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Pox Americana: The Great Smallpox Epidemic of 1775-82by Elizabeth A. Fenn
September 28, 1751. Time has left the early pages of his diary so damaged that the exact date remains uncertain. But it was probably on this day that nineteen-year-old George Washington set sail from Virginia to the island of Barbados with his older half brother, Lawrence. If their departure date is unclear, the brothers' purpose is not: The trip was intended to ease Lawrence's persistent cough and congested lungs, symptoms of the consumption that was to kill him within a year. In the eighteenth and nineteenth centuries, travel abroad was a favored treatment for consumption, the contagious disease that today we call tuberculosis. Early Americans understood consumption to be an ailment of heredity and climate, alleviated by salt air, mountain breezes, or whatever atmospheric conditions best suited a particular patient's constitution. It was the Washingtons' hope that Barbados would suit Lawrence.
The trip was difficult. Hurricanes regularly strafe the Caribbean in the early fall, and 1751 was no exception. The brothers and their shipmates endured a week of stiff gales, rain squalls, and high seas in late October, the effects of a nearby storm. They disembarked at Bridgetown, Barbados, on November 2, 1751. Although the purpose of the journey was to ease Lawrence's consumption, it was soon George who lay seriously ill--not from tuberculosis, but from smallpox.
On November 3, the day after landing, the two brothers begrudgingly accepted an invitation to dine at the home of Gedney Clarke, a prominentmerchant, planter, and slave trader with family ties to the Washingtons. "We went,--myself with some reluctance, as the smallpox was in his family," George wrote in his diary. His misgivings were justified. For a fortnight afterward, the two Americans plied the Barbadian social circuit, unaware of the virus silently multiplying in George's body. Then, on November 17, when the incubation period had passed, the infection hit hard. "Was strongly attacked with the small Pox," Washington wrote. Thereafter, his journal entries stop. Not until December 12, when he was well enough to go out once again, did George Washington return to his diary.
The brothers' stay in Barbados was brief. "This climate has not afforded the relief I expected from it," wrote Lawrence. On December 22, the brothers parted ways, George returning to Virginia and Lawrence opting for the more promising climate of Bermuda. Lawrence's health was failing fast. He spent the spring in Bermuda and then hurried desperately to his home at Mount Vernon, Virginia, where tuberculosis took his life on July 26, 1752.1
On Sunday, July 2, 1775, a much-older George Washington stepped out of a carriage in Cambridge, Massachusetts, to take command of the Continental army, newly established by the Congress still meeting in Philadelphia. Already, an American siege of nearby Boston was under way. The standoff was the outcome of the battles of Lexington and Concord in April 1775, when an angry throng of New England militiamen had routed a column of British troops attempting to seize a stash of munitions at Concord. Exhausted and humiliated, the king's soldiers had staggered sixteen miles back to Boston under relentless American sniper fire. Here they were trapped. The armed patriots were to besiege them in the city for the next eleven months.
By the time Washington arrived to command the American army in July, the confrontation had taken on an added dimension: It was not just military but medical as well. Smallpox was spreading through Boston. Washington knew how debilitating the disease could be, and he knew that the New Englanders who formedthe core of his Boston-based army were among those most likely to be vulnerable. It was a vulnerability they shared with a great many others in late-eighteenth-century North America.
When smallpox struck George Washington in Barbados in 1751, his diary entries stopped for twenty-four days. If this was not inevitable, it was nevertheless predictable. Rare was the diarist who kept writing through the throes of the smallpox. The void in Washington's diary is thus telling; its very silence speaks of a misery commonplace in years gone by but unfamiliar to the world today.
Although the route of infection is impossible to determine, it is most likely that Washington picked up Variola through direct contact with a sick member of the Gedney Clarke household. The contagious party may have been Mrs. Clarke herself, who was "much indisposed" at the time of the brothers' visit. If Washington had a face-to-face meeting with her, he might have inhaled tiny infectious droplets or his hands might have carried the contagion to his mouth or nose. Such an encounter is the most likely mode of infection, but it is by no means the only one possible. Even scabs and dried-out body secretions can transmit smallpox. If someone had recently swept the floors or changed the bedclothes in a sickroom in the Clarke home, desiccated but dangerous particles may have circulated aloft. Finally, one last form of transmission bears mentioning. Variola can survive for weeks outside the human body. Carefully stored, it retains its virulence for years.2 Thus it is conceivable that George Washington caught smallpox from an inanimate object (often cloth or clothing) contaminated with the virus.
How do we know that Washington caught smallpox in the Clarke household? The acknowledged presence of the disease there is one clue. Timing is another. The incubation period for smallpox usually ranges from ten to fourteen days. A twelve-day incubation is most common, with the first symptoms appearingthirteen days after exposure.3 George Washington's case was thus fairly typical. He dined at the Clarke home on November 3, and according to his diary, his first symptoms appeared fourteen days later.
We have no firsthand description of Washington's bout with the pox. But to judge by the experience of other victims, his early symptoms would have resembled a very nasty case of the flu. Headache, backache, fever, vomiting, and general malaise all are among the initial signs of infection. The headache can be splitting; the backache, excruciating. Lakota (Sioux) Indian representations of smallpox often use a spiral symbol to illustrate intense pain in the midsection. Anxiety is another symptom. Fretful, overwrought patients often die within days, never even developing the distinctive rash identified with the disease. Twentieth-century studies indicate that such hard-to-diagnose cases are rare. But eyewitness accounts suggest that in historical epidemics, this deadly form of smallpox may have been more common among Native Americans, who frequently died before the telltale skin eruptions appeared.4
To judge by the outcome of his illness, George Washington's "pre-eruptive" symptoms were not nearly so grave. The fever usually abates after the first day or two, and many patients rally briefly. Some may be fooled into thinking they have indeed had a mere bout of the flu. But the respite is deceptive, for relief is fleeting. By the fourth day of symptoms, the fever creeps upward again, and the first smallpox sores appear in the mouth, throat, and nasal passages. At this point, the patient is contagious. Susceptible individuals risk their lives if they come near.
