Prof: I want to turn to
the next topic,
which marks a new unit in our
course.
That is to say,
until now we've dealt with
bubonic plague,
in a series of talks and in
your first section meeting.
 
Now I'd like to look,
for comparative purposes,
at a very different high-impact
disease;
and this time and next we'll be
dealing with smallpox.
So, I think you deserve an
answer to the obvious questions:
why smallpox,
and why at this stage in the
course?
 
So, I want to give you a little
bit of explanation,
to see where we're going.
 
The first has to do with I
might call a varied intellectual
diet,
and I want us to deal with
diseases of very different
types,
and so we'll have to examine
the impact of different kinds of
infectious diseases.
 
Plague was a bacterial disease.
 
Smallpox instead is viral.
 
Plague was transmitted by
vectors.
You know the drill now,
the role of rats and fleas.
Smallpox instead is spread by
contact and airborne inhalation
of droplets.
 
Plague is a classic epidemic
disease, in the sense that it's
an outside invader that ravages
a locality for a season and then
departs.
 
Smallpox is different in that
it can be both endemic and
epidemic.
 
So, we'll see a different
dynamic.
It's also true that the social
responses to smallpox were quite
different.
 
Plague was associated with
terror and social disruption,
and in the New World we'll see
that it had an even more
dramatic impact on the Native--
smallpox did--on the Native
American population.
 
But in European conditions it
was a familiar endemic disease
with a less dramatic--
as a cause--was less dramatic
as a cause of social tensions
and disruption.
We'll see too that in terms of
impact, for chronology it makes
sense to look at smallpox at
this stage in our class.
It had long been present in
human history,
but there was an upsurge in
smallpox in the seventeenth and
eighteenth centuries that
accompanied the surge in the
demography of Europe.
 
And it also reflected the
transformation of social and
economic conditions associated
with the commercialization of
agriculture,
the onset of industrial
development,
and rapid, unplanned
urbanization,
with those associated
pathologies such as
overcrowding,
both at home and in the
workplace.
In those conditions,
smallpox was a great killer,
and it succeeded plague as the
most dreaded disease of the
late-seventeenth and the
eighteenth century.
In a sense, we're moving from
bubonic plague,
the most dreaded disease of its
era,
to--in a sense,
in terms of fear--to smallpox
as the next most dreaded disease
of the next period in the
eighteenth century.
 
But there's more to it that
that.
Smallpox, as you'll see in our
reading and in our lecture next
time, was also extraordinarily
important in terms of its impact
in the New World.
 
It led to a demographic
catastrophe for the Native
American population,
largely spontaneously,
but there were also intentional
acts of genocide involved.
So, we're going to see,
in terms of one of the themes
of our course,
that disease,
and particularly smallpox,
played an important role in the
big picture of history;
in conditioning or creating
factors that were important in
European settlement in the New
World,
and that led to the
introduction of African slavery,
as the Native American
population had no immunity and
perished from smallpox,
and therefore could not be
enslaved;
whereas Africans,
possessing immunity,
were imported to replace them.
 
Another major feature and
reason for dealing with smallpox
has to do with another theme of
our course, and that is public
health.
 
We've already dealt with plague
measures of public health.
You know what they are,
the plague measures:
boards of health,
quarantine, lazarettos,
sanitary cordons,
emergency burial regulations.
Smallpox, by contrast,
was to lead to a very different
but highly effective style of
public health;
that is, first inoculation and
then vaccination,
associated with Edward Jenner.
 
Even more spectacularly than
plague measures,
vaccination ultimately promoted
a victory over smallpox,
leading in 1980 to its total
global eradication,
at least naturally occurring
smallpox;
the first, and still as we
speak, the only human disease to
be so intentionally eradicated.
 
Unlike plague measures,
vaccination was a powerful tool
of public health.
 
Successful vaccines have
subsequently been developed
against other diseases:
measles, rubella,
whooping cough,
tetanus, diphtheria,
rabies, polio.
 
But again, like plague
measures, vaccines have been
controversial--
and we'll be talking about when
vaccines form an appropriate
strategy--
and eradication has been ever
more elusive for diseases other
than smallpox.
 
It may be that smallpox is a
special case,
rather than,
as many hoped,
a model for the eradication of
diseases sequentially,
one after another.
 
