Chapter XXIX: Part II: , Showing Predominance of Malarial Element . . . . 617 (28)

From a medico-legal point of view it is important to note that constitutional syphilis may follow vaccination, and yet have nothing to do with it. Suppose an infant to be born syphilitic, but with no visible manifestations of the taint. Let that child be vaccinated, and let the syphilitic dyscrasia afterward break forth. The ordinary inference would be that the syphilis was due to the vaccination; and in most instances this view would certainly be urged by the syphilitic parent, since it would {471} free him from suspicion. It is always easy to disprove such an allegation, however, for syphilis communicated in vaccination always shows itself first in the form of a chancre at the site of the vaccination. Therefore in any given case, unless this mode of onset can be proved, the syphilis is manifestly not of vaccinal origin. Some observers, it is true, are of the opinion that vaccination may evoke a pre-existing syphilis, to use Lanoix's term--_i.e._ that it may hasten the appearance of the characteristic manifestations, and even determine their localization at the site of the vaccinal inoculation. But, even allowing the truth of that proposition, in such a case the lesion would be constitutional, not chancrous.

It is well, nevertheless, to take precautions against being placed on the defensive in this way; and it may commonly be avoided by declining to vaccinate infants under three or four months old, since inherited syphilis generally manifests itself by that time. This prudence on our own behalf should not be carried so far, however, as to lead us to deny the benefit of vaccination to very young infants whenever the prevalence of small-pox is such that they are in obvious danger of exposure.

As regards its management, vaccinal syphilis does not differ from the ordinary form of the affection, and hence demands no other treatment than what is proper for the disease contracted in the usual way. It simply originates in an extragenital chancre.

Concerning the conveyance of other constitutional taints in vaccination our knowledge is very limited. The present tendency of pathological investigation is, however, to accord inoculability to many diseases that formerly were not imagined to possess that quality, so that in regard to other affections than syphilis it is prudent to use the utmost care in the choice of lymph. There is one supposed safeguard that does not seem to have the slightest title to be so regarded--namely, the notion that a typical pock cannot be developed on a person affected with a specific cachexia. There is no truth in the doctrine. Over and over again the writer has seen perfect vaccine pocks on persons whom he knew to be syphilitic.

Cutaneous affections of a non-specific character are sometimes observed to result from vaccination; that is to say, they follow close upon its performance, without any other known exciting cause. It may fairly be supposed that in many instances they would have shown themselves even if the vaccination had not been performed, for it is often the case that we are unable to speak positively in regard to the exciting cause of an eruption. Several years ago a striking case in point was related to the writer by a well-known physician of this city, S. S. Purple, in whose practice it occurred. Purple had engaged to vaccinate a child on a certain day, but for some reason the vaccination was not done. In about a week from the appointed day, however, erysipelas made its appearance, beginning on the left arm at the usual site of vaccination, and pursued its course to a fatal termination. To be sure, we are now speaking of non-specific affections, but erysipelas illustrates the proposition perfectly, notwithstanding its specific character.

Children with a tendency to eczema are prone to suffer an outbreak of that disease as the result of vaccination. In Jenner's time, indeed, it was considered not only that there was great risk of causing an aggravation of any slight eczematous eruption by vaccination, but that the mere {472} existence of the eczema, even in the most trivial form, was likely to interfere with the success of the vaccinal inoculation. This has been the general feeling of the profession. Quite recently, however, many observations have been recorded tending to show that the old dread of vaccinating an eczematous child was not altogether warranted. The question needs further study, and, while it is probably best to postpone the operation under ordinary circumstances, nothing should induce us to withhold its protective influence where there is any manifest danger of actual exposure to small-pox.

Although eczema is the most common of the cutaneous affections called forth or aggravated by vaccination, there are various forms of skin disease, some of them difficult to classify, that occasionally result. They are usually vesicular, pustular, or furuncular--that is to say, irritative. In the majority of instances it will be found either that the pock itself has followed an irregular course, being whitish, diffuse, and ending in an exaggerated although superficial incrustation, or that it has been subjected to injury. Still, in some cases neither of these conditions is the precursor of the skin affection. In many instances the latter can only be called nondescript. There seems to be some occult connection between vaccination and the curious skin disease described by the late Tilbury Fox of London under the name of impetigo contagiosa; and, indeed, Piffard of this city has found certain microphytes to be common to the crusting period of vaccinia and that of contagious impetigo. What the relation of the two affections is to each other, however, it is difficult to say.

Apart from impetigo contagiosa, the cutaneous complications that follow in the wake of vaccination possess no distinctive features, and their management differs in no wise from that of the same manifestations due to other causes.

