Pox

by Michael Willrich

  It could be worse. Discrete and confluent smallpox were subtypes of “variola vera,” or true smallpox. (“Ordinary type” is the preferred term today.) In a small percentage of cases, smallpox presented in far more severe forms. If a particularly virulent strain of the virus met with an extremely weak immune response at the cellular level, as sometimes occurred in children, the lesions remained flat, turned black or purple, and were said to feel “soft and velvety to the touch.” The patient’s body looked charred. This form of smallpox (now called “flat type”) was almost invariably fatal. Rarer still, and almost always fatal, were the various forms of “hemorrhagic” or “black smallpox,” in which the virus caused explosive bleeding. Through it all, patients suffering from hemorrhagic smallpox were said to exhibit “a peculiar state of apprehension and mental alertness.” They seemed to know exactly what was happening to them.46

  The best thing to be said about smallpox was this: when the disease was done with a person, it was done. The virions did not persist in the body. Smallpox survivors were forever immune. In most cases of variola vera, though, the skin never fully recovered. From 65 to 80 percent of patients bore deep scars on their faces, the pitted “pockmarks” that made smallpox unforgettable.

  During the Cleveland smallpox epidemic of 1901–3, in which 266 people died, Dr. William T. Corlett, a professor of dermatology and syphilology at Western Reserve University medical school, kept a photographic record of patients in the smallpox hospital. After poring over Dr. Corlett’s photos of patients—their cobblestoned faces, their blistered nakedness, the distant stares of those who can open their eyes—it should come as a relief to find one of a fully recovered man. It does not. He could be thirty. Or forty-five. He wears a heavy woolen suit, with a gold watch pin at the top buttonhole of his vest. He stands erect, chin up, his body squared off to the camera. But his face is just a few degrees askew, as if he can’t quite look the camera in the eye. His forehead, cheeks, nose, and chin are a dermatological rubble. The survivor’s proud, clamped mouth carries the weight of the photograph. But the unforgiving eyes command the viewer’s attention.47

  The scars of smallpox might fade with time, but they never went away. In the patent medicine marketplace of early twentieth-century America, unscrupulous purveyors touted newfangled procedures and ointments which, they promised, would make pockmarks disappear. In the same newspapers where the patent hucksters hawked their wares, the police blotters printed notices about wanted criminals. On any given day, the reader might be advised to keep an eye out for any number of physical markers in the hustle of the urban crowd—one suspect’s height, another’s build, yet another’s race. But one trait in particular—the smallpox marks tattooed indelibly on the suspect’s face—told the vigilant reader that the fugitive had a history of escaping tight situations.48

  Dr. William T. Corlett of Cleveland’s Western Reserve University took this photograph of a recovered smallpox patient. The scars were permanent. COURTESY OF THE DITTRICK MEDICAL HISTORY CENTER, CASE WESTERN RESERVE UNIVERSITY

  Not all “germs” are alike. Bacteria, which are much larger than viruses, are single-celled microorganisms, capable of reproducing on their own and metabolizing nutrition. Since the advent of penicillin in the 1940s, scientists and pharmaceutical companies have developed a widening range of antibiotics that work by killing or inhibiting the life-sustaining activities of various disease-causing microorganisms. Viruses are impervious to antibiotics. They are difficult to kill because they are not exactly alive. A virion is essentially an inert package of genetic information, encased in proteins. It can only replicate when it penetrates a vulnerable host cell. At that point, the virion sheds some of its protective layer and begins to convert the cell into a virion factory. The best way to help a human body beat a virus like variola is to teach the cells to recognize the virions and to respond quickly with a powerful immune response. For some viral diseases physicians artificially immunize patients by exposing their bodies to an inactivated (“killed”) or attenuated (“live” but weakened) form of the virus; for other diseases, a related virus does the trick. When preventive immunization works, the body reacts to an invasion of virus with an immune response that will prevent infection, or at least reduce the damage the virions can do.

