Pox: An American History Part 1

Pox : an American history.

Michael Willrich.

PROLOGUE.

NEW YORK, 1900.

Manhattan's West Sixty-ninth Street no longer runs from West End Avenue to the old New York Central Railroad tracks at the Hudson River's edge. In the s.p.a.ce now occupied by aging high-rise condominium towers and their long shadows, there once stood a low-slung street of tenements and houses. At the turn of the twentieth century, it was said to be the most thickly populated block in the most thickly populated city in the United States of America. Someone called it "All Nations Block," and, being a pretty fair description of the place, for a while the name stuck.

A brisk walk from the fashionable hotels of Central Park West, All Nations Block was a rough world of day laborers, bricklayers, blacksmiths, stonemasons, elevator runners, waiters, janitors, domestic servants, bootblacks, tailors, seamstresses, the odd barber or grocer, and, far outnumbering them all, children. Each morning, the children streamed east to Public School No. 94 at Amsterdam Avenue or to the crowded kindergarten run by the Riverside a.s.sociation at 259 West Sixty-ninth Street. That same foot-worn building housed the charitable a.s.sociation's public baths; in any given week, four hundred men or more paid a nickel for a towel, a piece of soap, and a shower that had to last. The tenement dwellers of All Nations Block did not choose their neighbors. It was the kind of place where an itinerant black minstrel actor, feeling feverish and far from his southern home, could find a bed for a few nights, in a great warren of rooms whose other occupants were Italian, Irish, Jewish, German, Swedish, Austrian, African American, or simply, so they said, "white."1 The men of the West Sixty-eighth Street police station knew the block and its ways well. The policemen came when the neighbors brawled, when jewelry went missing in an apartment by the park, or when the Irish boys of the All Nations Gang got too rough with the Chinese laundryman on West End Avenue. The police came once again on the night of November 28. A forlorn and drunken stonemason named Michael Healy, imagining himself to be under attack in his room ("They're after me," he had shouted, "See those black men!"), had hurled himself through a fourth-floor window and fell, in a cascade of gla.s.s, to, or rather through, the ground below. The Irishman made a two-by-two-foot hole in the surface, breaking through to some long-forgotten trench near the building's cellar. A neighborhood boy ran to the Church of the Blessed Sacrament on West Seventieth Street and summoned a priest. When the priest arrived, he crawled right through the hole and into the trench, which was already crowded with police, an ambulance surgeon, and Healy's broken but still breathing body. Before this subterranean congregation, the priest administered last rites. That was the way things went on All Nations Block. It was the night before Thanksgiving, the first of the new century.2 New Yorkers of a certain age would remember that Thanksgiving as the day the smallpox struck the West Side. The outbreak had in fact started quietly a few days earlier, on All Nations Block. The city health officers found the children first: twelve-year-old Madeline Lyon, on Tuesday, and on Wednesday, a child just across the street, identified only as a "white boy four years old." For the health officers to diagnose the cases with any confidence, the children must have been suffering for days, with raging fevers, headaches, severe back pain, and, likely, vomiting, followed by the distinctive eruption of pocks on their faces and bodies. Once the rash appeared and the lesions began their two-week metamorphosis, from flat red spots to hard, shotlike b.u.mps to fat pustules to scabs, the patients were highly contagious. The health officers removed the children, stripped their rooms of bedding and clothing, and disinfected the premises.3 The health department followed the same procedure with the five other cases that were reported elsewhere in Manhattan within hours of the Lyon case. One was a white domestic servant named Mary Holmes, who worked in an affluent apartment house on West Seventy-sixth Street. The other four were black, evidently from the neighborhood of the West Forties. They were Adeffa Warren, Lizzie Hooker, Susan Crowley, and Crowley's newborn daughter-these last two had been removed in haste from the maternity ward at Bellevue Hospital. Through interviews, health officers had established that the four black patients had come into contact with an unnamed infected "negress," who remained at large. How any of these patients might have been connected to the children on West Sixty-ninth Street, about a mile and a half uptown, remained uncertain. But the authorities were working on the a.s.sumption that the outbreak started on All Nations Block.4 The officers of the internationally renowned New York City Health Department, medical men given broad powers to police and protect the public health in one of the world's most powerful centers of capital, were not easily shaken by the odd case of smallpox among the wage earners. Now and then an infected pa.s.senger got past the U.S. government medical inspectors at Ellis Island or crossed into the city on one of its many railroad tracks, waterways, roads, footpaths, or bridges. Most New Yorkers had undergone vaccination for smallpox at one time or another-on board a steamship crossing the Atlantic, in the public schools, in the workplaces, in the city jails and asylums, or, if they possessed the means, in their own homes under the steady hand of a trusted family physician. When an isolated case of smallpox triggered a broader outbreak, the health officials took it as an unmistakable sign that the population's level of immunity had begun to taper off, as it did every five to ten years. The time had come to sound the call for a general vaccination. "We are not afraid of smallpox," said Dr. F. H. Dillingham of the health department, when the news broke that smallpox had reappeared on Manhattan. "With the present facilities of this department we can stamp out any disease."5 On Thanksgiving Day, as the Columbia University football team took the field against the Carlisle Indian School and three thousand homeless people lined up for a hot dinner at the Five Points House of Industry, a vaccination squad from the health department's Bureau of Contagious Diseases moved into West Sixty-ninth Street. The four doctors began a quiet canva.s.s of All Nations Block, starting with the immediate neighbors of the infected children. Health department protocol called for a thorough investigation of each case, in order to trace its origin, followed by the immediate vaccination of all possible contacts. In a place as densely inhabited as All Nations Block, everyone would have to bare their arms for the vaccine.6 With a willing patient, the vaccination "operation," as doctors called it, lasted just a minute or two. The doctor took hold of the patient's arm, scoring the skin with a needle or lancet. He then dabbed on the vaccine, either by taking a few droplets of liquid "lymph" from a gla.s.s tube or using a small ivory "point" coated with dry vaccine. Either way, the vaccine contained live cowpox or vaccinia virus that not long before had oozed from a sore on the underside of an infected calf in a health department stable. In the coming days, the virus would produce a blisterlike vesicle at the vaccination site. In due course, the lesion would heal, leaving a permanent scar: the distinctive vaccination cicatrix. If all went well, the patient would then enjoy immunity from smallpox for five to seven years, sometimes longer. And, of course, as long as a person was immune, she could not pa.s.s along smallpox to others.7 The health department's plan was to secure All Nations Block first and then follow the same procedure on the surrounding streets. In the coming days, health officers and police would maintain a quarantine on the block and enforce vaccination in the neighborhood schools. The health department would use all the available methods to fight the disease: total isolation of patients, quarantine of their living environment, vaccination of anyone exposed to the disease, disinfection of closed s.p.a.ces and personal belongings, and close surveillance of the infected district and its residents.8 It was a sensible protocol, born of medical science and the city's long experience with the deadliest contagious disease the world had ever known. Historically, smallpox killed 25 to 30 percent of all those whom it infected; most survivors were permanently disfigured with the dreaded pitted scars. Decades after the scientific revolution known as the germ theory of disease, biologists and doctors were still searching in their laboratories for the specific pathogen that caused smallpox. But they felt confident they had a strong understanding of the microbe's behavior: its pathological course in the human body, its epidemiological effects in a population, and the immunological power of vaccination to prevent the virus from attacking an individual or proliferating across an entire community. According to the state-of-the-art scientific knowledge, the "infecting germs" of smallpox spread unseen from one nonimmune person to another, communicated in a cough, a brush of bodies, or across the folds and surfaces of everyday things: an article of clothing, a Pullman porter's whisk broom, a piece of mail, a newspaper, a library book, a bit of currency, a shared cigarette. Because smallpox had an incubation period of ten to fourteen days, during which the infected person presented no noticeable symptoms, health officers strived to retrace the circuits of human contact in order to identify probable carriers and contain the outbreak.9 The vaccination corps had not been on the block long before the doctors realized the need for reinforcements, men armed with more than vaccine. As the physicians moved from door to door, rapping loudly and calling for the occupants to come out and be vaccinated, many residents refused to cooperate. The doctors tried to explain the danger, which could not have been easy given the many tongues spoken on the block. But many people would not submit to having their own or their children's arms sc.r.a.ped by the vaccinators without, according to The New York Times, "loud wails and even positive resistance." Receiving word of the worsening situation on All Nations Block, the commander of the West Sixty-eighth Street station dispatched a detail of six policemen to a.s.sist the doctors in "enforcing the vaccination."10 Well into the cool autumn night, All Nations Block echoed with the rapping of nightsticks on doors, the shouting and pleas of the residents within, and, through it all, the rattle of the horse-drawn ambulance wagons as they moved to and from the infected district. By midnight, the vaccination corps had discovered another twenty-two cases on the block, many of them little children, all of them, in the health officers' view, requiring immediate isolation. The ambulance wagons carried the patients five miles over rough city roads to the Willard Parker Hospital, the health department's contagious diseases facility at the foot of East Sixteenth Street on the East River, where the doctors gave them a more full examination. From there they were ferried off Manhattan and many more miles upriver to the city smallpox hospital, the "pesthouse" on North Brother Island, a nineteenacre wooded island situated between Rikers Island and the Bronx mainland. Pesthouses, public hospitals used to isolate poor people suffering from infectious diseases, were the most dreaded of American inst.i.tutions. The trip to North Brother Island was a grim journey into unknown territory. No known cure for smallpox existed. The pesthouse doctors could do little more than treat the patients' symptoms. It was up to the virus, and to each patient's own resources, to determine who among the infected would die in the seclusion of North Brother Island.

