Pox Americana: The Great Smallpox Epidemic of 1775-82

FOR PETER

Table of Contents

Title Page

FOREWORD

INTRODUCTION

1 - VARIOLA

2 - VIGILANCE

3 - CONTROL

4 - SURRENDER

5 - ENTIERROS

6 - TRADERS

7 - CONNECTIONS

8 - PASSAGES

EPILOGUE

NOTES

INDEX

Notes

Copyright Page

FOREWORD

e9781466808041_i0002.jpg My interest in the events recorded in this book developed piecemeal, over the course of twenty years. I first encountered the great smallpox epidemic of 1775–82 in 1980, when I was an undergraduate writing a senior essay on Native Americans in the Hudson Bay fur trade. Scattered throughout the writings of fur traders working for the Hudson’s Bay and North West companies were descriptions of a terrible smallpox outbreak that swept the Canadian interior in 1781–82. The descriptions were at once dreadful and captivating. They impressed me enough that I used a brief account of this local episode to conclude my essay, but my exploration of the topic stopped there. I had no concept of the vastness of the outbreak. Nor did I understand that the experience of Indians in what is now Manitoba and Saskatchewan was shared by hundreds of thousands of other people across the North American continent from 1775 to 1782.

I let it lie. I never forgot about the epidemic entirely, but I didn’t think about it either. Instead, I pursued other interests. A brief stint in graduate school in the early 1980s was followed by a longer stint working as an auto mechanic for eight years. It was during those years that I found the time to read broadly and eclectically, savoring words the way some savor fine food and drink. Although I do not recall the precise date, it was probably in 1994 that a friend loaned me a thick little novel titled The Horseman on the Roof, by the great French writer Jean Giono. It told the story of Angelo, an Italian nobleman making his way through nineteenth-century Provence as cholera erupted around him. The book enthralled me. I marveled at its physical expressiveness, at its juxtaposition of beauty and fear. It also transported me, not just to nineteenth-century France but (much to my surprise) to eighteenth-century Canada as well. Even as I labored at brake jobs and engine repairs, I found myself carried back to the Native Americans whose suffering was described in those Hudson Bay smallpox documents I had read more than a decade before. Eventually I could not stand it anymore. I wanted to write a story of my own, a story about smallpox.

My preliminary research yielded many surprises. The most stunning was simply that I was on to something big. At the start, I envisioned doing a sort of microhistory, a tightly focused study of a terrible epidemic in the Canadian fur country. But soon I realized that the Canadian outbreak was just one piece of a much larger puzzle, one missing many pieces but still breathtaking in scope—and huge. The pestilence had swept not only North America but parts of South America as well. Why didn’t we know about it? Why wasn’t this a part of our core knowledge of the era of the American Revolution?

Then I discovered that some people, a few people, did know about portions of it. Arthur J. Ray’s work on Canada and Marc Simmons’s work on New Mexico had appeared in print even before I discovered the epidemic in college. During my years turning wrenches, exciting studies by Jody Decker, Robert Boyd, Cole Harris, Robert Jackson, and Thomas Pearcy all had been published, works that shed light on the pestilence in specific locales, often with vague but tantalizing references to a larger background pandemic. What about this larger pandemic? I wondered. Surely it was a story that needed telling. Could I possibly write about the whole thing? In the end, I decided to try, and the result is this book.

Between the decision and the book was the research. My greatest discovery was the marvelous records kept by priests and friars in Catholic parishes throughout the Spanish empire in North America. These records consist almost solely of lists—of baptisms, of marriages, of burials—and quite naturally it was the burial records that interested me. I soon found that these lists of buried people all over Mexico and what is now the American Southwest had two seemingly contradictory qualities. Their sheer volume seemed overwhelming at first, and even now I admit that compiling the data they contain was as tiresome a research task as I have ever undertaken. They are, after all, simply lists. But in the months I spent on them, they became much more than that. Like the AIDS quilt or the Vietnam Memorial, the sheer volume of names and monotony of form made them monumental. The only time in my research when I found myself moved to tears was as I went through these lists of thousands and thousands of names. And my greatest regret is that I have found it impossible to write about these names in a way that does justice to the lives they represent.

