Her back hurt, but the change in her skin was painless, and she prayed and tried to remain optimistic. Her skin was growing darker and soft and a little puffy. It was slightly wrinkled, like the skin of an old person.
The red spots merged and flooded together, until much of her skin turned deep red, and her face turned purplish black. The skin became rubbery and silky smooth to the touch, with a velvety, corrugated look, which is referred to as crêpe-rubber skin. The whites of her eyes developed red spots, and her face swelled up as it darkened, and blood began to drip from her nose. It was smallpox blood, thick and dark. The nursing nuns, who were wearing masks and latex gloves, dabbed gently at her nose with paper wipes and helped her pray.
Smallpox virus interacts with the victims’ immune systems in different ways, and so it triggers different forms of disease in the human body. There is a mild type of smallpox called a varioloid rash. There is classical ordinary smallpox, which comes in two basic forms: the discrete type and the confluent type. In discrete ordinary smallpox, the pustules stand out on the skin as separate blisters, and the patient has a better chance of survival. In confluent-type ordinary smallpox, which Los had, the blisters merge into sheets, and it is typically fatal. Finally, there is hemorrhagic smallpox, in which bleeding occurs in the skin. Hemorrhagic smallpox is virtually one hundred percent fatal. The most extreme type is flat hemorrhagic smallpox, in which the skin does not blister but remains smooth. It darkens until it can look charred, and it can slip off the body in sheets. Doctors in the old days used to call it black pox. Hemorrhagic smallpox seems to occur in about three to twenty-five percent of the fatal cases, depending on how hot or virulent the strain of smallpox is. For some reason black pox is more common in teenagers.
The rims of Barbara Birke’s eyelids became wet with blood, while the whites of her eyes turned ruby red and swelled out in rings around the corneas. Dr. William Osler, in a study of black-pox cases at the Montreal General Hospital that he saw in 1875, noted that “the corneas appear sunk in dark red pits, giving to the patient a frightful appearance.” The blood in the eyes of a smallpox patient deteriorates over time, and if the patient lives long enough the whites of the eyes will turn solid black.
With flat hemorrhagic smallpox, the immune system goes into shock and cannot produce pus, while the virus amplifies with incredible speed and appears to sweep through the major organs of the body. Barbara Birke went into a condition known as disseminated intravascular coagulation (DIC), in which the blood begins to clot inside small vessels that leak blood at the same time. As the girl went into DIC, the membranes inside her mouth disintegrated. The nurses likely tried to get her to rinse the blood out of her mouth with sips of water.
In hemorrhagic smallpox, there is usually heavy bleeding from the rectum and vagina. In his study, Osler reported that “haemorrhage from the urinary passages occurred in a large proportion of the cases, and was often profuse, the blood coagulating in the chamber pot.” Yet there was rarely blood in the vomit, and somewhat to his surprise Osler noticed that some victims of hemorrhagic smallpox kept their appetites, and they continued to eat up to the last day of life. He autopsied a number of victims of flat hemorrhagic smallpox and found that, in some cases, the linings of the stomach and the upper intestine were speckled with blood blisters the size of beans, but the blisters did not rupture.
At the biocontainment unit at Wimbern, the victim’s deterioration occurred behind the chain-link fence, in a room out of sight. Dr. Paul Wehrle may have visited her (he thinks not), but there was nothing he could have said to her that would have helped, and nothing any doctor could do for her. He had seen hundreds of people dying of hemorrhagic smallpox, and he no longer felt there was any medical distinction among types and subtypes of the bloody form, that it was all an attempt by doctors to impose a scheme of order on something that was just a mess. By the time I spoke with him, the cases had flowed together in his mind, and he felt there was an inexorable sameness in the patients as the bleeding and shock came on. “It was perfectly horrifying,” he said.
