with water or glycerine. A convenient way of powdering a crust is to
rub it on a file or between two files. The paste is to be well rubbed
upon the abrasion. The insertion of a solid piece of crust into a
valvular incision is not to be recommended.
When the operation is finished it is well to keep the arm bare for
about five minutes, but not necessarily until the spot has become dry.
It is not well to apply any sort of plaster, but means should be taken
to prevent the underclothing from sticking to the abrasion. For this
purpose there is no objection to the shields that are furnished by the
surgical instrument-makers. Usually, however, nothing of the sort is
necessary.
THE STORAGE AND PRESERVATION OF VACCINE VIRUS.--Lymph should usually
be taken on the eighth day, inclusive--never after the areola has
formed. On the other hand, the writer's experience does not lead him
to coincide with those who state that the earliest lymph that can be
obtained is the most energetic. If it is to be dry-stored, the
substance to be coated with it (slips of quill, ivory, wood,
whalebone, glass, and the like) should be laid gently in the pool of
lymph that exudes on puncturing the pock, and allowed to dry,
preferably without the aid of artificial warmth. The layer of lymph
should be plainly visible after it has dried. A second coating is
advisable, as it serves to preserve the first.
Capillary glass tubes are either cylindrical or furnished with a
bulbous expansion at the middle, the latter form being most commonly
used. To charge a tube make sure that both ends are open, and then
submerge one end in the pool of lymph. Capillary attraction will cause
the tube to fill, and the process may be facilitated materially by
inclining the tube toward a horizontal direction, so that the
capillary attraction is not opposed by that of gravitation. Care
should be taken to keep the applied end of the tube constantly
submerged, or bubbles of air will enter it. The sealing may be done
with a blowpipe, by simply holding the ends in a flame, or by means of
sealing-wax or some similar substance. The satisfactory charging of
tubes demands some practice, but a little patience will enable any
intelligent person to succeed.
In regard to crusts, they should never be removed until the surface
beneath has become cicatrized and they have been partially detached by
the natural process. A crust torn off prematurely should never be
used, {480} and the same may be said of secondary crusts--_i.e._ those
that form by the desiccation of the discharge from the raw surface
left when the primary crust has been removed forcibly.
For the preservation of vaccine in these various forms tubes need only
be kept in a cool place. Dried lymph and crusts should be guarded
against dampness even more than against warmth. Their preservation may
be decidedly favored by over-drying, either in an exhausted receiver
or by keeping them in a closed vessel in the presence of sulphuric
acid, chloride of calcium, or some other substance having a strong
affinity for water. It is needless to say, however, that they should
not come into actual contact with any such agent. While this
artificial desiccation tends powerfully to preserve dried lymph, it
makes it more difficult to use. When dried lymph or a crust is to be
sent by mail or other conveyance, it should be wrapped in some
impermeably envelope, for which purpose gutta-percha tissue is very
convenient. Both these forms of virus should be kept in a cool place.
There is no objection to keeping them on ice, provided they are well
protected against moisture.
* * * * *
In conclusion, the writer wishes to say that the limited space at his
command has compelled the assumption of a dogmatic rather than an
inductive form in the construction of this article. To the reader who
may wish to pursue the subject further--and it will well repay
thorough study--he would recommend the following bibliography:
Ballard: _On Vaccination: its Value and Alleged Dangers_, London,
1868.
Bousquet: _Nouveau traité de la vaccine et des éruptions varioleuses_,
Paris, 1848.
Bryce: _Practical Observations on the Inoculation of Cow-pox_,
Edinburgh, 1809.
Ceely: _Observations on the Variolæ Vaccinæ_, Worcester, 1840.
Chauveau et al.: _Vaccine et Variole_, Paris, 1865.
Depaul: _Nouvelles recherches sur la véritable origine du virus
vaccin_, Paris, 1863; _De l'origine réelle du virus vaccin_, Paris,
1864; et al.: _De la syphilis vaccinale_, Paris, 1865.
Hardaway: _Essentials of Vaccination_, Chicago, 1882.
Hering: _Ueber Kuhpocken an Kühen_, Stuttgart, 1839.