The germ theory taught that contagious diseases such as smallpox did not arise spontaneously; they did not spring to life in vaporous miasmas from stagnant water or decomposing filth, as physicians and sanitarians had previously a.s.sumed. Doctors now understood smallpox to be caused by invisible life forms-"germs"-that could only survive and proliferate by infecting human carriers. There seemed to be no animal or insect vector for smallpox: no species of mosquito, rodent, or bird that carried the disease from person to person, place to place. If smallpox suddenly appeared in a previously healthy community, there were only two possible explanations: either viral material from a recent case had survived for a time in clothing or bedding or, more likely, someone had brought the pox into the community. On this point medical science reinforced the common reflex of human communities everywhere to blame sudden misfortune on their most marginal inhabitants, outsiders and "others."11 "What a potent factor in maintaining the prevalence of small-pox is that unemployed and largely unemployable degenerate, the habitual vagrant or tramp," observed a writer in the London-based Lancet, the preeminent English-language medical journal. "The fact that this parasite upon the charity and good nature of the community is in his turn a vehicle for the spread of other parasites, both animal and vegetable, is common knowledge but practically no compulsory steps have been taken to curtail seriously the vagrant's movements or to promote his elementary cleanliness."12 Suspicion fell immediately upon one of the infected patients en route to North Brother Island, the black minstrel actor who had just arrived on All Nations Block. A member of the traveling Wright Troupe, the man (whose name is lost to the historical record) had come north only a short time before and had taken a room in one of the houses where the sick children were later discovered. The rumor quickly spread that "this negro" had carried the germs in his body from Pittsburgh and, living in a house filled with playful innocents, infected at least one of them. That child, the theory went, infected cla.s.smates in the swimming bath of the Riverside Kindergarten. The theory had an easy plausibility; the white doctors of the health department, no less than the residents of All Nations Block, lived in an American culture of race that scorned black bodies as vessels of moral and physical danger. But perhaps there was more to the theory than a reflexive racism. Smallpox had been epidemic for several years in the American South, where it had spread first and most widely among black laborers in the coal mines, railroad camps, tobacco plantations, and crowded cabin settlements of the rising New South. Given the long incubation period of the disease, it might have been expected that an African American traveler would eventually bring the southern smallpox to New York. On two separate occasions during the preceding three years, smallpox epidemics had struck upstate communities. Each time the New York State Health Department had attributed the outbreaks to a traveling negro minstrel show.13 As the city health department grew concerned about the seemingly connected center of contagion, in the neighborhoods of the West Forties near Eighth Avenue, rumors circulated about a second suspect. He, too, was black. Albert Sanders, twenty-two, had suffered through nearly the full course of smallpox without medical attention before he was discovered; no patient found so far had been infected longer than he was. During this time Sanders had managed to mingle with many people. Unlike the minstrel man, Sanders had been in town for a while, and his name had appeared in the papers before. In the brutal West Side race riot of August 15, 1900, as hundreds of whites taunted and beat blacks in the African American neighborhoods along Eighth Avenue, Sanders had been listed among the injured, suffering from scalp wounds and cuts. Evidently the experience had not inspired in him a trust of whites, doctors included.14 Once two dozen cases of smallpox had turned up on the West Side, the question of the outbreak's precise origin became almost moot. Whoever had started it-the minstrel man of All Nations Block, the unnamed "negress," Albert Sanders, or someone else-the outbreak would now be difficult to contain.