Many people helped make this book possible. Kevin Clayton, Scott Clayton, Tommy Cutts, Jim Dewar, Daniel Emory, Stuart Gregory, Colin Hogan, Greg Marzen, Justin Meddock, Mark Painter, Erik Rahimtoola, Eddie Sain, Gene Sull, Henry Tate, and Brian Yeargan all have influenced my life more than they will ever know. Without their acceptance I would never have left the world of spark plugs and camshafts to pursue this project. Likewise, the cheerful flexibility of Wayne and Monie Clayton in the unforgiving world of automotive repair made it possible for me to earn a living even while I pursued the preliminary research that brought this book to life. For their support I am grateful. Florence Thomas, Ingrid Walsøe-Engel, David Montgomery, and Frank Snowden also provided valuable encouragement in the early stages of this project.

Many generous scholars responded to my queries and shared their own thoughts, ideas, and research with me, including Barbara Belyea, John Brooke, Robert Cain, Colin Calloway, Max Edelson, Jay Gitlin, David Hancock, Don Higginbotham, Marjoleine Kars, Steve Langdon, Wayne Lee, Michael McDonnell, Jim McMillan, Matt Mulcahy, John Nelson, Elizabeth Perkins, Paige Raibmon, Claudio Saunt, Marc Simmons, David Steinberg, Linea Sundstrom, Robert Tórrez, the members of the Triangle Early American History Seminar, and the members of the Columbia University Seminar on Early American History and Culture. Jack Nisbet encouraged my interests from the start and helped put me in touch with resources that shed light on the explorer David Thompson’s accounts of smallpox. Likewise, Sean Peake was kind enough to send me his own transcription of Thompson’s jumbled-up manuscript and to enlighten me regarding important issues of authorship within it. In the medical profession, Drs. D. A. Henderson, Sam Katz, Anne Nicholson-Weller, and Walter Rogan all helped me with important questions, and the immunologist Karen McKinnon patiently (and repeatedly) coached me in the intricacies of human immune response. Francis Black, a specialist in the epidemiology of isolated populations, likewise made valuable suggestions on more than one occasion.

Friends and family have provided more assistance than they can possibly know. Buzz Alexander, Janie Paul, Peter Hinks, Jason DeParle, Nancy-Ann DeParle, Michele Hoffnung, Eileen Roche, and Robert Broom all welcomed me into their homes during research trips that spanned the continent. Anne Nicholson-Weller encouraged me at every turn and gave me access to a reclusive writer’s paradise at a crucial time. To Marjoleine Kars I am grateful not only for introducing me to The Horseman on the Roof, but also for more than twenty years of steadfast friendship. My dear friend Florence Kuster did not live to see this book in print, but her enthusiasm for it shows in every page. My parents, Bob and Ann Fenn, and my brothers, Jon and Tim Fenn, all encouraged my work and expressed lively interest in its progress. By introducing me to the world of Geographic Information Systems, Tim dramatically changed the way I approached my research. I am grateful for his assistance in many, many ways.

For financial support, I would like to thank Yale University for the Marion C. Sheridan Fellowship that funded my first year of full-time research in 1996–97. I also benefited from a Jacob M. Price Visiting Research Fellowship from the William L. Clements Library that funded a research trip to Ann Arbor. To the Clements Library staff—John Dann, Brian Dunnigan, Rob Cox, John Harriman, Mary Pedley, Arlene Shy, Adolfo Tarango, and Don Wilcox—I am grateful for abundant encouragement, advice, and camaraderie. In the summer of 1997, a Mayers Fellowship from the Henry E. Huntington Library gave me the opportunity to utilize that repository’s collections. Peter Blodgett, Bill Frank, and Tom Lange all gave me valuable assistance during my time there, and Roy Ritchie’s enthusiasm for my work was undying. I would also like to thank Dale Harmon and his staff for allowing me to make the Durham Stake Family History Center of the Church of Jesus Christ of Latter-day Saints my home away from home for many months. Their patience with my requests never ceased to amaze me. At the History Collection of the New York Academy of Medicine, Michael North kindly answered my questions about the John Cochran Letterbook, and at the William Andrews Clark Memorial Library, Suzanne Tatian’s initiative rescued me from a disastrous day of research. George Miles at Yale University’s Beinecke Library provided helpful suggestions at several stages in this project. In addition, a Charlotte W. Newcombe Doctoral Dissertation Fellowship from the Woodrow Wilson National Fellowship Foundation gave me the luxury of writing for a year without outside distractions.

