The Demon in the Freezer

The Man in Room 151

On the last day of December 1969, a man I will call Peter Los arrived at the airport in Düsseldorf, West Germany, on a flight from Pakistan. He had been ill with hepatitis in the Civil Hospital in Karachi and had been discharged, but he wasn’t feeling well. He was broke and had been holed up in a seedy hotel in a Karachi slum. His brother and father met him at the airport — his father was a supervisor in a slaughterhouse near the small city of Meschede, in the mountains of North-Rhine Westphalia, in northern Germany.

Peter Los was twenty years old, a former apprentice electrician with no job who had been journeying in pursuit of dreams that receded before him. He was tall and good-looking — thin now — with a square, chiseled face and dark, restless, rather guarded eyes under dark eyelashes. He had short, curly hair, and he wore faded jeans. He was traveling with a backpack, in which he’d tucked brushes, pencils, paper, and a set of watercolor paints, and he carried a folding easel.

Peter Los is alive today in Germany. The details of his character have been forgotten by the experts, but his case and its aftermath haunt them like the ruins of a fire.

Los had been living in a commune in the city of Bochum while he studied to be an electrician, but the members of the commune had split ideologically. Some favored a disciplined approach to communal living, while others, including Peter, favored the hippie ideals of the sixties. In August 1969—the month of the Woodstock music festival — eight members of the Bochum commune, including Peter, packed themselves into a Volkswagen bus and set off for Asia on an Orientreise. There were six men and two women on the bus, and they were apparently hoping to find a guru in the monasteries of the Himalayas, where they could meditate and seek a higher knowledge, and possibly also find good hashish. They drove the bus down through Yugoslavia to Istanbul, crossed Turkey, and went through Iraq and Iran, camping out under the stars or staying in the cheapest places. They rattled across Afghanistan on the world’s worst roads, and the Volkswagen bus made it over the Khyber Pass. They hung out in Pakistan, but things didn’t go as well as they had hoped, and they didn’t connect with a guru. The two women lost interest in the trip and went back to Germany, and toward December, three men in the group drove the Volkswagen into India and down the coast to Goa, to attend a hippie festival called the Christmas Paradise. Peter stayed behind in Karachi, and ended up languishing with hepatitis in the Civil Hospital.

An eastbound train took Peter and his father and brother out of Düsseldorf, and traveled through the industrial heart of northern Germany, past seas of warehouses and factories made of brown brick. It is unlikely that Peter would have had much to say to his father at this point. He would have lit a cigarette and looked out the window. The train arrived at the Ruhr River, and it followed the course of the river into the fir-clad mountains of the Sauerland, winding upstream under skies the color of carbon steel, until it reached Meschede.

Meschede is a cozy place, where people know one another. It nestles in a valley at the headwaters of the Ruhr, beside a lake. It had been snowing in Meschede, and the hills and mountains surrounding the city were cloaked in snowy firs. It was New Year’s Eve. Peter and his family celebrated the new decade, and he caught up with old friends and rested, recovering from his illness.

The weather was cloudy and dark, but in the second week of January the clouds broke away from the mountains, and clear air poured down from the north, bringing dry cold and blue skies. At the same time, influenza broke out in the town, and many people became sick with coughs and fevers. Around Friday, January 9th, Peter began to feel strange.

He was tired, achy, restless, and by the end of the day he was running a temperature. Then, on Saturday, his fever spiked upward, and he was very sick in the night. On Sunday morning, his family called an ambulance, and he was taken to the largest hospital in town, the St. Walberga Krankenhaus. He brought his art supplies and his cigarettes with him.

Dr. Dieter Enste examined Peter. He was recovering from his hepatitis, but perhaps he had typhoid fever, which is contagious, and which he could have caught in the hospital in Pakistan. They placed him in the isolation ward, in a private room, Room 151, and they started him on tetracycline.

The St. Walberga Hospital was staffed by the Sisters of Mercy, who served as nurses. The hospital was spare, simple, neat, and spotlessly clean. The isolation ward took up the entire first floor of the south wing, which was a semidetached building, three stories tall, covered with brown stucco, with a staircase that ran through the middle. The nuns told Peter to keep his door closed and not to leave his room for any reason.

