Smallpox

The history of smallpox weaves together a number of topics covered in this section of the course on the human body: the humoral system, the influence of Islamic medicine on European medicine, the impact of indigenous knowledge on European thought, and constructions of race and gender.

I begin with a brief account of the modern understanding of smallpox, since this is inextricably intertwined with historical discussions of smallpox in the ancient world. Smallpox was an acute and often fatal viral infection. (I use the past tense because the virus was successfully eradicated in 1979, and now exists only in laboratories.) It was highly contagious and was generally transmitted from person to person by droplet infection, although occasionally infection could occur through contact with clothing or bedding used by a smallpox sufferer. The symptoms typically began twelve days after infection with the virus. The first symptoms were a high fever, headache, back and muscle pain, and occasionally vomiting or convulsions. In very severe cases, massive internal bleeding occurred and the patient died within a day or two. The most characteristic symptom of smallpox was a distinctive rash that appeared between two and five days from the onset of symptoms. The rash broke out all over the body, but generally most densely on the face, palms and soles. The rash had small pimples, which gradually developed into larger pustules (the “pox” or “pocks”). If these pustules grew to the point where they began flowing into each other, the patient generally died. If, after about eight or nine days, the pustules began to dry up and form scabs, the prognosis was good. Generally, if the patient made it this far, the scabs would fall off after a few weeks and he or she would recover. Smallpox survivors were sometimes left blind in one or both eyes, and most had at least some permanent scarring, often on the face. Infection with smallpox conferred life-long immunity to the disease.

The disease we now know as smallpox was present in the ancient world. There is forensic evidence of smallpox in at least one Egyptian mummy, and many ancient sources describe a disease that seems to closely resemble the modern clinical picture of smallpox. Several “plagues” described by ancient writers have been identified as smallpox, although these identifications remain controversial. One such plague is the Antonine plague, which began sometime in late 165 or early 166 CE and lasted until 180 CE. This plague occurred during the reign of the emperor Marcus Aurelius, whose personal physician was the famous physician Galen (129 – ca. 200/ca. 216). Galen was in Rome for at least a short time while the epidemic was raging, and he describes his treatment of plague victims. Indeed, the identification of the Antonine plague as smallpox rests largely on Galen’s observations of the symptoms and course of the disease. However, Galen did not discuss the epidemic in a systematic way. He mentioned the plague in several of his works, but always in the context of discussions of other topics. For example, in his treatise On Black Bile, he writes: “All diseases that stem from a bad temperament that is hot and dry, such as remittent fevers, produce thick dark blood. The present chronic infection, which has come about because of the long summer, also is the cause of blood which resembles that brought about by remittent fever.” (Galen, On Black Bile, 23.) Here, the plague ravaging the city of Rome is merely, “the present chronic infection” and it is one of a number of examples of diseases associated with black bile. Like many afflictions caused by an excess of black bile, it is precipitated by hot, dry weather. Galen notes that some plague victims “suffered an evacuation through the stomach” and then recovered. In other cases, “the whole body breaks out all over in black pustules” which dried out and then fell off. Both phenomena – the diarrhea and the pustules – Galen attributes to an excretion of dark blood or black bile.

In the Antonine plague, and other ancient plagues tentatively identified as smallpox, men, women and children seem to have been affected in relatively equal numbers. By the ninth century, when we have our first clinical description of smallpox, the disease had become endemic. Most people were exposed as children, and either died or recovered. If they recovered (and it appears that most did), they had lifelong immunity. Smallpox appears to have achieved an established place in Arabic, and later European, medicine at the point at which it ceased to be an epidemic.

The first medical writer to treat smallpox as a distinct disease and systematically to describe its causes and symptoms was the ninth-century Persian physician Abu Bakr Muhammad ibn Zakaria al Razi, known in Europe as Rhazes (ca. 850-925 CE). Before the ninth century, no one in Europe, the Middle East or northern Africa used a word that might reasonably be translated as “smallpox.” Physicians, historians, chroniclers, and other writers described “plagues” or “epidemics,” but there is little evidence that they drew connections between an outbreak in one time and place and another in a different time and place. The Hippocratic physicians, and later Galen, tended to see the precipitating causes of particular epidemics in specific atmospheric and weather conditions. Epidemics might also be blamed on the gods. In either case, each and every epidemic was essentially unique.

In his Treatise on Smallpox and Measles, Rhazes explained smallpox as a normal and necessary part of a child’s maturation. Blood, he claimed, was like wine:

the blood of infants and children may be compared to must, in which the coction leading to perfect ripeness has not yet begun, nor the movement towards fermentation taken place; the blood of young men may be compared to must, which has already fermented and made a hissing noise, and has thrown out abundant vapors and its superfluous parts, like wine which is now still and quiet and arrived at its full strength; and as to the blood of old men, it may be compared to wine which has now lost its strength and is beginning to grow vapid and sour.

