Revisioning smallpox in Revisioning smallpox in Mexico City-TenochtitlMexico City-Tenochtitlan, an,

1520-1950:1520-1950:chronology, contagiousness,

and control (charity, quarantine, inoculation and vaccination)

* * ** * *Robert McCaaRobert McCaa

chronology, contagiousness,chronology, contagiousness, and containment. and containment.

The roles of charity, quarantine, The roles of charity, quarantine, inoculation and vaccination.inoculation and vaccination.

Outline: Smallpox in Mexico C.Outline: Smallpox in Mexico C.» 0. Historiography0. Historiography

» Myths and misperceptionsMyths and misperceptions» An aside: epidemics in Ancient MexicoAn aside: epidemics in Ancient Mexico

» I. Chronology (periodicity)I. Chronology (periodicity)» Epidemic frequency in colonial timesEpidemic frequency in colonial times» Endemic in 19th and 20th centuriesEndemic in 19th and 20th centuries

» II. ContagiousnessII. Contagiousness» Genes or Care?Genes or Care?

» III. ContainmentIII. Containment» CharityCharity» VaccinationVaccination» Inoculation (out of order, in time)Inoculation (out of order, in time)

0. Historiography0. Historiography

Three questions on smallpox in Three questions on smallpox in Mexico City: chronology, Mexico City: chronology,

contagiousness, and containmentcontagiousness, and containment» 1. What was the periodicity of smallpox in 1. What was the periodicity of smallpox in

the history of the city?the history of the city?

» 2. Why did so many natives die from the 2. Why did so many natives die from the pox? Was it a matter of genes or ... (care)? pox? Was it a matter of genes or ... (care)?

» 3. How did smallpox become epidemic, then 3. How did smallpox become epidemic, then endemic, and finally extinct?endemic, and finally extinct?» a. Charity and quarantinea. Charity and quarantine» b. Vaccination: voluntary to compulsoryb. Vaccination: voluntary to compulsory» c. Inoculation: did it protect or propagate the pox?c. Inoculation: did it protect or propagate the pox?

» ““...on the very evening that the Aztecs drove the ...on the very evening that the Aztecs drove the conquistadors out of what is now Mexico City, conquistadors out of what is now Mexico City, killing many while routing the rest, a smallpox killing many while routing the rest, a smallpox epidemic began. --Oldstone, epidemic began. --Oldstone, Viruses, Plagues and Viruses, Plagues and HistoryHistory (Oxford, 1998 [derived from McNeil’s (Oxford, 1998 [derived from McNeil’s Plagues and PeoplePlagues and People])])

Pox myths: 1. chronology Pox myths: 1. chronology

» ““In Mexico, ever since 1520, the natives had In Mexico, ever since 1520, the natives had suffered from severe smallpox epidemics suffered from severe smallpox epidemics recurring every seventeen or eighteen years” recurring every seventeen or eighteen years” (Humboldt, John Black translation, 1811, p. 111).(Humboldt, John Black translation, 1811, p. 111).

» ““...on the very evening that the Aztecs drove the ...on the very evening that the Aztecs drove the conquistadors out of what is now Mexico City, conquistadors out of what is now Mexico City, killing many while routing the rest, a smallpox killing many while routing the rest, a smallpox epidemic began. --Oldstone, epidemic began. --Oldstone, Viruses, Plagues and Viruses, Plagues and HistoryHistory (Oxford, 1998 [derived from McNeil’s (Oxford, 1998 [derived from McNeil’s Plagues and PeoplePlagues and People])])

Pox myths: 1. chronology Pox myths: 1. chronology

» ““In Mexico, ever since 1520, the natives had In Mexico, ever since 1520, the natives had suffered from severe smallpox epidemics suffered from severe smallpox epidemics recurring every seventeen or eighteen years” recurring every seventeen or eighteen years” (Humboldt, John Black translation, 1811, p. 111).(Humboldt, John Black translation, 1811, p. 111).» ““As the number of inhabitants declined, due to As the number of inhabitants declined, due to epidemics, and as the number of susceptibles as epidemics, and as the number of susceptibles as well due to the immunity of survivors, in the 17well due to the immunity of survivors, in the 17thth century, the mortality curves flatten out. This century, the mortality curves flatten out. This resulted in fewer sick people and fewer deaths.” resulted in fewer sick people and fewer deaths.” --Bustamante (--Bustamante (400 años de la Viruela400 años de la Viruela, 1986)., 1986).

