“Showing upon the face and cheeks a form of the disease commonly known as ‘black smallpox.’ (...) The swelling and disfigurement of the face present a most striking appearance.”
A Practical Treatise on Smallpox by George Henry Fox, 1903
“Figs. 1 and 3 show the dried pustules remaining in the thickened skin of palm and sole after the crusts have fallen elsewhere. Fig. 2 shows the superficial desquamation which follows the falling of the crusts, producing rings of partly detached epidermis.“
A Practical Treatise on Smallpox by George Henry Fox, 1903
“Fig. 1 shows umbilicated pustules with an intense edema of the foot, considerably increasing in its size and causing much pain. Fig. 2 shows the epidermis raised in a large, irregular patch by the confluence of pustules.”
A Practical Treatise on Smallpox by George Henry Fox, 1903
“Showing numerous incipient papules upon the face. Those upon the forehead were the first to appear and are most prominent. the cheeks present a characteristic leathery appearance.”
A Practical Treatise on Smallpox by George Henry Fox, 1903
The following is an autopsy report discussing a case from the 1971 smallpox outbreak in Aralsk. I found it in a paper released by The Center For Nonproliferation Studies. This outbreak was suspected to have been caused by a weaponized strain of the virus encountered by the first patient on Vozrozhdeniye island in the Aral Sea. You can find the full document here.
I. Borisov AUTOPSY REPORT NO. 1
September 28, 1971
City of Aralsk
Infectious disease hospital
Infectious disease department
Deceased’s surname, first name, and patronymic – [Patient 3]
Age – 23 years old, female, teacher
Medical Examiner – Borisov
Present at the autopsy: Kinshymbaev, Misaleva, Maltsev, Leshkovich, Alekseeva, Kopotilov
Date of hospitalization – September 15, 1971
Date of death – September 28, 1971
Date of autopsy – September 28, 1971, 1100 hrs local time
Clinical diagnosis: September 21, 1971, smallpox, confluent form
Brief clinical post-mortem accompanied by data from laboratory tests and x-ray examination:
The patient became ill on September 13, 1971. She developed a headache, dizziness, nausea, and vomiting. On September 20, eruptions of a papular nature appeared on her face and chest, and then spread to her extremities and to the rest of her body. From the onset of the illness, she had a high temperature. Intoxication and cardiovascular insufficiency rapidly increased, and on September 28, at 0815 hours, the patient expired.
Basic diagnosis: smallpox
Complications: Dystrophic changes in parenchymatous organs.
Small foci of hypostatic pneumonia.
Report text:
Corpse is that of a female adult of normal physique and adequate nourishment. The hair on her scalp is short. Dry scabs and discolored spots indented in the center are located on various parts of her face. The skin of her trunk, extremities, palms, and soles is almost completely covered with pustules. Around the edges of the pustules is a hyperemic zone 1-2 mm [millimeters] wide. The center of each pustule has an indentation, and most are covered with a dry, black crust. The pustules have a multilocular structure and, in most cases, are filled with pus. On the sides of her thorax and in the area of her pelvis and thighs, large sections of epidermis have peeled away. Dermis with individual and confluent hemorrhages can be seen in these areas. Similar hemorrhages, mostly micropunctuated, can be seen on the skin of her shins and soles. In addition, on many parts of her body, large and small vesicles full of transparent, light-yellowish, opalescent fluid can be seen.
Circulatoryorgans: A small quantity of transparent, light-colored fluid is seen in the cavity of the pericardium. The layers of the pericardium are smooth and shiny. No irregularities are noted in the pericardium, endocardium, or cardiac valves. The intima of the coronary vessels is smooth and shiny. The myocardium is flaccid throughout, of a grayish-red color, and is dull in appearance. The intima of the aorta and of the large blood vessels is light yellow, smooth, and shiny. Only individual, slightly protruding, atheromatous plaques are visible in the initial part of the aorta.
Hematopoietic organs: The spleen is slightly enlarged, firm, and dark red in color. The capsule is somewhat taut, smooth, and shiny. When sectioned, the pulp is dark cherry in color, juicy, with [hyperplastic?] follicles. The pulp swab is moderate and sanguineous.
Peripheral and visceral lymph nodes are slightly enlarged, firm, grayish in color in section.
