Pox_ An American History - Michael Willrich [17]
The eruption appeared on the skin just as the fever broke, caused by the infection of the epidermal cells. The rash appeared first as small red dots (called macules) on the forehead and scalp, and often around the mouth and the wrists. Patients often got a “worried face,” a disturbing contraction of the facial muscles that some experienced doctors recognized as a diagnostic sign of smallpox. Within twenty-four hours the lesions spread over the body. They appeared so rapidly that even the most attentive patients found it difficult to track the order of their appearance. In the worst cases it would become difficult to distinguish the rash from the skin, but smallpox was, in its way, an orderly disease. It distributed itself in a characteristic centrifugal pattern that distinguished it from other skin diseases: it was most dense on the face, hands, and feet, though it also covered broad areas of the chest, back, trunk, arms, legs, and genitals.38
Over the next two weeks, the lesions followed a well-known clinical course. Wyman’s “Précis” ticked off the stages: “macule, papule, vesicle, and pustule, ending in desiccation and desquamation.” By the second day of the rash, a small raised bump (the papule) formed atop each red macule, rising just above the skin as the papule filled with fluid. Physicians described the papules as “shotty,” because they could be rolled between thumb and forefinger, as if shot from the blast of a hunter’s gun had become embedded under the skin.39
In a few more days, the papules evolved into vesicles, blisters with navellike depressions in their centers. (Physicians called the vesicles at this stage “umbilicated.”) The depressions gradually rounded out as the vesicles became filled with a pressurized fluid that started opalescent and gradually turned opaque. When that process was completed, after a few days, the lesions were called pustules. The puffy pustules had a yellowish gray color encircled by a red border. They reached their full size, like blood-engorged dog ticks, by the tenth day of the eruption. In the most common form of smallpox cases, the rash remained “discrete”: normal skin could still be seen between the lesions. But in more severe, “confluent” cases, there were so many pustules that they fused together, especially on the face. Dr. Long found it “almost impossible to paint a pen-picture” of the “terrible faces” of confluent patients.40
Throughout the eruption, the patient suffered. As if to trumpet the ascendance of the pustules, the fever returned, as did many of the symptoms that had attended the fever the first time around. By this time, the patient’s face was normally swollen and disfigured, the hands puffy and aching, the skin inflamed. Ulcers burned the mouth and throat, growing so large in some cases that the patient had the sensation of suffocating.
Stoner’s Handbook for the Ship’s Medicine Chest offered a concise description of the final clinical stages of smallpox, which occurred by the end of the eruption’s second week. First came the desiccation: “The pustules break, matter oozes out, crusts form, first on the face and then over other parts of the body following the order of the appearance of the eruption.” The secondary fever gradually abated. Then came the desquamation, or scaling off: “The crusts rapidly dry and fall off, leaving red spots on the skin.” This could take two or more incredibly itchy weeks. Given the reigning scientific beliefs, all scabs and crusts had to be carefully collected and incinerated.41
From the onset of fever to the separation of the scabs, smallpox typically lasted three to four weeks—though sometimes much longer. Throughout, there was not much an attending nurse or physician could do but try to ease the suffering. “As regards treatment, there is little to say,” wrote Dr.