How to eliminate the respiratory tract infection that often recurs

prof: i want to turn tothe next topic, which marks a new unit in ourcourse. that is to say,until now we've dealt with bubonic plague,in a series of talks and in your first section meeting. now i'd like to look,for comparative purposes, at a very different high-impactdisease; and this time and next we'll bedealing with smallpox. so, i think you deserve ananswer to the obvious questions:

why smallpox,and why at this stage in the course? so, i want to give you a littlebit of explanation, to see where we're going. the first has to do with imight call a varied intellectual diet,and i want us to deal with diseases of very differenttypes, and so we'll have to examinethe impact of different kinds of infectious diseases.

plague was a bacterial disease. smallpox instead is viral. plague was transmitted byvectors. you know the drill now,the role of rats and fleas. smallpox instead is spread bycontact and airborne inhalation of droplets. plague is a classic epidemicdisease, in the sense that it's an outside invader that ravagesa locality for a season and then departs.

smallpox is different in thatit can be both endemic and epidemic. so, we'll see a differentdynamic. it's also true that the socialresponses to smallpox were quite different. plague was associated withterror and social disruption, and in the new world we'll seethat it had an even more dramatic impact on the native--smallpox did--on the native american population.

but in european conditions itwas a familiar endemic disease with a less dramatic--as a cause--was less dramatic as a cause of social tensionsand disruption. we'll see too that in terms ofimpact, for chronology it makes sense to look at smallpox atthis stage in our class. it had long been present inhuman history, but there was an upsurge insmallpox in the seventeenth and eighteenth centuries thataccompanied the surge in the demography of europe.

and it also reflected thetransformation of social and economic conditions associatedwith the commercialization of agriculture,the onset of industrial development,and rapid, unplanned urbanization,with those associated pathologies such asovercrowding, both at home and in theworkplace. in those conditions,smallpox was a great killer, and it succeeded plague as themost dreaded disease of the

late-seventeenth and theeighteenth century. in a sense, we're moving frombubonic plague, the most dreaded disease of itsera, to--in a sense,in terms of fear--to smallpox as the next most dreaded diseaseof the next period in the eighteenth century. but there's more to it thatthat. smallpox, as you'll see in ourreading and in our lecture next time, was also extraordinarilyimportant in terms of its impact

in the new world. it led to a demographiccatastrophe for the native american population,largely spontaneously, but there were also intentionalacts of genocide involved. so, we're going to see,in terms of one of the themes of our course,that disease, and particularly smallpox,played an important role in the big picture of history;in conditioning or creating factors that were important ineuropean settlement in the new

world,and that led to the introduction of african slavery,as the native american population had no immunity andperished from smallpox, and therefore could not beenslaved; whereas africans,possessing immunity, were imported to replace them. another major feature andreason for dealing with smallpox has to do with another theme ofour course, and that is public health.

we've already dealt with plaguemeasures of public health. you know what they are,the plague measures: boards of health,quarantine, lazarettos, sanitary cordons,emergency burial regulations. smallpox, by contrast,was to lead to a very different but highly effective style ofpublic health; that is, first inoculation andthen vaccination, associated with edward jenner. even more spectacularly thanplague measures,

vaccination ultimately promoteda victory over smallpox, leading in 1980 to its totalglobal eradication, at least naturally occurringsmallpox; the first, and still as wespeak, the only human disease to be so intentionally eradicated. unlike plague measures,vaccination was a powerful tool of public health. successful vaccines havesubsequently been developed against other diseases:measles, rubella,

whooping cough,tetanus, diphtheria, rabies, polio. but again, like plaguemeasures, vaccines have been controversial--and we'll be talking about when vaccines form an appropriatestrategy-- and eradication has been evermore elusive for diseases other than smallpox. it may be that smallpox is aspecial case, rather than,as many hoped,

a model for the eradication ofdiseases sequentially, one after another. we'll be looking also atsmallpox because of its demographic and economiceffects. we talked, in terms of plague,of a mortality revolution, in terms of demography,and also of its impact on industrialization. smallpox and the successfulcontainment of smallpox through inoculation and vaccination alsohad a major impact on that

mortality revolution,and therefore also on economic development. we'll be looking also atcultural impact, and we'll see that smallpoxalso produced the cult of certain new saints;that it too became a theme in the arts and literature. more speculatively,we talked last time about the possible relationship of thesuccessful conquest of plague on the coming of the enlightenment.

