Plagues in World History (16 page)

Smallpox probably originated as a virus prevalent in an animal reservoir that then made the jump to humans following the domestication of animals some eleven or twelve thousand years ago. It is a member of the orthopoxvirus family, which includes viruses that also affect monkeys, rodents, cats, camels, elephants, and water buffalo and cattle; the last is probably the most likely contender as the vector that passed the smallpox virus from animals to humans.4 Even today, cowpox and buffalopox viruses can cause mild infections in human victims, typically by milking infected udders. There are two main types of the smallpox virus,
Variola major
and
Variola minor
, with the former being the more commonly occurring in human history and also the more deadly, killing on average about a third of its victims. Infection with
Variola minor
was almost a godsend, as it killed just 1 percent or less of those who contracted it, yet it conferred lifelong immunity to the disease, even in its more severe form. The virus itself was not physically seen and identified with an electron microscope until the 1940s, even though awareness of viruses as organisms distinct from bacteria, which was achieved through special, fine filters that could separate the two, was achieved by the end of the nineteenth century. The Latin term,
variola
, which in the Middle Ages came to mean “pox” and was probably derived from the Latin word for “spotted” (
varius
) or “pimple” (
varus
), was first used in connection with the disease during the sixth century C.E. It was at the very end of the Middle Ages, in around 1494, that smallpox acquired its name in order to distinguish it from a new disease to Europe that struck the soldiers of the French king, Charles VIII, as they were besieging Naples in that year;
la grosse vérole
, or “great pox,” also known as the “French disease,” was a venereal-type illness that some identify with syphilis just imported from the New World in the wake of Columbus’s voy-ages, while the older disease producing pustule symptoms was now called
la petite vérole
, or “small pox.”

Smallpox y 75

Smallpox’s symptoms were intimately bound up with how the disease was spread. After an incubation period of nine to twelve days, the victim typically experienced a violent fever accompanied by chills, nausea, aches and pains, and sometimes convulsions and delirium. Then a rash of small reddish spots appeared on the mucous membranes of the mouth, tongue, upper palate, and throat, which quickly enlarged and ruptured, releasing millions of viruses into the saliva, making the disease highly contagious at this stage from person to person by means of droplet infection. Next, the virus invaded the outer skin cells, forming raised pimples and then broader pustules filled with fluid (not pus) that became opaque and then slowly leaked out until the lesions dried up, scabbed over, and flaked off, which happened two to three weeks later. Scarring and sometimes blindness occurred, leaving the characteristic pockmarks that forever signaled to the world a victim of smallpox. Since the pustules formed heaviest on the face and the extremities, smallpox was a very visible disease, practically impossible to hide, so that even though the victim was infectious for as long as he or she exhibited its symptoms, it was also abundantly clear who had the disease and thus who should have been avoided.

Nevertheless, the scabs and liquid “matter” of smallpox victims present in their clothing or bedding (what the sixteenth-century physician Girolamo Fracastoro called the “fomites” or seeds of disease) could still have infected others even when no direct contact was made with the victims themselves; usually, however, smallpox contagion occurred through close, direct contact with victims, such as often happened among members of the same household, and when victims were in the most infectious stage of the disease during the first week of the rash appearing on their bodies. Some types of smallpox were invariably fatal, such as the “malignant”

variety—whereby the pustules were slower to mature and remained flush with the skin (hence the name “flat smallpox”); fulminating or hemorrhagic smallpox—characterized by massive bleeding internal y and into the skin, forming petechiae that made the skin appear black and turned the eyes red but with little to no pustules; and confluent smallpox, in which the pustules ran into each other and formed single, extensive sheets that peeled off to expose the inner epidermis and tissue that easily became infected, so that the victims died of secondary or opportunistic bacterial diseases rather than from the smal pox itself. Milder versions of smallpox included the less frequent
Variola minor
variety where scarring was less likely to occur, even though it had the same type of symptoms and method of transmission as the ordinary version, and “modified” smallpox, often confused with chickenpox, which typical y appeared in people previously vaccinated for the disease but in whom the vaccine was no longer effective.

The history of smallpox is mainly characterized by the differential way in which it strikes its victims, both within a given society or culture and between 76 y Chapter 2

sometimes competing civilizations. Smallpox in this respect is therefore quite different from plague, which confers no compensating immunity upon those who are made to suffer its ravages and which during the time of the Black Death in late medieval Europe had a notorious reputation, even if this was not borne out in fact, of equitably harvesting its victims, as evidenced by the popular Dance of Death artistic motif that was frequently associated with plague, in which various members of the social hierarchy, in descending order from pope and emperor on down to hermit and poor man, must all dance a reel with death.5 Smallpox then had a very different dynamic from plague, in which its impact was felt not so much through any massive mortality on the scale of the Black Death but instead through the simple reality that not everyone was killed off or even affected by the disease. There was thus a kind of disease “favoritism”

at work with smallpox, which could be quite vindicating for those fortunate enough to be immune, but rather demoralizing, to say the least, for those who were disproportionately impacted by it. This also meant that smallpox was much more disposed to interacting with other sociological and cultural factors besides disease, such as colonialism and imperialism, than plague, which tended to be more autonomous due to its overwhelming mortality and morbidity. In addition, one should keep in mind that smallpox is now an extinct disease, one that was uniquely conquered by modern medicine, which is quite a different experience from that of more intractable diseases that still plague us to this day, including tuberculosis, influenza, and, yes, plague.