Jenner: _An Inquiry, etc._, 2d ed., London, 1800.
Sacco: _Trattato di Vaccinazione_, Milano, 1809.
Seaton: _A Handbook of Vaccination_, London, 1868.
Steinbrenner: _Traité sur la vaccine_, Paris, 1846.
{481}
VARICELLA.
BY JAMES NEVINS HYDE, M.D.
Varicella is an acute disorder of infancy and childhood, in the course
of which appears a cutaneous exanthem of vesicular type, accompanied
at times by systemic symptoms of moderate severity, terminating in the
course of from three days to a fortnight, after the formation of
relatively few crusts upon the skin, with occasionally persistent
cicatrices.
SYNONYMS.--_Eng._, Chicken-pox; _Ger._, Windblattern, Schafpocken;
_Fr._, Varicelle; _Lat._, Variola notha, seu spuria; _Ital._,
Morviglione.
HISTORY.--The literature of the disease which is now best recognized
under the title of varicella has been, in the history of medicine,
wellnigh inextricably confused with that of variola. In the latter
part of the seventeenth and the early part of the eighteenth century
the distinction between typical forms of the two disorders became
apparent, and was described by Willan and Harvey in England, and other
writers in Germany, France, Holland, and Belgium. Among those who have
contributed to its literature may be named Hebra, Kaposi, Trousseau,
Simon, Thomas, Güntz, Henoch, Kassowitz, and Boeck.
ETIOLOGY.--Varicella is essentially a disease of early life, occurring
almost exclusively in infants and young children. It is a contagious
disorder, and at times, especially in hospitals and asylums for
children, occurs in apparently epidemic forms. The question relating
to the inoculability of the contents of its vesicular lesions is still
open, positive and negative results being recorded by different
experiments.[1]
[Footnote 1: The writer has purposely avoided, in the brief space here
devoted to the disease under consideration, entering into a discussion
of the question respecting the relation sustained by varicella to
variola. On one side are the views entertained by the Vienna school of
dermatologists, according to which there is but a single virus in
these several forms of disease--the variolous poison. On the other are
the opinions and the practice, largely based upon the latter, of most
English and American physicians, who deny the existence of any
relation between the pathological states recognized by them as
occurring in two entirely distinct affections.
My personal view may be briefly formulated as follows: Practically and
clinically, it is useful to regard these disorders as of a distinct
nature. The arguments, however, in favor of such absolute distinction
are not irrefutable. There is probably in both forms of disease but a
single virus, that of variola; but this, modified by evolution among
generations of vaccinated children, has, in this process of natural
cultivation or attenuation, produced a malady of tender years whose
attacks do not protect from variola and occur irrespective of
vaccination.]
SYMPTOMATOLOGY.--The period of incubation of the disease cannot be
said to be definitely established. At times, without question, an
entire fortnight elapses between the dates of exposure and the
evolution of the disease, but both longer and shorter intervals have
been recorded.
{482} If there be a prodromal stage of the disease, certainly in the
vast majority of the little patients it cannot be recognized. During
the last month the writer has observed the evolution of the disease in
twenty children gathered together in the Chicago Home for the
Friendless, no one of whom was recognized as ailing before the
eruption appeared. Occasionally the disease is preceded by mild or
even severe febrile symptoms, accidents sufficiently common in this
class of patients.
The exanthem, commonly the first symptom of the disorder, occurs in
the form of reddish puncta, from which rapidly develop rosy-colored
maculations, and these become tensely distended, transparent or
slightly yellowish vesicles, of the average size of a split pea,
though they are occasionally smaller or may enlarge to the dimensions
of a bean or small nut. The eruption appears first upon the upper
segment of the body, implicating the chest in front and behind, the
neck, the scalp, particularly the extremities, and quite sparingly the
face also, which may, however, entirely escape. In cases where the
eruption is profuse it may be completely generalized, involving
largely the trunk and extremities, the lesions, upon the back
particularly, being as closely set together as in discrete variola. In
many, even the majority, of cases the exanthem is much less profusely
developed, not more than a dozen or twenty vesicles springing from the
surface.