The rash now moves quickly. Over a twenty-four-hour period, it extends itself from the mucous membranes to the surface of the skin. On some, it turns inward, hemorrhaging subcutaneously. These victims die early, bleeding from the gums, eyes, nose, and other orifices. In most cases, however, the rash turns outward, covering the victim in raised pustules that concentrate in precisely the places where they will cause the most physical pain and psychological anguish: The soles of the feet, the palms of the hands, the face, forearms, neck, and back are focal points of the eruption. Elsewhere, the distribution is lighter.
If the pustules remain discrete--if they do not run together--the prognosis is good. But if they converge upon one another in a single oozing mass, it is not. This is called confluent smallpox, and patients who develop it stand at least a 60 percent chance of dying. For some, as the rash progresses in the mouth and throat, drinking becomes difficult, and dehydration follows. Often, an odor peculiar to smallpox develops. "The small-pox pustules begin to crack run and smell," wrote a Boston physician in 1722. A missionary in Brazil described a "pox so loathsome and evil-smelling that none could stand the great stench" of its victims.5 Patients at this stage of the disease can be hard to recognize. If damage to the eyes occurs, it begins now. Secondary bacterial infections can also set in, with consequences fully as severe as those of the smallpox.
Scabs start to form after two weeks of suffering, but this does little to end the patient's ordeal. In confluent or semiconfluent cases of the disease, scabbing can encrust most of the body, making any movement excruciating. The Puritan leader William Bradford described this condition among the Narragansett Indians in 1634: "They lye on their hard matts, the poxe breaking and mattering, and runing one into another, their skin cleaving (by reason therof) to the matts they lye on; when they turne them, a whole side will flea of[f] at once." An earlier report from Brazil told of "pox that were so rotten and poisonous that the flesh fell off" the victims "in pieces full of evil-smelling beasties."6
Death, when it occurs, usually comes after ten to sixteen days of suffering. Thereafter, the risk drops significantly as fever subsides and unsightly scars replace scabs and pustules. After four weeks of illness, only the lesions encapsulated in the palms of the hands and soles of the feet remain intact. Unlucky sufferers whose feet have hardened from years of walking barefoot sometimes shed the entire sole of the foot at this time, delaying recovery considerably. But in most cases, the usual course of the disease--from initial infection to the loss of all scabs--runs a little over a month. Patients remain contagious until the last scab falls off.
Although the timing and progress of George Washington's bout with smallpox appear typical, his infection may have been milder than most. According to one of his biographers, he escaped the disease with "only several very light scars on his nose."7 Most survivors bear more numerous scars, and some are blinded. But despite the consequences, those who live through the illness can count themselves fortunate. Immune for life, they need never fear smallpox again.
The case fatality rate of a disease is an indication of the number of deaths that occur among those who contract it. For the historical study of smallpox, these figures can be elusive, deceptive, and downright confusing. The reasons are various. For one thing, most twentieth-century surveys included both vaccinated and unvaccinated individuals. Because vaccinated persons tend to have mild forms of the disease if they catch it at all, studies that include them provide no usable comparison to mortality in the days before Edward Jenner's earth-shattering development of 1796. To confuse matters further, a new, much less virulent smallpox virus named Variola minor appeared in the 1890s, quickly supplanting Variola major in many parts of the world. This milder bug was not present in George Washington's day, and its emergence makes many twentieth-century studies unsuitable for assessing death rates in earlier times.
Given these problems with relatively modern data, one might expect appraisals of epidemics in centuries past to be more helpful in assessing the historical impact of the disease. Unfortunately, this is not the case. In outbreaks of smallpox before the emergence of Variola minor and before the development of vaccination, case fatality rates appear to have fluctuated wildly. The differences could be due to the particular vulnerabilities of a given population,the changing virulence of the virus, the availability of nursing care, or even the widespread presence of immune systems compromised by such factors as famine.
Despite these disclaimers and caveats, one historical trend is clearly identifiable in the documentary record. In general, Variola appears to have become more virulent in the three centuries leading up to 1800. In Florence, Italy, between 1424 and 1458, officials recorded only eighty-four smallpox deaths despite three epidemics of the disease in the same years. In mid-seventeenth-century London, the case fatality rate from Variola hovered around 7 percent. A famous outbreak in Boston, Massachusetts, in 1721 yielded a much higher rate of 15 percent. By 1792, in another outbreak in the same city, the rate reached 30 percent. A Scottish smallpox epidemic in 1787 also took the lives of a third of its victims. Just a few years later, a "virgin soil" epidemic--an outbreak in a population with no prior exposure to the disease--struck an isolated village on the Japanese island of Hachijo-Jima. Of the 86 percent of villagers infected, some 38 percent died. Finally, in what may be the only modern study with relevance for epidemics in the pre-Jenner era, an analysis of seven thousand unvaccinated smallpox cases in Madras, India, during the 1960s revealed a frightening case fatality rate of 43 percent.8
Another story lies beneath these broad, population-based figures. When attacked by Variola, certain individuals consistently fare worse than others. Here two recent studies are valuable. They show that the very old and the very young die in disproportionate numbers when smallpox erupts. The highest case fatality rates appear among those under the age of one and over the age of forty-five or fifty. The lowest rates occur in the five- to fourteen-year-old age group. The difference is dramatic: In one study, Variola took the lives of 29 percent of its victims under one year old and 32 percent of its victims over forty-five, but among five- to fourteen-year-olds, the case fatality rate was only 8 percent.9 Although both these studies included vaccinated individuals, there is no reason to think that similar age-related patterns (with highercase fatality rates) would not be detected in a wholly unvaccinated population.
