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The War Against Smallpox David W. Tschanz, MSPH, PhD

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Defense

Protection from smallpox was, at first, limited to appeals to the supernatural. In ancient Asia and Africa there were gods and goddesses you could pray to. In India, Shitala mata was the Hindu goddess of smallpox, while the Chinese recognized T'ou-Shen Niang-Niang as the disease's deity. Saint Nicaise, a bishop of Rheims who recovered from the pox (only to be killed by the Huns in 452) was adopted by the Church as its patron of pox victims.

Folk tradition held that smallpox victims could be helped by the color red ("erythrotherapy")-- a belief that resulted in some of the most curious treatments in the annals of medicine. Sufferers were dressed in red, bathed in red light and plied with red food and drink. No one has ever satisfactorily explained why the belief developed, but it died hard. Three clinical trials were conducted at the start of this century and among its adherents was a Nobel Prize winner, the dermatologist Niels Finsen.

Intelligence Gathering

The first important step towards eventual control occurred in 895 when Abu Bakr Muhammad ibn Zakariya ar-Razi (Rhazes), the great Persian-born Arab physician published A Treatise on the Small-pox and Measles. The work was the first to distinguish the clinical symptoms of smallpox from measles. Ar-Razi also described the seasonal variation of smallpox epidemics, although he misunderstood the cause of the disease, attributing it to the need of children's blood to ferment. Two generations later Haly Abbas (d. 994) noted that proximity to previous victims seemed to be one of the causes of the disease, thus suggesting the idea of contagion. Both men's work were translated into Latin and authoritatively influenced the treatment and recognition of smallpox for centuries.

Perimeter Defense

The first demonstrably effective preventive against smallpox was a process called variolation. By the Thirteenth Century the Egyptians had learned that if you rubbed fluid from a smallpox pustule into a scratch on an uninfected person he or she would develop a mild, nondisfiguring case of the disease and thereafter be immune. It is doubtful that the Egyptians invented the technique. Tribes in central Africa, Asia and China were found to be using the practice during the smallpox eradication campaign and it appears to have independently developed there.

The practice eventually spread throughout the Islamic world to Turkey, where Lady Mary Wortley Montague, the wife of the English ambassador to the Ottoman Caliph, learned of it in the early 1700s. She introduced it to England by having her four year daughter successfully inoculated with it in 1711.

With the proof that variolation could protect you from the worst ravages of smallpox, the process gained immensely in popularity. "To take the smallpox" was a carefully planned social event for many people. John Hancock's wife was bitterly disappointed at Martha Washington's decision to decline her "gracious invitation" and take variolation elsewhere.

Variolation was also put to military use. As mentioned above the British forces sent to the New World, the Americans, until the loss of Montreal drove the lesson home, were not. Washington finally received approval to variolate his troops in the spring of 1777.

While variolation could provide protection and prevent the terrible disfigurement a naturally occurring case of the disease almost inevitably caused in the Eighteenth Century, it was not without its drawbacks. You had to stay in quarantine while your mild induced smallpox ran its course, because you could give a full blown case of the disease to someone else. At the same time it was possible that you could die if you were inoculated with a particularly virulent strain. Still it was the best available remedy. And when one considers that the chances of dying from smallpox were as about 1 in 4 for naturally occurring smallpox as opposed to 1 in 100 from variolation, its popularity becomes self-evident.

Variolation was introduced into Europe just as smallpox was undergoing a resurgence and increase in virulence. One contemporary account described the situation: "When smallpox is epidemic, entire villages are depopulated, markets ruined and the face of distress spread over the whole country." In areas of central Europe in the Eighteenth Century a new born baby was not given a name until after he or she had experienced smallpox and survived. Hence the European medical profession greeted variolation with relief. It would also point to another alternative.

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