well, smallpox provides us witha second instance of the successful deployment of humanmeans to control a major cause of death and anguish,making life more secure and longer. it's suggested that a number ofleading philosophes were avid proponents of inoculation,including voltaire and condorcet. so, we'll be dealing with thoseissues. but this morning what i'd liketo do is to concentrate on

something more narrow,which is--but forms the basis for our understanding of theimpact of this disease-- its nature as a disease. how it affects the individualhuman body, and what were the treatments in the seventeenth,eighteenth centuries. let's begin with smallpox as adisease. smallpox, often nicknamed,for reasons we'll soon see, "the speckledmonster." it's a virus belonging to thefamily of orthopox viruses that

includes variola major,variola minor and cowpox. we'll talk about cowpox nexttime, because of its influence in the development ofvaccination. but our theme will concernvariola major and variola minor;especially variola major, which is thecausative agent, primarily, of smallpox. this is a picture of variolamajor, the largest of all

viruses, first seen by themicroscope in 1905. this causes classical smallpox. there's variola minor aswell, that first appeared in the twentieth century;and for our purposes we can afford to ignore it. it was of minor impact and now,like variola major, it's extinct as well. now, one question is,what's a virus? we talked about the termmicrobe;

microbe being a generic termfor microscopic organisms, including bacteria,like our friend yersinia pestis,the causative agent of bubonic plague,and viruses like variola major and variolaminor, the pathogens that causesmallpox. plague was caused by bacteria,and those, as you know--and will bestudying more on science hill-- are unicellular organisms thatare definitely and unequivocally

alive. they reproduce by dividing. they contain dna,plus all the cellular machinery necessary to read it,and to produce the many proteins that enable it to liveand reproduce. viruses are something different. and here there's a possibleconfusion lurking for the historian. the word "virus"itself is ancient.

in the humoral system,in fact, when diseases were seen to arise from assaults onthe body on the outside, one of the major environmentalinsults that was thought to lead to disease was the corrupted airor miasma, and this was influenced by apoison, that might be called a virus. so, if you do research onmedical history, you'll see the term"virus" used in an old sense for manycenturies.

but "virus"in present medical discourse is a term that dates its modernusage from the early twentieth century,and it refers to parasitic particles,perhaps 500 times smaller than bacteria. their existence was establishedby elegant scientific experiments in the first yearsof the century, completed by about 1903. but they couldn't actually beseen until the invention of

electron microscope in the1930s, and their functioning wasn'tunderstood until the dna revolution of the 1950s. so, viruses,we now know, consist of some of the elementsof life, stripped to their most basic. a virus really is nothing morethan a piece of genetic material wrapped in a protein case. they're particles that areinert on their own.

viruses lack the machinery toread dna, or to make proteins, or carry out metabolicprocesses. they can do nothing on theirown, and they cannot reproduce by themselves. their survival depends insteadon invading living cells. once inside,they highjack the cell and its machinery. the genetic code of thevirus--and the virus, after all, is almost nothingelse--gives the cell the message

it needs to reproduce morevirus, thus transforming cells intovirus producing factories, and in the process they destroythe host cell. as they produce more and moreviruses, and destroy more and morecells, the effect on the human body can be severe,even catastrophic, depending on the capacity ofthe immune system to contain or destroy the invasion. here we have,in a sense, the opposite of a

hippocratic idea of disease;the body assaulted, not from the outside,but rather from a parasitic pathogen deep within. there is an exotic debate,of course--are viruses alive? those who argue that they arealive, note that they're capable of transmitting geneticmaterial, one of the key indications of life. those who claim they're notalive, note that on their own they're inert,that they can't carry on

metabolic processes,or produce proteins. viruses, they note,are the ultimate parasites. virologists often say thatwhether you decide that viruses are alive or not is ultimately amatter or disciplinary perspective,or perhaps even personal preference. the reassuring point for us isthat, perhaps excepting theology, the answer doesn'treally matter. in any case,what we need to know is that

smallpox was caused by a virus,and a virus that has no animal reservoir. the disease was restrictedentirely to human beings, and that will prove to beimportant in making it eventually a good candidate foreradication. the name for the virus,variola, derives from the latinvarius, meaning spotted. and in england the disease,in fact, was popularly called,

as i've said,"the speckled monster." so, here's a picture of thesmallpox virus--oops, it's gone out;there it is. and that's a schematic image ofa smallpox virus. and as i said,there is a mutation that occurred in the twentiethcentury, causing the rise of variola minor,as well as variola major.