Barbara Birke remained alert and conscious nearly up to the end, which came four days after the first signs of rash appeared on her body. For some reason, variola leaves its victims in a state of wakefulness. They see and feel everything that’s happening. In the final twenty-four hours, people with hemorrhagic smallpox will develop a pattern of shallow, almost imperceptible breaths, followed by a deep intake and exhalation, then more shallow breaths. This is known as Cheyne-Stokes breathing, and it can indicate bleeding in the brain. She prayed, and the nuns stayed with her. The Benedictine priest, Father Kunibert, who had offered communion to Peter Los, ended up at Wimbern himself with a mild case of smallpox. He may have given Birke her last rites. As the end approaches, the smallpox victim can remain conscious, in a kind of frozen awareness—“a peculiar state of apprehension and mental alertness that were said to be unlike the manifestations of any other disease,” in the words of the Big Red Book. As the cytokine storm devolves into chaos, the breathing may end with a sigh. The exact cause of death in fatal smallpox is unknown to science.
PEOPLE WHO are coming down with smallpox often exhibit a worried look, known as the “anxious face of smallpox.” A five-year-old girl named Rialitsa Liapsis, who came from a Greek family living in Meschede, got a worried look and broke with severe pustulation in the Wimbern isolation unit. She had been in a room at St. Walberga diagonally across the hall from Peter Los, suffering from meningitis, though she had never seen Los’s face. Rialitsa spent eight weeks recovering from smallpox in the Wimbern unit, sobbing every day for her parents, who were forbidden to see her. The little girl shared her room with Magdalena Geise, a nursing student who had worked on the second floor and had never seen Los but had broken with severe ordinary smallpox. On the day after Barbara Birke died, Magdalena Geise lost her memory completely and blanked out for three weeks. Finally, as her scabs fell off and her mind returned, she did her best to comfort the scared little girl who was crying in the bed on the other side of the room. She did all she could for Rialitsa Liapsis. Magdalena was in Wimbern for twelve weeks, longer than anyone else, and when she emerged she had gone bald, and her face, scalp, and body were a horrendous mass of smallpox scars. She returned to work as a student nurse in the hospital, and wore a wig, but the patients were frightened by her appearance, and the doctors finally had to take her off the ward. A year later, Magdalena Geise’s hair began to grow back, but it would take her ten years to get over her feelings of embarrassment about her appearance. Her religious faith helped her. Eventually, she married, had children and grandchildren, and found deep happiness and fulfillment. Her appearance today is that of a normal middle-aged woman with no disfigurement. Rialitsa Liapsis grew up and had children, and today the two women are friends.
Barbara Birke had had a friend at the hospital, another nursing student, Sabina Kunze, a tall, angular young woman with blond hair. Birke’s death left an opening in the cloister, and Kunze decided to take her friend’s place, and she made the vows and devoted her life to the work that she felt her friend would have accomplished had she lived. In the stories of Rialitsa, Magdalena, and Sabina, we see that the human spirit is tougher than variola.
Most of the people who broke with smallpox were patients and staff from the second and third floors of St. Walberga, and almost none of them had seen Peter Los’s face. Doctors Richter and Posch, along with Wehrle, traced the spread of the virus and concluded that seventeen of the victims caught the virus directly from Los. Two other victims caught it from people who had caught it from Los. One of the people who caught it from him was a nun in a room in the cloistered corridor on the third floor. She survived, but another nun who was put in her room afterward came down with smallpox, went confluent, and died.
A man named Fritz Funke had arrived at the hospital one day to visit his sick mother-in-law, who was in the isolation ward at the same time Los was there. Funke waited a few minutes in a lobby, then put his head up to
a door that was propped open a crack. The door opened onto the isolation corridor. Funke pleaded through the crack with a doctor to let him in, but the doctor forbade it. During the minute or so that Fritz Funke had held his face up to the door, he inhaled a few particles of variola. He had been vaccinated as an adult, in 1946, but his immunity had worn off, and two weeks later Funke was rushed to Wimbern inside a plastic bag. He survived a wicked case of smallpox. Today, the bioemergency planners know Fritz Funke as the Visitor, and they wonder about his case and see it as a disturbing example of variola’s ability to spread easily through the air out of a hospital to a vaccinated visitor who barely poked his head into a ward. In the end, there were nineteen cases of variola after Los’s, and there were four deaths.