Respiratory organs: Both sides of the lungs in the upper and back sections adhere to the chest cavity with soft, whitish adhesions that are easily separated by a blunt instrument. Throughout the rest of the lungs, the pleural layers are smooth and shiny. Beneath the pleura and when sectioned, small (1.5 x 1.5 cm [centimeters]), firm, dark red spots can be seen in the upper and lower lobes. The section surface is smooth. Elsewhere, the lung tissue on the surface and in each section is light pink in color and soft. Under pressure, a foamy, pink fluid appears on the section surface. The mucosa of the pharynx, trachea, and large bronchi are edematous and hyperemic along nearly their entire length. Small, necrotic spots, not well defined, and micropunctutated hemorrhages, in some places confluent, can be seen on the mucosa. These changes are most pronounced in the pharynx and in the upper sections of the trachea. In the lumen of the trachea, there is a small quantity of thick, viscous mucus, slightly pink in color.
Digestive organs: The buccal mucosa is severely edematous and hyperemic. The tongue is edematous, covered with a viscous dirty-gray coating that is difficult to remove. When the coating is removed, a few small, necrotic spots and ulcerations can be seen. The pustules are similar to those found on the skin. The tonsils are enlarged, edematous, covered with a dirty-grayish coating. The pharynx mucosa is edematous, covered with a small quantity of viscous mucus. The esophageal mucosa is edematous throughout its length. Its upper third is severely hyperemic with small, necrotic spots and ulcerations and micropunctuated hemorrhages. The esophageal lumen contains solid [pterygium?], light yellow in color, and a small quantity of mucus. The stomach is of normal shape and size. Its mucosa is edematous; the mucosal rugosity is not well defined. In the areas at the bottom of the stomach and the large curvature, there are small ulcerations and micropunctuated hemorrhages. In the stomach lumen, some thick, viscous mucus can be seen. The duodenum mucosa is edematous. On the remaining length of the small intestines and colon, the mucosa is normal. In the small intestinal lumen, a small quantity of mucus that is of a slightly light-yellowish color can be seen. The colon lumen is filled with black, fecal masses. The liver is enlarged, light brown in color, and flaccid. Its capsule is smooth, shiny, and somewhat taut. When sectioned, the pattern of its lobules is not defined, the tissue is light yellow in color. Some quantity of dark red liquid blood flows from the section surface. The gallbladder is of normal size, and its lumen contains some quantity of liquid bile. The mucosa is velvety and of normal color.
The pancreas is lobular in nature, firm, edematous, and severely hyperemic. Its section tissue appears edematous and sanguineous.
Urogenital system: The kidneys are of normal size, firm, dark red in color. The capsule is smooth, shiny, and easily removed. The section pattern is well defined; the cortex is substantially thinned and pale yellow in color. The pelvic mucosa is unchanged. The adrenal glands are flat, firm, and their section pattern is well defined. The bladder is not large, and in its lumen, about 150 ml of light, transparent urine can be seen. The mucosa is pale pink in color. The uterus is of normal size, firm, and its mucosa is slightly edematous. The ovaries are whitish gray in color and firm. Under the middle part [word illegible] of the left ovary, there is a hemorrhagic spot 2 mm by 2 mm in size.
The brain was not autopsied.
The mucosa of the trachea, esophagus, and stomach were sampled for virological testing.
Pieces of the internal organs were sampled for histological testing. The patient expired as a result of smallpox, development of severe general intoxication, and associated severely dystrophic changes in the parenchymal organs.
While the patient was still alive, a smallpox culture was isolated from her.
Signed I. Borisov
Below is not the case discussed, but I thought it helpful to provide an image of confluent smallpox.
The Following are excerpts from the document pictured above. It discusses what was likely an outbreak of a weaponized smallpox which happened in 1971 in Kazakhstan. You can read the document in full here. Commentary on this paper by public health experts can be found here.
From 1936 to 1992, Vozrozhdeniye Island, an island in the western part of the Aral Sea whose territory is divided between Kazakhstan and Uzbekistan, was the major proving ground in the Soviet Union for the open-air testing of biological warfare (BW) agents. According to information provided by Z. A. Rakhmatulin, the former chief of staff at the test site during the 1980s, and by G. L. Lepyoshkin, the former general director of the National Center for Biotechnology in Stepnogorsk, a variety of BW agents were tested on Vozrozhdeniye Island, including the microbial pathogens that cause plague, anthrax, Q-fever, smallpox, tularemia, and Venezuelan equine encephalitis, as well as botulinum toxin. Some of the pathogens tested in aerosol form were genetically modified strains that produce atypical disease processes and are resistant to existing medications, potentially complicating diagnosis and treatment.