Pox myths: 2. contagiousness Pox myths: 2. contagiousness » ““...the Europeans’ capacity to resist certain ...the Europeans’ capacity to resist certain

diseases made them superior, in the pure diseases made them superior, in the pure Darwinian sense, to the Indians who Darwinian sense, to the Indians who succumbed.” --Jennings, succumbed.” --Jennings, The Invasion of The Invasion of AmericaAmerica (1975). (1975).

» ““...even in the nineteenth century when some ...even in the nineteenth century when some immunity had already been acquired by this immunity had already been acquired by this race...”--Stearns and Stearns, race...”--Stearns and Stearns, The Effect of The Effect of SmallpoxSmallpox (1945). (1945).

» ““...due to the immunity of survivors in the 17th ...due to the immunity of survivors in the 17th century, the mortality curves flatten out. century, the mortality curves flatten out. --Bustamante, --Bustamante, 400 años de la Viruela400 años de la Viruela, 1986., 1986.

Pox myths: 3. containment Pox myths: 3. containment » A. Charity: A. Charity:

» Did it make a difference? Did it make a difference?

» Was motivation self-interest or “Christian”? Was motivation self-interest or “Christian”?

» B. Quarantine: Did it work? B. Quarantine: Did it work? » C. Inoculation: C. Inoculation:

» When was it used? When was it used?

» Was its effect to prevent or propagate the disease?Was its effect to prevent or propagate the disease?

» D. Vaccination: D. Vaccination: » Why did smallpox become endemic in 19th century Why did smallpox become endemic in 19th century

Mexico? Mexico?

» Were there more smallpox deaths in the 19th than in Were there more smallpox deaths in the 19th than in prior centuries? prior centuries?

An aside:An aside:Ancient “Mexico” was no Ancient “Mexico” was no

“Golden Age”“Golden Age”

Ancient MexicoAncient Mexico» Epidemics existed (e.g., Epidemics existed (e.g., matlazahuatlmatlazahuatl, a , a

severe form of typhus), but not smallpox, severe form of typhus), but not smallpox, measles, malaria, yellow fever, or bubonic measles, malaria, yellow fever, or bubonic plague.plague.

» Epidemics in 1450, 1456, 1496, and 1507 Epidemics in 1450, 1456, 1496, and 1507 (according to (according to Anales de CuahtitlanAnales de Cuahtitlan))

» ““There’s hardly a person who walks who There’s hardly a person who walks who doesn’t complain of the bowels.”doesn’t complain of the bowels.”

» Skeletal archaeology shows porotic Skeletal archaeology shows porotic hyperostosis as nearly universal (perhaps hyperostosis as nearly universal (perhaps due to extreme dependence on corn). due to extreme dependence on corn).

11rabbitrabbit(1454):(1454):

“a“agreatgreat

hungerhungerkilledkilledmany many of the of the

people”people”

I. Smallpox chronology, I. Smallpox chronology, periodicityperiodicity

First epidemic, First epidemic, 1520:1520:

““Large bumps spread on Large bumps spread on people, some were people, some were entirely covered. entirely covered. They spread They spread everywhere, on the everywhere, on the face, the head, the face, the head, the chest, etc. chest, etc. [The disease] brought [The disease] brought great desolation; a great desolation; a great many died of it.”great many died of it.”

--Sahagun, --Sahagun, General HistoryGeneral History

Testimonies:Testimonies:Dating the epidemic...Dating the epidemic...

““It began in Tepeilhuitl [at the end of September].It began in Tepeilhuitl [at the end of September].......

The disease of the pustules lasted a full sixty days; The disease of the pustules lasted a full sixty days; after sixty days it abated and ended.after sixty days it abated and ended.

... ...

It broke out in Teotl eco, and it abated in It broke out in Teotl eco, and it abated in Panquetzaliztli. The Mexica warriors were Panquetzaliztli. The Mexica warriors were greatly weakened by it.”greatly weakened by it.”

--Sahagun, --Sahagun, General History General History

Dec. 1520: Death of Montezuma’s Dec. 1520: Death of Montezuma’s successor--from smallpoxsuccessor--from smallpox

“…“…he governed only 80 dayshe governed only 80 days…”…”

corpse enshrouded in corpse enshrouded in glyphs for smallpoxglyphs for smallpox

First epidemic: little effect on the First epidemic: little effect on the outcome of the conquestoutcome of the conquest

» Hugh Thomas, Hugh Thomas, Conquest of MexicoConquest of Mexico (1993): : “Extravagant” the notion that the smallpox “Extravagant” the notion that the smallpox epidemic had an effect on the outcome of epidemic had an effect on the outcome of the conquest.the conquest.