Peter Los entered the stage of crust, in which the pustules begin to lose their pressure. They can rupture and leak, and they begin to develop into brown scabs that cover the body. During this phase, the bed linens of the victim become drenched with pus and extremely offensive. This was the most dangerous phase of the illness, for death often happens at the beginning of the crust, just as the patient seems to be turning the corner. But Los pulled through, and eventually they set a date for his release. A German television show called Tage found out about it and made plans to interview him, but he had no interest in being seen by millions. Two days before he was due to be discharged, he either climbed the fence or someone let him out, and he went home to his family. Eventually, he left Meschede, moved to West Berlin, and took various odd jobs there. It is said he went to Spain and lived on a houseboat for a time.
ONE COLD, DRY DAY in April 1970, three months after Peter Los had been admitted to the hospital, an expert in aerosols from West Berlin arrived at St. Walberga, bringing with him a machine for making smoke. Doctors Wehrle, Posch, and Richter wanted to find out exactly how the virus had traveled through the hospital. The smoke man placed his machine in the middle of Los’s old room and loaded it with a can of black soot. The doctors raised the window a couple of inches, in a re-creation of what Los had done when he disobeyed the nuns. They also left the door to the lobby propped open a crack, as it had been during the outbreak, when Fritz Funke had put his face up to it and come away infected with smallpox.
The smoke man switched on his machine, there was a whining sound, and a cloud of black smoke poured out of a nozzle and headed for Los’s door and billowed down the hallway of the isolation ward. Paul Wehrle ran along with it. The smoke went through the cracked-open door and poured into the lobby, and from there it boiled up the stairs to the second floor and then went to the third floor. As it came out of the stairwell it drifted along the upper hallways. It got through the closed doors of the cloistered hallway on the third floor, and it sprinkled a number of sick nuns with black dust.
“The patients got more of a treatment than they’d bargained on when they went to the hospital,” Wehrle said to me. “They were individually sooted with high-grade soot.”
The soot had an energizing effect on the Sisters of Mercy—like a rock thrown into a hornet’s nest. They began running up and down the stairs, crying out, “Stoppt diesen Idioten aus Berlin! Schaltet seine Maschine ab!”—“Stop this idiot from Berlin! Turn the machine off!”
The smoke man ignored them.
Meanwhile, Richter and Posch had gone outdoors and were standing on the lawn. Wehrle heard them shouting, and he opened a window and looked out.
The smoke was seeping outdoors under the raised casement window and flowing in a thin, fanlike sheet up the walls of the hospital. Wehrle ran around and began opening the upper windows just a crack. To his amazement, the smoke came into the upper rooms from outside, having crept up the walls. Someone had contracted smallpox in each of those upper rooms. “It was quite a demonstration of physics, and it told us how the people had become infected,” Wehrle recalled.
The smoke man was not at all surprised. He hardly raised an eyebrow. This is exactly what smoke does, he explained to the smallpox doctors. When there’s a fire inside a building, naturally the smoke goes all through the building, and in cold weather it climbs the outside walls. Smallpox particles are the same size as smoke particles, and they behave exactly like smoke. A biological wildfire had occurred in Los’s room, and the viral smoke had gotten into the upper floors of the hospital.
Today, the people who plan for a smallpox emergency can’t get the image of the Meschede hospital out of their minds. It is a lesson in the way smallpox particles have a propensity to drift long distances, and in how a victim of the virus can escape notice for days in a hospital. People who are coming down with smallpox have days of early illness, when the virus is leaking into the air from their mouths but they haven’t begun to develop a rash on their skin. A doctor would never suspect that such a patient had smallpox, because it looks like flu. The virus had ballooned in Meschede, going out of one man’s mouth and into the bodies of many who had never seen him, most of whom had no idea of his existence until after they had become infected. Dr. Karl Heinz Richter and his colleagues had performed a remarkable feat of biodefense. They were well prepared, they were ready to move in an instant, they had huge respect for the virus, and they had the full force of the WHO’s Smallpox Eradication Program behind them. Even so, twenty percent of the people inside the south wing of the St. Walberga Hospital contracted smallpox. Eighty percent of them were on floors above Los’s floor, and with the exception of Father Kunibert, not one of them had provably seen Los’s face.