but we'll be concernedexclusively here with variola major;the main cause of smallpox historically. well, how was it transmitted? here we need to remember thatsmallpox is an exceedingly contagious disease. a smallpox patient shedsmillions of infective viruses into his or her immediatesurroundings, from the rash and from the opensores in the sufferer's throat.

the patient is infective fromjust before the onset of the rash until the very last scabfalls off weeks later. not everyone,of course, who is exposed is infected. living along with people withimmunity-- and leaving that aside--it hasbeen estimated that the chances are about 50:50 that asusceptible member of a household would contractsmallpox from an ill patient in the home.

the dominant manner to spreadsmallpox was by contact infection,droplets breathed out in face-to-face contact with asusceptible person and inhaled by that person. normally the spread was in thecontext of intense contact over a period of time;that is, a family member, or someone on a hospital ward,in an enclosed workplace--an office,a factory, a mine--a school classroom,an army barrack, a refugee camp.

and it's most easilytransmitted in dry, cool seasons. that's the primary mode oftransmission. there are two more,however, that are more relatively secondary. a second mode of transmissionis by what are called--another bit of jargon here--fomites. a fomite is simply an inanimateobject, capable of carrying infectious material from oneperson to another.

examples might be bed linen,clothing; the shroud from an infectedperson that transmits viruses from one body--that is,of the sufferer--to the next person. other examples are simplydoorknobs, eating utensils, and so on. so, that's a second mode oftransmission. there's a third too,that smallpox can be vertically transmitted;that is, from mother to infant.

it's possible for an infant tobe born with congenital smallpox. well, that's the mode oftransmission. what about its epidemiology? well, some favoring factorsinclude large urban populations. it's not coincidental thatsmallpox raged in western europe in the eighteenth century. the crowded living conditionsand workplaces were ideal for its transmission.

trade and the movement ofpeople, displaced people, warfare. people who assembled andreassembled in crowds were ideal for transmitting smallpox. the disease is known to haveafflicted ancient egypt. mummies are known to have beenvictims of smallpox. but the important point is thatit became endemic in europe, that became the world reservoirof infection, from which it spread by trade,colonization,

and in european cities itbecame, above all, a disease of childhood. but about a third of the deathsof children in the seventeenth century were due to smallpox. so, a reason then for dealingwith smallpox now, in our course,is that it was on a major upsurge in the seventeenth andeighteenth centuries. how was it named? why is it called smallpox?

a small point. but we need to know that it'sfrom a comparative description of its characteristic lesions. the "great pox"is a disease which we'll be dealing with pretty soon,which was syphilis, that creates large lesions andaffects adults. the smallpox had small lesionsand primarily affected children; at least in countries in whichit was endemic. another point we should knowabout smallpox is that after

infection, a person enjoys alifelong immunity. we need to know that becauseit's a major factor in the public health measures that thedisease eventually generated. well, what about its symptoms? how does it affect theindividual human body? after inhaling the virus,there's an incubation period, which normally lasts somethinglike twelve days. this is important in itsepidemiology because it allowed the spread of the disease;because an infected person had

ample time to travel beforefalling ill, and therefore time to take the disease with him orher and to spread it. now, i'm going to give someattention--perhaps more than you might like when you see theimages--to the symptoms of and there's a reason for that. part is that smallpox istremendously, terribly, terrifyingly painful. plus it leads--and this isimportant too, in the way that it impactedsociety--

it often produces lifelongscarring, disfiguring and blindness,and these in turn spread fear of it and terror. and, so, the very word smallpoxhas a particular resonance in popular imagination,associated with dread. people sometimes ask,in a course like this, which of the diseases weencounter was really the worst? the question doesn't permitempirical verification, because no one has eversuffered, mercifully,

all the afflictions we studyand had the opportunity to compare. but it is meaningful to notethe impression of those who lived through the times whensmallpox claimed its legions of victims. they thought--and thephysicians who treated them--that smallpox was theworst of human maladies; that was a term that was saidat the time. and this, in fact,was the view,

closer to home,of the illinois state board of health in 1902,where dr. donald hopkins wrote this:"in the suddenness and unpredictability of its attack,in the grotesque torture of its victims,in the brutality of its lethal or disfiguring outcome,and in the dread that it inspired, smallpox is the worst. it's unique among humandiseases." to the extent that that's true,it's also one of the reasons