The vesicles are superficial in situation, the firm papule which
precedes the variolous rash being altogether wanting. They are at
first transparent, their contents plainly showing through their
translucent roof-wall, composed only of the stratum corneum of the
epidermis. They are both acuminate and globular, and occasionally rest
upon a slightly hyperæmic integument. Umbilication rapidly occurs at
the apex, and simultaneously their contents become lactescent and
gradually sero-purulent. Occasionally vesicles are transformed into
genuine, coffee-bean-sized, pustules. Intermingled with these are
often seen illy-developed and abortive vesicles.
By the end of a period lasting from twelve hours to the second or
third day involution has usually begun, and the lesions, with and
without rupture--more often the latter--desiccate, and are thus
transformed into yellowish or yellowish and brown, circular,
circumscribed crusts resting upon an apparently unaltered integument.
These crusts are often so firmly attached that they do not fall
spontaneously before the lapse of from five to eight days. When this
exfoliation is ended there are left slightly hyperæmic pigmented
patches of corresponding size where the crusts had rested. A
destructive process occasionally results upon the surface of the face
at the base of such vesiculo-pustular lesions as have formed there, in
consequence of which a small depressed and superficial cicatrix is
left, which does not differ from that resulting from discrete variola.
These scars may be superficially seated and transitory in character,
or much deeper and persistent through life.
Throughout the course of the disease systemic symptoms may be
altogether wanting, or may occur in a mild, and much more rarely in a
severe, type. In some cases the temperature is increased by one or two
degrees upon the appearance of the exanthem, and often a febrile
movement of moderate grade may persist for forty-eight hours or
somewhat longer. Defervescence, however, is always rapid and perfect.
In very {483} rare cases there is a subsequent successive new
development of scanty vesicles, whose appearance is heralded by mild
exacerbations of fever.
Occasionally the vesicles may be recognized upon the mucous surfaces
of the lips, inside of the cheeks, tongue, palate, conjunctivæ, and
progenital regions of both sexes. Still more rarely the glands of the
throat become slightly tumid and painful.
The complexus of symptoms, in the large majority of all these little
patients, is that which pertains to a disorder of distinctly mild
type. The eruptive lesions are scanty and productive of but trifling
subjective sensations. Occasionally they are picked or scratched, and
thus become the seat of either pain or pruritus. In the febrile stage
the child is noticeably fretful for a period of perhaps twenty-four
hours. At the end of that time older children are frequently observed
engaged in their customary amusements in the nursery.
Severe types and complications of varicella are in general limited to
the little patients who are recognized as suffering from hospitalism.
Among these we see erysipelas, severe vaccinal eruptions, lesions of
inherited syphilis, and the sequelæ of morebilli and scarlatina, which
the disease both precedes and follows.
PATHOLOGY.--The anatomical structure of the lesions in varicella is
largely a matter of inference, since there has been but small
opportunity of studying the disorder as displayed in sections of the
morbid integument. Manifestly, the exanthem is exudative in type, the
serum in circumscribed areas lifting the superficial layer of the
epidermis from the deeper parts of the derm. Unquestionably, septa
occur in typically developed varicella chambers, similar to those seen
in variola--a pathological fact which is the corner-stone of the
doctrine relating to the unity of the two disorders. The serum
contained in these septa possesses an alkaline reaction. The formation
of a cicatrix is evidently due to the intensity of the process in
certain exceptional lesions, as a result of which the papillæ of the
corium are superficially destroyed. These sequelæ are often due to the
picking and scratching of the lesions.
DIAGNOSIS.--Varicella is to be distinguished from eczema pustulosum by
its mild febrile symptoms, the discreteness of its pustular lesions,
the absence of itching, and of infiltration of the skin in patches,
and its tendency to symmetrical development.
From impetigo and the impetigo contagiosa of Fox of London it will
often be scarcely differentiated. Inasmuch as these disorders are
frequently recognized among children suffering from varicella or
varicella convalescence, it can scarcely be doubted that these
diseases have been in the past often confounded, and that in many
cases it is practically impossible to distinguish between them.