Very young blood was like must, which is freshly pressed grape juice, the first stage in wine making. In order to turn must into wine, the vintner lets it ferment. As the must ferments, it bubbles and froths. When the fermentation process is complete, the bubbling and frothing stop, and you have wine. Something analogous happens in every human body as it matures. As the child’s blood is transformed from its must-like state to its mature wine-like state, it bubbles and froths and throws off waste vapors. These waste vapors are what cause the symptoms of smallpox, the fevers, aches, and most notably the rashes and pustules on the skin.  There is no way to stop this process; indeed, you don’t want to stop it since it is a natural part of growing up. And if you stop it, you will drive the waste vapors back inside the body, where they will almost certainly be fatal. However, if the blood ferments too fast and too vigorously, the child is also in grave danger of dying. What the physician should do, according to Rhazes, is to take steps to ensure that the fermentation occurs at a slower, gentler, more controlled rate. Rhazes recommends numerous treatments and dietary adjustments to manage smallpox. He also offers remedies to prevent and diminish the scarring and damage to the eyes that often followed a bout of smallpox. Throughout his treatise, Rhazes discussed smallpox as a serious and potentially life threatening disease that required careful management, but he does not describe it as a disease that was usually fatal. Rhazes notes that very occasionally adults do get the disease, and he attributes this to their blood not having made a full transition when they were young and in rare cases to “pestilential, putrid, and malignant constitutions of the air.” For excerpts from Rhazes’ Treatise on Smallpox and Measles, and a link to a full English translation of his work, see here.

The second important medical description of smallpox was that of the Persian physician ‘Ali ibn al-‘Abbas al-Majusi (died 982-994 CE), known in Europe as Haly Abbas. He described smallpox in his Complete Book of the Medical Art. Like Rhazes, Haly Abbas observed that smallpox was almost exclusively a disease of children. However, his explanation for this phenomenon differed from Rhazes’ explanation. All children according to Haly Abbas, were nourished in their mothers’ wombs with menstrual blood (this was not a novel idea; it goes back to Aristotle and Hippocrates). Haly Abbas posited that some menstrual blood was left in the child’s body after it was born. Menstrual blood was a toxic substance, so this was an unstable situation. Smallpox was the result of the body trying to rid itself of the remnants of menstrual blood still remaining in the blood after birth. When the remnants of menstrual blood were set in motion, they bubbled to the surface, causing fevers, aches, rashes and pustules. The menstrual blood could be set in motion by external or internal factors. The external factors were pestilential air and proximity to those with smallpox. These two factors were closely related, because Haly Abbas reasoned that the breath of smallpox victims poisoned the air and thus made others vulnerable to smallpox. There is a suggestion here that smallpox is contagious, but I would not push this too far because a person has to have excess menstrual blood in their body that can be agitated by contact with the breath of a smallpox victim. You can’t get smallpox just by being around someone with smallpox. In both cases, unhealthy air agitated the menstrual blood remaining in a child’s body, and precipitated a case of smallpox. The internal factor was a hot, moist diet. Again, this unhealthy diet set the menstrual blood in motion. Haly Abbas agreed with Rhazes that once this process started, it could not (and should not) be stopped, but only controlled.

Finally, the Persian physician Ibn-Sīnā (ca. 980 – 1037 CE), known in Europe as Avicenna, incorporated the ideas of both Rhazes and Haly Abbas on smallpox into his monumental Canon of Medicine. The Canon was translated into Latin in the twelfth century by Gerard of Cremona (c. 1114–1187) and became the most important medical text in Europe for centuries. It was THE standard textbook in medical schools all over Europe until the seventeenth century.

In the Middle Ages and early modern period, the European understanding of smallpox was basically taken over wholesale from Islamic writers. Europeans saw it as a disease of children and as an almost inevitable part of growing up. To take just one example, the seventeenth-century English writer Anthony Westwood declared:

That the mothers blood is the true cause of the Small Pox and Measles, and that is hence chiefly gathered, because among many thousands of men it is hard to find one, who once in his life hath not had these diseases. . . . It remains therefore that the Small Pox and Measles spring from the Mothers Blood, with which the child is nourished in the womb; for therein, be it never so pure, some impurities are found, which communicate their pollution to the parts of the child; and that pollution of the parts doth defile the masse of blood; and being provoked by some occasion, doth make the same to boyle, by help whereof the blood ferments and is putrefied, both it & the parts aforesaid. (Anthony Westwood, De variolis & morbillis: Of the small pox and measles [London, 1656], pp. 7-9)

Three things happened in the early modern period that radically changed the way Europeans thought about smallpox, and ultimately, the way they thought about disease more broadly. The first was that the disease itself became more virulent. The second was that Europeans came in contact with people who had very different ideas about the nature and cause of smallpox. And the third was that Europeans came in contact with people who had never experienced smallpox. Let me take each of these in turn.