» Chronology: Spaniards defeated June 30; Chronology: Spaniards defeated June 30; epidemic began in late Sept. and ended in epidemic began in late Sept. and ended in December; siege began in April, 1521.December; siege began in April, 1521.

» Diplomacy: Aztecs unable to maintain Diplomacy: Aztecs unable to maintain dominion over suppressed peoples.dominion over suppressed peoples.

» Strategy: Christians and their allies erected Strategy: Christians and their allies erected a total siege of the island city (won in Aug.)a total siege of the island city (won in Aug.)

22nd nd

epidemic, epidemic, 1538:1538:

“this year of 7 “this year of 7 rabbits [and rabbits [and

of 1533] many of 1533] many people died of people died of

smallpox”smallpox”----CodexCodex

Telleriano-Telleriano-RemensisRemensis

What was the periodicity of What was the periodicity of smallpox the city?smallpox the city?

» 1616thth c., 2: 1520, 1533 [?], 1538 c., 2: 1520, 1533 [?], 1538» rather infrequentrather infrequent

» 1717thth c., 5: 1615, 1653, 1663, 1673, 1696 c., 5: 1615, 1653, 1663, 1673, 1696» from mid-17th century: Humboldt’s rule of from mid-17th century: Humboldt’s rule of

every 17 or 18 years every 17 or 18 years » 1818thth, 6: 1711, 1733, 1748, 1761, 1779, 1797, 6: 1711, 1733, 1748, 1761, 1779, 1797

» probably the worst century for smallpox probably the worst century for smallpox epidemicsepidemics

» was this due to increased communication? was this due to increased communication? » 1919thth, 3: 1804, 1829, 1840, 3: 1804, 1829, 1840» 2020thth, 1: 1915 [during the revo--few deaths], 1: 1915 [during the revo--few deaths]

Testimonies: Virgin of Guadalupe Testimonies: Virgin of Guadalupe procession 1545:procession 1545:

» ““The precious friars gathered a great many The precious friars gathered a great many children, female and male, who had just reached children, female and male, who had just reached the age of six or seven; they went along flogging the age of six or seven; they went along flogging themselves. … As soon as they arrived at her themselves. … As soon as they arrived at her churchly home, the friars offered very many churchly home, the friars offered very many prayers. And God the giver of life willed that prayers. And God the giver of life willed that through the intercession and prayers of the through the intercession and prayers of the compassionate personage, his precious, revered compassionate personage, his precious, revered mother, the epidemic would begin to subside. mother, the epidemic would begin to subside. The next day, not many people were being buried The next day, not many people were being buried any longer, and finally perhaps two or three any longer, and finally perhaps two or three people as the epidemic came to an end.”people as the epidemic came to an end.”

Smallpox, 1650-1810 (near Mx. City)Smallpox, 1650-1810 (near Mx. City)Smallpox, typhus and famine were the big killers in Old MexicoBurials in Cholula (region near Mexico City)

log

ari

thm

ic s

cale

The Age of Pestilence and Faminevertical lines denote smallpox crises

1661 1676 1708 1734 1761 1779 1797

10

20

50

100

200

500

1000

2000

5000

10000

20000

typhus

faminetyphus

typhus

typhus

famine

smallpox

smallpoxsmallpox smallpox

smallpoxsmallpox

smallpox

smallpoxsmallpox

Smallpox: not a big killer in 19th Smallpox: not a big killer in 19th century Mexico City, century Mexico City, thanks to vaccinationthanks to vaccination

Nor in the 20th...Nor in the 20th... republicrepublic citycity

18981898 2346723467 187187

18991899 3826938269 178178

19001900 2764227642 685685

19011901 1341613416 53 53

19021902 2811628116 57 57

19031903 2398723987 300300

19041904 1687816878 159159

19051905 1030510305 203203

19061906 1421014210 696696

19071907 1985419854 184184......

republicrepublic citycity

19111911 390390

19121912 429429

......