By December 6, one week after Thanksgiving, the New York papers were calling the outbreak a full-blown smallpox epidemic, the worst in Manhattan since 1892. Three of the patients on North Brother Island had already succ.u.mbed to the disease: the servant Mary Holmes; twenty-year-old Elizabeth Oliver; and the Crowley infant, whose mother, it seemed, had not had the heart to name her. The pesthouse now held forty-four smallpox patients, with more arriving almost every day. All hopes of keeping the outbreak quarantined in a small area of the city had vanished when five-year-old Sadie Hemple, until recently a resident of West Sixty-ninth Street and pupil at the Riverside Kindergarten, turned up across the river in Hoboken with a case of smallpox. The virus had incubated in her body while she and her parents moved to their new home, a five-story tenement house where some twenty other children lived. The Hoboken authorities removed Sadie to their own pesthouse, in a place called Snake Hill. New York officials had to concede that the West Side outbreak had "overleaped the bounds" of All Nations Block.15 The health department's vaccination corps was now sc.r.a.ping the arms of the poor at the rate of fifteen hundred per day. Resistance to vaccination had abated in some of the infected areas-where the people were, in the words of one city vaccinator, "well scared up." More than five hundred poor people called each day for free vaccinations at the board of health's headquarters on West Fifty-sixth Street, most of them mothers with little children in tow. But with each new outbreak in another of the island's crowded tenement districts, the vaccination corps met fresh resistance. Over time, the corps would ever more closely resemble a military outfit. Across the city, private physicians and druggists bought up "hitherto unheard of quant.i.ties" of the health department's vaccine stock. At factories, department stores, and offices, employers told their employees to get vaccinated or not bother showing up. On Wall Street, the managers of the New York Stock Exchange set up their own on-site vaccination station. All employees had to submit to the procedure before they could take their positions in the great scrum of the trading floor.16 Among the many political effects of the widening epidemic in New York City was an earnest moral discourse, as the city's chattering cla.s.ses mulled the significance of the event. The ancient and filthy scourge of smallpox had struck at the very heart-and, it seemed to many, the very moment-of modern American civilization.

The New York Times, the moderately progressive voice of elite opinion, published a series of editorials in which it called the epidemic "a matter of grave public concern." The editors cautioned their affluent readers against indifference; the outbreak was no longer safely confined to "the congested tenements of one locality." "Public conveyances and places of public a.s.sembly bring all cla.s.ses together to such an extent that only the recluse can feel quite safe," the Times advised, "and not even the recluse if ministered to by servants who visit friends in the infected districts."17 Such a recognition of the inescapable interdependence of modern urban life stood as the grand unifying theme of the many disparate progressive reform campaigns of the turn of the century: movements for safer working conditions, social insurance for wage earners and their families, better housing for the poor, new programs to rehabilitate criminals, and innumerable measures to protect the public health. The same ethical and political logic, which held individual liberty subordinate to the collective interests of society, underlay the Times's call for universal vaccination: "This is not only a wise measure of personal precaution, but it is a public duty which every citizen owes to those with whom he comes in daily contact." The Times was prepared to take this logic to its furthest conclusion and endorse the most punitive measures for vaccination in the "great and crowded city." But the editors expected that such measures would prove unnecessary. The "anti-vaccination heresies" that had spread so perniciously in England and other foreign countries in recent years would find few followers in the United States, the Times insisted. "Here a saving common sense has prevailed in all cla.s.ses of the population, and smallpox works serious ravages only in remote corners inhabited by out-and-out savages." A progressive appeal to social interdependence, civic obligation, and enlightened common sense did not, in this instance, imply tolerance, empathy, or solidarity. Or good taste: three people had recently died in the city, ravaged by smallpox. Were they "savages"? 18 These were, of course, the overheated ruminations of editorial writers. The Times's editors got the high moral tone of the moment just right, and the facts of the historical events unfolding around them all wrong.

In December 1900, the United States was in the throes of an extraordinary five-year wave of smallpox epidemics. It was the worst visitation of smallpox in a generation or more, and the last Americans would experience on a continental scale, as a national event. From Alabama to Alaska, no state or territory was untouched. Smallpox made its way across an increasingly interconnected American landscape: from southern tobacco plantations to western mining camps to immigrant tenement districts in aging east coast cities; from the nation's capital in Washington to Filipino and Puerto Rican villages on the farthest edges of the new American empire. The epidemics did not confine themselves to a few "remote corners" of the country. Many major American cities experienced deadly epidemics. New Orleans reported nearly 1,500 cases and 450 deaths in 1900. In Philadelphia, smallpox infected 2,500 people and killed nearly 400. Boston recorded 1,600 cases and 270 deaths. And by the time the smallpox epidemic that started on All Nations Block was through with New York City in 1902, the health department had recorded 2,100 cases, and 730 men, women, and children lay dead.19 No reliable figures exist to quantify the overall damage done by small-pox to American lives, commerce, and property during these epidemic years. The U.S. Public Health and Marine-Hospital Service, the federal disease-control agency, conceded that its smallpox statistics were woefully incomplete. The federal officials dutifully published the data they received from state and local health boards, but in many states those agencies were just coming into their own. Many smallpox-infected communities lacked the will or the wherewithal to accurately report cases of infectious disease.

