By David A. Carrino
The Cleveland Civil War Roundtable
Copyright © 2023, All Rights Reserved
Editor’s note: This article was originally published in The Charger in November 2023.
Because Home sapiens occupies such a highly advanced position on the evolutionary scale, people too often lose sight of the fact that humans are biological units that are subject to the processes, limitations, and vagaries of biology. This reality about humans is perhaps no more evident than when mankind is helpless before a pathogenic disease. In such situations, humans, despite their lofty phylogenetic perch, become virtually powerless, at least for a time, against infectious agents that are far less complex biologically than Homo sapiens and far lower phylogenetically. Throughout history there have been diseases which, because of their severity and magnitude, had an enormous and alarming impact on society and caused fear among people as these diseases spread. Arguably the most notorious of these diseases was the bubonic plague during the Middle Ages. Another such disease was the flu pandemic of 1918-1919. More recently there was acquired immune deficiency syndrome (AIDS) and still more recently COVID-19. One of the most dreaded diseases during the 19th century, as well as in earlier times, was smallpox.
Smallpox is a serious, very contagious disease that is caused by the variola virus. The disease is characterized by lesions on most areas of the body. Two forms of smallpox are recognized: variola major, which is a more severe form having a fatality rate around 30%, and variola minor, which is less severe and has a fatality rate of 1%. The two forms of the disease are caused by different variola viruses. Both forms of the disease are accompanied by fever, malaise, muscle aches, headache, and lethargy, all of which begin prior to the appearance of the lesions. The lesions first emerge as a rash, which progresses to blisters, then pustules, and then scabs, which eventually fall off and can leave pitted scars. Smallpox has been afflicting humans for many centuries, and there is evidence that the disease has existed since before 1,000 B.C.E. (which, to dispel any conspiracy theory notions, makes it unlikely that the variola virus found its way into nature due to an accidental leak from a research laboratory or that the virus was specifically manufactured for use as a bioweapon).
The only known medical treatment for smallpox is immunization, and a smallpox immunization procedure was in use in various places around the world for quite some time prior to the Civil War. However, in 1796 English physician Edward Jenner made an important modification to this procedure that substantially improved the safety of smallpox immunization. Prior to 1796, smallpox immunization had been in use in Europe for decades and had been in practice in Asia even longer. But these immunizations involved deliberate exposure to the actual smallpox virus by inoculating recipients with material from smallpox lesions. For one such immunization procedure, fluid from pustules was applied into scratches that were made in the skin of a recipient. These immunization procedures obviously entailed serious associated risks, and Jenner developed an alternative to this risky procedure.
Jenner was aware of the folklore that milkmaids displayed immunity toward smallpox, and he insightfully reasoned that this was due to their exposure to cowpox, a viral disease in cows that can affect humans, but which is much milder than smallpox. In May 1796, a milkmaid named Sarah Nelmes came to Jenner for an examination of a rash on her hands, which Jenner diagnosed as cowpox, not smallpox. Jenner used this opportunity to test his hypothesis about the purported smallpox immunity of milkmaids. Using the skin-scratch inoculation procedure for smallpox immunization, Jenner took material from the lesions on Nelmes’ hand and exposed James Phipps, the eight-year-old son of Jenner’s gardener, to cowpox. Phipps developed the mild illness associated with a human case of cowpox, but then recovered after a few days.
The truly perilous and also probative part of Jenner’s experiment came a couple of months later when Jenner exposed Phipps to smallpox via the skin-scratch procedure. When Phipps did not develop smallpox, Jenner was no doubt quite relieved, if only because he did not afflict Phipps with a dreadful disease, but also because Phipps’ immunity was consistent with Jenner’s hypothesis and provided evidence in support of it. In all likelihood, Phipps’ parents were also quite relieved as was, probably most of all, James Phipps, himself. Many similar tests on other people proved that exposure to cowpox protects humans from smallpox. Jenner’s ingenious reasoning and subsequent detailed if risky experimentation laid the groundwork for the principle that exposure of humans to a similar but less dangerous immunogen can confer immunity to a more virulent pathogen, and this forms the basis for later forms of vaccination. In fact, the word “vaccine” is derived from the Latin word for cow (“vacca”).