In a seminar in 1982, Edmund S. Morgan encouraged my wide-ranging interests and inspired me with his crystal-clear prose. Many years later his advice and his friendship remain true, and I am grateful for both. My editor, Elisabeth Sifton, delighted me with the grace and clarity of her editorial suggestions. Thanks to her, I now know for certain that the rules of automotive engineering also apply to the written word: The best solution is always the simple one. Additional thanks go to John Demos not only for his interest and enthusiasm but also for his thoughtful critiques and literary suggestions. My debts to John Mack Faragher are too many to count. Johnny instantly and intuitively understood the significance of this work, and in the years since our first meeting in 1996, he has read this manuscript in many forms and provided incomparable advice, good cheer, and support.

My last and greatest debt is to Peter H. Wood, whose very being is woven into the fiber of these pages. Since I cannot begin to detail his contribution to my life and this work, I shall simply say thank you, from the bottom of my heart.

EAF

Hillsborough, North Carolina

July 2001

INTRODUCTION

e9781466808041_i0003.jpg The story that follows is about Variola major, the virus that causes smallpox. From 1775 to 1782, Variola ravaged the greater part of North America, from Mexico to Massachusetts, from Pensacola to Puget Sound. For the virus, the great pestilence represented a phenomenal success: It found countless new hosts, it multiplied rapidly, and it traveled vast distances. But in its wake it left death and despair, killing more than a hundred thousand people and maiming many more. With no respect for boundaries of race, class, or nationality, the opportunistic microbe swept an astonishing array of people and events into its maelstrom: missionaries, mariners, fur traders, explorers, planters, fishermen, hunters, farmers, homemakers, warriors, neophytes, trappers, soldiers, prisoners, and runaway slaves. By the time the pestilence was over, it had reshaped human destinies across the continent.

Today, it is hard to imagine the havoc that Variola once caused, for an entire generation has now come of age without knowing its ravages. In 1979, after a monumental campaign against a virus that had plagued humankind for three thousand years, the World Health Organization (WHO) certified that it had eradicated smallpox from the world. It was an enormous humanitarian triumph. But if eradication was a triumph, it was also a punctuation mark. It marked the close of an optimistic era in which public health officials had envisioned the imminent end of infectious disease itself. Already, at the time the eradication of smallpox was announced, the still-unknown and unidentified human immunodeficiency virus (HIV) had begun its silent transit around the world, representing only the deadliest of many new or resistant emerging diseases. Thus the elimination of one plague in 1979 was only replaced by the fear of new ones.

Even the conquest of smallpox may not be secure today. Here the failure is not medical but political. In the post-eradication world, the WHO had intended that only two repositories of Variola exist: one in the United States and one in Russia. The supplies of virus held in these locations were to be destroyed on June 30, 1999. Had everything proceeded as planned, it would have been the first time that humankind had knowingly and deliberately annihilated another species from the earth. But the much-anticipated rendezvous with the autoclave never took place. Instead, on April 22, 1999, some two months before smallpox was scheduled to meet its end, the United States announced that it would retain its stores of the virus. The decision was controversial. It came in response to new intelligence indicating that clandestine supplies of Variola were now at large in a world in which the virus was both coveted and feared as an agent of biological terror.

Beneath the pronouncements and posturing lies a profound tragedy. The eradication of smallpox came about through two decades of dogged shoe-leather epidemiology, as public health workers around the world went door to door, sometimes under extraordinary conditions, to track down and eliminate the Variola virus. In its final, intensified phase alone—from 1967 through 1979—the campaign cost the funding nations nearly $100 million.¹ It was marked, moreover, by extraordinary international cooperation despite the bellicose rivalries of the Cold War era. Considering this background, the reemergence of Variola as a threat to humankind today represents a failure every bit as great as the success that preceded it.

The last naturally occurring case of smallpox in the world appeared in Somalia in October 1977. The victim, a twenty-three-year-old cook named Ali Maow Maalin, was successfully quarantined, and all his contacts were quickly vaccinated. A three-thousand-year chain of transmission had been broken. The WHO workers who had labored so hard for so long had cause for celebration. But ten months later, a shocking report came out of Birmingham, England. A woman named Janet Parker had mysteriously taken ill with full-fledged smallpox. Parker was a medical photographer. Her studio at the Medical School of the University of Birmingham was in the same building as a smallpox laboratory, albeit upstairs and several rooms away. Somehow, in what is known as a laboratory outbreak, Parker had picked up the virus. She gave it to her family as well. At the age of seventy, Parker’s mother came down with smallpox and survived. Her father, aged seventy-seven, also showed symptoms, but before the disease could be diagnosed, he died of a heart attack, even while his daughter remained alive. In the midst of the chaos, the head of the laboratory from which the virus had escaped committed suicide. Janet Parker herself died of smallpox on September 11, 1978. Hers was the last known death from the disease.

