Michael R. Albert, MD; Kristen G. Ostheimer, MA; David J. Liewehr, MS; Seth M. Steinberg, PhD; Joel G. Breman, MD, DTPH
Albert MR, Ostheimer KG, Liewehr DJ, Steinberg SM, Breman JG. Smallpox Manifestations and Survival during the Boston Epidemic of 1901 to 1903. Ann Intern Med. 2002;137:993-1000. doi: 10.7326/0003-4819-137-12-200212170-00013
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Published: Ann Intern Med. 2002;137(12):993-1000.
Clinical records of 243 patients with smallpox consecutively admitted to the Southampton Street smallpox hospital in Boston, Massachusetts, during the 1901â€“1903 epidemic were reviewed. Smallpox was divided into five categories of varying severity; 47% of patients had varioloid, a relatively mild form of the disease usually occurring in previously vaccinated individuals with incomplete immunity. Survival information is available for 206 patients, of whom 36 (17.5%) died. Vaccination status, disease severity, and age were associated with survival, whereas sex, birthplace, and race were not. While full recovery often took weeks, most deaths occurred 7 to 14 days after the onset of symptoms, and all deaths occurred within 18 days of symptom onset. Smallpox was eradicated worldwide in 1977, but knowledge of the disease is essential because its cause, variola virus, is considered a potential biological weapon.
Clinical records were compiled in a single, bound book. Demographic information, smallpox type, and vaccination history were recorded at the beginning of a patient's record (name, age, and marital status are not shown but were listed at the top of the page). The patient was a 43-year-old woman who was discharged “well” on 22 March 1902. (From clinical records of the Southampton Street smallpox hospital, Francis A. Countway Library of Medicine, Boston Medical Library, Boston.).
The patient had been successfully vaccinated in infancy and was discharged “well” 2 weeks later. (From clinical records of the Southampton Street smallpox hospital, Francis A. Countway Library of Medicine, Boston Medical Library, Boston.).
The patient had been unsuccessfully vaccinated 3 months before admission. Pustules appear in the same stage (monomorphic)—a characteristic feature of smallpox. She was discharged “well” 1 month later, although facial pitting was noted. (From clinical records of the Southampton Street smallpox hospital, Francis A. Countway Library of Medicine, Boston Medical Library, Boston.).
The patient had a history of successful vaccination in infancy. On discharge 1 month later, he was described as “well”: “weak on legs but is apparently mentally sound … has one discharging boil on legs.” (From clinical records of the Southampton Street smallpox hospital, Francis A. Countway Library of Medicine, Boston Medical Library, Boston.).
The patient at day 4 ( ), day 6 ( ), and day 11 ( ) after the onset of illness. There appear to be purpuric lesions on days 6 and 11. A diagnosis of a hemorrhagic form of smallpox had been considered by staff shortly after admission. The patient died on day 12. (From clinical records of the Southampton Street smallpox hospital, Francis A. Countway Library of Medicine, Boston Medical Library, Boston.).
Survival stratified by vaccination status ( = 0.005) ( ); type of vaccination (global = 0.012; = 0.005 for successful vs. none; = 0.034 for recent primary vs. none) ( ); disease severity ( < 0.001) ( ); and age (global = 0.015; = 0.008 for patients younger than 5 years of age vs. patients 5 years of age or older and younger than 45 years of age; = 0.048 for patients 45 years of age or older vs. patients 5 years of age or older and younger than 45 years of age) ( ). Symbols indicate deaths, and the numbers of patients at risk are indicated at 7-day intervals along the x-axis.
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