Decided elevation of bodily temperature, umbilication of
symmetrically-disposed lesions, and a rapid involution of the disease
point to varicella. The two forms of impetigo occur without fever, are
usually scantily developed, and are much more apt to be pustular in
type, lacking, moreover, the halo of the varicella lesions. The latter
are also, on an average, smaller and more numerous. The two forms of
impetigo, finally, never display the generalized eruption of severe
varicella. The non-contagious variety of impetigo is much more
decidedly pustular in its lesions, and the latter spring from a deeper
plane of the epidermis.
{484} As to the eruptions due to vaccinia and vaccination, there can
be but little doubt that these also have been frequently confounded
with varicella. Efflorescences having origin in this way are very
largely impetiginous in type, and the conditions named above are then
to be regarded as distinctive differences, so far as any distinction
can, under these circumstances, be recognized. Impetigo, impetigo
contagiosa, and varicella are all sufficiently common accidents after
vaccination. No reliance can be placed upon characteristics described
as connected with a certain stuck-on appearance of the crust regarded
by Fox as characteristic of the crusts in impetigo contagiosa. In all
these vesiculo-pustular disorders of childhood desiccating serum and
sero-pus upon the surface result in the formation of crusts which have
a similar (so-called) stuck-on appearance.
Variola and varioloid of infants and children are to be distinguished
from varicella by the evidence of origin from such contagious
maladies; by the occurrence of prodromal symptoms; by the greater rise
in temperature during the febrile stage; by the typically papular
stage of the exanthem at its outset, and no less typically pustular
stage before the occurrence of desiccation; by the confluence of
lesions in confluent cases; and by the much longer and evidently
graver stadium of the disease. Distinctions between mild varioloid and
severe varicella in infancy and childhood will always tax to the
utmost the skill of the diagnostician. The sooner it is generally
understood that intermediate forms occur which cannot be positively
assigned to the one or to the other category, the better it will be
for both the profession and the laity. The fact that in the one case
there is generation of a variolous poison capable of producing a
contagious disease in adults, and in the other a malady which is known
to affect children only, renders the decision important. Scattered
papulo-vesicular and vesiculo-pustular lesions appearing after a high
fever, and pursuing a period of evolution longer than forty-eight
hours, should always awaken suspicion. Superficial lesions, on the
contrary, distinctly vesicular on the third day, or commingled with
minute, very superficial pustules, should be regarded as
characteristic of varicella.
The so-called varicella prurigo of Hutchison of London[2] includes
several of the disorders considered above under the titles impetigo,
impetigo contagiosa, and the vaccine rashes. The irritable condition
of the skin resulting from several of the exanthemata leaves it prone
to the development of a long list of cutaneous lesions, some of them
accompanied by pruritus in various grades, to each of which might be
given, according to the caprice of authors, a separate name.
[Footnote 2: _Lect. on Clin. Surg._, Lond., 1878, p. 15 _et seq._]
PROGNOSIS.--The prognosis of varicella, per se, is always favorable.
Only in the hospital cases, complicated by erysipelas and scarlatina
convalescence, may grave results be anticipated. The milder attacks
may leave persistent relics of their career in the form of one or more
depressed and persistent cicatrices, which become less conspicuous as
the patient approaches adult years.
TREATMENT.--Varicella is, in a large proportion of cases, successfully
treated by domestic management and the simpler remedies familiar to
those in charge of the nursery. Confinement for a brief time to the
{485} cradle or bed, and a proper regulation of the temperature of the
room and of the diet, are usually all that is required. Special
remedies may be indicated in isolated cases, but certainly none such
are demanded by the varicella. Efforts should be made to protect the
face lesions from the traumatism of picking and scratching, with a
view to prevent pitting.
Isolation of patients is not requisite, nor any process of
disinfection other than that which is incidental to a fresh supply of
pure air. Vaccination should be practised alike in the case of
children who have and who have not suffered from the disease.
{486}
SCARLET FEVER.
BY J. LEWIS SMITH, M.D.
HISTORY.--The terms scarlet fever and scarlatina are used synonymously
to designate one of the most common and fatal of the eruptive fevers.