Still, the admittedly spotty statistics of the federal health service suggest the broad chronological arc of the epidemics. At the beginning of 1898, smallpox was largely absent in the United States, apart from a few trouble spots, mostly in the South, including Birmingham, Alabama, and a hard-bitten Appalachian coal town called Middlesboro, Kentucky. As Surgeon General Walter Wyman of the Public Health and Marine-Hospital Service recalled, "[I]t was during the winter of 189899 that the disease began to a.s.sume great proportions." In 1899, the service reported more than 12,000 cases, from all over the South, followed by 15,000 cases, now in the mid-western states, too, in 1900. In 1901, the number of new cases surged to nearly 39,000. According to the Medical News, by then the distribution of smallpox in the United States had become "alarmingly general." In 1902-the year Wyman would remember as "the high-water mark" of the epidemics-the service counted 59,000 new cases. The agency tallied another 42,590 new cases in 1903. By the end of that year, the surgeon general a.s.sured the nation that "the disease has spent its force and will now continue to decrease until it practically disappears." In fact, smallpox did taper off dramatically in 1904, but the disease did not disappear. Smallpox would continue to trouble American communities until the last reported U.S. case occurred in 1949. All told, during the five-year wave of epidemics around the turn of the century, the federal service counted 164,283 American cases of smallpox. The actual number of cases may have exceeded five times that figure.20 But for American public health officials, the truly stunning statistic from those epidemics was the body count. It was shockingly low. According to the federal health service reports, only 5,627 people died. Again, the mortality figure was impressionistic at best; the Census Bureau independently reported nearly 4,000 smallpox fatalities in 1900 alone (more than five times the health service's figure for that year). Still, all agreed that the death toll was astonishingly, inexplicably, blessedly small. If smallpox had measured up to its historical virulence, the epidemics of 18981903 would have killed at least 50,000 Americans .21 Although in some places smallpox proved as destructive as ever, in the vast majority of American epidemics after 1898, the disease seemed to have lost its lethal force. Vaccinal protection could not explain the phenomenon: when the smallpox came, most Americans had not been vaccinated in years. It seemed a new "mild type" of smallpox had appeared on the epidemiological landscape, the likes of which the "civilized" nations of Europe, England, and the United States had never seen. No one could say how long the new pox would remain mild. Many medical authorities expected the disease to revert to cla.s.sic, malignant smallpox at any moment. For American health officials, the low mortality rate posed the greatest medical mystery-and the toughest political challenge-of the turn-of-the-century smallpox epidemics.22 The sudden appearance of a new mild form of smallpox altered the political calculus of compulsory vaccination-a measure that had been none too popular in late nineteenth-century America. To this day, medical experts consider smallpox vaccine, which contains a bovine virus called vaccinia, "the least safe vaccine available." Serious complications, including postvaccinial encephalitis and death, are rare: scientists expect one million vaccinations to cause three to five serious reactions. But milder reactions-rashes, fatigue, headache, fever, painfully tender arms-are common. In 1900, vaccination carried significantly greater dangers. The government compelled vaccination, but did little to ensure that American vaccine makers produced safe, effective vaccine. Newspaper stories, medical texts, and popular rumors linked vaccination to syphilis, teta.n.u.s, and the ubiquitous "sore arms" that caused countless American breadwinners to lose days or even weeks of work. Because the new pox killed less than 1 percent of the people whom it infected, many laypeople and even doctors refused to believe it was smallpox at all. In the absence of a recognizably horrific case of smallpox, many failed to see the benefit of vaccination. Many saw vaccination as the greater risk to life and limb. And their resistance to compulsory vaccination would help persuade the federal government to impose new regulatory controls on the American vaccine industry.23 But reasonable health concerns do not alone explain the widespread opposition to compulsory vaccination at the turn of the twentieth century. Antivaccinationism was an international phenomenon, but everywhere it reflected the social divisions and political tensions of its time and place. The roots of American antivaccination sentiment ran deep and wide. Race stymied smallpox control, as white taxpayers, particularly in the South, balked at paying for vaccine to protect blacks; meanwhile, African Americans rightly mistrusted government vaccinators whose chief aim was to protect the white community. Christian Scientists viewed compulsory vaccination as a violation of religious freedom. Physicians who practiced popular forms of alternative medicine decried government vaccination orders as yet another example of creeping "state medicine." Parents resented school vaccination mandates for encroaching on their domestic authority and for violating their children's innocent bodies. Antivaccination propagandists traced compulsory vaccination to a corrupt conspiracy between health officials, lawmakers, and vaccine manufacturers. On the broadest level, though, the vaccination question revealed a sharp uneasiness toward the authority of medicine and the power of the state at the height of the Progressive Era, a period of time when both inst.i.tutions were reaching more ambitiously than ever before into American life.24 Contrary to the Times's a.s.sertion, then, an unquestioning submission to vaccination was anything but the "common sense" of the American people during these smallpox outbreaks-even in the many places where local and state governments made such submission compulsory by law. Ordinary Americans responded to government vaccination orders in a variety of ways, ranging from ready compliance to violent riots. They organized antivaccination societies, conducted legislative campaigns (some of them successful) to repeal state vaccination laws, and flooded the courts with lawsuits challenging compulsory vaccination as a violation of their const.i.tutional rights. More often, people resisted public health authority in more private, mundane ways: by concealing sick family members at home, forging vaccination certificates, or simply dodging their legal duty to be vaccinated. In the aftermath of this nationwide fight against smallpox, the United States would remain, in the words of one of the nation's preeminent public health experts, "the least vaccinated of any civilized country."25 The aim of this book is to explain why this was so. To trace the origins and broader significance of smallpox and the "vaccination question" in Progressive Era America, I have found it necessary to stray far from the familiar narrative conventions of the epidemic tale. This is not a story of rising body counts and medical heroics-though the changing lethal power of the smallpox virus, the emergence of the modern vaccine industry, and the strenuous work of public health officials are all central to this narrative. Nor is the story told in these pages a comforting tale of human solidarity springing up in unexpected places: the tragic disaster that forces the people of a community to overcome their differences and work together to survive and rebuild. The smallpox outbreaks of the turn of the century did occasion such moments, and they are remembered here. But the history of these American epidemics is, inescapably, a history of violence, social conflict, and political contention. And that made all the difference .26 America's turn-of-the-century war against smallpox sparked one of the most important civil liberties struggles of the twentieth century. To readers versed in the scholarly literature about American civil liberties, this claim may sound curious (or even spurious). According to the conventional text-book narrative, the modern era of civil liberties properly begins with the famous free speech cases of the postWorld War I era, when the U.S. Supreme Court established new First Amendment protections for political dissent. But contemporaries of the period, including no less a giant of the American legal realm than Justice Oliver Wendell Holmes, Jr., of the United States Supreme Court, recognized that the celebrated free speech battles reprised const.i.tutional questions that the vaccination struggle had raised for Americans two decades earlier. As Justice Holmes wrote in a 1918 letter to Judge Learned Hand, "Free speech stands no differently than freedom from vaccination."27 In a burst of litigation arising from the smallpox epidemics, the critics of compulsion had carried the vaccination question all the way to the U.S. Supreme Court in 1905. They raised a broad set of questions about the nature of inst.i.tutional power and the bounds of personal liberty in a modern urban-industrial nation. Their demands went far beyond the right to speak out against the government. The critics of compulsory vaccination insisted that the liberty protected by the Const.i.tution also encompa.s.sed the right of a free people to take care of their own bodies and children according to their own medical beliefs and consciences. It was a bold but deeply problematic claim. And it brought the opponents of compulsory vaccination into direct conflict with the agents of an emerging interventionist state, whose progressive purpose was to use the best scientific knowledge available to regulate the economy and the population in the interests of the social welfare.28 This, then, is the story of a largely forgotten American smallpox epidemic that killed relatively few people but left a surprisingly deep impression on society, government, and the law. The story begins where the epidemics did, in the fields and work camps of the New South.

