Paleopathological Evidence

Although abundant documentary evidence for smallpox in antiquity exists, physical evidence is scant. The most striking indication of the disease is found in mummies. The mummy of Egyptian Pharaoh Ramses V, who was in his early thirties when he died in 1157 B.C., exhibited a pustular rash on the face, neck, shoulders and arms. Donald Hopkins, a physician and epidemiologist who was permitted to partially examine this mummy in 1979, describes a “rash of elevated ‘pustules,’ each about two to four millimeters in diameter...pale yellow against a dark brown-reddish background” (1983, 15). The image of the pharaoh’s face, covered in pustular-looking lesions, can be found in much of the literature addressing the history of smallpox.

Hopkins also comments on two additional Egyptian mummies described by paleopathologist M.A. Ruffer as having smallpox-like lesions (14). Ruffer and his colleague A.R. Ferguson, in 1910, studied tissue from one of the mummies microscopically. The vesicles they observed were typical of smallpox. Unfortunately, Hopkins was not allowed to remove pustules from Ramses V’s mummy to examine by electron microscopy, and attempts to use this technique to study tissue found on the shroud were unsuccessful (15).

At least one attempt to positively identify smallpox in mummies, however, was successful. Fornaciari and Marchetti (1986), utilizing an immunological assay, were able to identify smallpox as the agent responsible for the pustular lesions on a sixteenth century child’s mummy from Naples. Skin samples were rehydrated and incubated with human anti-vaccinia-virus antiserum, followed by immunostaining. The results confirmed what microscopic examination suggested, that the boy suffered from smallpox.

Skeletal evidence of smallpox in antiquity, however, is not so apparent. Although, as mentioned previously, joint lesions can occur in smallpox infections, it is possible that in skeletal remains it would be difficult to differentiate such pathology from other degenerative joint diseases. Cohen (1989, 108), in discussing skeletal evidence in prehistoric remains for various infectious diseases, asserts that identification of smallpox is controversial, but that it “may be identifiable from patterns of inflammation on the ulna.”

Evidence in modern populations is more apparent, and a pattern is clear. Eekels et al. (1964) reported three cases of osteomyelitis variolosa seen during a smallpox epidemic that occurred in the Republic of the Congo during 1961 and 1962. This osteomyelitis caused by the variola virus results in a debilitating swelling that occurred in 0.25 to 0.5 percent of patients – mostly children under age five - during epidemics of smallpox. Swelling and concomitant bone destruction is bilateral, typically in elbows, but also in wrists, hands, ankles, feet, and knees. Ankylosis – the fusion of joints – and secondary osteoarthritis can result.

Ortner and Putschar (1981, 228) report similar findings from work done in India and Indonesia in the 1960’s, and note that the bilateral elbow involvement is “uncommon in any other infection.” Incidence of this pathology may be the only indication of smallpox in skeletal remains of past populations. However, resemblance to other arthropathies, coupled with the fact that osteomyelitis variolosa occurs primarily in children – whose skeletal remains are not always well preserved – may account for the lack of skeletal evidence for smallpox in ancient populations.

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