to be used for the settlers’ protection, or as another unconscionable act of early germ warfare? How smallpox spread across New South Wales – and whether the material was the cause – is contested by historians. It was only a generation since British forces wrote about infecting Native Americans with smallpox, so it is no great stretch of the imagination to believe that the Sydney outbreak was a second horrifying example of biological warfare by the British. I shudder with shame to think that my ancestors could have been capable of such an abominable act.

  To this day people express concern that there are residual laboratory stocks of smallpox kept in Russia and the United States that could potentially be used in biological warfare. The rationale for keeping them is the questionable argument that they might be needed to make vaccines if smallpox re-emerged naturally, or if one of the stocks of smallpox was used for biological warfare. We know that chemical weapons are often used in modern warfare, in flagrant disregard of international law and despite international condemnation. It is frightening to contemplate the possibility that the smallpox stock might be used as a biological weapon by an unscrupulous regime, but trying to persuade the superpowers involved to destroy the smallpox stocks is about as likely to succeed as trying to persuade them to destroy their nuclear weapons.

  Variolation

  Such was the horror of smallpox that humans sought ways to prevent it from ancient times onwards. As we saw from the words of Thucydides in Chapter 1, it had long been recognised by physicians, scientists and indeed by historians that people who recovered from a disease were protected against it. In scientific terms, they had developed immunity.

  Gradually people came to see that giving someone an attenuated (milder) dose of smallpox might offer some protection against the full-blown disease. This practice, known as variolation (and sometimes confusingly called inoculation) developed, probably independently, in different parts of the world, and involved a variety of techniques.

  Ancient Chinese texts from the late ninth century record that particles of smallpox scabs were sometimes blown into a person’s nostrils to cause an infection. This implies the Chinese recognised that smallpox is transmitted by breathing in smallpox virus carried in aerosols from pustules that have burst (an aerosol is like a fine mist of particles). Voltaire wrote that the ancient Chinese ground up smallpox scabs into a powder and took them like snuff, although he does not give the source of this information. By the 16th century, during the Ming Dynasty, variolation was a common practice in China. After about a week, the person being variolated would develop smallpox pustules and get sick, but the disease was usually milder than naturally acquired smallpox. A scar was evidence the inoculation had wor
ked.

  The Royal Society in London was founded in 1660, and would become one of the most highly esteemed scientific establishments in the world. The society was informed about variolation in China by Dr Clopton Havers in 1700. Dr Emanuele Timoni, a doctor who had studied in Padua and Oxford and practised in Constantinople, was elected as a Fellow of the Royal Society in 1703. In 1714 he described in detail in a letter to the Royal Society how variolation was carried out in Turkey.

  On day 12 or 13 of the illness, the practitioner lanced the pustules of a child recovering from uncomplicated smallpox using a needle. The ‘pus’ was put in a clean glass bottle and closed with a tight stopper. It was quickly carried, nestled in the bosom or under the armpit to keep it warm, to the person who was to be variolated. This person’s upper arm was scratched several times with a needle or lancet, inducing minor bleeding. The pus and blood were mixed and the site was covered with an object such as a half walnut shell for a few hours.

  Medical opinion was divided on the benefits and risks of variolation. Smallpox was a terrible disease, but variolation was risky, and sometimes caused smallpox rather than preventing it. Naturally acquired smallpox used to kill between one in three and one in five people who caught it (20 to 30%), but would come and go in epidemics. Variolation resulted in fatal smallpox in between 1 in 50 and 1 in 200 people variolated (0.5 to 2%).

  This relatively high risk posed a huge quandary. It was considerably lower than the risk of dying from smallpox infection, but the choice must have been a terrible one for parents to make. Many preferred to let nature take its course, and hope their child never caught smallpox or recovered if they did, rather than risk causing the disease themselves by having their child variolated.

  It took two remarkable women to promulgate variolation successfully in the face of medical and public opposition. Lady Mary Wortley Montagu (1689–1762) was one of the great eccentric characters of her day. She came from an aristocratic background, the daughter of the Duke of Kingston, and in 1712 escaped from an intended arranged marriage by eloping with Sir Edward Wortley Montagu. She became an early feminist, a renowned and prolific letter writer and a poet, and took a keen interest in the customs and values of Muslim women.