ONE.

BEGINNINGS.

"To begin at the beginning, and I think it was the beginning," Dr. Henry F. Long wrote in his 1898 report to the North Carolina Board of Health, "the first smallpox experience we, of Iredell, had, was when the negro Perkins made his way from Neal's camp, on the M & M Railroad, to Charlotte."1 Henry Long was the superintendent of health of Iredell County, an area of low ridges and valleys known for its loamy soil and its many creeks. Most of the citizens were North Carolina natives, like their mothers and fathers before them. Long himself carried on the medical practice established by his father in Statesville, an old town of wide, elm-lined streets that served as the county seat. In the past twenty years, the hum of industry had altered the rhythm of life in the Piedmont. Farming families and respectable townspeople like the Longs had had to accustom themselves to growing numbers of wage earners and outsiders. Apart from farming wheat, the people now spent their days making furniture, processing tobacco, tending textile machines, working on the railroads, and, as ever, raising families. Until the winter of 1898, most folks in Iredell County had never seen a case of smallpox. Then that, too, changed.2 Harvey Perkins was fifty-seven years old that February, when he left his home in Pelzer, South Carolina, and traveled some one hundred and fifty miles north and east to seek work on the Mocksville & Mooresville extension of the Southern Railway. He arrived, the fever already upon him, at Neal's Camp, one of the turn-of-the-century South's ubiquitous railroad construction camps. He spent the night in a hut with two other laborers. As Long explained, patients in the preeruptive stage of smallpox already battled their unseen foe: "The pulse is strong, full and bounding. . . . The patient is restless and distressed and when sleep is possible has frightful dreams." When morning broke, Perkins noticed the first spots on his face. Guessing at their significance, and fearing that his new bosses would confine him in quarantine, he left camp without a word and slipped into the woods.3 All Harvey Perkins wanted was to get home to Pelzer, maybe by picking up a train in Charlotte, forty miles south of Neal's Camp. By the time Perkins walked the twelve miles to Mooresville, in southern Iredell County, the eruption was visible to anyone who cared to look him in the face. But a sick old black man did not usually attract much notice, especially from white people. Perkins spent the night. He resumed his journey the next day. He was just two miles from Charlotte when his strength finally gave out and he "fell by the wayside." A pair of bicyclists found him in the woods, his face and body covered with pocks. Perkins warned them not to come near. Local authorities transported him to the city pesthouse, a makeshift isolation hospital on the outskirts of Charlotte in Mecklenburg County, where Perkins discovered he was not alone. Dr. Long had not, in fact, begun at the beginning.4 Smallpox had been stalking North Carolina's southern border for months, maybe longer. Health officials in the lower South thought the disease confined to the African American sections of a few cities and to the dispersed settlements of black farmers, laborers, and families. Since the end of slavery, the white medical profession had paid African Americans little notice and offered little aid. Within the past year or so, smallpox had broken out, seemingly without warning, in parts of Florida, Alabama, Georgia, South Carolina, Tennessee, Kentucky, and Virginia. Some white physicians and laypeople dismissed the disease as a peculiar negro malady: "n.i.g.g.e.r itch," they called it. But Dr. Long and other seasoned public health officials knew better. "So far the disease has been almost exclusively confined to negroes," said the Kentucky Board of Health, in a circular t.i.tled "Warning Against Smallpox," "but this exemption of the white race cannot long be hoped for if it continues to spread."5 In late January, the North Carolina Board of Health issued a smallpox bulletin. The "justly dreaded disease" had crossed the state line. Wilmington, the state's largest city, had the dubious honor of reporting the first case, in "a negro train hand of the Atlantic Coast Line whose run was into South Carolina." Soon after, Charlotte health authorities discovered a case in a black railroad hand named William Jackson. He had recently returned from a run to Greenville, South Carolina, the very place Perkins had caught his train north. By the time Perkins arrived at the Charlotte pesthouse, there were three other people detained there. Within twenty-four hours, there would be four more. All of them were African American. Three of them were broken out with pocks, including William Jackson's four-year-old son Frank. Jackson himself was already dead. The remaining five inmates showed no symptoms, but since they had come into contact with the others they would be detained for two weeks.6 Charlotte was in a state of turmoil. The physicians who examined the pesthouse patients disagreed about whether the cases were smallpox at all. At the request of the state authorities, Surgeon General Walter Wyman of the United States Marine-Hospital Service, the federal government's civilian health corps, dispatched an officer to Charlotte. For Dr. Charles P. Wertenbaker, a surgeon in command of the service's station in Wilmington, diagnosing smallpox was fast becoming a specialty. In the quasi-military argot of the corps, Wertenbaker held the rank of "pa.s.sed a.s.sistant surgeon," meaning he was a midlevel officer who had pa.s.sed the service's famously rigorous examination for promotion. He told the mayor of Charlotte that all four patients had smallpox. The quarantined inmates would almost certainly develop the disease, too. Instead of segregating suspects from patients, pesthouse officials had put suspects to work nursing the sick.7 To Wertenbaker's eye, Perkins presented a "typical" case, in the "fifth day of the eruption." But in an old man smallpox was especially cruel. Perkins died in the pesthouse ten days later. He was buried in a nearby woods, more than a hundred miles from home.8 The citizens of Charlotte had dodged a bullet, Wertenbaker announced in a bulletin issued by the state board of health to drum up support for vaccination. Had Perkins been stronger, "he would have come into the city; he might have stood next to any one in a crowd and infected him, he might have come in contact with one of your servants, and in this way sent the disease into your homes."9 Dr. Henry F. Long learned the truth of these words. From the "seeds" of smallpox Perkins sowed at Mooresville arose the largest outbreak North Carolina had seen in years. An itinerant black preacher named A. B. Smoot unknowingly carried the disease from Mooresville to Statesville. More than sixty cases were eventually reported in Iredell County. It was anybody's guess how many more people suffered, as Perkins had aimed to, in the privacy of their own homes. Dr. Long set up a hospital and detention camp in the woods outside Statesville. He hired the recovered Reverend Smoot to drive the ambulance wagon. When Long tried to organize a county-wide vaccination campaign, he ran up against fierce opposition, most of it "from the whites." The city council gave Long power to vaccinate the citizens, with or without their consent. One state health official reflected, "The unreasoning prejudice of ignorance is extremely difficult to meet, and sometimes requires a resort to methods that are very obnoxious to Americans."10 As the summer heat climbed into the Piedmont, the Iredell County epidemic of 1898 ran its course. But as Long put the finishing touches on his report, the fetid odor of smallpox, "insupportable and tenacious," continued to haunt him. He was not going to escape that smell anytime soon. The North Carolina Board of Health, facing a widening epidemic in counties across the state, was about to create a full-time position for him: State Smallpox Inspector.11 The age of AIDS did not invent the notion of "Patient Zero." Epidemics are dramatic events of cultural as well as scientific meaning, and the hunt for an outbreak's first case has ever served needs and purposes other than those of medicine. One Alabama health officer reached all the way back to Genesis 3:15-the story of the serpent in the garden-to launch his narrative of the Greene County smallpox epidemic of 1883. The epidemic, he said, had begun with the arrival on an evening train from Birmingham of one Eliza Burke, the "colored woman 'who brought death and all our woe.' "12 Narrative accounts of smallpox outbreaks-whether recounted aloud to neighbors, scratched into a letter, or prepared, like Dr. Long's history, for a government report-rarely failed to include a few words about the first case. These sketches of suddenly infamous men and women cast flashes of light on obscure figures, most of them otherwise untraceable. The way these stories were told reveals at least as much about their tellers: their forensic cert.i.tude, their fixed ideas about race and place, and their faith that buried somewhere in the human wreckage of an epidemic lay the stuff of larger moral reckonings. The desire to begin at the beginning, with a cognizable first case, was particularly strong at a time when the actual agents of so much misery and loss-the unseen, unseeable particles of the variola virus-were so imperfectly understood.13 After the fashion of Harvey Perkins, or the minstrel actor who stayed over on All Nations Block, the alleged source of infection was typically an outsider or a marginal local figure whose work or wanderings brought him in promiscuous contact with strangers. Consider three first cases reported by county physicians to the Kentucky Board of Health during the outbreaks of 1898 and 1899: smallpox invaded Boyd County in the body of a deckhand who worked on a "steamboat plying between Pittsburgh and St. Louis"; the disease was spread around Clay County by "a young girl of bad reputation"; and it struck Lincoln County in the person of a peripatetic real estate salesman named Joseph Sowders, a white man whose taste for the "biled juice of the cereal corn" had landed him in a smallpox-ridden Catholic mission in Columbus, Ohio, before he stumbled home to Lincoln. When smallpox struck Los Angeles in the winter of 1899, infecting thirty-five people and killing seven, officials blamed unnamed "tramps or trainmen from Arizona." In port cities from New York to San Francisco, anyone arriving by boat, especially in steerage, loomed as a potential threat. North and south of the Mason-Dixon line, itinerant African Americans were the most prime of suspects: laborers "traveling afoot," performers in "Uncle Tom's Cabin" shows, missionary preachers, Pullman porters, coal miners, roustabouts, even, in the case of Columbia, South Carolina, a "runaway student" from a black college.14 Other reports attributed the spread of smallpox not to a single individual but to the undifferentiated inhabitants of entire encampments of people on the move: railroad camps, mining camps, logging camps, Army camps, convict labor camps, African American revival meetings, fairs, lodging houses, and any other short-lived settlement where strangers crowded in an unfathomable ma.s.s. "The camp as a focus of disease is more potent than all others," wrote Dr. James N. Hyde, a smallpox expert at Chicago's Rush Medical School. In such places, Hyde argued, people who had become adapted to the particular microbial environment of their distant homes were thrown together, "under subjection," unable to choose where or with whom they slept. "The chances of thus begetting disease are enormously multiplied."15 The United States was not just a nation of farms, small towns, and industrial cities. For the country's poorest working people, America was a vast archipelago of camps. Nothing did more than smallpox to reveal this rarely mentioned fact about American society at the turn of the twentieth century.