that smallpox appeals to themalevolent as a possible instrument of bioterror. it's well-known that a majoroutbreak of smallpox would spread death,maximize suffering, and lead to widespread fear,flight and social disruption. the symptoms are important toexamine as an integral part of this disease. and more generally,unless we appreciate the distinctive symptoms of each ofthe diseases we examine,

there's a distorting temptationto allow them to run together, the diseases,as so many interchangeable causes of death;a point of view that prevents us from understanding that eachof these epidemic diseases had a distinctive and differentimprint. smallpox was the disease thatit was, in part because of the dread that it generated;fear not only of death, but also of exquisitesuffering, maiming, disfiguring and blindness.

only with that in mind,can we understand why it's also so widely thought to be acandidate for bioterror. so, we'll look at images of thedisease. and i apologize to those of youwho've just finished breakfast or just about to have lunch. in any case,first after the incubation period, there's the pre-eruptivestage. the virus multiplies in thesystem for twelve days after incubation,and symptoms of disease begin

with a viral shower,as the pathogen is released into the bloodstream and spreadssystemically throughout the body,localizing eventually in the blood vessels of the skin,just below the superficial layers. the viral load released,and the efficiency of the body's immune response,determine the severity and type of the disease. onset is sudden,with fever of 100 to 102

degrees, and a general malaise. this, then, is the beginning ofperhaps a month of excruciating suffering and the danger ofspreading contagion. the early symptoms are fever,vomiting, severe backache, splitting frontal headache,and in children sometimes convulsions. sometimes the disease is sooverwhelming that it leads to what's called fulminatingsmallpox, which causes death withinthirty-six hours,

with no outward manifestationsat all; although post-mortem examsreveal hemorrhages in the respiratory tract,the alimentary tract or the heart muscles. let me give you a descriptionof a hyper-acute case of that kind. physicians wrote:"after three to four days, the patient has the generalaspect of someone who's passed through a long and exhaustingstruggle.

his face has lost allexpression, is mask-like, and there's a wont of tone inall muscles. when he speaks,this condition becomes more apparent, speaking as withevident effort, and the voice is low andmonotonous. the patient is listless andindifferent to surroundings. the mental attitude is similar. there's a loss of tension,a lengthening of reaction time, and defective control.

in the most fulminant cases,the aspect of the patient resembles that of someonesuffering from severe shock and loss of blood. the face is drawn and pallid. respiration is sighing orgasping. the patient tosses aboutcontinually, and cries out. his attention is fixed withdifficulty, and he complains only of agonizing pain;now in the chest, now in the back,the head or the abdomen."

but normally smallpox wasn'tfulminant quite like that, and the patient passed on tothe next phase, which was the eruptive one,exhibiting the classical symptoms of smallpox that led toits diagnosis. on the third day after onset,the patient usually felt a little better,and in mild cases he or she could return to normalactivities, with the unfortunate effectthat this spread the disease further.

but concurrently a rashappeared; a small round or oval,rose-colored lesion, known as a macule,that's up to a quarter-of-an-inch in diameter. the macules appeared first onthe tongue and palate, and then, within twenty-fourhours, it spread to cover the body,down to the palms of the hands and soles of the feet. on the cheek and forehead,the appearance is of severe

sunburn, and indeed thesensation felt by the patient is of scalding pain or intenseburning. there's a characteristicpattern, called centrifugal distribution;that is, that the rash is least spread on the trunk of the bodyand most densely apparent on the face and the extremities. let me show you a slide of avery ill little boy, and you can see thiscentrifugal pattern in which the rash is most apparent on theextremities,

rather than the trunk. on day two of the rash,a little further into the infection, the lesions alter. at this time the macule becomesharder, and generally rises above the surface intostructures known as papules, with a flattened apex. to the touch,they were said, by physicians,to feel like buckshot embodied in the skin.

and there we can see thepicture of a face, at that stage of the disease. the disease then moves on,by the fifth day of the rash, when fluid begins to accumulatein pockmarks, which are then raised and firmto the touch-- so we'll pass on--now calledvesicles. they've grown in size. they've changed in color fromred to bluish or purple. and they've transformed fromsolid to blister-like fluid.

