Excluding numerous variations the course is about as follows: Whilst the remainder of the eruption continues its accustomed course some of the spots suddenly become surrounded by a large inflamed area and the contents of the spots become hemorrhagic. Later the black crusts, which have resulted from the drying of the contents of the vesicles fall off leaving sharp-edged ulcers having a punched out appearance. The bottom of the ulcer is covered with discolored pus or small cheesy masses. The size of the ulcerations varies. They may remain about the size of a pea, or may enlarge to the size of a dollar or even become as large as a saucer. Enormous areas of ulceration may result from the union of several ulcers and the deeper tissues, fascia and muscles may be involved. Spivak (1895) has described destruction of the scrotum following varicella.
Varicella may predispose to tuberculosis in time same way that measles does. One may see a child with a latent tuberculosis which may be started into an active process by an attack of varicella.
Diagnosis.—This is as a rule easy, as variola is the only disease which causes any real difficulty. Well-marked smallpox cases offer no difficulty, even to those who know the disease from books only, nor does typical varicella cause any trouble, but atypical varicella and the lighter irregular forms of variola, such as occur after vaccination and revaccination, may be impossible to differentiate. The differences have already been fully considered. Of greatest importance are the absence of prodromes and the occurrence of all stages of the eruption at the same time. In doubtful cases there are only two criteria which may be relied upon: The origin of the case from variola and the capability of its causing the disease in others. A doubtful case of varicella should only be regarded as such in the absence of any possibility of smallpox infection. The methods of diagnosis on an etiological basis are unfortu nately not of value to time practicing physician.
The differential diagnosis from other diseased conditions must be made but this usually presents no difficulties. All diseases which may be confused with varicella or variola must be considered: Herpes, eczema, pemphigus, impetigo, scabies, varicella, urticaria vesiculosa, drug eruptions, erythema exudativum multiforme and, in the beginning, rubeola, measles and scarlet fever. In all cases the resemblance is a passing one and careful investigation will prevent any mistake.
An exception must be made in unusual cases of pemphigus. Vari cella especially in the newborn may cause a well-marked pemphigus, and it may be difficult or impossible to tell this from other forms of pemphigus. The longer duration of the true pemphigus eruption and the occurrence of varicella in other members of the family are points of importance. Sometimes in the papulopustular stage of erythema exudativum multiforme the diagnosis cannot be made for a day or two (see Fig. 70).
is usually regarded as such a harmless dis ease that little attention is paid to it either by the laity or physicians.
In spite of the fact that almost all cases, even those with severe symp toms, end favorably, there are still a sufficient number of unfavorable cases which should deter one from giving an unqualifiedly good prog nosis. Experience teaches us that weak newborn infants, and those suffering from bowel or lung diseases and above all tuberculous or scrofulous children may be made dangerously ill by varicella, especially when the patient is living in unhygienic surroundings. Fatalities are rare but may now and then result from the severity of the infection, from the location of the eruption, as in varicella-croup, and from secondary infections or complications.
most cases treatment is unnecessary. As long as there is fever or new papules appear the patient should be kept in bed.
As soon as the eruption has dried and an examination of the urine shows that the kidneys are not involved the child may leave the room.
The fever is rarely so high as to necessitate any drugs directed to the reduction of the temperature. Cooling draughts, cold compresses to the head and sponging with cool water is all that is neces sary. If severe brain symp toms come on, lukewarm baths up to five minutes in length, followed by spraying with colder water, may be used.
The formation of ulcers in the throat may render some treatment necessary as the pain often interferes with the proper nourishment of t he child. Rinsing the mouth with marshmallow tea to which borax or boric acid has been added may be employed.
All solutions containing alcohol, ethereal oils or irri tating substances as well as mechanical cleansing of the mouth with a tooth brush should be forbidden. In exceptional cases the pain is so great as to necessitate the painting of the ulcer with a 2-4 per cent. solution of cocaine (followed by rinsing of the mouth).
Great cleanliness should be exercised about the genitalia and if there is any inflammation, ointments containing boric acid or thymol should be used.
Daily baths may be given, but all rubbing and irritation of the skin should be carefully avoided and too hot water should not be used. Itching, if troublesome, may be allayed by lukewarm baths, fol lowed by dusting with some bland powder or by sponging with water to which vinegar or alcohol has been added. Internal medications may be necessary in some cases, antipyrin, phenaeetin or even morphia.
The hands should be kept clean and the finger nails should receive special attention. If scratching is not controlled by the child itself the hands or hands and arms should be restrained.
Infections of the skin and abscesses should be treated according to ordinary surgical principles.
The child should be watched (luring convalescence and if it does not recover its strength, careful regulation of the diet, tonics and even a change of climate may be advised.
Finally, in all cases in which variola is suspected, and in varicella, occurring in adults, vaccination should be practiced.