We'll be looking also at
smallpox because of its
demographic and economic
effects.
We talked, in terms of plague,
of a mortality revolution,
in terms of demography,
and also of its impact on
industrialization.
 
Smallpox and the successful
containment of smallpox through
inoculation and vaccination also
had a major impact on that
mortality revolution,
and therefore also on economic
development.
 
We'll be looking also at
cultural impact,
and we'll see that smallpox
also produced the cult of
certain new saints;
that it too became a theme in
the arts and literature.
 
More speculatively,
we talked last time about the
possible relationship of the
successful conquest of plague on
the coming of the Enlightenment.
 
Well, smallpox provides us with
a second instance of the
successful deployment of human
means to control a major cause
of death and anguish,
making life more secure and
longer.
 
It's suggested that a number of
leading philosophes were
avid proponents of inoculation,
including Voltaire and
Condorcet.
 
So, we'll be dealing with those
issues.
But this morning what I'd like
to do is to concentrate on
something more narrow,
which is--but forms the basis
for our understanding of the
impact of this disease--
its nature as a disease.
 
How it affects the individual
human body, and what were the
treatments in the seventeenth,
eighteenth centuries.
Let's begin with smallpox as a
disease.
Smallpox, often nicknamed,
for reasons we'll soon see,
"the speckled
monster."
It's a virus belonging to the
family of orthopox viruses that
includes Variola major,
Variola minor and
cowpox.
 
We'll talk about cowpox next
time, because of its influence
in the development of
vaccination.
But our theme will concern
Variola major and
Variola minor;
especially Variola
major, which is the
causative agent,
primarily, of smallpox.
 
This is a picture of Variola
major, the largest of all
viruses, first seen by the
microscope in 1905.
This causes classical smallpox.
 
There's Variola minor as
well, that first appeared in the
twentieth century;
and for our purposes we can
afford to ignore it.
 
It was of minor impact and now,
like Variola major,
it's extinct as well.
 
Now, one question is,
what's a virus?
We talked about the term
microbe;
microbe being a generic term
for microscopic organisms,
including bacteria,
like our friend Yersinia
pestis,
the causative agent of bubonic
plague,
and viruses like Variola
major and Variola
minor,
the pathogens that cause
smallpox.
Plague was caused by bacteria,
and those,
as you know--and will be
studying more on Science Hill--
are unicellular organisms that
are definitely and unequivocally
alive.
 
They reproduce by dividing.
 
They contain DNA,
plus all the cellular machinery
necessary to read it,
and to produce the many
proteins that enable it to live
and reproduce.
Viruses are something different.
 
And here there's a possible
confusion lurking for the
historian.
 
The word "virus"
itself is ancient.
In the humoral system,
in fact, when diseases were
seen to arise from assaults on
the body on the outside,
one of the major environmental
insults that was thought to lead
to disease was the corrupted air
or miasma,
and this was influenced by a
poison,
that might be called a virus.
 
So, if you do research on
medical history,
you'll see the term
"virus"
used in an old sense for many
centuries.
But "virus"
in present medical discourse is
a term that dates its modern
usage from the early twentieth
century,
and it refers to parasitic
particles,
perhaps 500 times smaller than
bacteria.
 
Their existence was established
by elegant scientific
experiments in the first years
of the century,
completed by about 1903.
 
But they couldn't actually be
seen until the invention of
electron microscope in the
1930s,
and their functioning wasn't
understood until the DNA
revolution of the 1950s.
 
So, viruses,
we now know,
consist of some of the elements
of life, stripped to their most
basic.
 
A virus really is nothing more
than a piece of genetic material
wrapped in a protein case.
 
They're particles that are
inert on their own.
Viruses lack the machinery to
read DNA, or to make proteins,
or carry out metabolic
processes.
They can do nothing on their
own, and they cannot reproduce
by themselves.
 
Their survival depends instead
on invading living cells.
Once inside,
they highjack the cell and its
machinery.
 
The genetic code of the
virus--and the virus,
after all, is almost nothing
else--gives the cell the message
it needs to reproduce more
virus,
thus transforming cells into
virus producing factories,
and in the process they destroy
the host cell.
As they produce more and more
viruses,
and destroy more and more
cells, the effect on the human
body can be severe,
even catastrophic,
depending on the capacity of
the immune system to contain or
destroy the invasion.
 