it's umbilicated as well. the process of what's calledvesiculation, the rise of this stage of therash, takes about three days and lasts a further three. it's at this stage that thephysical diagnosis of smallpox becomes reliable,with the disease presenting its most distinctive appearance. the patient experiencesincreasing difficulty in swallowing and in talking,due to extensive lesions in the

mucous membranes in the palateand the throat. and there's a child at thisstage of the disease. then by the sixth day of therash, pus begins to form in the pockmarks. the patient feels much worse. septicemia can set in. the pustules,as they're now called, begin to fill with yellowfluid, and the lesions become globular in shape;a process that takes about two

days, and they're fully maturedon the eighth day of the eruptive phase. the patient feels dreadful atthis point. fever has risen in proportionto the severity of the attack. the eyelids,lips, nose and tongue are tremendously swollen. and we can see a picture of anadult at that phase of the infection. at this point,the patient is almost totally

unable to swallow or talk,and deteriorates slowly, being drowsy most of the timeand restless at night. often he or she is in acondition of delirium, and thrashes about;may even try to escape. the psychological effectsweren't simply a sign of high fever. they resulted also from theinvolvement of the central nervous system in the infection,and the neurological effects and sequelae could often belasting and result in long-term

impairment. then, by the ninth day of therash, the pustules were firm andembedded in the skin, and for this reason werelikely--and this was important in the impact of the disease--to leave permanent scars and deep pits on the face,or wherever they appeared on the body;if you can imagine by at this stage. another unpleasant aspect atthis stage was that a terrible

sickly smell developed,the fetor of smallpox, that physicians claimed that itwas impossible to describe but was found to be overpowering. it's now nearly impossible forthe patient to drink, and even milk caused intenseburning sensations in the throat. the patient experiences greatloss in weight--as much as thirty to forty pounds in anadult--and may suffer from frank starvation.

in addition,there's a complete loss of muscle tone,while the face, in severe cases,takes on the appearance of a cadaver,making the patient almost unrecognizable,even to his or her closest relatives. the scalp may be one largelesion, and tangled with hair. and lesions,as you can imagine, under the nails of fingers andtoes were exquisitely painful.

i want to show anotherdisturbing image--this was important, but you can look awayif you like--which was the lesions of the eyes. because smallpox was a majorcause of blindness, as well as death anddisfigurement, in this period. well, after about ten tofourteen days of rash, scabs appear,and these contain live smallpox virus as well,and are highly infective and

important in the spread of thedisease by fomites. at this point,the fluid portion of the pustule is absorbed,leaving behind the solid part. large areas of the skin maybegin to peel off, leaving deeper tissues raw andexposed. these areas are all painful,and contribute to the frightening appearance and themisery of the patient. fatal cases often occurred fromabout the eighth day, and an important reason wastoxemia, because these lesions

were susceptible to infection. so, attentive nursing,good hygiene and sound nutrition reduced the likelihoodof that sort of complication. and, to that degree at least,the prosperous, the well-nursed and well-caredfor were more likely to survive. the appearance of the patientwas often described by physicians as mortification;the still living patient taking on the appearance of beingmummified, and the skin of the face fixedin a grotesque mask,

with the mouth permanently open. the appearance of scabs andcrusting though was a favorable sign in terms of prognosis forthe patient. but they did lead to one finaltorment of the disease, which was an intolerableitching that accompanied that period;indeed, a large portion of the scarring that resulted fromsmallpox was undoubtedly due to patients scratching and tearingat their lesions. well, the appearance anddistribution of the pustules was

of major importance fordiagnosis, and it could be what was called"discrete smallpox," where the rash was--each lesion was distinct and separated from the next. and this meant that you had acase fatality rate of as low as about nine percent;you had a ninety percent chance of survival. if instead the lesions weremuch closer together--semi-confluent it wascalled--the case fatality rate

rose to something likethirty-seven percent. or in cases of what was called"confluent smallpox," in which the lesions touchedone another and formed a network surrounded by islands ofunaffected skin, the case fatality rate wasabout sixty-five percent. so, the appearance of thelesions was very important in your prognosis. the rarest form was hemorrhagicsmallpox, which had a hundred percentmortality,

so-called because the naturalclotting mechanisms of the blood were impaired,and the victim died of massive internal hemorrhaging. overall, the case fatality ratefor smallpox was estimated to be about thirty to forty percent. the virus then attacked notonly the skin and the throat, but also the lungs,the heart, the liver and other internal organs,and could result in hemorrhaging and death.