He settled in on that Sunday morning and quickly began to feel better, and his fever almost went away. Even so, the nuns forbade him to leave the room, not even to use the bathroom, though it was directly across the hall. They made him use a bedpan, and they emptied it for him, and he washed himself at the sink in his room. The steam radiator under the window hissed and banged, and it made his room feel stuffy. He wanted a cigarette. He slid open one of the room’s casement windows just a crack, got out his cigarettes, and lit one. The nuns were not happy with that, and ordered him to keep his window closed.

That Sunday, a Benedictine priest named Father Kunibert made rounds through the hospital, offering holy communion to the sick. He was an older man, not strong on his legs, and he worked his way down through the building, so that he wouldn’t have to climb stairs. On the first floor at the end of the corridor, he put his head in Room 151 and asked the patient if he wished to receive communion. The young man was not interested. The medical report informs us that he “refused communion” and that “the priest was advised that his services were not desired.”

When the nuns weren’t looking, Peter continued to smoke, with his window open a crack. Cold air would pour in, filling the room with a brisk scent of the outdoors mixed with chirps of sparrows.

The tetracycline wasn’t working, so the doctors started him on chloramphenicol. He had a sense of creeping malaise, an anxious feeling that things weren’t right, that the drugs weren’t working on his typhoid. He was restless, couldn’t get comfortable, and he took out his colors and his brushes and began to paint. When he became tired of that, he sketched with a pencil. There wasn’t much to see out his window — a nursing sister in a white habit hurrying down a walkway, patches of snow, branches of bare beech trees crisscrossing a sky of cobalt blue.

Monday and Tuesday passed. Every now and then a nun would come in and collect his bedpan. His throat was red, and he had a cough, which was getting worse. The back of his throat developed a raw feeling, and he sketched and painted. At night, he may have suffered from dreadful, hallucinatory dreams.

The inflamed area in his throat was no bigger than a postage stamp, but in a biological sense it was hotter than the surface of the sun. Particles of smallpox virus were streaming out of oozy spots in the back of his mouth and were mixing with his saliva. When he spoke or coughed, microscopic infective droplets were being released, forming an invisible cloud in the air around him. Viruses are the smallest forms of life. They are parasites that multiply inside the cells of their hosts, and they cannot multiply anywhere else. A virus is not strictly alive, but it is certainly not dead. It is described as a life-form. There was a cloud of amplified virus hanging in Room 151, and it was moving through the hospital. On Wednesday, January 14th, Peter’s face and forearms began to turn red.

Stripper

The red areas spread into blotches across Peter Los’s face and arms, and within hours the blotches broke out into seas of tiny pimples. They were sharp feeling, not itchy, and by nightfall they covered his face, arms, hands, and feet. Pimples were rising out of the soles of his feet and on the palms of his hands, and they were coming up in his scalp and in his mouth, too. During the night, the pimples developed tiny, blistery heads, and the heads continued to grow larger. They were rising all over his body, at the same speed, like a field of barley sprouting after rain. They were beginning to hurt dreadfully, and they were enlarging into boils. They had a waxy, hard look, and they seemed unripe. His fever soared abruptly and began to rage. The rubbing of pajamas on his skin felt like a roasting fire. He was acutely conscious and very, very scared. The doctors didn’t know what was wrong with him.

By dawn on Thursday, January 15th, his body had become a mass of knob-like blisters. They were everywhere, all over, even on his private parts, but they were clustered most thickly on his face and extremities. This is known as the centrifugal rash of smallpox. It looks as if some force at the center of the body is driving the rash out toward the face, hands, and feet. The inside of his mouth and ear canals and sinuses had pustulated, and the lining of the rectum may also have pustulated, as it will do in severe cases. Yet his mind was clear. When he coughed or tried to move, it felt as if his skin were pulling off his body, that it would split or rupture. The blisters were hard and dry, and they didn’t leak. They were like ball bearings embedded in the skin, with a soft, velvety feel on the surface. Each pustule had a dimple in the center. They were pressurized with an opalescent pus.