News of Jenner’s vaccination procedure reached the U.S. late in the 18th century, and smallpox vaccination in the U.S. began early in the 19th century. Most of this vaccination occurred along the east coast, and the vast majority of people in rural areas were unvaccinated. Despite Jenner’s improved procedure, smallpox remained a serious problem, and severe outbreaks continued to happen worldwide. For example, at the time of Abraham Lincoln’s Gettysburg Address, the city of Washington was in the midst of a serious outbreak. It was well-known that Washington was not the healthiest place in which to live, as noted by William Stoddard, who has been called “Lincoln’s forgotten secretary.” Stoddard, who was an assistant to John Hay and John Nicolay, wrote that the city of Washington was “unhealthy to a degree positively alarming” and further wrote with regard to conditions in Washington, “The number of kinds of fevers, colds, sore throats, rheumatics, small pox, gun-shot wounds, and delirium tremens…is enough to convince any man that ‘there is something wrong about the air of the place.'”
When Lincoln delivered his Gettysburg Address on November 19, 1863 and for some time thereafter, he was suffering with an illness that most accounts state was a mild case of smallpox. One of the doctors who examined Lincoln called the illness “a touch of the varioloid” (varioloid being a word to indicate a mild form of smallpox). But is that really what Lincoln’s illness was? On the train ride to Gettysburg, Lincoln began to feel ill. Lincoln’s son Tad had taken ill prior to Lincoln’s departure. Tad was febrile and weak, but no other details of his illness were recorded. On the trip to Gettysburg, Lincoln said that he felt weak. The next day, the day when Lincoln delivered the Gettysburg Address, he said that he felt dizzy, and Hay observed that as Lincoln was delivering the address, his face was “a ghastly color.” On the return trip to Washington, Lincoln took very ill. He was weak and feverish and complained of a severe headache. William Johnson, Lincoln’s African American valet, put a wet towel to Lincoln’s head to relieve the pain, and Lincoln spent much of the train ride lying down. In light of Lincoln’s illness, it is remarkable that he was able to summon the strength to deliver his address and perhaps even more remarkable that he was able to endure Edward Everett’s two-hour oration.
After returning to the White House, Lincoln’s illness worsened. His fever intensified, and he began to suffer with malaise, exhaustion, and backache. Two days after his return, a rash appeared on Lincoln’s body, and on the next day blisters appeared. It was at this time that Lincoln was told of the diagnosis of varioloid. In spite of the dreadful news that he had contracted this dangerous and highly contagious disease, Lincoln still maintained his renowned humor, which Lincoln displayed when he replied to the diagnosis by asking the doctor if he had noticed all of the people who were waiting to see Lincoln. When the doctor replied that he had seen the crowd, Lincoln, referring to his contagious disease, quipped, “They are there, every mother’s son of them, for one purpose only; namely, to get something from me. For once in my life as President, I find myself in a position to give everybody something.”
During the next few days, Lincoln was confined to a sickroom, and his doctor did not allow Lincoln to receive visitors. Five days after the appearance of the blisters, there was peeling and itching of Lincoln’s skin. William Stoddard recorded that smallpox vaccinations were administered to the White House staff. Lincoln remained confined until early December, and even John Hay was not allowed to see him at this time. There is no account of whether the lesions on Lincoln’s skin became pustules, but when Lincoln was permitted to meet with a reporter on December 6 after the illness had subsided, the reporter noted, “His face is slightly marked.” Lincoln was still weak at this time and lacked his usual stamina. He had lost weight, and it was not until the middle of December that he was able to fully conduct the duties of his office. Lincoln’s health did not return to normal until the middle of January 1864.
