A history of smallpox in America

This past Presidents’ Day, I thought it would be a good idea to talk briefly about the role that smallpox played in the life of our first president and it’s important role in the American Revolution. For those who would like to learn about this in greater detail, I would highly recommend the book, Pox Americana: The Great Smallpox Epidemic of 1775-82, written by Elizabeth A. Fenn.

In 1751, when George Washington was 19 years old, he and his brother Lawrence traveled to Barbados, a trip intended to help Lawrence’s persistent cough due to tuberculosis.

According to Fenn:

On November 3, the day after landing, the two brothers begrudgingly accepted an invitation to dine at the home of Gedney Clarke, a prominent merchant, 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. ..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 again, did George Washington return to his diary.

Smallpox did not exist in the Americas, until it was brought from Europe where it was endemic (constantly present). Settlement of the east coast of North America in 1633 in Plymouth, Massachusetts was accompanied by devastating outbreaks of smallpox among Native American populations and later among the native-born colonists.

At the time of the Revolutionary War, there were several outbreaks of smallpox. Because survival after the disease confers lifelong immunity, this gave a decided advantage to the British, many of who had been exposed to the disease earlier in life. There were even reports that the British were practicing what we would now term biological warfare, by deliberately spreading the disease within Boston and by sending infected people out of the city to spread the epidemic in the American lines.

There were only two ways of dealing with smallpox at the time-isolation or inoculation. Isolation meant preventing susceptible people from coming in contact with the disease, usually by quarantine for affected individuals.  Inoculation or variolation, as it was called, required taking a bit of matter from one of the pustules of a smallpox victim and introducing it under the skin of someone who had never had the disease. The resulting case of smallpox was much lighter and greatly decreased the chances of death and scarring. The process was not altogether benign- unless isolated, those who had received inoculation would be contagious to others, and some who were inoculated actually died of the disease they were trying to avoid.

George Washington, Commander in Chief of the Continental Army,was initially hesitant to have his Revolutionary War troops inoculated during a smallpox outbreak writing, “should We inoculate generally, the Enemy, knowing it, will certainly take Advantage of our Situation.” However, by 1777, faced with mounting smallpox epidemics,  battle delays caused by illness among the troops, and fear among potential fighters of getting smallpox if enlisting,  Washington devised an elaborate plan to deal with smallpox. Washington ordered mandatory inoculation of all recruits who had not had the disease.

The inoculation campaign had to be conducted with great secrecy. Though it would protect soldiers in the long run and decrease fear of enlistment, it would also incapacitate large numbers for weeks at a time, rendering the Continentals vulnerable to assault. Ultimately, however, it became clear that the spread of smallpox through the ranks presented a graver threat to the army—and would kill more individuals—than the Redcoats. Recruits were quarantined in camps and inoculated before being sent out to fight.

- Garance Franke-Ruta

Medical historians credit this move by Washington as a pivotal one. Smallpox threatened to kill more soldiers than the British, and it was through Washington’s efforts that the Continental Army was able to turn this situation around and fight at full strength.

About smallpox

Smallpox is a disfiguring and potentially deadly infectious disease caused by the Variola major virus. Before smallpox was eradicated, there were two forms of the disease worldwide: Variola major, the deadly disease, and Variola minor, a much milder form. According to some health experts, over the centuries smallpox was responsible for more deaths than all other infectious diseases combined.

The last naturally occurring case of smallpox was reported in 1977. In 1980, the World Health Organization declared that smallpox had been eradicated. Currently, there is no evidence of naturally occurring smallpox transmission anywhere in the world. Although a worldwide immunization program eradicated smallpox disease decades ago, small quantities of smallpox virus officially still exist in two research laboratories in Atlanta, Georgia, and in Russia.

Transmission

Smallpox is highly contagious. In most cases, people get smallpox by inhaling droplets of saliva, which are full of virus, during face-to-face contact with an infected person. When someone becomes infected, they do not immediately feel sick or shed virus to their household contacts. In addition, they have no symptoms for 10 to 12 days. After the virus has multiplied and spread throughout the body, a rash and fever develop. This is the “illness” portion of the disease, and it’s when someone is most infectious.

Some risk of transmission lasts, however, until all scabs have fallen off. Contaminated clothing or bed linens also can spread the virus. Those caring for people with smallpox need to use special safety measures to ensure that all bedding and clothing from the infected person are cleaned appropriately with bleach and hot water. Caretakers can use disinfectants such as bleach and ammonia to clean contaminated surfaces.

Symptoms

Symptoms of smallpox infection usually appear within 10 to 12 days after exposure to the virus. The first symptoms of smallpox may be difficult to distinguish from other flu-like illnesses and include:

  • High fever
  • Fatigue
  • Malaise
  • Headache
  • Backache
  • Rash

A characteristic rash, most prominent on the face, arms, and legs, follows 2 to 3 days after the first symptoms. The rash starts with flat red lesions (sores) that develop at the same rate. After a few days, the lesions become filled with pus. They begin to crust early in the second week. Scabs develop and then separate and fall off after about 3 weeks.

Treatment

There is no proven treatment for smallpox. People with the disease can benefit from intravenous fluids and medicine to control fever or pain as well as antibiotics for any secondary bacterial infections that may occur. If an infected person gets the smallpox vaccine within 4 days after exposure to the virus, it may lessen the severity of illness or even prevent it. The majority of people with smallpox recover, but death may occur in up to 30 percent of cases. Those who do recover are often left with disfiguring scars.

Michele Berman is a pediatrician who blogs at Celebrity Diagnosis.

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