Here we have,
in a sense, the opposite of a
Hippocratic idea of disease;
the body assaulted,
not from the outside,
but rather from a parasitic
pathogen deep within.
 
There is an exotic debate,
of course--are viruses alive?
Those who argue that they are
alive, note that they're capable
of transmitting genetic
material, one of the key
indications of life.
 
Those who claim they're not
alive, note that on their own
they're inert,
that they can't carry on
metabolic processes,
or produce proteins.
Viruses, they note,
are the ultimate parasites.
Virologists often say that
whether you decide that viruses
are alive or not is ultimately a
matter or disciplinary
perspective,
or perhaps even personal
preference.
 
The reassuring point for us is
that, perhaps excepting
theology, the answer doesn't
really matter.
In any case,
what we need to know is that
smallpox was caused by a virus,
and a virus that has no animal
reservoir.
 
The disease was restricted
entirely to human beings,
and that will prove to be
important in making it
eventually a good candidate for
eradication.
The name for the virus,
Variola,
derives from the Latin
varius,
meaning spotted.
 
And in England the disease,
in fact, was popularly called,
as I've said,
"the speckled
monster."
 
So, here's a picture of the
smallpox virus--oops,
it's gone out;
there it is.
And that's a schematic image of
a smallpox virus.
And as I said,
there is a mutation that
occurred in the twentieth
century, causing the rise of
Variola minor,
as well as Variola
major.
 
But we'll be concerned
exclusively here with Variola
major;
the main cause of smallpox
historically.
 
Well, how was it transmitted?
 
Here we need to remember that
smallpox is an exceedingly
contagious disease.
 
A smallpox patient sheds
millions of infective viruses
into his or her immediate
surroundings,
from the rash and from the open
sores in the sufferer's throat.
The patient is infective from
just before the onset of the
rash until the very last scab
falls off weeks later.
Not everyone,
of course, who is exposed is
infected.
 
Living along with people with
immunity--
and leaving that aside--it has
been estimated that the chances
are about 50:50 that a
susceptible member of a
household would contract
smallpox from an ill patient in
the home.
 
The dominant manner to spread
smallpox was by contact
infection,
droplets breathed out in
face-to-face contact with a
susceptible person and inhaled
by that person.
 
Normally the spread was in the
context of intense contact over
a period of time;
that is, a family member,
or someone on a hospital ward,
in an enclosed workplace--an
office,
a factory, a mine--a school
classroom,
an army barrack, a refugee camp.
And it's most easily
transmitted in dry,
cool seasons.
 
That's the primary mode of
transmission.
There are two more,
however, that are more
relatively secondary.
 
A second mode of transmission
is by what are called--another
bit of jargon here--fomites.
 
A fomite is simply an inanimate
object, capable of carrying
infectious material from one
person to another.
Examples might be bed linen,
clothing;
the shroud from an infected
person that transmits viruses
from one body--that is,
of the sufferer--to the next
person.
 
Other examples are simply
doorknobs, eating utensils,
and so on.
 
So, that's a second mode of
transmission.
There's a third too,
that smallpox can be vertically
transmitted;
that is, from mother to infant.
It's possible for an infant to
be born with congenital
smallpox.
 
Well, that's the mode of
transmission.
What about its epidemiology?
 
Well, some favoring factors
include large urban populations.
It's not coincidental that
smallpox raged in Western Europe
in the eighteenth century.
 
The crowded living conditions
and workplaces were ideal for
its transmission.
 
Trade and the movement of
people, displaced people,
warfare.
 
People who assembled and
reassembled in crowds were ideal
for transmitting smallpox.
 
The disease is known to have
afflicted Ancient Egypt.
Mummies are known to have been
victims of smallpox.
But the important point is that
it became endemic in Europe,
that became the world reservoir
of infection,
from which it spread by trade,
colonization,
warfare.
 
And in European cities it
became, above all,
a disease of childhood.
 
But about a third of the deaths
of children in the seventeenth
century were due to smallpox.
 
So, a reason then for dealing
with smallpox now,
in our course,
is that it was on a major
upsurge in the seventeenth and
eighteenth centuries.
How was it named?
 
