Clinical Manifestations and Pathology

The incubation period was about 12 days. Onset was abrupt and prostrating: high fever, headache, and pain in the back and muscles; and, in children, sometimes vomiting and convulsions. In the severest infections, extreme toxemia and massive hemor-raging into the skin, lungs, and other organs could cause death swiftly before the appearance of more than a slight rash. In the great majority of cases, the sufferer survived to experience the characteristic rash 2 to 5 days after onset. In most cases the rash appeared more densely on the face, palms, and soles than on the trunk. In another few days, the small pimples of the rash turned to pustules, which in extreme cases were confluent, almost always indicating a lethal infection. William Bradford observed cases like this among Amerindians near Plymouth in North America in 1633-4. He describes their pustules as "breaking and mattering and running one into another." Complications may have been common in Amerindians. Those cited just above seem to have had a pneumonic secondary infection: "And then, being very sore, what with cold and other distempers, they die like rotten sheep."

Drying and crusting of the pustules began on the eighth or ninth day after the first eruptions. The scabs fell off 3 or 4 weeks after onset, and the victim was well again, barring complications. Among the possible sequelae were blindness and, at least occasionally, male infertility. The probable sequel was a pocked and scarred face, appalling to others as well as to the survivor. Literature is full of references to women thus robbed of their smooth skins, from Ben Jonson's cry-"Envious and foule Disease, could there not be One beautie in an Age, and free from thee?" - to Charles Dickens's heroine of Bleak House, who after recovery remarks bravely, "It matters very little ... I hope I can do without my old face very well."

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