Pregnant women, like infants and the elderly, fare badly under Variola's assault. Here again, modern studies include both vaccinated and unvaccinated individuals. They nevertheless show that the impact of smallpox on pregnancy is dire. Of early-term pregnancies, almost 75 percent end in spontaneous abortions or stillbirths. Of late-term pregnancies, nearly 60 percent terminate in the same way. While some babies are born alive, 55 percent of them die within two weeks, usually within three days of birth. The maternal prognosis is similarly grim. In the prevaccination era, it is likely that half of all pregnant women infected with Variola developed what is called hemorrhagic smallpox, the most deadly form of the disease known, with a case fatality rate exceeding 96 percent. 10
Finally, smallpox sufferers in the throes of famine not surprisingly do worse. Blindness in particular seems more common among malnourished victims, but other complications may occur more frequently as well. Ironically, because scarcity causes people to circulate broadly in their search for food, it may help spread contagious pathogens such as Variola. A recent study of America's northern plains Indians indicates that historically, epidemic smallpox often appeared after times of starvation."11
Age, pregnancy, and nutritional status all influence the impact of Variola on particular individuals. Are these the only variables? Probably not. Entire populations of people seem to die in disproportionate numbers when smallpox strikes. Nowhere has this been more apparent, or more catastrophic, than among Native Americans. For the indigenous residents of the New World, Christopher Columbus's famous voyage of 1492 brought an abrupt end to thousands of years of isolation from the infectious diseases of Europe, Africa, and Asia. No one--not a single individual--had acquired immunity to Variola or any other Old World pathogen. Everyone was susceptible.
With its first New World landfall, Variola gained access to millionsof potential victims with no acquired immunity. It was as though a spark had landed in a forest laden with thousands of years of dried timber. The results were explosive; the consequences, unspeakable. In horrific virgin soil smallpox epidemics, the rate of infection could be higher than 80 percent, and the death tolls ghastly. Eyewitness estimates of mortality in early New World smallpox outbreaks routinely approached and often exceeded 50 percent. "In some provinces half the people died, and in others a little less," wrote a Franciscan friar of an epidemic in Mexico in 1520. William Bradford reported that when Variola struck the Indians of the Connecticut River valley in the winter of 1633-34, it caused "such a mortalitie that of a 1000" who contracted the disease,"above 900. and a halfe of them dyed, and many of them did rott above ground for want of buriall."12 Such numbers point to case fatality rates that far surpassed those found in Old World populations.
Why was case fatality so high among Native Americans? It is possible that in fact it was not. The temptation to overstatement may have proved irresistible for eyewitnesses trying to convey the horror of the nearly universal sickness in virgin soil smallpox epidemics. Yet the consistency of the reports is striking. A fur trader, Samuel Hearne, estimated that the epidemic of 1781 "carried off nine-tenths" of the Chipewyan Indians northwest of Hudson Bay. A North West Company servant charged the same wave of pestilence with "sweeping off three fourths" of the natives on the Canadian plains. In a minor outbreak at Sandusky, Ohio, in 1787, four out of six Indians who caught the smallpox died. Similarly, of a party of forty Indians who visited the Missouri River post of Fort Union during the plains epidemic of 1837, "more than one-half" reportedly died.13
These reports are merely representative examples. Though exaggeration no doubt existed, the sheer number of such accounts suggests that the pox was indeed more deadly among Native Americans than among Old World peoples. Some observers even said so directly. "Although many Spaniards die also, smallpox killsincomparably more Indians," wrote a missionary in northern Mexico's Sonoran Desert. A similar report came from Louisiana: "Two distempers, that are not very fatal in other parts of the world, make dreadful ravages among them," wrote a Frenchman of the local natives; "I mean the small-pox and a cold, which baffle all the art of their physicians."14
Definitive explanations for Variola's peculiar virulence among Native Americans remain elusive, but historical evidence and modern science both yield clues. As entire Indian communities succumbed to Variola in the early epidemics, mortality stemmed not just from the pestilence itself but also from famine and thirst as the raging contagion left no one well enough to care for the ill. Fear justifiably compounded the problem. "They are frightened of going nigh one to another as soon as they take bad," wrote a Hudson's Bay Company trader in 1781. "So the one half for want of indulgencies is starved before they can gather Strength to help themselves." In faraway Baja California, a Dominican friar echoed these words, attributing the high case fatality rate there to factors that included "lack of proper care among the heathen" and a subsequent "lack of food." Victims of later outbreaks reaped a significant benefit from Variola's earlier ravages, for survivors with acquired immunity could tend to their needs as they battled the disease. "Good nursing care," in the words of one distinguished smallpox scholar, "is of far more importance than any other form of treatment."15 This was always true of the disease.
Native American healing customs may also have exacerbated the effects of Variola. "Their injudicious treatment of that infectious malady, generally renders it fatal," wrote an observer in 1784. Perhaps the most universal practice was the sweat bath. "For a relief, in nearly all of their diseases, they resort to their grand remedy, sweating," wrote an observer of the tribes of the northern plains. The English traveler Nicholas Cresswell saw a sweat lodge in use among the Delawares in 1775. The sick Indian, he observed, entered the lodge "wrapped in his Blanket," after which "his friends put in large stones red hot and a pail of water, thenmake up the door as close as possible." The patient then doused the stones with water, filling the chamber with steam. "He continues in this little hell as long as he is able to bear it," Cresswell explained. 16
If the heat of the sweat bath worsened the effect of smallpox's fever, what followed could have even more serious consequences: "Whilst reeking with sweat, and dissolving in streams of warm moisture, they rush out into the open air, quite naked, and suddenly plunge into the deepest and coldest stream of running water that can be found, immersing their whole body in the chilling flood." A Salish Indian woman named Mourning Dove described the results of this practice as she recounted her grandmother's story of the first smallpox outbreaks in the American Northwest. "Some tried to use the sweat lodge, but when they jumped into cold water after sweating, they got worse and died faster," she explained. If the victim was too weak to swim, drowning could result. Contemporary accounts often reported drownings among Indians who sought relief from the heat of the pox in the cooling waters of lakes and streams. "The unfortunate Indians, when in the height of the fever, would plunge into a river, which generally caused instant death," remarked one fur trader.17
Jumping into cold water while desperately ill was indeed a dangerous practice. But despite the gibes of literate observers, it must be said that in many ways native medical care differed little from that of European colonists. "The Indian, when he falls ill, has recourse first to his roots and sacredly regarded herbs; he purges and sweats inordinately; fasts for days together," wrote J. D. Schöpf. So too did colonists utilize sweating, fasting, bleeding, blistering, vomiting, and an array of medicines that ranged from mercury to laxatives to human excrement itself.18 It is possible that the difference was one of degree, expressed in Schöpf's use of the word "inordinately" in his litany of Indian cures.