  We know all of this because of the exponential growth of scientific knowledge that has occurred since the introduction of the germ theory of disease during the second half of the nineteenth century. In the 1860s and 1870s, laboratory pioneers such as the French chemist Louis Pasteur and the German physician Robert Koch marshaled increasing evidence behind an idea that we now take for granted. Overthrowing long-held medical beliefs, the new theory proposed that contagious and infectious diseases arose neither from the grossly deficient “constitutions” of their sufferers nor from atmospheric “miasmas” arising from stagnant water; rather, specific diseases were caused by particular microorganisms. From the late 1870s into the early twentieth century, laboratory scientists identified one pathogenic “microbe” after another (including the bacteria that caused cholera, consumption, gonorrhea, and typhoid). As scientific knowledge of bacteria, viruses, and other “germs” accumulated, so did understanding of the mechanisms and pathways by which those germs circulated across populations: contaminated food and water, casual contacts, insect vectors, and so on. From these new understandings of the etiology of infectious diseases arose new strategies for policing them. To the ancient practices of isolation and quarantine were added antispitting ordinances, food and milk regulations, and a growing arsenal of vaccines, antitoxins, and serums. In the United States, where many physicians had been slow to embrace the germ theory (and laypeople had been slower still), health officials of the local, state, and federal governments approached the twentieth century with a greatly enlarged sense of their duties and powers.49

  The history of smallpox vaccination has a special but curious relationship to this scientific revolution. Smallpox was the granddaddy of infectious diseases: the deadliest scourge in recorded history and the one upon which the field of immunology was founded. Smallpox variolation (using live variola virus) and vaccination (using the live viruses of cowpox or vaccinia) were the oldest practices of preventive immunization. In fact, they were practiced long before the germ theory took shape. Both techniques had been developed without the benefit of microscopes and laboratory smears, through experiments based upon everyday observations about the disease. Pasteur himself saluted this lineage when he proposed, in 1881, that the term “vaccination” be universalized to apply to preventive inoculation with other infectious agents.50

  Variolation was practiced in China and India as early as the tenth century. It probably originated in the commonplace observation that people with pockmarks never contracted smallpox. The practice entailed introducing a small amount of material from the pustules or scabs of a smallpox patient into the body of a healthy person. In China, the common method was nasal insufflation: scabs were ground into a fine powder and then snorted. In India, the pus material was inserted into the skin. Variolation normally produced a mild attack of smallpox, followed by long-lasting immunity. The practice spread far and wide from its Asian (and perhaps African) origins. By the early eighteenth century, variolation spread into Europe from the Balkans and from Turkey into England. Called “inoculating the smallpox” or simply “inoculation” by the English, it grew increasingly common in Britain and the colonies—especially when epidemics threatened. In the terrible Boston epidemic of 1720–21, Reverend Cotton Mather and Dr. Zabdiel Boylston caused a public firestorm by promoting inoculation. In 1777, as North American smallpox epidemics took more than 100,000 lives, General George Washington ordered the compulsory variolation of all new recruits into the Continental Army. The wide adoption of variolation during the eighteenth century is perhaps all the evidence one needs of the severity of smallpox, for the practice carried serious risks. The artificially induced attack was not always mild: as many as one in fifty died. Even worse, during the
infection the inoculated person could infect others with full-blown smallpox.51

  Vaccination descended directly from variolation, and it came about in much the same way. In the late eighteenth century, it was a commonplace observation among the country people of smallpox-ridden parts of England and Europe that milk hands and milkmaids rarely had pockmarks. An English country doctor named Edward Jenner, who had himself suffered a harsh bout of smallpox following his childhood inoculation, had trouble persuading dairy workers to take the pox. The workers, Jenner later explained, had the “vague opinion” that they had been protected by their exposure to diseased cows. Some of the workers had pocklike ulcers on their hands, gotten by milking cows whose teats were broken out with cow-pox. From one such ulcer, on the hand of a milkmaid named Sarah Nelmes, Jenner extracted the pus that he inserted, just beneath the surface of the skin, on the arm of a young servant named James Phipps on May 14, 1796. Jenner later repeated the experiment on several other children. After several months, he inoculated the children with smallpox. In every case, it failed to take. The children’s bodies resisted the variola virus. Vaccination, which takes its name from the Latin word for cow, was born. The new technique had neither of the limitations of variolation: it did not give people smallpox, and it did not cause them to spread it either.52