The pustules began to touch one another, and finally they merged into confluent sheets that covered his body, like a cobblestone street. The skin was torn away from its underlayers across much of his body, and the pustules on his face combined into a bubbled mass filled with fluid, until the skin of his face essentially detached from its underlayers and became a bag surrounding the tissues of his head. His tongue, gums, and hard palate were studded with pustules, yet his mouth was dry, and he could barely swallow. The virus had stripped the skin off his body, both inside and out, and the pain would have seemed almost beyond the capacity of human nature to endure.

When the Sisters of Mercy opened the door of his room, a sweet, sickly, cloying odor drifted into the hallway. It was not like anything the medical staff at the hospital had ever encountered before. It was not a smell of decay, for his skin was sealed. The pus within the skin was throwing off gases that diffused out of his body. In those days, it was called the foetor of smallpox. Doctors today call it the odor of a cytokine storm.

Cytokines are messenger molecules that drift in the bloodstream. Cells in the immune system use them to signal to one another while the immune system mounts a response to an attack by an invader. In a cytokine storm, the signaling goes haywire, and the immune system becomes unbalanced and cracks up, like a network going down. The cytokine storm becomes chaotic, and it ends with a collapse of blood pressure, a heart attack, or a breathing arrest, along with a stench coming through the skin, like something nasty inside a paper bag. No one is certain what happens in the cytokine storm of smallpox. The virus is giving off unknown proteins that jam the immune system and trigger the storm, like jamming radar, which allows the virus to multiply unhindered.

In 1875, Dr. William Osler was the attending physician in the smallpox wards of the Montreal General Hospital. He called the agent that caused the sweet smell of smallpox a “virus,” which is the Latin word for poison. In Osler’s day, no one knew what a virus was, but Osler knew the smell of this one. When there were few or no pustules on the skin, he would sniff at a patient’s wrists and forehead, and he could smell the foetor of the virus, and it helped him nail down the diagnosis.

Around midday on Thursday, January 15th, five days after Peter Los had been admitted to the hospital, the doctors began to suspect that he had die Pocken—smallpox. Smallpox causes different forms of disease in the human body. Peter had classical ordinary smallpox.

The scientific name for smallpox is variola, a medieval Latin word that means “blotchy pimples.” The name was given to the disease around A.D. 580 by Bishop Marius of Avenches, in the Vaud region of Switzerland. The English doctor Gilbertus Anglicus described the basic forms of smallpox disease in 1240. The virus is an exclusively human parasite. Smallpox virus can naturally infect only Homo sapiens. It comes in two natural subspecies, variola minor and variola major. Minor is a weak strain that was first identified by doctors in Jamaica in 1863, and is also called alastrim. While it causes people to pustulate, for some reason it rarely kills. Variola major kills around twenty to forty percent of infected humans who are not immune to it, depending on the circumstances of the outbreak and how virulent, or hot, the strain is. As a generality, doctors say that smallpox kills one out of three people.

Virus particles are also known as virions. Smallpox virions are very small. About one thousand of them would span the thickness of a human hair. It may be that you can catch smallpox if you inhale three to five infectious virions, or particles. No one knows the infectious dose of smallpox, but experts believe it is quite small.

Dieter Enste and the other doctors had not considered the idea that Peter Los might have smallpox because the young man had no rash for several days, and he had gotten a vaccination just before he had left Germany. He had gotten a second vaccination when he was in Turkey, but his vaccinations had not taken — he had not developed a scar on his arm, which meant that he had not become immune.

The St. Walberga doctors took a scalpel, cut a pustule on his skin, and drained a little of the opalescent pus onto a swab. They put it in a test tube, and a state official got in a Mercedes and drove the pus at a hundred and twenty miles an hour along the autobahn to a laboratory at the state health department in Düsseldorf.