Why is it called smallpox?
 
A small point.
 
But we need to know that it's
from a comparative description
of its characteristic lesions.
 
The "great pox"
is a disease which we'll be
dealing with pretty soon,
which was syphilis,
that creates large lesions and
affects adults.
The smallpox had small lesions
and primarily affected children;
at least in countries in which
it was endemic.
Another point we should know
about smallpox is that after
infection, a person enjoys a
lifelong immunity.
We need to know that because
it's a major factor in the
public health measures that the
disease eventually generated.
Well, what about its symptoms?
 
How does it affect the
individual human body?
After inhaling the virus,
there's an incubation period,
which normally lasts something
like twelve days.
This is important in its
epidemiology because it allowed
the spread of the disease;
because an infected person had
ample time to travel before
falling ill, and therefore time
to take the disease with him or
her and to spread it.
Now, I'm going to give some
attention--perhaps more than you
might like when you see the
images--to the symptoms of
smallpox.
 
And there's a reason for that.
 
Part is that smallpox is
tremendously,
terribly, terrifyingly painful.
 
Plus it leads--and this is
important too,
in the way that it impacted
society--
it often produces lifelong
scarring,
disfiguring and blindness,
and these in turn spread fear
of it and terror.
 
And, so, the very word smallpox
has a particular resonance in
popular imagination,
associated with dread.
People sometimes ask,
in a course like this,
which of the diseases we
encounter was really the worst?
The question doesn't permit
empirical verification,
because no one has ever
suffered, mercifully,
all the afflictions we study
and had the opportunity to
compare.
 
But it is meaningful to note
the impression of those who
lived through the times when
smallpox claimed its legions of
victims.
 
They thought--and the
physicians who treated
them--that smallpox was the
worst of human maladies;
that was a term that was said
at the time.
And this, in fact,
was the view,
closer to home,
of the Illinois State Board of
Health in 1902,
where Dr.
Donald Hopkins wrote this:
"In the suddenness and
unpredictability of its attack,
in the grotesque torture of its
victims,
in the brutality of its lethal
or disfiguring outcome,
and in the dread that it
inspired, smallpox is the worst.
 
It's unique among human
diseases."
To the extent that that's true,
it's also one of the reasons
that smallpox appeals to the
malevolent as a possible
instrument of bioterror.
 
It's well-known that a major
outbreak of smallpox would
spread death,
maximize suffering,
and lead to widespread fear,
flight and social disruption.
The symptoms are important to
examine as an integral part of
this disease.
 
And more generally,
unless we appreciate the
distinctive symptoms of each of
the diseases we examine,
there's a distorting temptation
to allow them to run together,
the diseases,
as so many interchangeable
causes of death;
a point of view that prevents
us from understanding that each
of these epidemic diseases had a
distinctive and different
imprint.
Smallpox was the disease that
it was, in part because of the
dread that it generated;
fear not only of death,
but also of exquisite
suffering, maiming,
disfiguring and blindness.
 
Only with that in mind,
can we understand why it's also
so widely thought to be a
candidate for bioterror.
So, we'll look at images of the
disease.
And I apologize to those of you
who've just finished breakfast
or just about to have lunch.
 
In any case,
first after the incubation
period, there's the pre-eruptive
stage.
The virus multiplies in the
system for twelve days after
incubation,
and symptoms of disease begin
with a viral shower,
as the pathogen is released
into the bloodstream and spreads
systemically throughout the
body,
localizing eventually in the
blood vessels of the skin,
just below the superficial
layers.
 
The viral load released,
and the efficiency of the
body's immune response,
determine the severity and type
of the disease.
 
Onset is sudden,
with fever of 100 to 102
degrees, and a general malaise.
 
This, then, is the beginning of
perhaps a month of excruciating
suffering and the danger of
spreading contagion.
The early symptoms are fever,
vomiting, severe backache,
splitting frontal headache,
and in children sometimes
convulsions.
 
Sometimes the disease is so
overwhelming that it leads to
what's called fulminating
smallpox,
which causes death within
thirty-six hours,
with no outward manifestations
at all;
although post-mortem exams
reveal hemorrhages in the
respiratory tract,
the alimentary tract or the
heart muscles.
 
