The Speckled Monster by Jennifer Lee Carrell Page A

her—still guarding against fear—was that her rash was already quite thick. At this early stage, that was a dangerous sign.
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    In the eighteenth century, as in the twentieth, doctors distinguished four main types of smallpox, though they labeled them with different names and distributed them with different logic across the branches of the smallpox family tree. Everyone who dealt with it realized that the best of this bad disease was “distinct” or “discrete” smallpox, which presented a rash scattered thinly enough so that the pocks remained separate—or distinct—with patches of normal skin in between. In “confluent” smallpox, sometimes called “coherent,” the rash was so dense that across much of the body—especially the face, hands, and forearms, where it was always thickest—the pocks ran together into one huge festering sore; little to no normal skin was left. In everyday terms, these victims were said to be “very full.”
    The remaining two types—flat and hemorrhagic—were once often lumped together (sometimes with confluent) as “malignant smallpox.” In “flat,” “crystalline,” or “warty” smallpox, the slow-growing blisters usually ran together, but never really rose much above the surface of the skin and did not fill with the same kind of thick yellow pus found in discrete and confluent pocks. Instead, shallow ripples spread across the skin’s surface, stretched over sores buried in its deepest levels; large strips of the top layer of skin, along with the delicate coverings of most mucous membranes (inner nose, mouth and throat, anus, vagina), eventually just sloughed off. Almost three quarters of these cases were children under fourteen.
    Hemorrhagic smallpox was subdivided into two kinds, “early” and “late,” both marked by profuse bleeding at every orifice, as mucous membranes and blood vessels seemed to melt away. In the early type, once known as “the purples,” death came before any pocklike rash broke out, though the skin transformed to dark purple velvet. In late hemorrhagic smallpox, victims survived long enough for blisters—often flat in type—to appear, but they quickly filled with blood, darkening to bruised purple and black, ringed with red. In both kinds of hemorrhagic smallpox, it was not the bleeding, but heart failure or fluid in the lungs (pulmonary edema) that proved the immediate cause of death. Nearly all these cases were adults; two thirds were women.
    These malignant cases were relatively rare (just over 9 percent of the total number of smallpox cases), but they were death sentences so terrible to behold that they loomed monstrous in the imagination. Flat smallpox carried about a 3.5 percent chance of survival; in late hemorrhagic smallpox it was 3.2 percent. Early hemorrhagic smallpox had no survivors.
    Eighteenth-century doctors saw these malignant types as crop failures. Flat and purple smallpox did not ripen properly, while confluent cases quickly grew overripe. Twentieth-century doctors explained all three of these serious developments as the results of differing degrees of immunodeficiency; some people with otherwise healthy immune systems inexplicably had little to no power to fight back against the variola virus. As early as the seventeenth century, it was known that such weakness in the face of smallpox ran in families—the Stuarts, for example. Pregnancy was another high-risk factor, already obvious to early doctors.
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    In Lady Mary’s sickroom, the first days sped by in pairs. The first prerash fever had been much the most uncomfortable stage so far. As the red spots flowed down her body across the following two days, she began to feel better. With her fever still falling, she felt better still as the spots bubbled into blisters for another two days. “How is my boy?” she kept asking.
    â€œStill