19221922 1196611966 542542

19231923 1307613076 401401

19241924 1296412964 124124

19251925 1100811008 36 36

19261926 54775477 22 22

19271927 66386638 5 5

......

republicrepublic citycity

19431943 40114011 64 64

19441944 23502350 17 17

19451945 10541054 3 3

19461946 561 561 4 4

19471947 549 549 22 22

19481948 11011101 32 32

19491949 461 461 16 16

19501950 153 153 7 7

19511951 54 54 0 0

19521952 31 31 0 0

II. ContagiousnessII. Contagiousness

2. Why did so many natives die 2. Why did so many natives die from the pox: genes or care? from the pox: genes or care?

» Genetic interpretation, a crude Darwinism, Genetic interpretation, a crude Darwinism, is favored (Stearn and Stearn, Jennings, is favored (Stearn and Stearn, Jennings, Bustamante, and others).Bustamante, and others).

» The role of care, on first experience: The role of care, on first experience: » Natives did not know how to care for the illNatives did not know how to care for the ill

» Adult caregivers were themselves ill from the Adult caregivers were themselves ill from the diseasedisease

Jennings, Jennings, The Invasion of The Invasion of AmericaAmerica (1975:22) (1975:22)

» ““...the Europeans’ capacity to resist certain ...the Europeans’ capacity to resist certain diseases made them superior, in the pure diseases made them superior, in the pure Darwinian sense, to the Indians who Darwinian sense, to the Indians who succumbed.” succumbed.”

» ““smallpox was smallpox...the Indians on the smallpox was smallpox...the Indians on the north [bank of the Rio Grande] had as little north [bank of the Rio Grande] had as little biological immunity to this epidemic scourge as biological immunity to this epidemic scourge as the Aztecs had.” the Aztecs had.”

» ““...even in the nineteenth century when some ...even in the nineteenth century when some immunity had already been acquired by this immunity had already been acquired by this race...”--Stearns and Stearns race...”--Stearns and Stearns

Bustamante, Bustamante, 400 anos de 400 anos de viruelas en Mexicoviruelas en Mexico::

• ““Los seres humanos, aislados en AmLos seres humanos, aislados en Améérica por rica por miles de años, formaron una población miles de años, formaron una población inmunológicamente autóctona, con factores de inmunológicamente autóctona, con factores de susceptibilidad o de resistencia diferentes a los de susceptibilidad o de resistencia diferentes a los de la gente del Antiguo Mundo.”la gente del Antiguo Mundo.”

• ““As the number of inhabitants declined, due to As the number of inhabitants declined, due to epidemics, and as the number of susceptibles as epidemics, and as the number of susceptibles as well, due to the immunity of survivors in the 17th well, due to the immunity of survivors in the 17th century, the mortality curves flatten out. This century, the mortality curves flatten out. This resulted in fewer sick people and fewer deaths.”resulted in fewer sick people and fewer deaths.”

nor was there anyone to give them bread or nor was there anyone to give them bread or anything else.” --Motolinanything else.” --Motoliníaía

Testimonies: care? Testimonies: care? (text vs. pictures, 1582)(text vs. pictures, 1582)

““Many others Many others died of died of starvation, starvation, because as because as they were they were all taken all taken sick at once, sick at once, they could they could not care for not care for each othereach other, ,

III. ContainmentIII. Containment

III.A. CharityIII.A. Charity

Charity,Charity,1544-1544-1545:1545:killerkiller

epidemic epidemic (not (not

smallpox)smallpox)among among

the the Indians Indians

Order Order establishing establishing

block-by-blockblock-by-blockcharity charity

commissions, commissions, Mexico CityMexico City7 Nov., 17977 Nov., 1797

Charity campaign not begun until Charity campaign not begun until week nine of epidemic (1797)week nine of epidemic (1797)

III.B. Vaccination, III.B. Vaccination, 1804-19521804-1952

How did smallpox become How did smallpox become epidemic, then endemic, and epidemic, then endemic, and

finally extinct?finally extinct?» Epidemic: throughout colonial era to 1840.Epidemic: throughout colonial era to 1840.

» Endemic, 1840-1954: from voluntary Endemic, 1840-1954: from voluntary (1804) to compulsory vaccination (1882)(1804) to compulsory vaccination (1882)

» Extinction, 1903-1954: Extinction, 1903-1954: » mandatory universal vaccination by six mandatory universal vaccination by six

months of age throughout the Republic (1903)months of age throughout the Republic (1903)

» mobile brigades to quarantine, vaccinate, and mobile brigades to quarantine, vaccinate, and suffocate outbreaks (1931-)suffocate outbreaks (1931-)