  When Jenner published his first results in a 1798 paper, his claims bred skepticism and controversy among medical men and laypeople. An English political cartoon from the period depicts a gaggle of country bumpkins lined up to get jabbed in the arm by the bewigged Dr. Jenner. The right half of the frame is a riotous scene filled with men and women who have already taken the vaccine. Horns, hooves, and entire cows spring forth from their arms, faces, and rear ends. The cartoon is titled, “Cow Pock—or—the Wonderful Effects of the New Inoculation!” Despite opposition, vaccination spread far and wide with remarkable speed. Jenner estimated that within three years, 100,000 people had been vaccinated in England. By that time, Professor Benjamin Waterhouse of Harvard University had brought vaccination to the United States.53

  More than half a century before the germ theory, then, the fundamentals of preventive immunization were in place. And yet at the turn of the twentieth century, smallpox remained full of mystery. The causative agent had not been identified, the process of human transmission was imperfectly understood, and the exact nature and biological effects of the vaccine strains in circulation were largely matters of conjecture and debate. What scientists and physicians could say for certain, based upon a century of medical experience, was that vaccination worked. Wyman’s “Précis” summed up the medical consensus: “The most efficient means for preventing the spread of smallpox is by vaccination. The protection, provided the [vaccine] virus is pure, is believed to be as complete against contagion as is that of smallpox against a second attack.” Unlike a bout with actual smallpox, the authors cautioned, vaccination conferred only a temporary immunity, perhaps five years or more. Accordingly, the “Précis” advised that communities encourage revaccination, whenever smallpox became prevalent, to “continue this protection indefinitely.”54

  In the best scenario, vaccination prevented a person exposed to smallpox from getting the disease at all. Even when a previously vaccinated person did contract the disease, the vaccination accelerated the clinical course of smallpox, producing a milder form of the disease called “varioloid.” The patient remained infectious until recovered: “The most virulent form of smallpox may rise from exposure to varioloid,” the “Précis” warned. But fatalities were rare and pockmarks uncommon. Physicians found that if they vaccinated a person infected with smallpox during the first five or six days of the incubation period, the patient would normally suffer a mild case of the disease.55

  Despite the power of this revolutionary scientific technology, England and America did not rush to embrace compulsion. Some European governments established compulsory vaccination of infants in the first decades of the early nineteenth century: Bavaria in 1807, Denmark in 1810, Norway in 1811, Bohemia and Russia in 1812, Sweden in 1816, and Hanover in 1821. But England, the birthplace of Jennerian vaccination, did not enact its first compulsory measure until 1853. It applied only to children.56 Until the mid-nineteenth century, the thorny legal question regarding vaccination in the United States concerned the right of local communities to use tax money to provide free vaccination for the poor. Things began to shift after England adopted compulsion. In 1855, Massachusetts became the first American state to require public schoolchildren to get vaccinated. Between the end of the Civil War and the turn of the twentieth century, public officials and lawmakers gradually built a legal regime of compulsory vaccination in America. By the 1890s, that regime included federal inspection of immigrants at the nation’s borders, some form of compulsory vaccination for public schoolchildren in most states, and general vaccination orders issued by county courts, city councils, and local boards of health during epidemics.57

  Sol Ettinge, “Vaccinating the Poor.” The engraving pictures a New York City police station house during the 1872 smallpox epidemic. From Harper’s Weekly, March 16, 1872. COURTESY ROBERT D. FARBER UNIVERSITY ARCHIVES AND SPECIAL COLLECTIONS DEPARTMENT, BRANDEIS UNIVERSITY