Today, despite rumors and intelligence reports, we live in a smallpox-free world. The pages that follow make our good fortune clear.

Variola’s relationship to humankind is both parasitic and paradoxical. To thrive and multiply, the virus has to have a host. But for the host species—unlucky Homo sapiens—Variola is the most unruly of guests. It inflicts unspeakable suffering upon its victims. It blinds, scars, and maims. In the end, it also confers either immunity or death. For the parasite, this presents a problem. Variola consumes its human hosts as a fire consumes its fuel, leaving spent bodies, dead or immune, behind. To survive, the virus has to find a constant supply of new victims. In a large urban population, such individuals might become available through immigration or childbirth. But elsewhere, if Variola is to succeed, it has to travel. It has to find more hosts and then, inexorably, still more.

Variola has no animal vector. It is not transmitted by insects like malaria or by water like cholera. It passes only from one human being to another. As a result, Variola’s story is necessarily a story of connections between people. As it ravaged North America in the years 1775–82, the virus showed that a vast web of human contact spanned the continent well before Meriwether Lewis and William Clark made their famous journey to the Pacific in 1804–06. Smallpox highlighted these contacts, illuminated their nature, and added a new dimension to their consequences.

In many regions of North America, Variola was by the late eighteenth century an old enemy with a well-established place in the annals of colonial conquest. The natives of Mexico—to choose only the most famous example—had endured a horrific epidemic of smallpox in conjunction with Hernan Cortés’s triumph over the Aztecs between 1519 and 1521. Repeated bouts of Old World pestilence occurred in the years that followed. Smallpox may have been the most deadly of these plagues, but others too earned the respect and fear of America’s indigenous peoples. Measles, influenza, mumps, typhus, cholera, plague, malaria, yellow fever, scarlet fever, whooping cough, and diphtheria all wreaked havoc in the two and a half centuries between Cortés’s conquest and the American Revolution. By the time the first shots sounded in the great anti-imperial conflict that has come to epitomize the late eighteenth century, this Pandora’s box of disease (with comparatively minor assistance from warfare and alcohol) had decimated the natives of the Western Hemisphere many times over.

The smallpox pestilence of 1775–82 was thus a relatively late development in a region (North America including Mexico) that had already witnessed considerable depopulation thanks to a plethora of Old World diseases. Four things, however, make this huge wave of sickness worth studying. First, it may well constitute the first continental episode of disease in the history of North America. (If not, it is certainly the first that is clearly identifiable.) Second, although the smallpox scourge of 1775–82 coincided almost perfectly with the American Revolution and took many more American lives than the war with the British did, it remains almost entirely unknown and unacknowledged by scholars and laypeople alike. Third, unlike so many earlier outbreaks of contagion, this one is extensively documented in the historical record. And fourth, by directing our attention to events elsewhere on the continent in an era in which historians have previously focused largely on the eastern seaboard, the plague highlights the geographic and demographic gaps in our historical canon. While colonial independence reshaped global politics forever, the contagion was the defining and determining event of the era for many residents of North America. With the exception of the war itself, epidemic smallpox was the greatest upheaval to afflict the continent in these years.

Smallpox transmission through North America, 1775–82

Aztec record of the first smallpox epidemic, from the Codex Florentino. Courtesy Library of Congress

Two versions of an Aztec image of smallpox, 1520, possibly representing an Aztec ruler who died of the disease. These are copies made by scholars of the original Codex en Cruz, which is so damaged that it is barely legible. Courtesy University of Utah Press

It was an upheaval that left telltale signs behind. In 1792, an English sea captain named George Vancouver led an expedition to America’s northern Pacific seaboard. His charge was twofold: He was to establish British dominion in the region after a diplomatic squabble with Spain, and he was to survey the coastline for an entrance to the elusive, indeed mythical, Northwest Passage. But in May 1792, it was neither Spain nor the Northwest Passage that preoccupied the famous British navigator. It was his observations of Indian villages along the shores of the Strait of Juan de Fuca, the waterway that separates what is now British Columbia’s Vancouver Island from Washington State’s Olympic Peninsula. Something, he believed, was terribly wrong. He had first noticed it after setting up camp at what he called Port Discovery (Discovery Bay), on the strait’s southern shore. There, wrote Vancouver, we found a deserted village capable of containing an hundred inhabitants. The houses had crumbled, and once-worn paths had given way to weeds, amongst which were found several human sculls, and other bones, promiscuously scattered about.² Where, the captain wondered, were all the people?