During his tenure as state smallpox inspector, Dr. Long developed his own theory about the origin of the great wave of epidemics that struck the southern states beginning sometime in 1897: it all started in a single labor camp in Mexico. A few years before the southern epidemics, Long explained, a railroad contractor from Birmingham had taken a crew of African American railroad workers across the border to do a job. They contracted smallpox in the camp there and brought the disease back home with them. From Birmingham smallpox had slowly made its way, in the bodies of itinerant black workers, to the east and north, unnoticed or at least unremarked by the white public health authorities. Maybe the narrative of the North Carolina outbreaks properly began there. 16 Epidemiological uncertainty made moral certainty easier. A common, cautionary theme pervades this acc.u.mulating archive of smallpox narratives: "The pestilence that walketh in darkness" travels unseen in the bodies of the strangers and outliers who move among us. And it is fearful indeed.17 At the end of the nineteenth century, smallpox still reigned as the most infamous and loathsome of infectious diseases. Since the 1870s, serious epidemics of smallpox had grown relatively uncommon in the United States, but that did not lessen the fears attached to the disease. Nor did the fact that Americans of the period were far more likely to fall ill or die from diphtheria, influenza, scarlet fever, typhoid fever, or consumption. Smallpox occupied a special place in the hall of human horrors. As J. N. McCormack, secretary of the Kentucky Board of Health, put it, "One case of smallpox in a tramp will create far more alarm in any community in Kentucky than a hundred cases of typhoid fever and a dozen deaths in the leading families."18 The 1898 outbreaks coincided with the centennial commemorations of the invention of vaccination. In 1798, the English physician Edward Jenner had published his first paper on his experiments with smallpox vaccination (which he had conducted in 1796). Newspaper articles, magazine stories, and public speeches across the United States regaled Americans about the horrors of smallpox and the scientific triumph of Jennerian vaccination. In a speech to the "plain people" of Winston, North Carolina, "Colonel" A. W. Shaffer of the state board of health proclaimed that smallpox had been a "vile destroyer" since before "the first century of the Christian era." "Great kings and royal princes, stately women of high degree and matchless beauty, and babes at the mother's breast fell alike before its destroying blast and were disfigured and deformed for life, or thrust into the same hole with the filthy carca.s.ses of their meanest subjects."19 Shaffer did not exaggerate. The variola virus had been entangled with human history, to devastating effect, for millennia. No one knows when or how the virus first infected human beings. The earliest unequivocal descriptions of smallpox date to the fourth century A.D. in China, but scientists have long believed that the pustules found on the cheeks of Egyptian mummies from the twelfth century B.C. were caused by smallpox. Smallpox may have emerged as early as six thousand years ago-when the introduction of irrigated agriculture enabled human civilizations to grow large and dense enough to sustain the disease. By the time of Christ, smallpox was probably commonplace in the thickly populated valleys of the Nile and Ganges rivers, spreading from there across southwestern Asia. An inveterate camp follower, variola hitchhiked in the bodies of traders, soldiers, and other migrants. It spread east along the Burma and Silk roads and into China. In the eighth century, Islamic armies carried it through North Africa into the Iberian Peninsula. By the end of the tenth century, its expanding territory included much of southwestern Asia and the Mediterranean littoral of Africa and Europe. Many places had yet to be touched by the disease. But during the next six hundred years, smallpox became endemic in much of Europe, from whence it spread to most inhabited regions of the world. By the end of the eighteenth century, when Jenner first introduced vaccination in England, 400,000 Europeans were dying each year from smallpox.20 If the early history of smallpox remains mysterious, the origin of the variola virus itself is murkier still. The most plausible theory holds that the virus originated in a rodent, made the species leap to humans, adapted to its new host, and never went back. This much is certain: the variola virus has a special affinity for humans. Variola is one species in a larger genus of disease agents-the orthopoxviruses-that infect diverse members of the animal world. There is cowpox, monkeypox, racc.o.o.npox, camelpox, and so on. Many of those poxviruses infect multiple species. Cowpox, for example, has naturally occurred in cows, gerbils, rats, large cats, rhinoceroses, elephants, and humans. But the natural host range for variola is decidedly more narrow. It only infects people.21 The bond between variola and humans is not merely a virological curiosity. It is a fact of epidemiological and even world-historical significance. It is perhaps the essential fact about a virus that killed at least three hundred million people during the twentieth century alone-more than all of the century's wars. There is no animal reservoir or vector for smallpox. It cannot be transmitted by mosquitoes (as with malaria) or lice (typhus) or rat fleas (bubonic plague) or domestic animals (anthrax). Nor, for that matter, can smallpox infect people through their sewage-tainted water supplies (as does cholera) or contaminated food (typhoid fever). Smallpox can spread only from one person to another, normally through face-to-face contact.22 Smallpox is, as George W. Stoner observed in his Handbook for the Ship's Medicine Chest (1900), a "self-limited disease." An attack followed a distinctive clinical course for which there could be but two outcomes: smallpox either killed its victim or left the survivor immune for life. Although particles of the virus could persist for long periods in scabs on the bodies of the dead, variola did not remain in a living body after convalescence. There was no chronic recurrence, as in many herpes viruses. Smallpox survivors did not become symptomatic and infectious time and time again. They could never again get or spread the disease. This, rather than an appreciation for the poetry of the situation, was why Dr. Long hired Reverend Smoot to drive the pesthouse wagon.23 Human beings appear to be universally susceptible to the variola virus. Unless they have been made immune by a previous infection with variola or another orthopoxvirus-such as cowpox or vaccinia, the princ.i.p.al viruses used in vaccination-they will almost certainly develop smallpox if the virus particles enter their respiratory tracts.