Microscope

Karl Heinz Richter was a smallpox expert in the Düsseldorf office of the state health department, a medical doctor with a kindly face and a flop of hair on one side. He wore stylish metal-framed eyeglasses and a gray sweater under a jacket, which gave him a comfy but up-to-date look. Dr. Richter, along with a team of doctors and technicians, analyzed the pus taken from Peter Los’s skin. They put a little dried flake of the pus in an electron microscope — a tubelike instrument, six feet tall — which could magnify an image up to twenty-five thousand times. Then they took turns looking into the viewing hood; they would have to vote on the diagnosis.

Dr. Richter saw a vista of exploded human skin cells. Mixed in with the cellular debris were thousands of small, rounded bodies that looked like beer kegs. Some experts refer to them as bricks. The view in the microscope seemed vast, for magnified twenty-five thousand times, the flake of pus would have been an object nearly the size of a football field, and the little bricks in it lumps the size of raisins, and there could have been hundreds of thousands of them in the flake. These were virions of a poxvirus, and the vote was unanimous: this was smallpox.

The pox bricks had a crinkly, knobby surface, rather like a hand grenade — some experts call this feature the mulberry of pox. (A mulberry is a small fruit, the size of a thumbnail, which looks like a blackberry.) There are many species and families of poxviruses; smallpox is an orthopox, a poxvirus of animals. Poxviruses are among the largest and most complicated viruses in nature. A pox particle itself either makes or consists of around two hundred different kinds of protein, and many of the proteins are locked together into the particle like a Chinese puzzle. Pox scientists are slowly picking apart the structure of the mulberry of pox, but so far nobody has figured out the full design. Experts in pox find the pox virion mathematical in its structure and almost breathtakingly beautiful. At the center of the mulberry there is an odd shape that looks like a dumbbell, which scientists call the dumbbell core or the dogbone of pox. Inside the dumbbell, or dogbone, there is a clump of DNA, which is the long, twisted, ladderlike molecule that contains the genome of smallpox — the complete blueprint and operating software for variola. The steps of the ladder of DNA are the letters of the genetic code. The genome of smallpox has about 187,000 letters, which is one of the longest genomes of any virus. Smallpox uses a lot of this code to defeat the immune system of its human host. It has about two hundred genes (which make the virus’s two hundred proteins). By contrast, the AIDS virus, HIV, has only ten genes. In terms of the natural design of a virus, HIV has a simple design that works well. HIV is a bicycle, while smallpox is a Cadillac loaded with tail fins and every option in the book.

Poxviruses are one of the few kinds of viruses that are just large enough to be seen in the best optical microscopes (in which they look like fine grains of pepper). The infinitesimal palaces of biology extend far into the unseen. It is hard for the mind to grasp just how small is small in the microscopic universe of nature, but one way is to imagine a scale of nature built on the scale of the Woodstock music festival, which took place in a natural amphitheater at Max Yasgur’s farm in Bethel, New York. It held up to a half-million people. Seen from low orbit above the earth, the crowd of people at Yasgur’s farm would have looked something like this:

If a cell from the human body, in its natural size, were placed on this representation of the Woodstock festival, the cell would be an object about the size of a Volkswagen bus parked at the real festival. Bacterial cells are smaller than the cells of animals. If a single cell of E. coli (the main type of bacteria that lives in the human gut) were placed on the Woodstock on this page, it would be an object the size of a smallish watermelon, perhaps sitting on the grass beside the Volkswagen bus. A spore of anthrax would be an orange. On that same scale, a particle of smallpox would be a mulberry. (The particles of the common cold are the smallest virus particles found in nature; a cold virus would be a marijuana seed under the seat of the Volkswagen bus parked at Woodstock.) Three to five mulberries of smallpox floating into the air out of the Woodstock dot on the page would be invisible to the eye and senses, yet they could start a global pandemic of smallpox.

As Dr. Richter pondered the view in the microscope, he was not unprepared for the national emergency it implied. Three years earlier, he had laid out a plan for what would be done if smallpox broke out on his watch. Now it was happening. He lined up an older pox expert, Dr. Josef Posch, and they were joined by another colleague, Professor Helmut Ippen. They organized a quarantine at the hospital, they got vaccine ready, and they gathered biohazard equipment, which Richter had previously stockpiled. He also made a telephone call to the offices of the Smallpox Eradication Program at the World Health Organization (WHO) in Geneva, Switzerland, asking for help.