Vancouver was no newcomer to the region. In 1778, he had landed at Nootka with Captain James Cook and spent several months cruising the spectacular mountainous shoreline of British Columbia and Alaska. He thus had a touchstone of sorts for judging what he saw.

The mystery soon deepened. Just a few miles from their campsite, on a neck of land marking the entrance to Puget Sound, Vancouver and his men found another deserted Indian village, much in the same state of decay as that which we had examined at the head of port Discovery. Elsewhere too, the scull, limbs, ribs, and back bones, or some other vestiges of the human body, were found in many places promiscuously scattered about the beach, in great numbers. The country was abundant. It had salmon and fresh water sufficient to answer all purposes in supporting a very numerous body of inhabitants. Any one of the deserted villages the men had seen could have contained the whole sum of the Indians they encountered. Something had happened, Vancouver concluded. A land this delightful should not have been so thinly inhabited. In his view, all the evidence indicated that at no very remote period this country had been far more populous than at present.³

Perhaps Vancouver was misguided. Perhaps he was, as one writer has suggested, mildly obsessed by the idea of depopulation. ⁴ If so, he was not alone, for the navigator’s crew confirmed his perceptions. Officers from the expedition found Discovery Bay so littered with human remains that it seemed a general cemetery for the whole of the surrounding country. The pilot Peter Puget observed Several deserted Villages to the south as he explored the sound that bears his name today. And on a survey to the northward, the midshipman Thomas Manby noted a great many deserted Villages, some capable of holding many hundred Inhabitants. Where domestic life had once reigned, brambles and bushes now grew. For Manby, as for Vancouver, the conclusion was obvious. By some event, he wrote, this country has been considerably depopulated, but from what cause is hard to determine. ⁵

There were clues among the few Indians the visitors saw. As they probed the narrow confines of Washington’s Hood Canal, Vancouver and his men encountered a group of sixty natives, probably a party of Twana-speaking Coast Salish. The Indians received the Englishmen hospitably, offering them fish and receiving in return trinkets which delighted them excessively. One of their hosts had suffered very much from the small pox, the captain noted, and scars from the disease were seen on many. Several of the Indians had even lost the sight of one eye, Vancouver added, most probably a consequence of that baneful disorder.⁶

A similar report came from the botanist Archibald Menzies. Menzies had already served as an expedition scientist to Captain Cook, a position once turned down by a young English physician named Edward Jenner. Now, just a few years before Jenner was to stun the scientific community with his development of a smallpox vaccine, Menzies bore witness to Variola’s ravages nearly halfway around the world. On May 21, 1792, as he and his companions charted the intricate coastline of Puget Sound, Menzies recorded an encounter with three Indians. The men were stout fellows, he wrote, two of them were much pitted with the small pox & each destitute of a right eye.⁷

Smallpox could explain the blindness, the scars, and the other disfigurements. But could it explain the desolation of the coastline? George Vancouver was not sure. As he pondered the bone-littered landscape around him, he acknowledged the constraints that time and perspective placed on his understanding of events that had preceded him. It was not very easy, he wrote, to draw any just conclusions on the true cause from which this havoc of the human race proceeded: this must remain for the investigation of others who may have more leisure, and a better opportunity, to direct such an inquiry.⁸ Today, with more leisure and a better opportunity than Vancouver had in 1792, we turn to the tumult, and the virus, that shaped his times.

1

VARIOLA

e9781466808041_i0007.jpg 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 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. 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 formed the 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 appearing thirteen 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.

Two images of smallpox from the Sicangu Lakota winter count of Battiste Good. The figures include dots for pustules as well as the spiral symbol for pain—indicated here in the midsection. The image on the left represents the first documented smallpox outbreak on the northern plains in 1734–35. The image on the right represents an outbreak more than a century later, in 1860–61. Garrick Mallery, Picture-Writing of the American Indians, Tenth Annual Report of the Bureau of Ethnology to the Secretary of the Smithsonian Institution, 1888–’89 (1893; rpt., New York: Dover, n.d.), 1:300, 325

Smallpox. World Health Organization photograph, National Library of Medicine, Bethesda. Maryland. A014034

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.

Smallpox: communicability, symptoms, and pathogenesis

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