(…) The Soviet medical report contained in this occasional paper describes an unusual outbreak of smallpox in the city of Aralsk, Kazakhstan, in 1971. From August to October, a total of ten cases of smallpox were recorded, three of them fatal. The undeniable fact is that people in Aralsk became infected with smallpox at this time. How could the virus have suddenly appeared out of nowhere in the middle of Kazakhstan, a thousand kilometers from the nearest border?
(…) In view of what has been learned in recent years about the former Soviet BW program, it seems that the most likely source of the smallpox outbreak was the test site on Vozrozhdeniye Island. Simply put, the index case and the nine residents of Aralsk who became infected with smallpox in 1971 were in the wrong place at the wrong time. They all suffered, and three of them died, because they were unprotected and had not been informed about the secret testing of deadly pathogens that was taking place nearby without their consent.
(…) The 1971 smallpox outbreak in Aralsk was unusual because the Soviet Union had eradicated endemic smallpox from its territory in 1936. (…) Soviet health authorities kept the Aralsk outbreak secret and did not report it to the World Health Organization (WHO), as required under international agreement. (…) In this case, however, there may have been another reason for keeping the smallpox outbreak under wraps—the Aralsk outbreak could have originated in a field test of weaponized smallpox virus at the nearby Soviet biological warfare (BW) testing grounds on Vozrozhdeniye Island in the Aral Sea.
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(…) The other four infected adults (ages 24, 36, 38, and 60) contracted smallpox despite having been vaccinated. Three were described as having “varioloid smallpox” with only a few scattered lesions evident on physical examination, and one with a classical “discrete” rash. In short, three people, all unvaccinated, developed the hemorrhagic form of the disease and died. Six others also contracted smallpox in either a modified or typical discrete form.
(…) Nearly 50,000 residents of Aralsk were vaccinated in less than two weeks, and many hundreds were placed in isolation in a makeshift facility on the outskirts of town. Transportation into and out of Aralsk was almost completely halted, and more than 5,000 square meters (54,000 square feet) of living space in the homes of local residents were disinfected, along with 18 metric tons of household goods.
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(…) Although the overall mortality in the two outbreaks was similar (three out of ten cases in Aralsk, 35 out of 175 cases in Kosovo, p>.43 by Fisher’s exact test), critical differences between the two outbreaks are also evident. There were three patients with hemorrhagic smallpox (all fatal) in Aralsk, but five such cases in Kosovo, where the total number of smallpox cases was much larger (p<.005 by Fisher’s exact test). This observation suggests that the clinical manifestations were somewhat more severe in the Aralsk epidemic.
Hemorrhagic smallpox was rare in most outbreaks and was almost universally fatal. (…) Although the Aralsk outbreak data are insufficient to support a firm conclusion, the seemingly high percentage of hemorrhagic cases and the skewing of the distribution to very young children suggest that either unusual “host factors” (e.g., nutritional status, genetic resistance), or an unusual strain of the virus, were responsible for this distinctive feature of the Aralsk outbreak.
(…) Further, of the six adults with confirmed smallpox in Aralsk, five had been vaccinated. Because it is not known how many of the later- quarantined “contacts” of Patients 1, 2, and 3 were vaccinated, nor how many years had passed since their last vaccination, it is impossible to calculate vaccine effectiveness in the Aralsk outbreak. However, the efficacy of the smallpox vaccine (sometimes also called “rate of protection”) is usually described as being in excess of 90 percent. The official report states that there were approximately 30 direct contacts of Patients 3 and 4 (including Patients 7–9); those contacts that developed clinical disease had all been vaccinated. In addition, the index case (Patient 1) had been vaccinated, but not Patient 3. These data suggest that the variola virus strain involved in the epidemic may have been somewhat vaccine- resistant.
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(…) How did the index case in the 1971 Aralsk outbreak become infected with smallpox? The official report does not offer a conclusive explanation but presents three hypotheses. According to the first of these: Members of the crew and of the research team went ashore on July 29 in the town of Uyaly in the Kzyl-Orda region (…) According to this scenario, Patient 1 was the source of the disease’s outbreak in the city of Aralsk. She contracted smallpox at the end of July, 1971, either in Uyaly or in Komsomolsk-on-Ustyurt.
(…) The second hypothesis put forward in the official report is that the infection was introduced directly into the city of Aralsk from the southern borders of the Soviet Union via land or water transportation.