Beyond issues of care and custom, genetic factors may also have contributed to the demographic catastrophe that resulted from the arrival of Variola and other Old World microbes in theAmericas. Some have speculated that thousands of years of isolation from the plagues of Europe, Africa, and Asia meant that Native Americans were not genetically selected to survive infections such as smallpox.19 Instead, evolution would have favored traits that enhanced life in the relatively disease-free New World environment. Amerindians therefore may lack what is known as innate immunity to smallpox. Innate immunity, as opposed to acquired immunity, encompasses a broad array of mechanisms the body can use to fend off disease. Examples include not only the receptors of certain immune cells but also such traits as blood type, stomach acidity, and mucus in the respiratory system, all of which influence the body's vulnerability to various pathogens. As a barrier to infection, even the skin itself can be part of one's innate immunity.20 It is not likely, however, that we shall ever learn the precise ways in which these mechanisms dealt with Variola. Today, there are neither medical nor moral reasons to conduct human studies with the virus.
In fact, research now points in a different, although related, direction. Medical tests show that when Native American peoples are exposed to most pathogens, their immune response is fully as robust as that of other populations. "In no instance was the level of induced antibody inferior to that usually observed elsewhere," wrote the epidemiologist Francis L. Black after measuring the immune response of several Amazonian tribes.21 Upon initial exposure to a given microbe, a New World native probably has as good a chance of survival as a European, an African, or an Asian.
All this changes once the bug starts circulating. Studies indicate that compared with Old World populations, indigenous Americans possess little diversity in immune system antigens. In other words, despite a healthy, vigorous response, the immune systems of American Indians are strikingly similar to one another. This homogeneity may make indigenous Americans more vulnerable when contagion strikes. Studies of measles in Old World populations indicate that the disease is much more virulent when transmitted by a consanguineous family member than when transmittedby an unrelated person. Mortality nearly doubles when the measles virus passes between cousins and nearly quadruples when passed between siblings. This occurs because measles and other viruses mutate constantly, adjusting quickly to the immune systems of individual hosts. When the contagion passes from one family member to another, much of the adaptive work is already done. The virus is tailor-made for attacking the unlucky victim.22
The implications for indigenous Americans may well have been profound. The immune system antigens found in Native American populations are so homogeneous that in the case of measles, transmission of the virus between two random individuals in a New World population is comparable to transmission between family members in an Old World population. Historically, as measles made its way through a community, American Indians may well have confronted a virus uniquely equipped to circumvent their immune systems.23 Small wonder that the results were so dramatic.
Granted, smallpox is not measles. Yet it is probable that a similar process of mutation and transmission occurred not just with smallpox and other viruses but to a limited extent even with bacteria. 24 Thanks to the eradication of smallpox from the world, it is not likely that we shall ever know precisely how Variola adapted to its genetically similar New World hosts. But anecdotal accounts indicate that the adaptation may have been successful indeed for the virus. As it stands, immune system uniformity is one of the best explanations to date for the extraordinarily high case fatality rates among American Indians in successive waves of smallpox. The years to come may yield added insights into this phenomenon, as medical science is only beginning to appreciate the significance of genetic diversity in fending off infectious disease.
Regardless of genetics, the most important single determinant of vulnerability to smallpox was prior exposure. In the towns and cities of England, smallpox was endemic--that is, constantly present--bythe middle of the eighteenth century. This meant that exposure to Variola was likely early in life, and as a result, immunity prevailed among grownups. Even in rural market towns where the pox was not endemic, outbreaks tended to occur in five-year cycles. Here too, immunity was common by adulthood.25 It is probable, if not inevitable, that similar patterns existed throughout Europe.
In America, by contrast, neither smallpox nor immunity was nearly so widespread. By the time musket fire marked the historic turn of events at Lexington and Concord, Variola had been present in North America for more than two and a half centuries. One scholar has counted twenty-three separate smallpox epidemics of varied extent and impact that left their mark on Indian groups ranging from the Coahuiltecans of Texas to the Montagnais-Naskapis of Quebec and Labrador. At times the pestilence affected colonists as well as Indians. By the late eighteenth century, only western Canada, Alaska, and Alta (upper) California appear to have escaped the pox entirely, and even in these regions, early episodes may simply have escaped documentation.26
Despite their impressive number and extent, these early American epidemics do not mean that either smallpox or immunity was common. They were not. Variola needs an endless train of new victims to survive. In eighteenth-century Europe, these victims became available thanks to closely packed cities, immigration, natural increase, and rapid communication between regions. But eighteenth-century North America was different. It had neither the population density nor the transportation networks needed to sustain the ongoing, endemic presence of the virus. The result was that years could pass between outbreaks, allowing the number of susceptibles to balloon as native-born Americans across the continent came of age without exposure to the virus. When epidemics then occurred, they could be catastrophic, affecting grownups as well as children and crippling entire communities.
Because smallpox leaves not just death but also immunity inits wake, prior outbreaks influence the shape of those that follow. For Americans on the eve of the Revolutionary War, the most recent epidemics had occurred in the late 1750s and early 1760s, often in association with military campaigns. In New York, eastern Canada, and the Great Lakes region, many Indian allies of New France had caught smallpox during the Seven Years' War. Many others had suffered from it in 1763, in the Ohio country, where British soldiers tried to spread the disease among their enemies during Pontiac's Revolt. In the South, Variola had infected Indians involved in the Cherokee War of 1759, and during 1760 it spread not just to the Cherokees' neighbors the Catawbas and Creeks but also to the white and black colonists of South Carolina and Georgia. Mexico likewise had endured a serious outbreak in 1761-63 that extended from the central highlands into Baja California and northern Sonora. In western Texas, smallpox had struck the Lipan Apaches in 1764, and in the lower Mississippi Valley, it struck the Chickasaws and Choctaws at approximately the same time. Finally, the cities of Philadelphia and Boston had also witnessed epidemics in this period.27 All these smallpox outbreaks left pockets of immunity behind.