Together these facts about the variola virus begin to explain the epidemiology of smallpox-its behavior in human communities. When the virus entered a population, smallpox tended to be pa.s.sed around until most people had been infected. In small, relatively isolated populations, such as most towns of colonial North America, the virus would soon die out. The virus particles did not normally survive for long outside the human body, and when the ranks of vulnerable humans were exhausted, variola had no place to replicate. For smallpox to become endemic in a given population (prevalent for a long period at a relatively low level), there had to be a steady influx of susceptible bodies, whether through significant levels of in-migration or by natural reproduction. This is why in societies where endemic smallpox existed, such as European or English cities in the eighteenth century, small-pox was known as a disease of children. Most children born in London had smallpox before their seventh birthdays; the disease was a rite of pa.s.sage. In English towns, nine out of ten fatal smallpox cases occurred in children under five. It was endemic smallpox that the nineteenth-century British historian Lord Thomas Macaulay famously called "the most terrible of all the ministers of death." "The smallpox was always present," he wrote, "filling the churchyard with corpses, tormenting with constant fear all whom it had not yet stricken, leaving on those whose lives it spared the hideous traces of its power, turning the babe into a changeling at which the mother shuddered, and making the eyes and cheeks of the betrothed maiden objects of horror to the lover."24 Of course, the "speckled monster" earned its worldwide infamy by its horrific epidemics. Major smallpox epidemics arose in two distinct epidemiological situations. In a so-called virgin soil population, one that had never been afflicted with smallpox or had been spared the virus for many years, a single epidemic could be devastating. In 1241, the people of Iceland had such an encounter with variola: some twenty thousand of the island's seventy thousand people died. The experience of indigenous populations of the Americas with epidemics of smallpox after the arrival of the Europeans in 1492 is well known if not easily fathomed. Many factors may have contributed to the extraordinarily high susceptibility of sixteenth-century American Indians to smallpox, including malnutrition, dislocation, and poverty-problems caused or exacerbated by the violent process of European colonization. But the likelihood that American Indians and their ancestors had no previous contact with the disease helps explain mortality rates that ran from 50 to 80 percent. Variola was the deadliest killer in a terrible onslaught of alien microorganisms that, by some historical estimates, may have decimated as much as 90 percent of the precontact population of the Americas.25 A different sort of epidemic occurred in well-populated places where smallpox was more or less always present, such as parts of late eighteenth-century Europe and England. The number of susceptible individuals in a community gradually built up over time, creating fodder for an "epidemic year," when smallpox became suddenly widespread and lethal. In this situation, where a majority of the adult population, including most of the breadwinners, was immune from previous infection, an epidemic could cause untold misery without seriously threatening the population's subsistence. 26 As with many infectious diseases, the incidence of smallpox rose and fell with the seasons. Climate, social factors, and the traits of the virus itself conspired to make smallpox a disease of the winter and spring. Variola remained viable longer at cooler temperatures. And the tendency of humans to crowd together indoors during the winter months made the virus's journey from person to person a short one.