(...) The third hypothesis presented in the official report: A scenario of infection via the open-air market has also been thoroughly checked. (…) However, no evidence was established that people with smallpox arrived from those regions and visited the home of [the father of Patients 1 and 2] or the market’s director, or that goods such as rugs and other wool artifacts were bought or sold there.
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(…) On May 25, 2002, the author (Zelicoff) contacted the index case, Patient 1, by telephone and conducted an extensive interview of about two hours
Patient 1 confirms that, as a recent graduate of the Fisheries Institute in Aralsk, she sailed on the Lev Berg in 1971. She disputes, however, several key aspects of the official report. Most significantly:
+ Patient 1 insists that she did not disembark from the Lev Berg at any of the ports of call along its route, (…) Patient 1 noted that official policy allowed only the male members of the crew to leave the ship, and that this rule was strictly enforced.
+ The official report states that Patient 1 became ill en route to Aralsk. Yet Patient 1 recalls feeling well on the ship and only becoming ill shortly after arriving home in Aralsk.
+ She states that no one on board the Lev Berg developed illness or fever through August 11, when the ship returned to Aralsk.
(…) If Patient 1’s recollections are accurate, it is unlikely that she was exposed to smallpox at any of the ship’s ports of call on the Aral Sea. It is also unlikely that she was secondarily infected by any of the male crew members who went ashore, because no one on board became feverish or otherwise sick during the voyage.
(…) it is most likely that his sister, Patient 1, became ill on or about August 11, roughly thirteen days earlier. This is precisely in line with her oral history and at variance with the official report, where the date of onset of her illness is given as August 6. It is extremely unusual for patients with smallpox to transmit the disease after the first week of clinical illness, further discrediting the official report. It is therefore most likely that she became infected with smallpox during the last days of July 1971.
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(…) It is now known that beginning in 1936, the Soviet Ministry of Defense used Vozrozhdeniye Island in the Aral Sea as a site for BW field testing.15 The island offered a number of advantages: it was isolated and surrounded by water, making security relatively easy. (…) Finally, the blistering hot temperatures and intense solar radiation insured that microbial pathogens tested in the open environment would die quickly and hence would not inadvertently escape from the island.
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(…) Referring to the map, the Lev Berg was probably south of Vozrozhdeniye Island on or about July 30. Could an open- air test or a laboratory accident involving a virulent strain of variola virus have resulted in the inadvertent contamination of the research vessel? Dr. Pyotr Burgasov, a former chief sanitary physician of the Soviet Union who is notorious for his now- discredited claim that the Sverdlovsk anthrax outbreak of 1979 resulted from “contaminated meat,” was interviewed in the Russian press in November 2001. He is quoted as having said:
“On Vozrozhdeniye Island in the Aral Sea, the strongest formulations of smallpox were tested. Suddenly I was informed that there were mysterious cases of disease in Aralsk. A research ship of the Aral fleet came 15 kilometers away from the island (it was forbidden to come any closer than 40 kilometers). The laboratory technician of this ship took samples of plankton twice a day from the top deck. The smallpox formulation—400 grams of which was exploded on the island—“got her” and she became infected. After returning home to Aralsk, she infected several people, including children. All of them died. I suspected the reason for this and called the Chief of the General Staff of the Ministry of Defense and requested that the train from Alma-Ata to Moscow be forbidden to stop at Aralsk. As a result, an epidemic around the country was prevented. I called Andropov, who at that time was chief of the KGB, and informed him of the exclusive recipe of smallpox in use on Vozrozhdeniye Island. He ordered that not another word be said about it. This is a real biological weapon! The minimum radius of contamination was 15 kilometers. One could imagine what would have happened if instead of one laboratory technician, there had been 100 to 200 people.”
Burgasov’s statement is unclear on some points and inaccurate on others. For example, the claim that “all of them died” is certainly not correct. Nevertheless, Burgasov, who was highly placed in the Soviet government at that time, must have known which pathogens were tested on Vozrozhdeniye Island and if major mishaps had occurred. Thus, although some of the details of his admission are false, the general thrust seems credible: Patient 1 was exposed to smallpox virus released as part of a BW field test on Vozrozhdeniye Island on or about July 30. An infection contracted on that date would have resulted in the onset of fever approximately 13 days later—on August 11, 1971, precisely when Patient 1 states her illness began. The localized epidemic then followed her arrival in Aralsk.
