Varicella

“ 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. ”

“ 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. ”

“ Some months later the mother being out of violet powder, again used the particular powder to the infant, and at once the sores reappeared. The powder was then burned. A. D., aged three years, was attacked about Christmas 1877 by varicella. During recovery and while the pocks were dying away, she herself purchased a packet of the particular powder, which was then used for dusting the eruption about the pudenda. Almost at once the dying vesicles became sores which turned black and discharged matter; on healing they left scars. ”

“ Among the infectious diseases known to be due to specific germs are the following: typhoid, typhus, relapsing fevers, cholera, diphtheria, croup, tuberculosis, pneumonia, malaria, yellow fever, erysipelas, septicæmia, anthrax, tetanus, gonorrhea, etc.; and among the infectious diseases the germs of which have not as yet been discovered are the following: scarlet fever, measles, smallpox, syphilis, varicella, etc.
The part of the body and the organs in which the [Pg 239] germs first find their entrance, or which they specifically attack, vary with each disease ”

“ A nonsystemic infection consisting only of a local skin lesion may occur upon cutaneous exposure to a strain of low virulence or when the pig is partly immune. In such cases the organism is eliminated without inducing septicemia and the lesion disappears. In the more typical systemic infection caused by virulent organisms, bacteremia usually develops within 24 hours after exposure. The organism usually can no longer be cultured from blood or most body organs after a few days but may persist, often for months, in the joints and in lymphoid tissue such as tonsils, Peyer's patches, and spleen. ”

“ It is curious also to observe, that the virus, which with respect to its effects is undetermined and uncertain previously to its passing from the horse through the medium of the cow, should then not only become more active, but should invariably and completely possess those specific properties which induce in the human constitution symptoms similar to those of the variolous fever, and effect in it that peculiar change which for ever renders it unsusceptible of the variolous contagion. ”

“ SMALLPOX or Variola.—Smallpox is an acute infectious disease. It has a sudden onset with a severe period of invasion which is followed by a falling of the fever, and then the eruption comes out. This eruption begins as a pimple, then a watery pimple (vesicle) which runs into the pus pimple (pustule) and then the crust or scab forms. The mucous membrane in contact with the air may also be affected. Almost all persons exposed, if not vaccinated, are almost invariably attacked. It is very contagious. It attacks all ages, but it is particularly fatal to young children. ”

“ The world is much indebted to the great discoverer of the good effects of inoculation, whose name is unknown; and our own country to Lady Wortley Montague for its introduction into this part of Europe. By inserting the variolous contagion into the arm, it is not received by the tonsils, as generally happens, I suppose, in the natural small-pox; whence there is no dangerous swelling of the throat, and as the pustules are generally few and distinct, there is seldom any secondary fever ”

“ One kind of contagion [14] is more subtile than another; for there is a sort, which is taken into the body by the very breath; such as I have elsewhere said to exist in the plague, small pox, and other malignant fevers. But there is another sort, which infects by contact alone; either internal, as the venom of the venereal disease; or external, as that of the itch, which is conveyed into the body by rubbing against cloaths, whether woollen or linnen. Wherefore the leprosy, which is a species of the itch, may pass into a sound man in this last manner ”

“ It was the doctor's practice to make as slight an incision as possible upon the skin, and there to lodge a thread saturated with the variolous matter. When his patients became indisposed, agreeably to the custom then prevailing, they were directed to go to bed and were kept moderately warm. Is it not probable then, that the success of the modern practice may depend more upon the method of invariably depositing the virus in or upon the skin, than on the subsequent treatment of the disease? ”

“ The taking of virus from a child, or an adult, should never be allowed, as constitutional diseases are often transmitted in that way. Vaccination is performed by making a small incision in the skin and introducing the virus on the point of a lancet or needle. On the third day, if the desired result has been attained, a small red spot may be seen. This increases in size, becomes elevated, and, by the sixth day, is filled with a clear, yellow liquid. About the eighth day, the pustule is fully formed, when symptoms of small-pox are usually felt,—headache, shivering, loss of appetite, etc. ”

“ The blood and muscular tissues are not always virulent, even in cases of generalised tuberculosis.
The virulent organisms usually enter the body through the lymphatic system; invasion proceeds from the point inoculated towards the nearest lymphatic glands and thence along the chain of lymphatic vessels, and the lesions extend, attacking the internal organs more or less rapidly. The body does not necessarily become fatally infected as a consequence of accidental or even experimental infection, for the bacillus may itself be destroyed by the phagocytes, or the lesion may remain purely local. ”

“ Variola may be confounded with bronchitis or pneumonia if complicated with these troubles and the eruption is absent from the exterior, but it is of little moment, as the treatment for both is much the same. When the eruption is in the neighborhood of the genital organs the disease has been mistaken for dourine. In variola the eruption is a temporary one; the nodes and pustules are followed by shallow ulcers and rapid cicatrization unless continued in the vagina or on the penis by the rubbing of the walls and filth which accumulates; there are apt to be pustules at other parts of the body. ”