Let me give you a description
of a hyper-acute case of that
kind.
 
Physicians wrote:
"After three to four days,
the patient has the general
aspect of someone who's passed
through a long and exhausting
struggle.
His face has lost all
expression, is mask-like,
and there's a wont of tone in
all muscles.
When he speaks,
this condition becomes more
apparent, speaking as with
evident effort,
and the voice is low and
monotonous.
The patient is listless and
indifferent to surroundings.
The mental attitude is similar.
 
There's a loss of tension,
a lengthening of reaction time,
and defective control.
 
In the most fulminant cases,
the aspect of the patient
resembles that of someone
suffering from severe shock and
loss of blood.
 
The face is drawn and pallid.
 
Respiration is sighing or
gasping.
The patient tosses about
continually, and cries out.
His attention is fixed with
difficulty, and he complains
only of agonizing pain;
now in the chest,
now in the back,
the head or the abdomen."
But normally smallpox wasn't
fulminant quite like that,
and the patient passed on to
the next phase,
which was the eruptive one,
exhibiting the classical
symptoms of smallpox that led to
its diagnosis.
On the third day after onset,
the patient usually felt a
little better,
and in mild cases he or she
could return to normal
activities,
with the unfortunate effect
that this spread the disease
further.
 
But concurrently a rash
appeared;
a small round or oval,
rose-colored lesion,
known as a macule,
that's up to a
quarter-of-an-inch in diameter.
 
The macules appeared first on
the tongue and palate,
and then, within twenty-four
hours,
it spread to cover the body,
down to the palms of the hands
and soles of the feet.
 
On the cheek and forehead,
the appearance is of severe
sunburn, and indeed the
sensation felt by the patient is
of scalding pain or intense
burning.
There's a characteristic
pattern, called centrifugal
distribution;
that is, that the rash is least
spread on the trunk of the body
and most densely apparent on the
face and the extremities.
 
Let me show you a slide of a
very ill little boy,
and you can see this
centrifugal pattern in which the
rash is most apparent on the
extremities,
rather than the trunk.
 
On day two of the rash,
a little further into the
infection, the lesions alter.
 
At this time the macule becomes
harder, and generally rises
above the surface into
structures known as papules,
with a flattened apex.
 
To the touch,
they were said,
by physicians,
to feel like buckshot embodied
in the skin.
 
And there we can see the
picture of a face,
at that stage of the disease.
 
The disease then moves on,
by the fifth day of the rash,
when fluid begins to accumulate
in pockmarks,
which are then raised and firm
to the touch--
so we'll pass on--now called
vesicles.
They've grown in size.
 
They've changed in color from
red to bluish or purple.
And they've transformed from
solid to blister-like fluid.
It's umbilicated as well.
 
The process of what's called
vesiculation,
the rise of this stage of the
rash, takes about three days and
lasts a further three.
 
It's at this stage that the
physical diagnosis of smallpox
becomes reliable,
with the disease presenting its
most distinctive appearance.
 
The patient experiences
increasing difficulty in
swallowing and in talking,
due to extensive lesions in the
mucous membranes in the palate
and the throat.
And there's a child at this
stage of the disease.
Then by the sixth day of the
rash, pus begins to form in the
pockmarks.
 
The patient feels much worse.
 
Septicemia can set in.
 
The pustules,
as they're now called,
begin to fill with yellow
fluid, and the lesions become
globular in shape;
a process that takes about two
days, and they're fully matured
on the eighth day of the
eruptive phase.
 
The patient feels dreadful at
this point.
Fever has risen in proportion
to the severity of the attack.
The eyelids,
lips, nose and tongue are
tremendously swollen.
 
And we can see a picture of an
adult at that phase of the
infection.
 
At this point,
the patient is almost totally
unable to swallow or talk,
and deteriorates slowly,
being drowsy most of the time
and restless at night.
Often he or she is in a
condition of delirium,
and thrashes about;
may even try to escape.
The psychological effects
weren't simply a sign of high
fever.
 
They resulted also from the
involvement of the central
nervous system in the infection,
and the neurological effects
and sequelae could often be
lasting and result in long-term
impairment.
 