One possible consequence of Lincoln’s illness was the death of his valet, William Johnson. Johnson had ministered to Lincoln on the train trip from Gettysburg to Washington and reportedly also for a time after the return to the White House. Sadly, Johnson contracted smallpox and died of the disease in January 1864. Lincoln had met Johnson in Illinois and brought Johnson to Washington with him. Because the permanent servants in the White House refused to accept Johnson into the staff, Lincoln helped Johnson find a job with the treasury department, although Johnson was allowed to accompany Lincoln on certain trips. After Johnson’s death, Lincoln paid Johnson’s debts, sent money to Johnson’s family, and arranged and paid for Johnson’s burial in Arlington Cemetery. Lincoln did not believe that he was the source of Johnson’s smallpox, as evidenced when Lincoln told a reporter, “He did not catch it from me, however; at least I think not.” Perhaps this was wishful thinking on Lincoln’s part, since Lincoln was extremely fond of Johnson. It will never be known with certainty where Johnson contracted smallpox, but smallpox was quite prevalent in Washington at that time, so it is not unlikely that Johnson caught the disease from someone other than Lincoln.
In contrast to Johnson, Lincoln, after a few frightful weeks, survived his illness, and this is one of those historical outcomes that had a profound effect on the course of the United States. But how close did Lincoln really come to dying? There is evidence that those near Lincoln, such as Hay, Nicolay, and Stoddard, feared that he would die. Hay recorded in his diary on November 26, “The President quite unwell.” Stoddard wrote that he, Hay, and Nicolay engaged in “mournful consultations over the idea that all the country would go to ruin if Abraham Lincoln should die.” On the other hand, the doctors who examined Lincoln gave a diagnosis of varioloid, and this led afterward to the generally accepted thinking that Lincoln had a mild case of smallpox. But is this correct? Just how severe was Lincoln’s smallpox? Or phrased in a different and catchy way, how ‘small’ was Lincoln’s smallpox? Was his smallpox not very ‘small,’ that is, was it a mild case of smallpox? Or was Lincoln’s smallpox extremely ‘small,’ in other words, full-blown smallpox?
In considering this issue, it is important to understand that the word “varioloid” is used to indicate a mild case of smallpox, such as smallpox that is made less severe by a person’s acquired immunity to the disease due to either prior infection or vaccination. But if Lincoln had varioloid, as the doctors who examined Lincoln diagnosed, then presumably Lincoln had either smallpox or smallpox vaccination at some earlier time in his life. In this regard, an article appeared in 2007 in the Journal of Medical Biography in which the authors, Armond Goldman and Frank Schmalstieg Jr., did a retrospective analysis of Lincoln’s post-Gettysburg Address illness and concluded that Lincoln had full-fledged smallpox. Goldman and Schmalstieg were faculty members in the pediatrics department at the University of Texas Medical Branch in Galveston, Texas and had expertise in and did research in immunology.
For their analysis, Goldman and Schmalstieg used published works of Lincoln contemporaries such as John Hay and John Nicolay, some biographies of Lincoln, a summary of Lincoln’s illness in a book about the history of smallpox, an account (as recalled by another doctor who heard this account) of the consulting visit by the doctor who pronounced the diagnosis as “a touch of the varioloid,” and a day-by-day brief listing of Lincoln’s life published by the Lincoln Sesquicentennial Commission. Goldman and Schmalstieg indicated that one difficulty in their retrospective analysis of Lincoln’s post-Gettysburg Address illness is that Lincoln’s personal physician, Robert Stone, who ministered to Lincoln at this time, recorded nothing about Lincoln’s illness in his extensive case notes. Some have suggested that perhaps Stone was being secretive about Lincoln’s illness for fear of alarming the public. Lacking potentially valuable information from Stone, Goldman and Schmalstieg made their conclusion about Lincoln’s illness based on what has been recorded about it.
Goldman and Schmalstieg state that the known clinical features and etiology for Lincoln’s illness are consistent with smallpox as opposed to some similar diseases, such as varicella (chickenpox), monkeypox, and rickettsialpox. Hence, these other diseases were ruled out as the illness that afflicted Lincoln. Goldman and Schmalstieg then considered whether Lincoln had full-fledged smallpox as opposed to a mild case of smallpox (that is, varioloid). One possible reason for a mild case of smallpox is that Lincoln had variola minor (the less severe form of smallpox) rather than variola major (the more severe form of smallpox). However, variola minor did not appear in the U.S. until late in the 19th century, so this could not have been the disease that Lincoln had. Another reason for a mild case of smallpox is immunity to the smallpox virus due to either prior infection or vaccination, that is, immune-modified smallpox as opposed to immune-unmodified smallpox. It is not known if Lincoln had ever been immunized against smallpox, but Goldman and Schmalstieg assert that Lincoln’s recorded symptoms as well as the duration of the disease “more closely approximated immune-unmodified variola major than immune-modified variola major.” Thus, based on the available information, Goldman and Schmalstieg concluded that Abraham Lincoln’s post-Gettysburg Address illness was full-fledged smallpox.
