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By Root 373 0

Long. Cold compresses and cool drinks for the fevers. Morphine for the back pain. Vaseline ointments for the exfoliating scabs. A few ounces of whiskey sometimes bought the patient a moment’s peace. Dr. Llewellyn Eliot, who ran the District of Columbia Smallpox Hospital during the winter epidemic of 1894–5, said he tried every treatment regimen he could think of: “the expectant, the bitartrate of potash, the salicylic acid, the antiseptic, and, finally, the do-nothing.” Still, good nursing care could make all the difference. As late as the 1970s, studies showed that in developing countries, where hospital facilities were typically “poor” and “grossly overcrowded” (a fair description of most American smallpox hospitals circa 1900), smallpox patients cared for by devoted family members, in their own homes and villages, had a higher chance of survival .42

In a run-of-the-mill case of smallpox, as it had been known from time immemorial until the twentieth century, the sufferer had about a one-in-four chance of dying from the disease: a case-fatality rate, in epidemiological parlance, of 25 percent. Beneath this historical average lay wide variation, caused by differences in viral strains and the particular susceptibilities and immune responses of different individuals and groups. In cases of discrete smallpox, the case-fatality rate could be as low as 10 percent; in confluent cases, it could run to 60 percent or higher. Age also affected the prognosis. Mortality was highest in infants, lowest for young children, and from there it tended to rise with age. Smallpox was especially severe in pregnant women. It often caused miscarriages or stillbirths, and fetuses could be infected in utero.43

Some outbreaks were so sudden and severe as to defy comprehension. In March 1900, the Atlanta Constitution reported that the small community of Jonesville, Mississippi, was “honeycombed with smallpox of the most virulent and loathsome form.” The case-fatality rate was 75 percent. Nearly one hundred people died. Entire families perished. It all happened so fast that city officials could do little more than order coffins .44

When death came, it usually occurred around the tenth or eleventh day of the disease. Scientists still do not know exactly how smallpox killed. By the tenth day, the variola bricks had piled up in cells throughout the body, including many of the vital organs. Still, the disease did not normally destroy the organs. The slow, painful death from smallpox was usually caused by severe viral toxemia—a generalized poisoning of the body. In the final moments, most patients suffered respiratory failure.45

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