  For Surgeon General Wyman, the case for compulsion was simple: it worked. He reminded Americans of the lesson of the Franco-Prussian War of 1870–71. As the French and Prussian armies collided, the war unleashed a pandemic of smallpox that killed more than half a million people in Europe, including some 143,000 German civilians. Both France and Prussia had poorly vaccinated civilian populations. But the armies differed dramatically. The thoroughly vaccinated Prussian army, 800,000 men strong, suffered only 8,463 cases of smallpox and just 457 deaths (a case-fatality rate of 5.4 percent). The smaller, sparsely vaccinated French army counted 125,000 cases and 23,375 deaths (18.7 percent). After the war, many European countries enacted new legislation compelling vaccination (and in some places subsequent revaccination) as a basic duty of citizenship.58

  As epidemics broke out in the United States during the next few years, American state and local governments responded with measures of their own. Again, the German example proved irresistible. By an 1874 law, the unified German state required all citizens to submit to vaccination and revaccination. In 1899 the disease took only 116 lives in Germany, a nation of 50 million people. For Wyman, the success of vaccination imposed a clear moral responsibility upon American citizens and their governments. “Smallpox is a disease so easily prevented by vaccination that the smallpox patient of to-day is scarcely deserving of sympathy,” he wrote in December 1899, as the wave of epidemics that had begun in the South moved across the country.59

  But vaccination carried its own well-known health risks, and compulsory measures clashed with medical beliefs, religious tenets, the rights of parents, and dearly held notions of personal liberty. As nations tightened their smallpox vaccination laws in the late nineteenth century, those efforts ran up against strong, even violent, antivaccination movements, in the metropoles and in their overseas colonies. Antivaccination riots rocked Leicester, Montreal, and Rio de Janeiro. Since the 1870s American antivaccination leagues had challenged compulsory measures in the statehouses; after 1890, they began turning to the courts as well. Across the United States, citizens resisted public health authority by burning down pesthouses built in their neighborhoods, running away from vaccinators, fighting with police, forging vaccination certificates, or, perhaps most commonly, by quietly taking care of their sick loved ones in their own homes, instead of surrendering them to the authorities.60

  American supporters of compulsory vaccination—including public health officials, the rising professional class of physicians, and the editorial writers for major newspapers such as The New York Times—often dismissed the opposition as an insignificant coterie of “imbecile cranks” who had fallen under the spell of foreign ideas. But the opposition was far more broad and complicated than that. It did not arise solely from a transatlantic critique of mode
rn state medicine. Nor did it spring, fully formed, from American traditions of rugged individualism and constitutional liberty. The turn-of-the-century epidemics in particular would reveal that opposition to government-mandated smallpox vaccination grew up in the same soil from which had sprung compulsion itself: the conflict-laden realm of everyday social and political life in local communities.61

  The variola virus itself played no small role in the vaccination controversies that embroiled communities across the United States. As reports of outbreaks reached Washington from communities across the South during 1898 and 1899, many local physicians, public health officers, and political leaders commented that smallpox did not seem its old self. And the more people smallpox struck, the bigger the “kick” the public put up against vaccination. 62

  Dr. Henry F. Long was one of the first southern medical men to report on this unprecedented new situation. Harvey Perkins had died as expected. But something peculiar happened to the sixty-two others who landed in Dr. Long’s pesthouse during the months after Perkins made his long walk through the woods of Iredell County: every last one of them survived.

  TWO

  THE MILD TYPE

  A peculiar new form of smallpox invaded communities across the American South during the last three years of the nineteenth century. The mysterious disease brought little of the horror people expected from smallpox. For every hundred people infected, only one or two died. Physicians and lay-people often mistook the symptoms for chicken pox, measles, or some other eruptive disease. The eruption passed through the normal stages, but the pustules typically remained superficial and discrete. Miraculously, most people recovered without pockmarks. At first the new pox reportedly spread almost exclusively among African Americans. Because of its unprecedented mildness and its reputation for infecting “none but negroes,” the new smallpox was allowed to gain a beachhead in the southeastern United States. Local governments were slow to respond until someone died or the disease crossed the color line. In this way, isolated cases became outbreaks, outbreaks became full-scale epidemics, and a disease whose ultimate capacity for destruction no one could foretell made its way from place to place.1