THE TECHNICS OF VACCINATION.--This aspect of our theme involves a number of separate considerations. It will be convenient to give our attention first to the matter of the choice of virus. The question arises at once as to the selection between animal vaccine and the humanized variety. In a broad sense the term animal vaccine includes--1. Virus derived directly from a case of so-called spontaneous cow-pox. 2. Variola vaccine--_i.e._ the virus of an affection of the cow resulting from variolation. 3. The virus of horse-pox (not strictly vaccinal). 4. Retro-vaccine--_i.e._ the virus of an affection produced in the cow by the inoculation of vaccinia from the human subject. 5. The virus of a disease (true vaccinia) propagated through a series of bovine animals from the so-called spontaneous cow-pox, being the virus now commonly understood by the term, and the variety here referred to when it is not stated to the contrary.

By humanized vaccine we understand that which is obtained from the human subject, no matter how short or how long its descent from the cow. As regards animal vaccine, we may practically exclude from consideration all but the last variety mentioned, that being the one to which, in the great majority of instances, the term is now restricted. This narrows the question down to the choice between virus that has been propagated through a number of bovine animals (practically, calves) from the spontaneous disease in the cow, and that which, whatever its original source, has already passed through the human system.

{473} The variety first mentioned, sometimes called primary vaccine, is generally spoken of by authors as not very trustworthy as regards its infective power (that is, not to be counted on to take), and as prone to give rise to undue inflammatory complications when its use does prove successful. These unpleasant qualities might be explained by the supposition that primary vaccine is not apt to be at its best when it is now and then obtained. Practically, however, it may be dismissed without further consideration, for it is seldom to be had.

The second form--variola-vaccine--is manifestly improper to be used whenever genuine vaccine is to be obtained, unless, indeed, we shut our eyes to the accumulating evidence that variola-vaccine, so called, is not vaccine at all. Furthermore, it is a question whether its use, as well as all attempts to produce it, should not be forbidden by law.

The third variety, if such it may be called, it does not seem legitimate to use in the present state of our knowledge, since it is not yet proved satisfactorily that horse-pox possesses the full protective power of cow-pox, or is free from objections that do not arise in connection with the latter.

As to retro-vaccine, while the writer is unable to see any positive reason against its use, neither can he see any reason why it should be superior to humanized vaccine, as such, save that during the period of its bovine propagation it is not liable to become contaminated with the poison of syphilis. The idea that an enfeebled stock of humanized vaccine can have new life infused into it by passing through the system of the cow is not reasonable primâ facie, and there are no particular facts to support it. By ensuring freedom from the danger of communicating syphilis retro-vaccination doubtless served a good purpose at one time, but now, since the remarkable and enduring excellence of the Beaugency stock is so well established, there seems to be no excuse for a further resort to the practice.

The last of our five forms of animal vaccine, that produced by the continued propagation of spontaneous cow-pox through calves, is what is now known as animal vaccine par excellence. Its advantages over the other forms are so obvious that it alone should figure in any comparison between animal and humanized vaccine. That being understood, what are the relative merits of animal and humanized vaccine? It should be stated, in the first place, that bovine virus should be compared with virus that has long been humanized, for lymph of but a few removes from the bovine animal does not show any noteworthy differences from animal vaccine itself.

In behalf of humanized virus it is maintained--1, that it is a more trustworthy preventive of small-pox; 2, that it is superior in its infective property, so that it is surer to take; 3, that it is more prompt in its action, thereby affording more speedy protection to persons who have actually been exposed to small-pox; 4, that its virulent property is easier of preservation, wherefore it is more to be depended on when it is necessary to keep it on hand for a long time or to transmit it to great distances; 5, that its use requires less skill, or, rather, less special knowledge of the peculiarities of the animal virus; 6, that it is less violent in its effects; 7, that it is less apt to give rise to irregular, and therefore more or less abortive and non-protective, forms of pock.

{474} The first of these propositions, which asserts that humanized vaccine confers greater protection against small-pox than the animal virus, was warmly maintained by those who opposed animal vaccination on its first introduction into this country; but now the record of the past thirteen years, during which period bovine virus has more and more borne the brunt of the fight against small-pox, has disproved it in the judgment of all competent and fair-minded observers. So far, indeed, as the facts have been analyzed, they go to show that the reverse is the case--that bovine virus confers a more complete and a more lasting protection. Direct observation on this point is strengthened by the collateral fact that revaccination became at once astonishingly successful when the use of animal vaccine first gained currency, whereas now it is again declining in success; the explanation of which latter circumstance is, that it is now found difficult to revaccinate those whose primary vaccination was done with bovine virus--a striking indication of the permanence of the protection accomplished with the latter.