Turn-of-the-century medical experts, well versed in the germ theory, a.s.sumed that some life form, invisible to the naked eye, caused smallpox. But they could only guess at its nature. "The contagious principle, probably a microbe, has not been discovered," declared an authoritative 1899 pamphlet, prepared by Marine-Hospital Service scientists for Surgeon General Wyman. Since the introduction of the germ theory, European and American scientists had hunted for the disease agent under their microscopes. A few reported seeing traces of smallpox "germs." Orthopoxviruses are among the largest known viruses, but they are still extremely small. According to one modern writer, it would take three million of them, laid out in rows, to pave over a standard typographic period. An actual sighting would not be possible until the invention of the electron microscope in the 1930s. In 1947 Canadian and American scientists finally viewed the particles, or virions, of variola.27 Since that time, variola virions have often been called bricks, because of their shape: a three-dimensional rectangle with slightly rounded edges. The name fits for other reasons as well. Each virion is made up of a combination of a hundred different proteins, which interlock in a structure so durable that it enables the virions to survive for a time in the open air. The k.n.o.bby protein exterior of each brick protects the genetic jewel within: a molecule of double-stranded DNA. By attaching itself to and then penetrating a susceptible cell, usually in the mucous membranes of the throat or lungs, a single virion has the power to trigger an unstoppable process of genetic replication that can turn a healthy person into a corpse.28 For all of its mysteries, the clinical features of smallpox were fairly well understood in January 1899, when Surgeon General Wyman issued his "Precis upon the Diagnosis and Treatment of Smallpox." The timing was significant. The disease was invading communities, mostly in the South, where neither the laypeople nor the physicians had seen a bona fide case of smallpox in many years, if ever. The "Precis" was, in no small measure, a political doc.u.ment. Wyman aimed to remind people of the necessity of vaccination, to sh.o.r.e up confidence in the nation's vaccine supply, to clarify the national government's limited responsibilities, and to spur the fiscally conservative local and state governments to take action.29 Wyman's officers in the Marine-Hospital Service disseminated the "Precis" widely, especially in the South. The report reflected state-of-the-art American medical knowledge about smallpox. Wyman's description of the clinical course of smallpox squares with descriptions of the disease found in medical treatises and journals from the period, as well as the accounts of local cases written by physicians such as Dr. Henry Long. The vast scientific literature on smallpox produced since that time has generally confirmed that clinical picture, while shedding new light on the virological and pathological processes that underlay the disease. Unlike the vast majority of physicians alive today, these turn-of-the-century experts had firsthand experience with smallpox. For them smallpox was not a frozen stockpile preserved, like ancient DNA sealed in amber, in a carefully guarded government laboratory vault and read about in medical journals. For them small-pox was still a part of the known world.30 Perhaps the most significant misunderstanding about smallpox shared by the authors of the "Precis" and many of their scientific contemporaries had to do with the mechanics of disease transmission. They understood correctly that smallpox could be spread by the pa.s.sage of "the microbe" from one person's respiratory system to another's. In fact, a person suffering from smallpox shed virions in each droplet of saliva. A single breath, cough, laugh, sigh, or spoken word was enough to launch the virions into the air. When one or more particles touched down upon the mucous membrane of another person's mouth, nose, throat, or lungs, the process of viral replication began within hours.

Where the "Precis" went wrong was in its insistence that such face-to-face contacts const.i.tuted a lesser threat than did the scabs and crusts of dried pus that fell from the skin of a convalescent patient. "The contagion is tenacious," the "Precis" stated, "and may be conveyed by persons and by fomites, such as hair, clothing, paper, letters, furniture, etc., or it may be spread through the air by means of the wind blowing the dust containing the virus." This belief in the infectious power of "fomites," contaminated objects of countless variety, led to the conclusion that smallpox was what nineteenth-century sanitarians called a "filth disease"-dangerous to all but spread chiefly by the lower orders. As the "Precis" put it, smallpox was "more common among the colored races, probably on account of their condition of living in small, crowded rooms, with slight regard for cleanliness."31 The "Precis" got the infective nature of variola about half-right. The crowded sleeping quarters that the world's poorest people called home-be it a sharecropping family's one-room cabin or a bamboo hut-were prime variola territory. It surprised no one when, two weeks after Harvey Perkins shared a hut with two other workers at Neal's Camp, reports reached Charlotte that two cases of smallpox had broken out in the encampment. There were obvious obstacles to maintaining personal hygiene and health under such circ.u.mstances. Still, scientists now believe that "filth" had little to do with the spread of smallpox. Laboratory tests have shown that the virions in smallpox scabs can, under optimal conditions, retain their infectivity for years. But the virions are so tightly bound within the hard fibrin mesh of the scab that it takes heavy grinding to release them. For this reason, many experts have concluded that fomites were "relatively unimportant" transmitters of infection, compared with the spread of virions in sneezes and coughs. This does not mean that infection by fomites never occurred-contaminated bed linen, in particular, readily transmitted infection-but the long-standing a.s.sociation of smallpox with the filthy poor was grounded more in cla.s.s and racial bias than in medical reality.32 Once the first virion penetrated the first cell in a person's respiratory tract, the incubation period began. During this period, most people presented no symptoms-perhaps a little malaise or gastric discomfort. Meanwhile, the variola bricks silently but explosively replicated and spread in the host's lymph nodes, spleen, and bone marrow. Over time, the virions piling up in the patient's cells would number in the quadrillions. The incubation normally lasted from ten to fourteen days. The "Precis" gave twelve days as the norm. Such medical facts determined the politics of smallpox control. Conservative health officials enforced two weeks as the term a smallpox "suspect," showing no symptoms, could be held against her will in a quarantined house or detention camp.33 When the symptoms finally came, they struck with such unexpected force that the "Precis" called the onset the "Invasion." The patient felt a sudden chill, followed by severe pain in the loins and lower back, a splitting headache, and a high fever, in some cases surging to 106 degrees F. The pulse raced. Many patients vomited. The tongue grew thick with a brown coating; the appet.i.te vanished, but the thirst was unquenchable. Some adults grew delirious. Some children were rocked by convulsions.34 In this early phase, as Dr. Long learned while attending to patients in the Iredell County pesthouse, smallpox remained inscrutable even to the trained medical eye. It could be typhoid fever, malaria, la grippe, or dengue. For the patient, these feverish days felt like a bad case of the flu, and some managed to carry on with their work. President Abraham Lincoln is believed to have been fighting the preeruptive fever of smallpox when he delivered the Gettysburg Address on November 19, 1863. One listener described the president's appearance as "sad, mournful, almost haggard." The rash appeared two days later.35 Smallpox patient from the Cleveland epidemic of 190103. This photograph was taken by Dr. Homer J. Hartzell, who headed the city's smallpox hospital. COURTESY OF THE DITTRICK MEDICAL HISTORY CENTER, CASE WESTERN RESERVE UNIVERSITY In a typical case, the fever fell by the second or third day. The const.i.tutional symptoms abated. The patient felt better. So much so, a nineteenth-century nurse's manual noted, that he might "suppose himself convalescent." Unknown to the patient, the lesions had already begun rising, about twenty-four hours earlier, on the mucous surfaces of the mouth, the back of the throat, and more generally throughout the alimentary and respiratory tracts. Modern virologists call this eruption the "enanthem." The enanthem tu