Sporadic Sporadic vaccination vaccination

campaigns, often campaigns, often impelled by an impelled by an

imminent imminent outbreak, outbreak, converted converted

smallpox from smallpox from epidemic to epidemic to

endemic killerendemic killer

Testimonies: Dr. Luis MuTestimonies: Dr. Luis Muñozñoz, , chief medical officer (1864)chief medical officer (1864)

» ““The vaccine, more widely extended than The vaccine, more widely extended than inoculation had ever been, diminished in a inoculation had ever been, diminished in a considerable way the number of people at risk considerable way the number of people at risk (‘(‘aptasaptas’), and at the same time removed the ’), and at the same time removed the reservoir (‘reservoir (‘focosfocos’) of contagion which was ’) of contagion which was necessary for the disease to thrive.”necessary for the disease to thrive.”

By 1900, smallpox was no By 1900, smallpox was no longer a Big Killer in Mexicolonger a Big Killer in Mexico

III. C. Inoculation, III. C. Inoculation, 1797 1797

““...from the distinguished inaction of the ...from the distinguished inaction of the Spaniards, inoculation was soon relinquished; Spaniards, inoculation was soon relinquished;

and no other country in Europe and no other country in Europe has suffered so little from the Small Pox.”has suffered so little from the Small Pox.”

--Moore, --Moore, History of the SmallpoxHistory of the Smallpox, 1815, p. 288, 1815, p. 288

The inoculationist shell gameThe inoculationist shell game

» Compare fatility rates from natural Compare fatility rates from natural smallpox with that from inoculation smallpox with that from inoculation

» But, never consider the public health issue But, never consider the public health issue that inoculation without quarantine that inoculation without quarantine condemned to death many innocents. condemned to death many innocents.

» Only in the 19th century would inoculation Only in the 19th century would inoculation w/o quarantine become manslaughter (e.g., w/o quarantine become manslaughter (e.g., Moore, Moore, History of SmallpoxHistory of Smallpox, 1815, p. 305), 1815, p. 305)

Did inoculation protect or Did inoculation protect or propagate the disease?propagate the disease?

» Inoculation protected the inoculated: Inoculation protected the inoculated: case fatality rate from artificial pox was case fatality rate from artificial pox was 1/10th rate from natural pox (1%:10%)1/10th rate from natural pox (1%:10%)

» Without quarantine, propagated the diseaseWithout quarantine, propagated the disease» Mexico City, inoculation with consent: yesMexico City, inoculation with consent: yes» Durango, universal inoculation: noDurango, universal inoculation: no» Chiapas, sporadic...varied village to villageChiapas, sporadic...varied village to village» London, inoculation with little quarantine: yesLondon, inoculation with little quarantine: yes» Boston, “general” inoculation: yesBoston, “general” inoculation: yes

Inoculation w/o quarantine began Inoculation w/o quarantine began before mortality was countablebefore mortality was countable

Testimonies: Testimonies: “Scurrilous verses”, 1797“Scurrilous verses”, 1797

Inoculations have been invented by the most poor Inoculations have been invented by the most poor and needy doctorsand needy doctors

……

One One seessees that the inoculated are infected that the inoculated are infected

Unfortunate Mexico, one regrets that Unfortunate Mexico, one regrets that the poor the poor doctors have infected youdoctors have infected you

With With experience one sees the evidenceexperience one sees the evidence for this for this

The very poor and hungry doctors who bring the The very poor and hungry doctors who bring the smallpox have invented [inoculation].smallpox have invented [inoculation].

Case of Durango Case of Durango

» Eighty-seven percent of the susceptible Eighty-seven percent of the susceptible population (4,400 individuals) was inoculated in a population (4,400 individuals) was inoculated in a matter of days, of whom about one percent died. matter of days, of whom about one percent died.

» Among those infected with the natural pox, the Among those infected with the natural pox, the fatality rate was ten times as great. fatality rate was ten times as great.

» The risks for the few women who were pregnant The risks for the few women who were pregnant at the time were, in contrast, horrifying. at the time were, in contrast, horrifying. » Of nine who were inoculated, one died and two Of nine who were inoculated, one died and two

aborted. aborted.

» Natural pox struck three. One died, and all aborted.Natural pox struck three. One died, and all aborted.

Mass inoculation worked for Mass inoculation worked for Indians of Chiapas Indians of Chiapas (correlation between (correlation between

inoculation rate and decline in inoculation rate and decline in mortality 1779 to 1797)mortality 1779 to 1797)

London: Inoculation made the old London: Inoculation made the old mortality ceiling the new floormortality ceiling the new floor

Case of London Case of London

» Not widely practiced and had, at best, a marginal Not widely practiced and had, at best, a marginal effect on mortality (Branton).effect on mortality (Branton).