The WHO occupies a building constructed in the nineteen fifties on a hill above Geneva. It is surrounded by the flags of the world’s nations. In 1970, the Smallpox Eradication Program (SEP) was a relatively new effort at the WHO — it was inaugurated in 1966. The smallpox program operated out of a cluster of tiny cubicles on the sixth floor — the cubicles were exactly four feet wide, but they had a magnificent view southward across Lake Geneva toward Mont Blanc. Although the cubicles of the smallpox program were tiny and jammed together, the unit had a deserted feel, because at any given time more than half of the staff members were away, dealing with smallpox in various parts of the earth.

Dr. Richter ended up talking with an American doctor on the staff named Paul F. Wehrle, who spoke a little German. Dr. Wehrle (his name sounds like whirly) was a tall, thin, courtly epidemiologist with brown hair and green eyes who had a habit of wearing a jacket and tie with a white shirt when he went into the field, because he felt that a well-dressed doctor would inspire confidence in the midst of the shit terror of a smallpox outbreak. Wehrle now lives in quiet retirement with his wife in Pasadena. “I have unfortunately turned eighty,” he remarked to me, “but fortunately I have all of my hair, most of my teeth, and at least some of my brain.”

When Dr. Richter told him what was going on in Meschede, Dr. Wehrle understood the picture only too well. The WHO rule was to keep smallpox patients out of hospitals, because they could spread the virus all too easily — hospitals are amplifiers of variola. Smallpox could essentially sack a hospital, infecting doctors and nurses and patients, and from there the virus would continue out into the community and beyond. The WHO recommended keeping smallpox patients at home under the care of vaccinated relatives. Since there was nothing a doctor could do for a patient with smallpox, it was just as well to keep the patient away from doctors.

Wehrle went down the hall to a double cubicle that was occupied by a tall, assertive medical doctor named Donald Ainslie Henderson. Everyone called Henderson “D.A.,” including his wife and children. D. A. Henderson was the head of the Smallpox Eradication Program. He was six feet two inches tall, with a seamed, rugged, blocky face, thick, straight, brown hair brushed on a side part, wide shoulders, big-knuckled hands, and a gravelly voice. Wehrle and Henderson discussed strategy, and Henderson made some telephone calls. The young man in the hospital at Meschede could start an outbreak across Europe. Henderson told Wehrle to go to Germany. Wehrle got a taxi to the airport, and that afternoon he was on a flight to Düsseldorf. Meanwhile, Henderson made arrangements to have one hundred thousand doses of smallpox vaccine shipped from Geneva to Germany immediately.

While Paul Wehrle was en route to Meschede, Dr. Richter and the German health authorities got Peter Los out of the St. Walberga Hospital — fast. The police closed off the hospital, and a squad of attendants dressed in plastic biohazard suits and with masks over their faces ran inside the building and wrapped Los in a plastic biocontainment bag that had breathing holes in it. He lay in agony inside the bag. The evac team rushed him out of the building on a gurney and loaded the bag into a biosafety ambulance, and with siren wailing and lights flashing, it took him thirty miles along winding roads to the Mary’s Heart Hospital in the small town of Wimbern. This hospital had a newly built isolation unit that was designed to handle extremely contagious patients. The Wimbern biocontainment unit was a one-story building with a flat roof, sitting in the middle of the woods. They placed Los on a silky-smooth plastic mat designed for burn victims, and he hovered on the edge of death. Construction crews began putting up a chain-link fence around the building.