Whether this malady occurred prior to the Christian era is uncertain.
It is believed by some that the plague of Athens, 430 years before
Christ, vividly described by Lucretius, and by Thucydides, who was
attacked by it, was scarlet fever of a peculiarly malignant type
(Richardson); but, as will be seen from the following extracts from
Thucydides, the plague differed in important particulars from
scarlatina of the present time: "Internally, the throat and the tongue
were quickly suffused with blood, and the breath became unnatural and
fetid. There followed sneezing and hoarseness; in a short time the
disorder, accompanied by a violent cough, reached the chest.... The
body externally was not so very hot to the touch, nor yet pale: it was
of a livid color, inclining to red, and breaking out in pustules and
ulcers." Loss of sight and gangrene of the extremities were common
results in those who recovered, and adults appear to have been
affected as frequently as children. "The dead lay as they had died,
one upon another, while others, hardly alive, wallowed in the streets
and crawled about every fountain craving for water. The temples in
which they lodged were full of the corpses of those who died in them."
Lucretius says of this plague, "If any one for a time escaped death
(as was possible, either by reason of the foul ulcers breaking or by
means of a black discharge from the intestines), yet consumption and
destruction awaited him at last; or, as was often the case, an
excessive flux of corrupt blood, attended with violent pains in the
head, issued from the obstructed nostrils, and by this outlet the
whole strength and substance of the man passed away. He, moreover, who
had escaped this violent flux of foul blood was not certain wholly to
recover, for still the disease was ready to pass into his nerves and
joints, and into the very genital organs of the body. And of those who
suffered thus, some, fearing the gates of death, continued to live,
though deprived by the steel of the virile part, and some, though
without hands and feet, and though they lost their eyes, yet persisted
to remain in life, so strong a dread of death had taken possession of
them. Upon some, too, came forgetfulness of all things, so that they
knew not even themselves."
Gangrene of the extremities, loss of sight, a violent cough, loss of
memory, etc. are not symptoms of scarlet fever, so that in my opinion
{487} the plague of Athens, if correctly described by the historian,
was a different malady.
Caspar Morris, in his essay on scarlet fever, states his belief that
Seneca, who lived in the first century of the Christian era, described
an epidemic of the malignant form of scarlatina in his portrayal of
the pestilence that visited Thebes during the half-mythical age of
Oedipus, six centuries before Christ. Seneca's description of the
symptoms of this plague is as follows:
Piger ignavos
Alligat artus languor, et ægro
Rubor in vultu, maculæque caput
Sparsere leves; tum vapor ipsam
Corporis arcem flammeus urit
Multoque genus sanguine tendit
Oculique regent, et sacer ignis
Pascitur artus. Resonant aures,
Stillatque niger naris aducæ
Cruor; at venas rumpit hiantes.
Languor, redness of the face, light spots upon the head, distension of
the cheeks with blood, distortion of the eyes, a flushed appearance of
the limbs, tinnitus aurium, and a discharge of black blood from the
nostrils, certainly indicated a very malignant form of disease, but to
believe that it was identical with the scarlet fever of the present
time requires considerable credulity. From the fact that it devastated
Thebes we infer that it occurred largely among adults, differing,
therefore, from the modern scarlet fever, whose victims are chiefly
children. The same uncertainty hangs over epidemics during the first
centuries of the Christian era.
The first clear and undoubted portrayal of scarlet fever is found in
the medical literature of the sixteenth century. Sydenham and his
contemporaries in the seventeenth century witnessed epidemics of it,
studied its nature more thoroughly, and consequently acquired a more
accurate knowledge of it than that possessed by their predecessors. It
was in this century that measles and scarlet fever were
differentiated. During the last two hundred years scarlatina has been
the subject of monographs too numerous to mention. It has long been
regarded as one of the most important maladies of childhood, on
account of its frequency and the great mortality that attends it, so
that numerous cases and many epidemics are every year related in the
medical journals. By this vast accumulation of observations and the
patient and thorough use of the microscope our knowledge of scarlet
fever has become full and accurate.