a major danger was alsosecondary bacterial infection of the lesions;a very common cause of mortality. meanwhile, the lesions of themouth and throat were of great epidemiological importance,because they're the source of the viruses that commonly formdroplets in the air and infect others. also, the tongue became swollenand misshapen. there was difficulty breathing.

the patient became hoarse,swallowing was difficult. and all of that was important. there were other sources ofanguish and suffering: blindness, scarring anddisfigurement, respiratory complications. but after the drying up of therash, the patient began to recover. and among the population thatsurvived, the symptoms declined and thepatient regained strength and

possessed a lifelong immunityfrom a second exposure. all of this led,of course, as you can imagine, to tremendous fear of thedisease--as in this picture--of variola. well, how did physicians dealwith this disease? smallpox no longer occursnaturally anywhere on the planet. but it's worth remembering thatthere is still no specific remedy or cure for the disease.

treatment, should a case appeartoday, would be largely supportive,depending above all on intensive nursing,to keep the lesions scrupulously clean,to prevent bedsores and to minimize the breakdown of theskin. in addition,modern medicine would replace lost fluids and nutrients,and would administer antibiotics, not to deal withthe virus, but with the bacterialinfections that are its

complications. what were traditional remedies? some of them were surprising. one was a great vogue in thecolor red. there was a vogue to hang redcurtains around the bed of a patient. red furniture was brought intothe sickroom, and patients,including queen elizabeth i of england, were wrapped in redblankets.

later on, the discovery ofultraviolet rays in fact gave new impetus to this traditionalmania for red, and red glass went up onwindows. in the late nineteenth century,medical journals published studies suggesting also that redlight could be soothing to the eyes of the sufferer,and that perhaps it prevented scarring of the skin. so, that was one factor. another idea that was verycommon was to open the pustule

with a golden needle,to drain the fluid, and then sometimes the lesionswere cauterized in an attempt to prevent scarring;procedures that were exceedingly painful. the next idea was what wascalled "the hot regimen,"to pile the sufferer with blankets,to induce him or her to sweat profusely,to rid the body of the over-abundant humor.

or the patient could beimmersed in a hot bath. light and fresh air,according to this therapeutic fashion,were deemed to be harmful, and the patient was kept in thedark, if possible,with minimal ventilation. sunlight was said to aggravatethe disease and increase scarring. and sometimes patients weregiven internal medications, sudorifics, to help theevacuation of the excess humor.

the opposite was also tried,the so-called "cold regimen,"to keep the room cool, and frequently to sponge downthe patient with cold water, to place-ice bags on the face. then there was purging andbloodletting. there was also theadministration of opiates, in the nineteenth century,and especially morphine, to calm the patient indelirium. astringent eye drops wereresorted to.

a particularly perverse theory,with no empirical basis, was the idea that scarring onthe face could be reduced or prevented by causing moreintense irritation of the skin elsewhere;so that mustard plasters, mercury and corrosives wereapplied on the back, in order to save the face. there were also all kinds oflocal applications to the face, to try to prevent scarring. nitrate of silver,mercury, iodine,

mild acids, a lotion of sulfur;all of those had their vogues. there were ointments andcompresses of virtually every substance known to man. some physicians held the theorythat their preparations would soften the lesion and mitigatescarring. so, indeed, ingenious doctorsapplied lint, boric acid or glycerin;or they covered the face with a mask, leaving holes for theeyes, nose and mouth. or they wrapped the face andhands in oiled silk.

alcoholic beverages wereadministered to deteriorating patients to revive their energy. and sometimes deliriouspatients were actually tied to their beds. some doctors recommendedrestraints, such as splints, in later stages,to prevent patients from scarring their faces byscratching. after hearing of all of thesetreatments for smallpox, perhaps you'll appreciate thework of thomas sydenham,

in the seventeenth century,the so-called english hippocrates,who decided that the wealthy and noble who received extensiveattention and treatment for smallpox perished of the diseasemore frequently than the poor, who had no access to treatment. and his advice was that thebest physician was the one who did the least. he was an advocate oftherapeutic minimalism. he advised instead a simplecool regimen,

giving his patients fresh airand light bed coverings. well, that's how the diseaseafflicted the human body. what i want to do next time,now that we understand this terrible disease and thesuffering it caused, is to deal with its impacthistorically, its effect on society,and to look at the development of a public health strategy,which was to be vaccination.