When epidemiologists study the spread of infectious diseases, they work with mathematical models. A key in any of these models is the average number of new people who catch the disease from each infected person. This number is technically called R-zero but more simply is called the multiplier of the disease. The multiplier helps to show how fast the disease will spread. Most experts believe that the multiplier of smallpox in the modern world—a world of shopping malls, urban centers, busy international airports, tourism, cities and nations with highly mobile populations, and above all nearly no immunity to smallpox—would be somewhere between three and twenty. That is, each person infected with smallpox might give it to between three and twenty more people. Experts disagree about this. Some feel that smallpox is hardly contagious. Others believe it would spread shockingly fast. The fact is, nobody knows what the multiplier of smallpox would be today, and there is only one way to find out. If it has a mulitplier of something between five and twenty, it will likely spread explosively, because five or fifteen or twenty multiplied by itself every two weeks or so can get the world to millions of smallpox cases in a few months, absent effective control. It has taken the world twenty years to reach roughly fifty million cases of AIDS. Variola could reach that point in ten or twenty weeks. The outbreak grows not in a straight line but in an exponential rise, expanding at a faster and faster rate. It begins as a flicker of something in the straw in a barn full of hay, easy to put out with a glass of water if it’s noticed right then. But it quickly gives way to branching chains of explosive transmission of a lethal virus in a virgin population of nonimmune hosts. It is a biological chain reaction.
Peter Los gave variola to seventeen people. Thus the initial multiplier of the disease was seventeen. Then the multiplier dropped dramatically under the effect of vaccinations and quarantine, and went quickly to zero. The chain reaction stopped. The human population was like a nuclear reactor, and the vaccine was a set of emergency control rods that were in place and ready to go, and were slammed into the reactor as fast as possible by doctors who knew exactly what they were doing.
“The main lesson of Meschede,” Paul Wehrle said to me, “is that you have to be sure of the vaccine you are using.”
DURING THE SCABBING PHASE, the survivors of the Meschede outbreak shed many small dark discs of dried brown skin. The scabs peppered their bedsheets and clothing, and were found scattered on the ground where they had walked. The scabs were the lifeboats of variola. The virus particles were nested in a protective web of clotted blood�
�the scabs were survival capsules raining from the bodies of now recovering and immune people. The virus could wait patiently for some time in a dry scab, in the hope of finding another nonimmune host, if hope is a word that can be applied to a virus. Variola encountered walls of resistant humanity extending all around it, and the ring of containment held at the headwaters and mountains of the Ruhr—variola disappeared from that place on the earth, and has not been seen there since.
TO BHOLA ISLAND
Jumper
THOUSANDS OF YEARS AGO
SOMEWHERE BETWEEN ten thousand and three thousand years ago, smallpox jumped from an unknown animal into a person and began to spread. It was an emerging virus that made a trans-species jump into people from a host in nature. Viruses have many means of survival, and one of the most important is a virus’s ability to change natural hosts. Species become extinct; viruses move on.
There is something impressive about the trans-species jump of a virus. The event seems random yet full of purpose, like an unfurling of wings or a flash of stripes as a predator makes a rush. A virus exists in countless strains, or quasi-species, that are changing all the time yet are stable as a whole; together, they make a species. The quasi-species of a virus are like the surface of a flowing rapids, buffeted and shaped by the forces of natural selection. The form of the virus is stable, even while the edges and surface of the river are ever in motion and shifting a little, and the river of the virus always seeks new outlets. If a particular strain of a virus that lives in an animal manages to invade a person, it may be able to replicate there, and it may get to someone else. If it keeps moving, the result is an unbroken chain of human-to-human transmission. The virus has opened a new channel to immortality. This is what HIV did about fifty years ago in central or west Africa, when two different types of HIV seem to have jumped out of sooty mangabey monkeys and chimpanzees, and began spreading in people. Very often, when a virus jumps species, it is particularly lethal in its new host.
The Demon in the Freezer Page 5