Prior epidemics were not the only influence on patterns of susceptibility and immunity. By the mid-eighteenth century, many Americans had learned ways to control the pox's spread. This was particularly true in the English colonies, where smallpox was probably better understood than any infectious disease other than syphilis. For Anglo-Americans who wanted to protect themselves against Variola then, two options existed: isolation or inoculation. Each had risks, and each had advantages. Both were used regularly and at times effectively. Both also revealed that while no one had yet viewed a virus through a microscope, the contagious nature of smallpox was widely understood.
In theory, isolation was simple. It meant preventing contact between susceptible individuals and the Variola virus. One way of doing this was quarantine. Even though they often attributed epidemic disease to supernatural intervention, Americans of allstripes did not hesitate to impose quarantine when smallpox broke out. "Whoever is accidently attacked by the small-pox," wrote a French traveler through eighteenth-century Virginia, "is carried to a lonely house in the middle of the woods and there he receives medical assistance." Infected towns, he explained, were likewise "cut off from all communication with the rest of the country." The Puritan settlers of the Massachusetts Bay Colony had implemented quarantine as early as 1647 in an attempt to keep ships arriving from Barbados from spreading disease. Later, the provincial assembly passed "An Act to Prevent Persons from Concealing the Small Pox," which ordered that a red warning flag be flown outside any infected household. A South Carolina ordinance called for sentinels outside pox-infested homes and required householders to post notices to warn susceptible citizens. In Virginia, guards turned people away from infected residences in both Williamsburg and Winchester. Rhode Island colonists, who condemned smallpox as "a contagious and most dirty disease," set up quarantine at "Pest, or Smallpox Island" (now Coasters Harbor Island) off Newport. Similarly, South Carolina officials established a "Pest House" on Sullivans Island to quarantine occupants of incoming ships, particularly those carrying slaves from West Africa. By the late 1700s, Pennsylvania stood out as the only English colony that did not enforce local quarantine laws.28
English colonists were not the only Americans to impose quarantines. Devastated by successive epidemics since the sixteenth century, some Indian groups also utilized the practice, indicating that they too recognized the pox's infectious nature. In 1759 and 1760, when Variola struck the inhabitants of the "lower" Cherokee town of Keowee, their kinsfolk in the "upper" towns implemented a quarantine to keep the contagion at bay. "The People of the Upper Towns are in such Dread of the Infection," reported a Georgia correspondent for the Pennsylvania Gazette, "that they will not allow a single Person from the above named Places to come amongst them."29
Another isolation strategy was flight. It lacked the organizationand state sanction of quarantine, but it too represented an effort to keep susceptible and sick people apart. Wherever smallpox broke out, vulnerable individuals took to their heels in the hope of avoiding it. In South Carolina in 1698 and 1699, the pox reduced one band of Indians "to 5 or 6 which ran away and left their dead unburied." During Boston's horrible epidemic of 1721, some 900 of the town's 10,700 citizens took to the countryside. When the disease struck again a generation later, nearly 2,000 out of 15,000 fled. Many Cherokee Indians did the same during the 1759-60 outbreak at Keowee, whence it was reported that those who had "not yet had that Distemper, were gone to the Woods."30
The strategy of isolation, especially by running off, had risks. The greatest was that by fleeing, fugitives from the pestilence would in fact spread it. Because of smallpox's asymptomatic incubation period, infected individuals could easily escape with others, not knowing they already carried the plague. When South Carolina's Keowee Cherokees took to the woods, they "carried smallpox into the Middle Settlement and Valley," where they infected others in their tribe. Likewise, refugees from Boston in 1751 may have started the outbreaks that afflicted Concord and other outlying towns.31 In all, flight may have done more to spread smallpox than to prevent it.
The other drawback to the strategy of isolation, whether by quarantine or by flight, was quite simply that it did nothing to address the issue of susceptibility. Those who successfully dodged one outbreak remained vulnerable when the next one struck. In the busy world of the late eighteenth century, marked by an expansion of commerce among communities around the globe, chance encounters with the Variola virus were increasingly likely. Continued susceptibility to smallpox meant living a life of incessant dread.
Inoculation offered the risky alternative to a life of fear. Utilized for hundreds of years in parts of Asia and Africa, the procedure was nevertheless unknown among Europeans until the early eighteenth century. Shortly after 1700, word of the practicereached Europe from a number of sources. One was the Puritan minister Cotton Mather. In a famous letter from Boston in 1716, Mather described to his London colleagues an interview he had conducted with his "Coromantee" slave, Onesimus. The cleric had asked the African whether he had ever had smallpox. "Yes, and, No," came the response, and Onesimus proceeded to tell Mather "that he had undergone an Operation, which had given him something of ye Small-Pox, & would forever præserve him from it." Simultaneously, other accounts of this peculiar practice were arriving in Europe from Asia, as travelers abroad sent word of it home. The most famous of these correspondents was Mary Wortley Montagu, who observed inoculation in Constantinople, where her husband was the British ambassador. "The small-pox, so fatal, and so general amongst us," she wrote to a friend in 1717, "is here entirely harmless, by the invention of ingrafting."32
The procedure, both frightening and fascinating, consisted of deliberately implanting live Variola in an incision, usually on the patient's hand or arm. The result of this inoculation (also called variolation) was predictable: After an abbreviated incubation period, smallpox ensued. But the symptoms were surprising. Patients who took the virus by inoculation had fewer pustules, less scarring, and a much-reduced case fatality rate compared with other victims of Variola. Why? By the late eighteenth century, a partial explanation could be found in some inoculators' deliberate efforts to derive their infectious matter from less severe cases. But this was not always the practice, and for the most part, the lighter symptoms of inoculated smallpox have yet to be fully explained.a Regardless of the reasons, the reward was enormous: Inoculees, like others who survived smallpox, acquired immunity for life.