Retrospective analyses of illnesses are not easy, and Goldman and Schmalstieg are careful in their article to point out that their retrospective analysis of Lincoln’s post-Gettysburg Address illness was difficult to do because of the paucity of available information. For example, Goldman and Schmalstieg admit in their article that it would have been helpful to know if Lincoln had been vaccinated against smallpox. No evidence exists that Lincoln was ever vaccinated, but absence of evidence is not evidence of absence, and this is one complication in the analysis by Goldman and Schmalstieg. As a result of the difficulties with their retrospective analysis, Goldman and Schmalstieg’s conclusion about Lincoln’s post-Gettysburg Address illness cannot be considered ironclad. But if Goldman and Schmalstieg’s conclusion is correct, it is extremely fortunate for the U.S. that Lincoln survived the disease. Moreover, whenever those who agree with this conclusion hear in a lecture or in a conversation that in the weeks following the Gettysburg Address Lincoln suffered from varioloid, they can respond by saying that Lincoln’s illness may have been much ‘smaller’ than that.
Sources (Click on the book titles below to purchase from Amazon. Part of the proceeds from any book purchased from Amazon through the CCWRT website is returned to the CCWRT to support its education and preservation programs.)
A number of sources were used for this article. The most useful sources are as follows.
Abraham Lincoln’s Gettysburg Illness by Armond S. Goldman and Frank C. Schmalstieg Jr. (published in Journal of Medical Biography, volume 15, number 2, pp. 104-110, May 2007)
Smallpox Visits the White House by Stanley M. Aronson (published in Medicine & Health Rhode Island, volume 85, number 2, p. 47, February 2002)
Abraham Lincoln, Smallpox, and the Gettysburg Address by Matthew W. Lively
Abraham Lincoln’s Gettysburg Smallpox by Rebecca Beatrice Brooks
Abraham Lincoln and Smallpox by Feather Schwartz Foster
The Greatest Killer: Smallpox in History by Donald R. Hopkins (1983)
Inside the White House in War Times by William O. Stoddard (1890)
Dispatches from Lincoln’s White House: The Anonymous Civil War Journalism of Presidential Secretary William O. Stoddard by William O. Stoddard, edited by Michael Burlingame (2002)
Lincoln’s White House Secretary: The Adventurous Life of William O. Stoddard edited by Harold Holzer (2007)
Mr. Lincoln & Friends: William O. Stoddard; The Lehrman Institute
A Surgeon’s Life: The Autobiography of J.M.T. Finney by John Miller Turpin Finney (1940)
Mr. Lincoln at Washington; The Lehrman Institute
The Lincoln Log: A Daily Chronology of the Life of Abraham Lincoln, 1863; Lincoln Sesquicentennial Commission
Smallpox by Mayo Clinic Staff
Assessment of Future Scientific Needs for Live Variola Virus; National Academy of Sciences
Smallpox: The Course of the Disease by the Editors of the Encyclopaedia Britannica
Laboratory Differentiation between Variola Major and Variola Minor by K. R. Dumbell, H. S. Bedson, and E. Rossier (published in Bulletin of the World Health Organization, volume 25, number 1, pp. 73-78, 1961)
Variolation vs. Vaccination: 18th Century Developments in Smallpox Inoculation by Talya Housman
Smallpox; U.S. Food & Drug Administration
About Edward Jenner; The Jenner Institute
Lessons from Abraham Lincoln by Stan Phelps
Suffering from Smallpox after Gettysburg, Lincoln May Have Infected His Valet by Michael S. Rosenwald
William H. Johnson Citizen: An Abraham Lincoln Story by Alan E. Hunter