Then, by the ninth day of the
rash,
the pustules were firm and
embedded in the skin,
and for this reason were
likely--and this was important
in the impact of the disease--
to leave permanent scars and
deep pits on the face,
or wherever they appeared on
the body;
if you can imagine by at this
stage.
 
Another unpleasant aspect at
this stage was that a terrible
sickly smell developed,
the fetor of smallpox,
that physicians claimed that it
was impossible to describe but
was found to be overpowering.
 
It's now nearly impossible for
the patient to drink,
and even milk caused intense
burning sensations in the
throat.
 
The patient experiences great
loss in weight--as much as
thirty to forty pounds in an
adult--and may suffer from frank
starvation.
 
In addition,
there's a complete loss of
muscle tone,
while the face,
in severe cases,
takes on the appearance of a
cadaver,
making the patient almost
unrecognizable,
even to his or her closest
relatives.
 
The scalp may be one large
lesion, and tangled with hair.
And lesions,
as you can imagine,
under the nails of fingers and
toes were exquisitely painful.
I want to show another
disturbing image--this was
important, but you can look away
if you like--which was the
lesions of the eyes.
 
Because smallpox was a major
cause of blindness,
as well as death and
disfigurement,
in this period.
 
Well, after about ten to
fourteen days of rash,
scabs appear,
and these contain live smallpox
virus as well,
and are highly infective and
important in the spread of the
disease by fomites.
At this point,
the fluid portion of the
pustule is absorbed,
leaving behind the solid part.
Large areas of the skin may
begin to peel off,
leaving deeper tissues raw and
exposed.
These areas are all painful,
and contribute to the
frightening appearance and the
misery of the patient.
Fatal cases often occurred from
about the eighth day,
and an important reason was
toxemia, because these lesions
were susceptible to infection.
 
So, attentive nursing,
good hygiene and sound
nutrition reduced the likelihood
of that sort of complication.
And, to that degree at least,
the prosperous,
the well-nursed and well-cared
for were more likely to survive.
The appearance of the patient
was often described by
physicians as mortification;
the still living patient taking
on the appearance of being
mummified,
and the skin of the face fixed
in a grotesque mask,
with the mouth permanently open.
 
The appearance of scabs and
crusting though was a favorable
sign in terms of prognosis for
the patient.
But they did lead to one final
torment of the disease,
which was an intolerable
itching that accompanied that
period;
indeed, a large portion of the
scarring that resulted from
smallpox was undoubtedly due to
patients scratching and tearing
at their lesions.
Well, the appearance and
distribution of the pustules was
of major importance for
diagnosis,
and it could be what was called
"discrete smallpox,"
where the rash was--
each lesion was distinct and
separated from the next.
 
And this meant that you had a
case fatality rate of as low as
about nine percent;
you had a ninety percent chance
of survival.
 
If instead the lesions were
much closer
together--semi-confluent it was
called--the case fatality rate
rose to something like
thirty-seven percent.
Or in cases of what was called
"confluent smallpox,"
in which the lesions touched
one another and formed a network
surrounded by islands of
unaffected skin,
the case fatality rate was
about sixty-five percent.
So, the appearance of the
lesions was very important in
your prognosis.
 
The rarest form was hemorrhagic
smallpox,
which had a hundred percent
mortality,
so-called because the natural
clotting mechanisms of the blood
were impaired,
and the victim died of massive
internal hemorrhaging.
 
Overall, the case fatality rate
for smallpox was estimated to be
about thirty to forty percent.
 
The virus then attacked not
only the skin and the throat,
but also the lungs,
the heart, the liver and other
internal organs,
and could result in
hemorrhaging and death.
 
A major danger was also
secondary bacterial infection of
the lesions;
a very common cause of
mortality.
 
Meanwhile, the lesions of the
mouth and throat were of great
epidemiological importance,
because they're the source of
the viruses that commonly form
droplets in the air and infect
others.
 
Also, the tongue became swollen
and misshapen.
There was difficulty breathing.
 
The patient became hoarse,
swallowing was difficult.
And all of that was important.
 
There were other sources of
anguish and suffering:
blindness, scarring and
disfigurement,
respiratory complications.
 
But after the drying up of the
rash, the patient began to
recover.
 
And among the population that
survived,
the symptoms declined and the
patient regained strength and
possessed a lifelong immunity
from a second exposure.
All of this led,
of course, as you can imagine,
to tremendous fear of the
disease--as in this picture--of
Variola.
 