That same day, Dr. Richter and Dr. Posch organized vaccinations for everyone at St. Walberga, patients and staff alike. They were given a special German vaccine that was scraped into their upper arms with a metal device called a rotary lancet, and then the doctors and their colleagues conducted interviews, trying to find out who had come into contact with Peter Los. Anyone who had seen Los’s face was assumed to have breathed smallpox particles. Twenty-two people were taken to the Wimbern hospital and put into quarantine. Everyone who had been in the south wing of St. Walberga but had not seen Los’s face was placed under quarantine inside the hospital, and they were ordered to remain there for eighteen days. Folding cots were brought in and set up in the bathrooms, where the medical staff slept. There wasn’t enough room to hold everyone, so the authorities took over a nearby youth hostel and several small hotels in the mountains and put people there, too. After a hospital worker escaped from quarantine and went home to his family, the authorities boarded up the doors of St. Walberga and nailed them shut, and stationed a police cordon around the hospital.

Paul Wehrle arrived in Meschede on the evening of January 16th, having traveled by train from Düsseldorf. He was met at the station by Richter and Posch. (Richter did the driving, since Posch had lost an arm in the Second World War.) They took Wehrle to a hotel, and they stayed up most of the night, planning a quarantine and vaccination campaign. The Germans wanted to vaccinate people with the special German vaccine, but Wehrle did not trust it. It was a killed vaccine that the German government had been using for many years, but the WHO doctors believed it didn’t give people much immunity. “The German vaccine had one small problem. It didn’t work,” Wehrle claims. “It was as close to worthless as a vaccine can be, only I couldn’t say that to the Germans and live, because they tended to be a bit protective of their vaccine.” He liked and respected the German experts and didn’t want to offend them, but he gently urged them to give everyone at the hospital a second vaccination with the WHO vaccine. It couldn’t hurt to have two vaccinations and might help, he said, and they agreed. He also persuaded them to use the WHO vaccine for the larger vaccination in Meschede.

The WHO maintained a stockpile of millions of doses of smallpox vaccine in freezers in a building in downtown Geneva they called the Gare Frigorifique — the Refrigeration Station. Much of the vaccine in the freezers had been donated to the Smallpox Eradication Program by the Soviet Union. The traditional vaccine for smallpox is a live virus called vaccinia, which is a poxvirus that is closely related to smallpox. Live vaccinia infects people, but it does not make most people very sick, though some have bad reactions to it, and a tiny fraction of them can become extremely sick and can die.

A staff member from the Gare Frigorifique drove a couple of cardboard boxes full of glass ampules of the Russian vaccine to the Geneva airport — one hundred thousand doses took up almost no space. The vaccine did not need to be kept frozen, because after it was thawed it would remain potent for weeks. Thousands of smallpox-vaccination needles were also shipped to Germany. They were a special type of forked needle called a bifurcated needle, which has twin prongs.

As quickly as possible, the German health authorities organized a mass vaccination for smallpox all around the Meschede area. This was known as a ring-vaccination containment. The smallpox doctors intended to encircle Peter Los and his contacts with a firewall of immunized people, so that the tiny blaze of variola at the center would not find any more human tinder and would not roar to life in its host species.

Meschede came to a halt. People left their jobs and homes, and lined up at schools to be vaccinated, bringing their children with them. A fear of pox — a Pocken-angst—spread across Germany faster than the virus. People who drove in cars with license plates from Meschede found that gas stations wouldn’t serve them, nor would restaurants. Meschede had become a city of pox.

Nurses and doctors gave out the vaccine. A person who was working as a vaccinator would stand by the line of people, holding a glass ampule of the vaccine and a small plastic holder full of bifurcated needles. The vaccinator would break the neck of the ampule and shake a needle out of the holder. She would dip the needle into the vaccine and then jab it into a person’s upper arm about fifteen times, making bloody pricks. You could have blood running down your arm if the vaccination was done correctly, for the bifurcated needle had to break the skin thoroughly. Each glass ampule was good for at least twenty vaccinations. As people passed in the line, a vaccinator could do hundreds of vaccinations in an hour. Each needle was put into a container after it had been used on one person. At the end of the day, all the needles were boiled and sterilized to be used again the next day.