Ann Carmichael and Arthur Sliverstein argue that between the fifteenth and sixteenth centuries, a relatively mild endemic form of smallpox was replaced with a much more virulent and deadly form of the virus. By the seventeenth century, smallpox was an epidemic disease that rivaled plague in its mortality rates. This was very different from the form of the disease Rhazes, Haly Abbas and Avicenna had described, and it caused Europeans to seek other explanations for the cause and spread of smallpox. Contagion became a more popular and persuasive explanation. For example, the seventeenth-century English physician Gideon Harvey (1636/7–1702) asserted that plague and smallpox, “are both contagious Diseases, and originally caused by malign particles received out of the Air into the Body” (Gideon Harvey, A Treatise of the Small-pox and Measles [London, 1696], p. 43)

Another important event in the fifteenth century was European contact with the peoples of west Africa. Smallpox was endemic in Africa as well, and many groups on the African continent had developed the practice of inoculation. In inoculation, a small amount of matter from the smallpox pustules is introduced under the skin of a healthy person. Done correctly, this can induce a mild case of smallpox that then confers life long immunity to the disease. This practice had no analog in European medicine and was deeply puzzling to European observers. Numerous slave owners, especially in the West Indies and in North America, reported that Africans had a practice of infecting healthy people with matter from the pustules of smallpox sufferers. Some Europeans looked on this practice with distaste, as a “superstitious” and barbaric ritual rather than an effective medical practice. Others took an even darker view, believing that their slaves were deliberately poisoning themselves in an attempt to commit suicide and avoid a life of slavery. But some Europeans did notice that Africans who practiced inoculation were less likely to die of smallpox than those who were not inoculated. On some slave plantations, masters allowed (indeed demanded) that slave medical practitioners (who had learned the technique in Africa) inoculate their (white) children along with slave children. Very gradually, the technique began to be discussed by European medical practitioners. It should be noted that Africans were not the only group that practiced a form of inoculation.   European travelers to China and Turkey reported similar (but not identical) practices. In the eighteenth century, European and American medical practitioners began to adopt the technique of inoculation and practice it at home. Two figures that were key in getting the technique accepted into “western” medicine were the English noblewoman, Lady Mary Wortley Montagu (1689-1762) and the Boston physician Zabdiel Boylston (1676-1766). Lady Mary had suffered from smallpox and been left badly scarred by the disease. She had lost a beloved younger brother and several friends to the disease. She was keen to protect her children from a similar fate. She was also the wife of the British ambassador to Turkey. While she was in Turkey, she witnessed the practice of inoculation and convinced a physician to try the technique on one of her children. (You can read a letter she wrote to a friend from Turkey about the procedure here.) When she returned to England, she was successful in pressuring the leading London physicians to try the technique. After a test of inoculation on prisoners, the technique was used on the royal children and rapidly became widespread in England. Zabdiel Boylston learned about inoculation from one of his slaves, who had been inoculated in Africa. The slave, Onesimus, described the procedure to Boylston, who experimented on other slaves and his own children. During a smallpox epidemic in Boston in 1721, he became involved in a fierce controversy over the efficacy of inoculation. But the practice ultimately became widespread in America as well. Smallpox inoculation is widely considered to be one of the great public health triumphs of the eighteenth century. And it is a triumph that owes its genesis to African medical theories and practices.

Finally, European views of smallpox were altered by their encounters with the indigenous peoples of the Americas. These peoples had no natural immunity to a number of European diseases. Consequently, when they were exposed to them after European conquests in the fifteenth century, their mortality rates from these diseases were far higher than they were in Europe. Indigenous populations were devastated by influenza, bubonic plague, measles and typhus, but the deadliest disease of all was smallpox. Smallpox had close to one hundred percent mortality rates among native populations. To give a sense of the demographic disaster occasioned by contact with Europeans, the population of Hispaniola (the island that today contains the countries of Haiti and the Dominican Republic) was halved in 1496 and again in 1497. The rate of decline slowed a bit after this, but was still catastrophic. By 1508, there were only about 60,000 Taino remaining on the island. By 1514, the number was halved. By 1518, only about 11,000 Taino survived. Other indigenous populations suffered similar losses. Europeans noted the high rates of disease and death with some puzzlement (but not a great deal of distress). Some attributed the epidemics that wiped out the Taino (and other groups) to a divine sign that their lands were intended for Europeans. Others argued that the fact that Europeans were healthier than the indigenous peoples meant that they were better suited to the land and climate than the original inhabitants (and thus clearly had a divine mandate to take exploit the land and its resources). Although Europeans were beginning to think of smallpox as a contagious disease, that in no way explained why native peoples were so much more susceptible, and so much more likely to die if they contracted the disease. This experience too had enormous impact on Europeans views of smallpox and disease generally. This was not a phenomenon that could be explained in humoral theory, and that occasioned a search for theories that COULD account for what Europeans were observing in the “new” world.