“ One of them, Hester Walkley, I attended with that disease when she lived in the service of a Farmer in the same village in the year 1782; but neither this woman, nor any other of the patients who had gone through the Cow Pox, received the variolous infection either from the arm or from mixing in the society of the other patients who were inoculated at the same time. This state of security proved a fortunate circumstance, as many of the poor women were at the same time in a state of pregnancy. ”

“ On the other hand, he found the weakened virus could be again strengthened by inoculating a feeble animal such as a guinea-pig a day or two old with it, and then inoculating stronger and stronger animals: an increase in strength was gained with each inoculation, until at last the virus could attack the strongest. A similar increase in virulence appears to occur in plague, where animals, especially rats and mice, seem to be affected before human beings, and not only increase the virulence of the microbes, but convey the infection. ”

“ It grows readily on most media at the temperature of the body, but, like the glanders bacillus, soon loses its virulence in cultivations. It may be obtained in pure cultures from the lymph glands, and from the abscesses that are formed in the groin or other positions in which the glands become enlarged and softened. It may also be found in the spleen and in the blood, and, in the case of patients suffering from the pneumonic form of the disease, even in the lungs and in the sputum. It has also been found in the faeces and urine. ”

“ The most important congenital infections are syphilis, gonorrhœa, tuberculosis, variola, typhoid, pyogenic infection, tetanus, measles, scarlatina, influenza, meningitis, malaria, recurrent fever, pneumococcus, colon bacillus and others, mostly very rare. ”

“ Sometimes instead of a vesicle there appears a hard elevated nodule, in color like a red raspberry. With this there is usually no areola, and no constitutional symptoms develop. The growth is usually an evidence of poor virus. It may persist for some time before absorption.
The course may be abortive,—i.e., the vesicle does not develop completely; pustulation comes early and the crust is shed and the scar formed before the end of the second week. This course is normal though not invariable in revaccinations.
The scar may be poorly marked, even when the vaccination has run a typical course. ”

“ Following entry into the epithelium via an abrasion, the virus multiplies in the stratum germinativum of the epidermis. Hydropic degeneration occurs, followed by necrosis of infected cells. Intracellular edema (hydropic degeneration) and intercellular edema account for vesicle formation (Madin and Traum 1955) . Virus spreads from cell to cell as the infection progresses. Local lymph nodes may become involved, with extensive lymphocyte destruction and congestion; a low-level viremia occurs and may account for some secondary lesions. ”

“ Indeed it becomes almost a criterion by which we can determine whether the infection will be received or not. It seems as if a change, which endures through life, had been produced in the action, or disposition to action, in the vessels of the skin; and it is remarkable too, that whether this change has been effected by the Small Pox, or the Cow Pox, that the disposition to sudden cuticular inflammation is the same on the application of variolous matter. ”

“ These indurated nodules retain the virus and their power to give out contagion for almost an indefinite time, and predispose to the causes which we have studied as the common factors in developing a chronic case into an acute case; that is, an inflammatory process wakens their vitality and produces a reinfection of the entire animal. The blood of an animal suffering from chronic glanders and farcy is not virulent and is unaltered, but during the attack of acute glanders, while the animal has fever, the blood becomes virulent and remains so for a few days. ”

“ HANNAH EXCELL an healthy girl of seven years old, and one of the patients above mentioned, received the [Pg 40] infection from the insertion of the virus under the cuticle of the arm in three distinct points. The pustules which arose in consequence, so much resembled, on the 12th day, those appearing from the insertion of variolous matter, that an experienced Inoculator would scarcely have discovered a shade of difference at that period. ”

“ These cases usually show moderate enlargement and tenderness of some group of lymphatic glands. It is in this mild form of plague that we are most apt to find the primary vesicle or phlyctenule at the site of the flea bite.
Ordinarily, man is so susceptible to plague that there is no reaction at the site of inoculation but in these mild cases there is an inflammatory reaction resulting in a vesicle or pustule, which may teem with plague bacilli. In such cases it is extremely important to search for such primary vesicles and examine for plague bacilli. ”

“ This contagion is beyond question a living something which multiplies with great rapidity under proper conditions, and, escaping from the bodies of those infected with the disease, in one way or another, reaches other individuals. It is beyond question true that the virus passes from the body of those infected by means of the urine and feces, and it [Pg 189] is likely that the secretions from the mouth and nose frequently contain the germs that cause the fever. ”

“ In diphtheria, scarlatina, small-pox, measles, etc., these epithelial scales come off in vastly greater quantities than in health, carrying with them, in greater or less virulence, the peculiar infection in the body whence they have arisen. The greater their number and the more favorable the nidus in which they become deposited, the more likely they are to become transplanted as primary centers of infection. ”

“ Variola in the horse, while it is identical in principle, general course, complications, and lesions with variola in other animals, is a disease of the horse itself, and is not transmissible in the form of variola to any other animal; nor is the variola of any other animal transmissible to the horse. Cattle and men, if inoculated from a case of horsepox, develop vaccinia, but vaccinia from the latter animals is not so readily reinoculated into the horse with success. If it does develop, it produces the original disease. ”

“ While it is generally admitted that all forms of endocarditis, even of the most benign character, are originally due to infection, it is certain that in those of the second group the organisms which have entered the bloodstream through a lesion of the uterus, lung or other tissue, are endowed with very great virulence. ”