While inoculation and variolation refer to essentially the same thing, neither should be confused with vaccination, introduced tothe world by Edward Jenner in An Inquiry into the Causes and Effects of the Variolae Vaccinae, published in 1798. In Jenner's now-famous experiment of 1796, the English physician deliberately infected an eight-year-old boy, James Phipps, with cowpox, a much milder disease that was closely related to smallpox. Several months later, Jenner inoculated Phipps with smallpox and found that he could not produce an infection. Thanks to his exposure to cowpox, the boy was immune. It was, in the words of one historian, "as if an Angel's trumpet had sounded over the earth."33 Unlike variolation, vaccination did not oblige patients to endure an actual case of smallpox to acquire immunity. But in George Washington's day, vaccination was not an option. Jenner's tract on the subject appeared in print only a year before Washington died. Throughout the eighteenth century, Americans seeking immunity to Variola had only two choices: to contract the disease naturally or to contract it by inoculation. Either one meant going through smallpox.
Inoculation was risky business, and many did die from the illness they inevitably (and necessarily) contracted through the procedure. But in the midst of a severe epidemic, the hazards of variolation paled by comparison to the hazards of catching the disease naturally. When Cotton Mather convinced Zabdiel Boylston to try the operation during Boston's 1721 outbreak, death from naturally contracted smallpox occurred in 15 percent of cases, while death from inoculated smallpox occurred in only 2 percent of cases.34 Smallpox "received by Inoculation," an opponent of the experiment later admitted, "is not so fatal, and the Symptoms frequently more mild, than in the accidental Contagion."35
The procedure was grueling despite its promising results. It began with a dietary regimen that many practitioners imposed on patients before the operation took place. The experience of the Massachusetts patriot John Adams was typical. In 1764, when another in a series of epidemics struck Boston, Adams decided to undergo inoculation rather than chance natural infection. Several doctors, including the radical Dr. Joseph Warren, attended Adams and his brother. They "prepared me, by a milk Diet and a Courseof Mercurial Preparations, till they reduced me very low," Adams wrote later. In good spirits nevertheless, the two brothers took regular "Vomits," stimulated by syrup of ipecac. "Did you ever see two Persons in one Room Iphichacuana'd together?" John wrote to his wife-to-be, Abigail. "I assure you they make merry Diversion. We took turns to be sick and to laugh. When my Companion was sick I laughed at him, and when I was sick he laughed at me."36 Ingestion of milk and mercury continued apace, Adams said. It "salivated" him "to such a degree" that he soon suffered from classic signs of mercury poisoning: "Every tooth in my head became so loose that I believe I could have pulled them all with my Thumb and finger." Other food was closely regulated. For breakfast the doctors allowed "Pottage without salt, or Spice or Butter," and they enforced "abstinence from all, but the cool and the soft."37
After a week of preparation, the inoculation took place. "Dr. Perkins demanded my left Arm and Dr. Warren my Brothers," John reported. "They took their Launcetts and with their Points divided the skin for about a Quarter of an Inch and just suffering the Blood to appear, buried a Thread ... in the Channell."38 The thread bore on it the Variola virus, collected from the pustules of an earlier victim.
Adams took his inoculation in a house with nine others undergoing the procedure under the care of different doctors. While he and his brother could eat "as much Bread and as much new pure Milk, as much Pudding, and Rice, and indeed as much of every Thing of the farinaceous Kind as We please," the others faced many more restrictions. "No Bread, No Pudding, No Milk is permitted them," Adams wrote, noting that only "a Mixture of Half Milk and Half Water" was allowed. Beyond this, he said, "every other Day they are tortured with Powders that make them as sick as Death and as weak as Water."39 The effect of this nutritional regimen (not to mention mercury poisoning) on the outcome of inoculated smallpox remains unknown. But given the general correlationof malnutrition and poor outcomes in modern cases of the disease, it was most likely negative.
When the incubation period had run its course and Adams finally broke out in the smallpox, his letters to Abigail virtually ceased. He had an "Absolute Fear," he told her, of sending "Paper from this House, so much infected as it is, to any Person lyable to take the Distemper but especially to you."40 Despite his light symptoms, the rigors of smallpox must also have constrained him from writing, just as it had constrained George Washington a dozen years before. Few were the writers who kept to their routine through the discomfort of smallpox, even in mild cases taken by inoculation.
Once he had emerged from the worst of it, Adams wrote that he had suffered little, especially compared with others in the house: "None of the Race of Adam, ever passed the small Pox, with fewer Pains, Achs, Qualms ... than I have done." In fact, he bragged, he only had eight or ten pockmarks to show for the ordeal. Not all were so lucky. "Pretty high Fevers, and severe Pains, and a pretty Plentiful Eruption has been the Portion of Three at least of our Companions," he told Abigail. In spite of his own good fortune, he gave her a stern warning: "Don't conclude from any Thing I have written that I think Inoculation a light matter."41 Abigail did not undergo variolation herself until 1776.