Each successfully vaccinated person became infected with vaccinia. They developed a single pustule on the upper arm at the site of the vaccination. The pustule was an ugly blister that leaked pus, and oozed and crusted, and many people felt woozy and a little feverish for a couple of days afterward, for vaccinia was replicating in their skin, and it is not a very nice virus. Meanwhile, their immune systems went into states of screaming alarm. Vaccinia and smallpox are so much alike that our immune systems have trouble telling them apart. Within days, a vaccinated person’s resistance to smallpox begins to rise. Today, many adults over age thirty have a scar on their upper arm, which is the pockmark left by the pustule of a smallpox vaccination that they received in childhood, and some adults can remember how much the pustule hurt. Unfortunately, the immune system’s “memory” of the vaccinia infection fades, and the vaccination begins to wear off after about five years. Today, almost everyone who was vaccinated against smallpox in childhood has lost much or all of their immunity to it.

The traditional smallpox vaccine is thought to offer protective power up to four days after a person has inhaled the virus. It is like the rabies vaccine: if you are bitten by a mad dog, you can get the rabies vaccine, and you’ll probably be okay. Similarly, if someone near you gets smallpox and you can get the vaccine right away, you’ll have a better chance of escaping infection, or if you do catch smallpox, you’ll have a better chance of survival. But the vaccine is useless if given more than four to five days after exposure to the virus, because by then the virus will have amplified itself in the body past the point at which the immune system can kick in fast enough to stop it. The doctors had started vaccinating people at St. Walberga Hospital five and six days after Peter Los had been admitted. They were closing the barn door just after the horse had gone.

The incubation period of smallpox virus is eleven to fourteen days, and it hardly varies much from person to person. Variola operates on a strict timetable as it amplifies itself inside a human being.

The Student Nurse

Eleven days after Peter Los arrived at St. Walberga Hospital, a young woman who had been sleeping on a cot in one of the bathrooms woke up with a backache. She was a nursing student, seventeen years old, and I will call her Barbara Birke. She was small, slender, and dark haired, with pale skin and delicate features. She was a quiet person whom nobody knew much about, for she had been working at the hospital for only two weeks, and had been living in the nursing school dormitory while she received her training. The previous year, Barbara had been a kitchen helper in a Catholic hospital in Duisburg, where she had converted to the Catholic faith (her family was Protestant), and she had set her sights on becoming a nurse. She had spent Christmas with her family and had told her parents that she intended to become a nun, but she wanted to finish nursing school before she made up her mind. The Sisters of Mercy had reserved a place for her in the cloister.

Barbara Birke had never seen Los’s face. She always worked on the third floor of the hospital, and she had been tending to a sick elderly man in Room 352, near the head of the stairwell that went down through the middle of the building. She had received both the German vaccine and the WHO vaccine a few days earlier.

Birke told the doctors that she wasn’t feeling well, and they saw that she had a slight temperature. They immediately gave her an intravenous dose of blood serum taken from a person who was immune to smallpox. Smallpox-immune serum is blood without red blood cells — a golden liquid — and it is full of antibodies that fight the virus. They put Birke inside a plastic bag, and she lay in the bag while an ambulance carried her on the winding road to Wimbern and through the fence to the isolation unit.

Barbara Birke developed a worried, anxious look, while a reddening flush began to spread across her face, shoulders, and arms, and on her legs. Her fever went up, and her backache grew worse. Her skin remained smooth, and no pustules appeared, although the reddening deepened in color. When the doctors pressed their fingers on her skin, it turned white under the pressure, but when they released their fingertips the blood came rushing back in a moment, filling under the skin. The doctors recognized this sign, and it was very bad.

I don’t know how much the doctors told Birke of what they understood was coming. The red flush across her face deepened until she looked as if she had a bad sunburn, and then it began to spread downward toward her torso. It was a centrifugal rash that had begun on the extremities. She developed a few smooth, scattered, red spots the size of freckles across her face and arms. More red spots began to appear closer to her middle, following the movement of the creeping flush. She was forbidden to have any visitors, and there were no telephones at Wimbern that the patients could use. She couldn’t speak with her family.

The red spots began to enlarge, and there were more and more of them. They began to join together, like raindrops falling on a dry sidewalk, gradually darkening the pavement: she was starting to flood with hemorrhages beneath the skin.

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.