The second assertion--that humanized virus succeeds more readily than the bovine variety--is still maintained by many, but, it may confidently be said, by few if any whose experience with good animal vaccine has been large. The truth is, that every large public vaccination service in the country is now carried on almost solely with bovine virus, and that results are thus achieved that were not dreamed of in former times. Individual experience cannot weigh against this fact, but may be explained, rather, by what modicum of truth there may be in the fifth proposition, or by the assumption (surely a legitimate one, in view of the number of irresponsible and ignorant purveyors of animal vaccine that have thrust themselves before the profession since the advantages of the practice were established by the labors of others) that those whose observation leads them to a conclusion at variance with that reached by the great majority of trained observers have really been unfortunate in the quality of the virus with which they have been supplied. Whatever the explanation may be, however, there is nothing more certain than that the use of animal vaccine, properly carried out, is daily furnishing results that have never been excelled, if they have been equalled, in the employment of humanized virus on a like scale.

The third suggestion--that the humanized virus acts the more promptly of the two, and is therefore to be preferred for immediate protection--is plausible, since the areola (the alleged sign of systemic infection) forms somewhat later around a pock produced by animal virus than around one that is the result of vaccination with the humanized variety. The difference is one of a few hours only at the most, and it is not by any means a general occurrence; still, we may concede that in this respect the use of humanized virus is to be preferred under certain circumstances.

As to the fourth statement--that humanized virus is more tenacious of its infective property--strictly speaking, there is not a particle of truth in it. In the case of liquid lymph preserved in capillary tubes it has the semblance of truth, but, for reasons that will be more fully set forth hereafter, that is because it is difficult to get the virulent portion of bovine lymph out of the tube. In the form of dried lymph (the only form that ought to be used) animal vaccine may be sent to all parts of the world, and may be kept any reasonable length of time and without {475} special care, without undergoing sensible deterioration, if tested by one who is familiar with its peculiarities and aware of the care that should be taken in using it. Under ordinary circumstances there is no difficulty about preserving animal vaccine with its energy practically unimpaired.

The statement that the use of humanized virus demands less special knowledge than that of bovine virus is conceded at once. That special knowledge is easily mastered, however, and no man fitted to practise medicine will look upon its acquirement as a bugbear or a hardship.

The impression, almost universal thirteen years ago, that humanized vaccine is less severe in its local and constitutional effects than the animal virus has been eradicated from the minds of all but those who still follow the teachings of the older writers rather than yield to what daily experience has been teaching during these thirteen years, or those who reason from exceptional cases rather than from a general drift. The truth seems to be this: with revaccinated adults animal vaccine acts somewhat more severely than the humanized virus; in infants, on the other hand, its action is not so violent as that of the humanized variety.

Concerning the seventh and last claim put forward in behalf of humanized vaccine--that it is less apt to give rise to irregular or spurious pocks--we may say that no form of irregularity has been observed by those who have lately used the bovine virus that was not well known to the older writers, who founded their observations wholly, or almost wholly, on the use of the humanized virus; nor is there any proof that such irregularities are more common now than formerly. The truth seems to be, that these irregular forms of pock seem to prevail at certain times, and not at other times, regardless of the particular stock of virus used, other things being equal. Why this should be so we do not know, but the fact is beyond dispute.

To sum up, then, we can only say that in barely one particular--that of promptness of action--can humanized virus justly be credited with any superiority, while in every other essential respect it is inferior, so far as any difference is to be observed.

What, on the other hand, are the points of superior excellence attaching to bovine virus? Setting aside certain extravagant assertions that have sometimes been made in its behalf, such as that it far exceeds the humanized virus in its protective virtue (which may be true, but is not yet proved), they may be put in general terms in the form of a denial of all the particular claims that we have enumerated as having been put forth for its rival. Such a denial, it has been seen, seems to the writer to be justified, save in the one particular that perhaps we should accord to humanized virus the merit of speedier action, and consequently greater certainty of protection, in cases of actual exposure to small-pox.

Besides these negative points in its favor, the foremost advantage of animal vaccine is the guarantee it gives that, properly used, no syphilitic contamination will result. On this point no argument is needed, for the cow is insusceptible to syphilis.