The twelve years that separated John's and Abigail's inoculations saw notable advancement in the procedure. In England, the inoculator Robert Sutton and his sons worked through the 1760s toward a new, modified technique that became known as the Suttonian method. Under the Suttons' influence, the grueling preparatory regimen first waned and then disappeared entirely. Deep incisions also fell by the wayside as the Suttons found that shallow ones yielded good results with fewer complications. In addition, following a technique practiced in South Carolina as early as 1738, the Suttons acquired their infectious matter from another inoculee, not from a victim of the natural smallpox. Finally, whileacknowledging that inoculees required "air," the Suttons insisted that they seek it in private, quarantined from the community at large.42
Because of the profits to be made, the Suttons for years tried to keep their methods concealed. Not until 1796 did Daniel Sutton, one of Robert's six sons, publish The Inoculator, or, Suttonian System of Inoculation. Fortunately, those they trained were not so secretive. As early as 1767 Thomas Dimsdale published a tract in London outlining the basics of the modified technique. A New York publisher reprinted it in 1771, and word of Dimsdale's improved procedure, basically the same as the Suttons', spread gradually through the English colonies. By July 1776, when Abigail Adams and her children went through inoculation in Boston, some of the changes were already evident. "I now date from Boston" she wrote to her husband, "where I yesterday arrived and was with all 4 of our Little ones innoculated for the small pox."43 She mentioned no milk diet, no mercury, no preparations whatsoever.b
Controversy attended inoculation from the start. When Cotton Mather supported Dr. Zabdiel Boylston's experiments in Boston in 1721, the result was uproar and shock. Was it not, asked one minister, "a distrust of God's overruling care" to inoculate? Dr. William Douglass (who later had a change of heart) reckoned it a sin "to propagate infection by this means." The furor culminated in the firebombing of Mather's house on November 13, 1721. "COTTON MATHER, You Dog, Dam you," said the note attached to the bomb: "I'l inoculate you with this, with a Pox to you."44 Regardless of God's will, critics of inoculation had legitimate cause for concern. The practice might impart immunity to those who went through it, but it could also spread the disease and spark new epidemics. While sick, inoculees were active carriers of Variola. Theywere capable of infecting others until the last scab fell off, and they often showed little regard for the contagious nature of the disease or for those they put at risk. Five days after her inoculation on July 12, 1776, Abigail Adams attended "a very Good Sermon" and "went with the Multitude into Kings Street to hear the proclamation for Independence read and proclamed."45 When she began experiencing the "many dissagreable Sensations" of the pox three days later, she nevertheless went "out to meeting" yet again. In early August, still under inoculation, she proclaimed proudly: "I have attended publick worship constantly, except one day and a half ever since I have been in Town."46
Such conduct did not stem from ignorance of the pox's contagious character. A few months earlier, "fearfull of the small pox," Abigail Adams had avoided traveling into Boston from Braintree.47 She had used smoke to sterilize the letters she received from her husband-to-be while he went through variolation in 1764. Indeed, this was the very woman whose future husband had avoided even letter writing at the height of his own infection for fear of contaminating her. Abigail Adams did not know about viruses or the way they worked, but like most colonists, she was clearly aware that smallpox was contagious.
In fairness it should be said that there is no evidence that she infected anyone as a result of her actions. Nor can it be said that her behavior was unusual. As early as 1722 and 1723, colonial observers noted that many patients under inoculation continued "to do all Things, as at other times." Among bedridden inoculees, visitors were common: "Ordinarily the Patient sits up every Day, and entertains his Friends, yea ventures upon a Glass of Wine with them." Even if these callers were themselves immune, they could carry active viral particles into the streets when they left. The Boston doctor James Thacher was no more responsible than Abigail Adams when he had himself inoculated during the very same outbreak that prompted her to go through the procedure. "I ... have passed through the disease in the most favorable manner," he wrote in his journal, "not suffering one day's confinement."48As a medical man he certainly knew what the consequences of not "confining" himself could be.
Not surprisingly, it was largely for fear of contagion that inoculation often elicited protest and apprehension. In 1767, when the inoculator John Smith set up shop in Yorktown, Virginia, some residents objected "to his bringing the Infection into a Country or Neighbourhood that is free from it." He brought with him contagious "matter enough to infect the world," and Virginians feared he might open "A second Pandora's Box." It took less than a year to confirm their fears. "Mr. John Smith hath rendered himself very blamable," wrote William Nelson in February 1768, by "suffering some of his Patients to go abroad too soon: so that the Distemper hath spread in two or three Parts of the Country." Among those released prematurely were some college students who carried the smallpox to Williamsburg, where it proved to be a most dangerous strain. Of those who caught it, Nelson said, "two out of three have died." Only "the Care of the Magistrates" brought the epidemic to a halt.49
It was cases like this that so frequently made inoculation unpopular in the English colonies. Riots and other crowd actions characterized much of the Anglo-American political scene from the 1760s until well after the Revolutionary War. Although the protests usually targeted royal authority, they also struck at inoculation hospitals when public health seemed threatened. Even as John Smith set up his ill-fated inoculation business at Yorktown, riots broke out over a similar venture in nearby Norfolk. There, despite local objections, two doctors, John Dalgleish and Archibald Campbell, had begun inoculating patients at Campbell's home. When they refused to desist, an angry crowd torched the house and forced the patients within to flee in a downpour of rain. Massachusetts colonists likewise took matters into their own hands when they felt threatened by variolation. After inoculation hospitals opened in Salem and Marblehead in 1774, rioting residents razed one institution and closed both. They also tarred and feathered four Salem men caught stealing clothes that had beenhanging outside one hospital, clothes that might well have contaminated the community.50
Because the practice was so controversial, inoculation often came under legal restriction. In response to the Williamsburg outbreak of 1768, the Virginia legislature received numerous petitions "setting forth the destructive Tendency of Inoculation with the Small-Pox; and therefore praying that no such Practices may be allowed in Virginia." While the House of Burgesses never banned inoculation entirely, the regulations it imposed in 1770 were so restrictive that the effect was nearly the same. In Charleston, the first inoculation control law came in 1738, when the city passed "An Act for the better preventing of the spreading of the infection of the Small Pox." The ordinance imposed a hefty fine of five hundred pounds on anyone giving or receiving inoculation within two miles of the city. New York followed suit in 1747, with an executive proclamation "strictly prohibiting and forbidding all and every of the Doctors, Physicians, Surgeons, and Practitioners of Physick, and all and every other persons within this Province, to inoculate for small pox any persons or person within the City and County of New York, on pain of being prosecuted to the utmost rigour of the law."51
