Part 76

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 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.

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.

As with most of the infectious maladies, scarlet fever extended to the Western World through European shipping. It was brought to North America about the year 1735. Tardily it spread to South America, where it appeared in 1829, and more recently it has been established in Australia. It entered Iceland in 1827, and Greenland in 1847.

ETIOLOGY.--The evidence is strong that scarlet fever does not originate de novo--that it does not spring from certain atmospheric or telluric conditions, but is produced by a definite specific principle, since countries have been free from it for centuries till it was imported by commerce. That it appears in certain localities without any known exposure is attributed to the fact that the poison is so subtle and transmissible that it is {488} conveyed long distances in articles of merchandise, even in small packages, so that those who chance to open them or come in contact with them are infected. It is believed that reading matter transmitted through the mails has in many instances been the medium of infection.

The theory that the acute infectious maladies are caused by micro-organisms, or, as they are now designated, microbes, commonly discarded at first and believed to be chimerical, is rapidly gaining ground in the profession, and appears to be fully established as regards certain of them. These parasites, barely visible under high powers of the microscope, and ascertained to be vegetable by their behavior under certain chemical agents, exist in immense numbers in the blood, tissues, and secretions of patients suffering from the infectious maladies, especially in the graver cases of them; and the microscope shows that these organisms vary in shape and appearance so as to admit of classification.

The germ theory has now become so important that it cannot be ignored in a monograph relating to so important an infectious malady as scarlet fever. The relation of microbes to the infectious diseases has been made the subject of investigation by Pasteur, Toussaint, and others in France, and by many in Germany, with most interesting results. The belief held by many, and which seemed very plausible, was that the microbes, instead of sustaining a causative relation to the maladies in which they occur, were the result of these maladies--that they sprang into existence in consequence of the vitiated state of the blood and tissues, just as fungi appear on decaying substances or as the Oidium albicans appears in certain morbid conditions of the buccal surface and secretions. Obviously, in order to elucidate this matter and determine the relation of these parasites to the diseases in which they occur, it was necessary to experiment on animals, but, unfortunately, as a bar to successful experimentation many of the most important infectious maladies which afflict the human race, as typhus and typhoid fevers, the marsh fevers, and syphilis, do not occur in animals, or they occur in a changed and mitigated form. Others, however, can be produced in their typical character in animals, as diphtheria, and others still originate in animals and are transmitted from them to man, as anthrax or splenic fever of the herbivora and hydrophobia. Very interesting and important results have been produced by experimental researches with the microbes of certain of these diseases, which, if applicable to the common and fatal infectious maladies of an analogous nature in man, may yet result in immense benefit in mitigating the virulence of those affections which are the scourge of childhood and which sensibly diminish the increase of population. It has been found possible to cultivate the microbes contained in the blood, tissues, and secretions in certain of the infectious diseases, and after a series of cultivations, so that these organisms are far removed from the animal substance which contained them, and with which they were so intimately associated in the individual, they have been employed for inoculation--with this important result, that the primary disease was reproduced. This seems to indicate beyond question the causative relation of these parasites to the diseases in which they occur. Experiments with the result which I have stated have been made with the microbes of splenic fever, chicken cholera, murrain, and certain other maladies.