A second consideration in its favor is, that it can always be had in large quantities at short notice. The young practitioner of the present day can scarcely appreciate the importance of this fact, but whoever remembers the comparative helplessness in which, in past years, he has found himself in the face of a sudden outbreak of small-pox, not knowing which {476} way to turn for an adequate supply of vaccine, will at once concede its force.

On the whole, then, it must be said that bovine virus is entitled to the preference as a rule, but that possibly it is well to resort to humanized lymph of early removes under the special circumstances above referred to. On no account should long-humanized vaccine be used so long as our present stocks of animal virus maintain the excellence they have thus far preserved, nor should humanized virus of any sort be preferred in the general run of cases.

Passing now to a consideration of the various forms of vaccine, disregarding its source, there are practically these three: the crust, liquid lymph preserved in capillary tubes, and dried lymph.

Until recently the crust, or scab, was much used in this country. Its capability of being preserved unimpaired for a long time was a valid excuse for this, especially in regions remote from the great channels of communication, and it was in such districts that the use of the crust was chiefly practised. That excuse scarcely exists now, for there are few physicians who cannot obtain a better form of vaccine within a very short time. The objections to the crust are two: 1. Most crusts are inert. Especially is this true of bovine crusts, which are wellnigh worthless. It must be confessed, however, that when once a crust has proved itself active it may be trusted to retain its infective property for a very long time. The writer has made successful use of crusts seven years old that had made the voyage to Japan and back; and they were bovine crusts too. Still, the rule is, that crusts are untrustworthy. 2. Their use is apt to be followed by undue inflammation, probably of septic origin, for they almost invariably contain putrescent or readily putrescible elements. It has even happened to the writer to cut open a crust that to all appearance was typical and innocent, and to find in its interior a cavity occupied by a pulpy, stinking slough. Manifestly, such material is unfit to be introduced into the system of any human being.

In regard to liquid lymph in tubes, it is not much used in this country, and its employment elsewhere is on the decline. At first thought, it would seem to be the best form of all, but experience does not bear out this view. In this form humanized lymph is vastly superior to animal lymph, but with every possible care in charging and sealing the tubes it is not uncommon to find their contents putrid. There are low vegetable organisms that are supposed to prey on the vaccinad. If there is any truth in this supposition, those organisms are certainly favored in their destructive luxuriance by keeping the lymph liquid, thus furnishing them with the best possible culture-fluid. Be this as it may, the fact is well ascertained that tube-lymph does not keep well. It has been mentioned already that bovine lymph stored in tubes is decidedly inferior to the same form of humanized lymph. This was long ago recognized by propagators of animal vaccine, but the cause remained a mystery until Warlomont of Brussels suggested that it was due to one of the physical peculiarities of animal lymph--that, namely, as already hinted at, by virtue of which its formed elements tend to attach themselves to any surface presented to them, leaving the supernatant liquid a mere inert compound of water, albumen, and salts; so that in the case of tube-lymph the virulent elements remain attached to the glass, and only the inert constituents {477} are really used. This theory is exceedingly ingenious and plausible, but the writer is not aware that it has been proved. He does know, however, that in some South American countries, where calf lymph in tubes is used with success, the custom is to grind the tubes to powder, and inoculate with the resulting magma, glass and all. This practice is certainly not to be commended.

Dried lymph is the most efficient of all forms of vaccine, and, kept as it ought to be, it retains its infective power long enough to answer all ordinary requirements. The writer has used it three years old with success. It may commonly be counted on for six weeks. One fact should be borne in mind, however: the longer dried lymph has been kept the more care is necessary in its use, for by long keeping it becomes very hard, so that it is a work of patience to dissolve it off from the surface on which it was deposited. Failure to accomplish its solution is the most common cause of a lack of success in its employment.

The various forms of stored vaccine are esteemed by the writer in the following order: 1, dried bovine lymph; 2, dried humanized lymph; 3, humanized tube-lymph; 4, humanized crusts; 5, bovine tube-lymph; 6, bovine crusts.

The age and other circumstances under which it is best to vaccinate children constitute a point for practical consideration. It may first be mentioned that pre-natal vaccination has been advocated by some authors; that is to say, the vaccinal infection of the foetus in utero by vaccinating the mother during gestation. There seems to be respectable testimony going to show that the end may thus be accomplished, but a weighty objection arises in the fact that this mediate vaccination of the foetus produces no physical sign of its success, so that doubt must always be felt as to whether or not the procedure has been efficacious. Moreover, it is seldom indeed that a child needs protection before its birth, provided we protect the mother, for it is well known that vaccinia will overtake and destroy the variolous infection, even when the latter has had two or three days' start. The practice has been chiefly urged by Bollinger. It is not likely to come into general use.