» In London, inoculation is correlated with a surge In London, inoculation is correlated with a surge in deaths due to smallpox (previous graph).in deaths due to smallpox (previous graph).

» Quakers in London: increase in deaths due to Quakers in London: increase in deaths due to smallpox epidemics (see Branton)smallpox epidemics (see Branton)

» % increase in deaths by age during years of % increase in deaths by age during years of smallpox epidemics vs. normal years. smallpox epidemics vs. normal years. ageage 1730-491730-49 1750-741750-74 1775-991775-992-92-9 1.121.12 1.261.26 1.231.23

Moore, Moore, History of SmallpoxHistory of Smallpox, 1815 , 1815

» ““Had it been possible formerly to have persuaded Had it been possible formerly to have persuaded every human being to have submitted to every human being to have submitted to inoculation, a great saving of human lives would inoculation, a great saving of human lives would have ensued: but this was impracticable; and the have ensued: but this was impracticable; and the experience of a century has shewn, that partial experience of a century has shewn, that partial inoculation, by diffusing contagion, multiplied inoculation, by diffusing contagion, multiplied deaths.” (p. 303).deaths.” (p. 303).

Moore, Moore, History of SmallpoxHistory of Smallpox, 1815 , 1815 » 303: “All the benefits of inoculation, without the 303: “All the benefits of inoculation, without the

mischiefs, might however have then been mischiefs, might however have then been obtained, by precluding the inoculated, while the obtained, by precluding the inoculated, while the infection was upon them, from intercourse with infection was upon them, from intercourse with persons who had not already passed through the persons who had not already passed through the Small Pox. But instead of this salutary Small Pox. But instead of this salutary precaution being even now adopted, there are precaution being even now adopted, there are miscreants of the medical profession, so miscreants of the medical profession, so stimulated by avarice, and so divested of stimulated by avarice, and so divested of humanity, as to disseminate the contagion of humanity, as to disseminate the contagion of Small Pox through the most populous quarters of Small Pox through the most populous quarters of London.”London.”

Gil, Gil, Disertación físico-médicaDisertación físico-médica, 1784 , 1784 » ““I am not opposed to inoculation, if it is I am not opposed to inoculation, if it is

administered with the necessary precautions.” administered with the necessary precautions.”

» ““Inoculation propagates the pestilent effects of Inoculation propagates the pestilent effects of smallpox, if exact measures are not taken to smallpox, if exact measures are not taken to quarantine both the natural and artificially quarantine both the natural and artificially infected.” infected.”

» On London, Gil cited evidence from the Bills of On London, Gil cited evidence from the Bills of Mortality (paragraph 41) showing that a Mortality (paragraph 41) showing that a substantial increase in smallpox deaths followed substantial increase in smallpox deaths followed the general adoption of inoculation in the City the general adoption of inoculation in the City after 1747. His analysis was correct (and after 1747. His analysis was correct (and unnoticed). unnoticed).

Conclusions &Conclusions &ReflectionsReflections

Conclusions... (Mexico)Conclusions... (Mexico)» Battle against smallpox evoked multiple Battle against smallpox evoked multiple

responses from authorities and populaceresponses from authorities and populace

» Care and containment were marginally Care and containment were marginally effective... until vaccination.effective... until vaccination.

» Inoculation spread the disease, except Inoculation spread the disease, except where it was “general” or quarantine was where it was “general” or quarantine was faithfully practiced.faithfully practiced.

» Vaccination contained the disease and Vaccination contained the disease and reduced fatalities, even though universal reduced fatalities, even though universal practice was impossible.practice was impossible.

ReflectionsReflections

» Monocausal explanations of the Monocausal explanations of the demographic catastrophe (e.g., Cook, demographic catastrophe (e.g., Cook, Born Born to Dieto Die, Cambridge, 1998) should be , Cambridge, 1998) should be reconsidered.reconsidered.

» Genetic explanations do not fit well with the Genetic explanations do not fit well with the history of smallpox (or indeed with the fear history of smallpox (or indeed with the fear of biological terrorism). of biological terrorism).

» Charitable instincts regarding smallpox Charitable instincts regarding smallpox were remarkable, although not particularly were remarkable, although not particularly effective. effective.

chronology, contagiousness, and control (charity, quarantine,

inoculation and vaccination)EEndnd