Well, how did physicians deal
with this disease?
Smallpox no longer occurs
naturally anywhere on the
planet.
 
But it's worth remembering that
there is still no specific
remedy or cure for the disease.
 
Treatment, should a case appear
today,
would be largely supportive,
depending above all on
intensive nursing,
to keep the lesions
scrupulously clean,
to prevent bedsores and to
minimize the breakdown of the
skin.
In addition,
modern medicine would replace
lost fluids and nutrients,
and would administer
antibiotics, not to deal with
the virus,
but with the bacterial
infections that are its
complications.
 
What were traditional remedies?
 
Some of them were surprising.
 
One was a great vogue in the
color red.
There was a vogue to hang red
curtains around the bed of a
patient.
 
Red furniture was brought into
the sickroom,
and patients,
including Queen Elizabeth I of
England, were wrapped in red
blankets.
Later on, the discovery of
ultraviolet rays in fact gave
new impetus to this traditional
mania for red,
and red glass went up on
windows.
In the late nineteenth century,
medical journals published
studies suggesting also that red
light could be soothing to the
eyes of the sufferer,
and that perhaps it prevented
scarring of the skin.
 
So, that was one factor.
 
Another idea that was very
common was to open the pustule
with a golden needle,
to drain the fluid,
and then sometimes the lesions
were cauterized in an attempt to
prevent scarring;
procedures that were
exceedingly painful.
 
The next idea was what was
called "the hot
regimen,"
to pile the sufferer with
blankets,
to induce him or her to sweat
profusely,
to rid the body of the
over-abundant humor.
 
Or the patient could be
immersed in a hot bath.
Light and fresh air,
according to this therapeutic
fashion,
were deemed to be harmful,
and the patient was kept in the
dark,
if possible,
with minimal ventilation.
Sunlight was said to aggravate
the disease and increase
scarring.
 
And sometimes patients were
given internal medications,
sudorifics, to help the
evacuation of the excess humor.
The opposite was also tried,
the so-called "cold
regimen,"
to keep the room cool,
and frequently to sponge down
the patient with cold water,
to place-ice bags on the face.
 
Then there was purging and
bloodletting.
There was also the
administration of opiates,
in the nineteenth century,
and especially morphine,
to calm the patient in
delirium.
Astringent eye drops were
resorted to.
A particularly perverse theory,
with no empirical basis,
was the idea that scarring on
the face could be reduced or
prevented by causing more
intense irritation of the skin
elsewhere;
so that mustard plasters,
mercury and corrosives were
applied on the back,
in order to save the face.
 
There were also all kinds of
local applications to the face,
to try to prevent scarring.
 
Nitrate of silver,
mercury, iodine,
mild acids, a lotion of sulfur;
all of those had their vogues.
There were ointments and
compresses of virtually every
substance known to man.
 
Some physicians held the theory
that their preparations would
soften the lesion and mitigate
scarring.
So, indeed, ingenious doctors
applied lint,
boric acid or glycerin;
or they covered the face with a
mask, leaving holes for the
eyes, nose and mouth.
Or they wrapped the face and
hands in oiled silk.
Alcoholic beverages were
administered to deteriorating
patients to revive their energy.
 
And sometimes delirious
patients were actually tied to
their beds.
 
Some doctors recommended
restraints, such as splints,
in later stages,
to prevent patients from
scarring their faces by
scratching.
After hearing of all of these
treatments for smallpox,
perhaps you'll appreciate the
work of Thomas Sydenham,
in the seventeenth century,
the so-called English
Hippocrates,
who decided that the wealthy
and noble who received extensive
attention and treatment for
smallpox perished of the disease
more frequently than the poor,
who had no access to treatment.
 
And his advice was that the
best physician was the one who
did the least.
 
He was an advocate of
therapeutic minimalism.
He advised instead a simple
cool regimen,
giving his patients fresh air
and light bed coverings.
Well, that's how the disease
afflicted the human body.
What I want to do next time,
now that we understand this
terrible disease and the
suffering it caused,
is to deal with its impact
historically,
its effect on society,
and to look at the development
of a public health strategy,
which was to be vaccination.
 
 