Nowhere was inoculation more restricted and unpopular than in New England. Most New England cities imposed very strict quarantines and banned all smallpox inoculation except when epidemics broke out. Some years after the American Revolution, the physician Benjamin Waterhouse wondered at the restrictions New Englanders had tolerated in order to avoid infection from smallpox. "New England," he wrote, was "the most democratical region on the face of the earth," yet the people there had "voluntarily submitted to more restrictions and abridgments of liberty, to secure themselves against that terrific scourge, than any absolute monarch could have enforced."52
By contrast, regulations were lax in the middle colonies, where exposure and immunity to Variola were common. Perhaps this was due in part to the large proportion of foreign-born settlers in theregion, many of whom had had smallpox as children. With less to fear from the disease, residents of the middle colonies seemed downright cavalier in their attitudes. In Pennsylvania, officials rarely enforced the province's lone quarantine statute, and only once did they enforce it against smallpox. Inoculation hospitals flourished not only here but also in Maryland, New Jersey, New York, and even Connecticut. Statutory restrictions in New England and the South meant that elsewhere, variolation could be a profitable business affair. Enterprising physicians from the middle colonies cast their nets broadly in the quest for patrons from regions where the procedure was banned. In 1769, a Baltimore inoculator named Henry Stevenson ran an advertisement in Rind's Virginia Gazette promising that clients would be "carefully and tenderly dealt with" and extending reduced prices to slaveowners seeking to have their black laborers immunized. (Cut-rate prices very likely meant cut-rate care.) Other inoculators from the middle colonies ran similar ads in the Virginia papers, "knowing," in the words of one, "that the legislature of your Colony have prohibited Inoculation."53
In New England, contingents of wealthy friends traveled to the middle colonies together to undergo the procedure in "classes." So lucrative was the practice that when some Rhode Island residents sought to establish an inoculation hospital in 1763, they cited among other reasons the "Large Sums of Gold and Silver Money" that would be "Saved and Kept within the Colony." When New Yorkers got wind of the plan, they worried that it would "stop one Source of Profit to this City and East Jersey, whereto Numbers are constantly resorting from the above mentioned Colony."54
Despite variolation's growing visibility in the English colonies, the operation nevertheless remained inaccessible to most North Americans in the late eighteenth century. There were several reasons for this. Obviously, some people lived in colonies where inoculationwas banned. But in any case, settlers in the English colonies represented only one portion of North America's vast human population. Even by the time of the Revolutionary War, most Americans, including Indians across the continent and nearly everyone in New Spain, still had not heard of inoculation. It is likely that African slaves in the Spanish colonies, like Onesimus in New England, had some knowledge of the procedure, but if they utilized it among themselves before 1779, it probably went unrecorded. Variolation did not see common use in Spain until the 1770s, and there is no known evidence of the practice in Spain's North American empire prior to 1779. In Canada, inoculation appears to have won more widespread acceptance--probably because of its gradual implementation in France in the 1750s and 1760s.55 Still, the extent of variolation in the former French colony should not be exaggerated. It was very likely an urban phenomenon.
Economics imposed limits on the accessibility of inoculation. Even where the practice was known and permitted, price placed it beyond the reach of most Americans. One inoculator in an unnamed locale charged two pounds per person for the procedure in 1764. In Philadelphia, the fee was around three pounds. At the short-lived hospital off Marblehead, Massachusetts, it was a whopping five pounds, fifteen shillings. These sums are huge--the equivalent of hundreds of dollars today--but in the midst of an epidemic they may have been even higher. Accusations of price gouging were not unknown.56 Benjamin Franklin, a staunch advocate of inoculation, recognized that cost was an enormous obstacle for most people. "The expence of having the operation perform'd by a Surgeon," he wrote, "has been pretty high in some parts of America." For a tradesman with a large family, "it amounts to more money than he can well spare." The time requirement was likewise prohibitive. Neither artisans nor the working poor could afford three to four weeks away from their families and labors. Thus it is hardly surprising that in 1774, when smallpox spread through Philadelphia and claimed the lives of some three hundredsouls, "the chief of them were the children of poor People."57
These economic constraints go far to explain the public outcry and crowd actions against inoculation. For the well-to-do, the operation represented a chance to avoid the dangers of smallpox caught in the "natural" way. But for those who could not afford it, variolation put them at greater risk than before, since wealthy individuals, such as Abigail Adams, might expose them to the disease while undergoing the procedure. Thus it was often affluent Americans who championed inoculation and laboring Americans who fought against it. The opposition point of view can be easily misunderstood. It stemmed not from "fear and superstition," as one historian has suggested, but from a realistic appraisal of working-class risks and opportunities.58
The introduction of Suttonian inoculation in the 1760s dropped the price somewhat and made the procedure a little more accessible. In addition, poor and working people sometimes gained access to variolation in crisis situations. During the Boston outbreak of 1764, for example, at least five hundred of Boston's poor eventually received inoculation for free. Likewise, during the 1774 epidemic in Philadelphia, a group of twelve well-to-do citizens established a Society for Inoculating the Poor.59 But for the most part, the practice remained too expensive and too time-consuming for common folk to afford. Immunity thus tended to concentrate in the upper classes, for whom variolation was an established and affordable protocol. When an epidemic broke out in the English colonies, its victims were most likely to be the uninoculated, nonimmune poor.
By July 1775, when Washington surveyed the Continental troops arrayed before Boston for the first time, a complicated patchwork of immunity and susceptibility had emerged across North America. Variola's ravages in the early 1760s meant that people living in New Spain and in the East were the likeliest to have acquired immunity from prior exposure. Yet even in these regions, susceptibleindividuals were in the clear majority. Among the indigenous peoples living west of the Mississippi and north of New Mexico, immunity (like smallpox itself) was practically unheard of.
Other immunological trends can also be discerned. Because importations of Variola were more frequent in bustling seaports and commercial hubs, acquired immunity was more common among city dwellers than among country folk. Similarly, thanks to the availability of inoculation, denizens of the middle colonies were less likely to be vulnerable than residents of New England or the South. Inoculation had the additional effect of concentrating immunity among the well-to-do. Even age could make a difference, for older people stood a better chance of having lived through the disease than their younger neighbors and kin. Finally, Native Americans, like anyone else, won immunity if they survived Variola's ravages, but they appear to have suffered extraordinarily high case fatality rates when the virus struck.
The New Englanders of Washington's army at Boston were only one piece of this elaborate patchwork, but most of them were vulnerable. As the commander in chief contemplated the danger posed by the smallpox now spreading through the besieged city, he must have thought back to his own youthful encounter with the disease. He knew all too well that it incapacitated its victims and often killed them. If Variola got loose, the impact on the Continental forces could be devastating. The storm clouds building over Boston that summer signaled the onset not just of war but of pestilence.
Copyright © 2001 by Elizabeth A. Fenn
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