The major epidemics of smallpox around the world and throughout history amply reveal its distinguishing, differential characteristic. Perhaps the first outbreak to receive the attention of ancient historians of disease was the Plague of Athens of 430–426 B.C.E., as chronicled by Thucydides. We have already explored in the introduction the issues of identifying the Plague of Athens with smallpox and its long-term impacts upon Athens’ conduct of the Peloponnesian War. Smallpox accords well not only with Thucydides’ description of symptoms but also with his account of its rapid spread; although the disease seems to have died down after 426, giving the Athenian population a chance to recover its former numbers, its early timing may well have set the stage for the city’s conduct during the rest of the war by supposedly undermining its celebrated veneer as a civilized, moral standard-bearer for Greece—or, to borrow Thucydides’ phrase as put into the mouth of Pericles, as the “school of Hellas”—that was used to justify the war in the first place.

But for our purposes here, the main thing to be noted about the Plague of Athens is how it coincided with war and at the same time with a lopsided mortality and morbidity that affected only one side in the conflict, a fact that was duly noted by Thucydides. This naturally suggested to the Athenians that their Smallpox y 77

enemies, the Spartans, who seemed immune to the disease, must have deliberately planted the epidemic among them as part of a campaign of biological warfare; this was all the more easy to believe as the Athenians themselves had apparently employed this tactic during their siege of Cirrha in the sixth century, when they poisoned a stream supplying water to the city. Rationally speaking, however, observers like Thucydides recognized that overcrowding in the city, as refugees poured in at the start of the war to take cover behind the “long wal s” from the Peloponnesian army that was ravaging the countryside, was really at the root of the outbreak. Athenian trade and its cosmopolitan openness to foreigners, which was so celebrated by Pericles in his “Funeral Oration” to honor the first Athenian dead in the war, as reported by Thucydides, must have also played a role in bringing the disease to Athens, just as the closed-door policy of Sparta ensured its virtual quarantine. Psychologically speaking, this differential quality to the Plague of Athens had its demoralizing effect on the populace, a factor that nonetheless the Spartans failed to exploit due to their own fears of contracting the illness.6 As we will see, however, the later history of smallpox was to prove not so forgiving.

The next major outbreak of smallpox to be recorded in history is believed to be the Plague of the Antonines, which struck the Roman Empire beginning in 165 C.E., during the reign of the last of the Five Good Emperors, Marcus Aurelius Antoninus (161–180), who seems to have died of the disease, and extending perhaps into that of his son, Lucius Aurelius Commodus Antoninus (180–192).

While no hard mortality statistics are available for this epidemic, best estimates are that it carried off 10 percent of the empire’s population, which would be enough to make an impact, certainly, but not so much that a relatively swift recovery could not be made. Nonetheless, it has been argued that, once again, smallpox was ill timed to coincide with war, when the empire began facing challenges from the Parthian Empire in the east and from the Germans to the north; the loss of manpower to disease at such a critical time may have made a difference in Rome’s future ability to fight off the “Barbarian” threat and compelled it to recruit soldiers from among the Germans themselves in order to make up the numbers, a policy that would have grave implications later by the end of the empire in the fifth century.7

The Middle Ages saw an important breakthrough in medical diagnosis and treatment of smallpox when the Persian physician, Muhammad ibn Zakariyā

al-Rāzī (865–925), known simply as Rhazes in the West, composed his
Treatise on the Smallpox and Measles
based on his experience treating patients as head of the hospital at Baghdad, the capital of the Abbasid caliphs. Rhazes provided the first definitive symptomatology of smallpox, distinguishing it from measles primarily by the presence of severe backache, but he also noticed that smallpox was characterized by a “continuous fever,” a “stinging pain in the whole body,” a 78 y Chapter 2

“violent redness of the cheeks and eyes,” as well as a “pain in the throat and breast,” all of which were also noted by Thucydides during the Plague of Athens.

Rhazes also supplied the important evidence that smallpox was primarily a child-hood disease in his time, which indicates that it had by now become endemic to the Eurasian continent as a regularly occurring disease.8

By far the most controversial, notorious, and studied outbreak of smallpox in human history seems to be that which occurred in the American hemisphere—Mexico, the Caribbean, and Central, South, and North America—beginning in the early sixteenth century and raging through to the next century and beyond. This has been called nothing less than an American “Holocaust” or “Apocalypse” of mortality among the native populations of these regions, but it must be remembered that it took at least a century for such demographic losses to be registered in what records we have; what is more, a panoply of diseases besides smallpox helped bring about the catastrophe, including other directly contagious ills like measles, influenza, pneumonic plague, and mumps, as well as those spread by other means such as an insect vector or contaminated water supplies, which would include typhus, bubonic plague, yellow fever, malaria, and cholera. Smallpox, however, was among the earliest and apparently most deadly diseases to strike the Americas, making landfall first on the island of Hispaniola (modern-day Dominican Republic and Haiti) in 1518 and then the mainland of Mexico in 1520 in the wake of the expedition of Hernán Cortés that culminated with the conquest of the Aztec Empire. Around the same time, during the 1520s, smallpox also arrived in Guatemala, Panama, and Ecuador in Central and South America. Throughout the rest of the century, smallpox reappeared somewhere in the western hemisphere on a regular basis almost every other decade; it finally appeared in Brazil in 1562, and by the end of the century it was the turn of the natives in North America to also feel its wrath. Smallpox seems to have arrived first in the southwestern United States and northern Mexico during the 1580s and 1590s, then the northeastern region in the second or fourth decade of the seventeenth century, followed by Florida and the southeast in 1655, and finally the Pacific Northwest and Great Plains during the 1780s. In the latter two regions, smallpox continued its ravages even into the first half of the nineteenth century, before federal vaccination efforts took effect. Even though Old World diseases came later to Brazil and North America compared to the rest of the hemisphere, and native populations there were more dispersed than in the population centers of the Aztec and Inca empires, declines are estimated to be just as great as anywhere else, especially since Brazil and North America became just as much, if not more, active in the slave trade from Africa, which was another source of disease introduction to the New World.9