The suppurative infiltration of the ulcerations may be the cause of a severe tonsillitis with fever. Girode (1S93) has described a case of pseudomembranous angina due to the streptococcus occurring in the course of varicella. The fever lasted eight days with severe general symptoms and there was a complicating orchitis. Perforation of the soft palate from an ulcerating varicella pustule has also been observed (Kaupe, 1903).
Involvement of the eye is not infrequent and this generally consists of a vesicle on the edge of the lid or upon either the ocular or palpebral conjunctiva. This gives rise to great discomfort and suffering on the part of the patient and may result in a phlegmon of the lid. More rarely the cornea may be involved. This comes on with marked inflammation and in favorable cases healing takes place with a clouding of the cornea. In unfavor able cases, the inflammation extends into the eye as it so frequently does in smallpox. [For literature see Oppenheim (1905) and Cerf (1901)]. It is not unusual for the varicella, vesicles to form in the auditory canal. I once saw vesicles in opposite ends of the canal causing occlusion accom panied by great pain, deafness, and tinnit.us. Attention may be drawn to the presence of vesicles in the nose by nasal hiemorrhage. Sometimes a purulent inflammation follows and for weeks there may be bloody and purulent discharges which form crusts in the nose and these greatly interfere with breathing.
The eruption is more frequent on the genitalia of girls than of boys. In the former it is located on the labia while in the latter it is seen on the glans or prepuce. In boys discomfort is rare (Coombs described a 1(1 hour anuria) but in girls, vulvitis, painful urination or even anuria may be observed. Through scratching or uncleanliness, ulcers, phleg mons, necrosis, lymphadenitis and even general infection may result.
Of especial importance is the occurrence of the eruption in the larynx and trachea. This has been fully described by French authori ties, notably by Ilarlez (1S9S) Marfan and (1896), Roger and Bayeux (1S9S) and Lannoise (1S96). The symptoms are like those of a severe case of croup, hoarseness, a barking cough, dyspncea, cyanosis, smothering attacks and asphyxia. Intubation and tracheotomy may be necessitated but sometimes the patient is beyond helping. Cerf collected seven cases, four of which died. The diagnosis in the early stages may be impossible owing to the difficulties of laryngoscopic examinations in young children.
This may be the case where the trouble in the larynx begins before the appearance of the eruption as frequently happens. Without an inspection of the larynx one can never be sure there is not a complicating diphtheria and the early use of diphtheria antitoxin is advisable.
Prodromal rashes are rare in varicella but in sonic epidemics they may be quite frequent. llenoch has described prodromal rashes re sembling scarlet fever coming on several hours before varicella rash. Thomas noted a similar rash fifteen hours before. Fleischmann (1S70) observed a measles-like prodromal rash lasting forty eight hours. Cerf has collected forty five cases of prodromal varicella rashes.
As a rule these rashes appear from two to twenty-four hours before the vesicles but rashes simultaneous with or appearing after the vesicles have been reported. At the same time as the appearance of these rashes, or some hours before, there are often high fever, vomiting, diarrhoea, loss of appetite, headache, dizziness, joint pains, and difficulty of swal lowing. Burning sensations, itching and subsequent desquamation are not observed. About six-sevenths of the prodromal rashes in varicella. resemble scarlet fever, the others are like measles, lurmorrhagie or mixed. The rash rarely covers the entire body and areas of normal skin may usually be noted. The color of the rash is generally a uniform bright red, more rarely either pale or livid red. These rashes last on an average about twenty-four hours, often less, but they may remain for two days or, in exceptional cases, for five or six days. In many cases where there are prodromal rashes there are severe general symptoms or complications.
But few authors ascribe any specific odor to varicella. Heim, how ever, was of the opinion that it had a. distinctive odor quite different from that of variola.
Complications and Sequel. —The complications and sequehe of varicella arc rare but nevertheless are as numerous in variety as those met with after other infectious diseases. Xephritis is the most impor tant of the complications. This was known from very early times but the first important observations were made by Henoch in 1SS-1. The nephritis following varicella is rarer and more benign than that follow ing most of the acute infectious diseases. There may be little to call attention to the condition and it may disappear without. being detected unless urinary examinations are made as a matter of routine. The cases may be divided into three classes according to their intensity. Unger and later Cerf have made the following divisions: (1) latent nephritis in which there are no symptoms and albuminuria is only discovered when looked for; (2) light nephritis in which there is marked albutninuria and some oedema but no severe symptoms and (3) severe nephritis with fever, marked albuininuria, anuria, cramps, gastro intestinal disturbances. urtemia, etc.