There is no special objection to vaccinating an infant at any time after birth, but usually it is well to defer the operation until the child is about three months old, unless there is actual danger of exposure to small-pox. Yet it is not well to postpone vaccination until the period of dentition, for the combined irritation of the two disturbing elements may prove decidedly uncomfortable if not serious.

Something is to be said as to the time of the year to be chosen. In New York the bad custom prevails, especially among the poorer classes, of having children vaccinated only in April, May, or June--just the part of the year in which erysipelas is most rife. The hot months should not generally be chosen, for any source of irritation is apt to be felt more severely by infants during the summer heat. However, no circumstances should be looked upon as a positive bar to vaccination in case of actual danger of exposure to small-pox, and in large towns children should never be taken into public conveyances or carried into any promiscuous assemblage until they have been protected by vaccination.

The next question is as to the part of the body that should be selected for the inoculation. The region of the insertion of the left deltoid muscle {478} is usually chosen--the left rather than the right, because most nurses habitually carry an infant on their own left arm, so that the child's left arm is uppermost, and hence less exposed to injury. The region of the deltoid insertion is comparatively free from the irritation of muscular contraction, and it is easily accessible. If two insertions are made, it is well to make one of them over the deltoid insertion and the other at a point about an inch distant on the line of the posterior border of the same muscle, for there the lymphatic connection with the axillary glands is less free, so that adenitis is not so much to be feared. To avoid a scar in a locality that may be exposed to view on certain occasions some mothers prefer that their daughters should be vaccinated on the lower limb. To this there is no special objection, further than that the lower limb is rather more exposed to rough handling than the arm. If the leg is chosen, the point of junction of the two heads of the gastrocnemius is an eligible situation.

The actual operation is performed in various ways. The old inoculators generally made an incision through the whole thickness of the skin, so that a pellet of subcutaneous fat rolled up into the little wound. This is wholly unnecessary; furthermore, it is objectionable, for it decidedly increases the risk of inflammatory complications. Still more to be avoided are the methods by inserting a seton imbued with the virus and by hypodermic injection or other like procedures. The best way is, simply to remove the horny layer of the cuticle, so as to expose the succulent portion of the epidermis. This surface is somewhat red, and from it a slight exudation of lymph will be observed, but there need not be the least flow of blood. By this procedure it is not uncommon to vaccinate a sleeping child without waking it. It is not only admissible, but preferable, not to wound the derma at all. Such an abrasion is easily made with an ordinary lancet, which, contrary to the advice sometimes given, should be very sharp; but no cutting or scratching should be done with it, only scraping with the convex part of its edge, precisely as in using an ink-eraser. Scratching instruments (such as the rake-like vaccinator often used or a row of needles set in a handle) are not easy to adapt to varying degrees of plumpness of the arm, and are apt to make too deep scratches, one at either side, while the skin between the two is scarcely touched. Whatever instrument is chosen, it should not be used again until it has been thoroughly cleansed--made chemically clean--which can be accomplished only by heating it or by wiping it off and then dipping it into a strong disinfectant solution.

Some individuals are refractory to vaccination, but complete insusceptibility is exceedingly rare. Various expedients have been resorted to in rebellious cases, such as vesication with ammonia-water, maceration of the skin for some hours with glycerine, and the like. The writer has known these devices to succeed, but he has not seen the slightest advantage in the plan recommended by Ceely, that of using a wound some hours old rather than one just made, although he has tried the experiment many times. It is not necessary to make a large abrasion; one as large as the little finger-nail is ample.

The next step is to apply the virus, and it should be so applied as to bring it into contact with every part of the denuded surface. In what is known as arm-to-arm vaccination, or its equivalent, calf-to-arm {479} vaccination (by all means the most successful method, although not often practicable in this country), the liquid lymph, fresh from the vaccinifer's pock, is simply applied, when it will at once become diffused over the abraded surface without any special pains being taken to accomplish that end.

If dried lymph is used, particular care should be taken to see that it is actually dissolved and transferred from the substance on which it was dried to the abraded surface. Failure to accomplish this is the cause of almost all the lack of success that inexperienced vaccinators meet with. The lymph should be moistened with water, or, if it is quite old, with glycerine, before the abrasion is made, so that it may have time to dissolve. It should then be rubbed upon the abraded spot vigorously, and at least for the space of a full minute.

In the use of tube-lymph no other precautions are necessary than in arm-to-arm vaccination, but, simple as this method is, its results are unsatisfactory.

Crusts should be reduced to a powder, and then made into a thin paste 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.

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.