VARICELLA

Synonyms.—Chicken-pox; Water-pox; Variolæ spuriæ; Fr., Variolette; Ger.,
Spitzblattern.

Definition.—A contagious febrile systemic affection of benign
type, occurring chiefly in children, and characterized by an eruption
of discrete, scattered, superficially seated, thin-walled, usually small
pea-sized vesicles.

It seems strange that even at this late date there should still exist
physicians who look upon small­pox and chicken-pox as identical. This
was the teaching of the Vienna school under Hebra, and this view was
maintained by Kaposi, but it need scarcely be said that those holding
this opinion to­day are extremely few and isolated, and that even a
suggestion of such an association to American and English minds is
received with complete incredulity, and opposed by all extended clinical
observation and experience and the facts evolved by the effect of
vaccination.

Symptoms.—The eruption may be the first evidence recognizable
by the patient, appearing without appreciable systemic disturbance.
On the other hand, there may be for several hours or one or two days
premonitory symptoms of slight malaise, chilliness, and mild febrile
action, which in average cases are scarcely sufficiently well marked to
elicit more than passing attention. Exceptionally however, in extremely
susceptible children and in cases in which the eruption is extensive, the
prodromal disturbance may be relatively severe. The eruption makes
its appearance slowly, as a rule, and never all at once, presenting usually
first upon the trunk and head, more especially the scalp. If seen in
their earliest formation, or if the development of the later lesions is
watched, the first stage is, as a rule, noted to be a small hyperemic spot,
in the center of which a minute, elevated, vesicopapule or vesicle appears,
pin­point to pin-head in size, rapidly growing to small pea-sized, the
pinkish or reddish peripheral portion of the macule or spot usually
measurably or completely subsiding during the vesicular evolution.
New lesions continue in an ill-defined, crop-like manner or irregularly,
several or more at a time for twenty-four to forty-eight hours, and some­
times slightly longer.

The eruption, when sufficiently developed,—usually in from several
hours to a day after it begins,—is noted to consist of scattered vesicles
of scanty or abundant or variable number, and in various stages of forma­
tion; usually some clearly defined, rounded, translucent, small or large
pea-sized vesicles, with practically no areola, some with a small areolæ
band; others with minute beginning vesicular lesions presenting at the
central point of small pinkish or reddish spots or macules. In short,
various stages of the lesional formation can usually be seen, although
in some instances many are fairly well-rounded and mature pea-sized

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vesicles, many of which stand out from the skin without surrounding
band of redness; others are somewhat irregularly shaped. In some of
the vesicles the walls are somewhat flaccid, always thin, often ruptured
accidently. In larger lesions, and especially if of slow formation, while
the enlargement from a pin-head-sized vesicle into that of a pea-sized
is taking place by peripheral extension, the central part has already
begun to dry, and is, compared to the fresher peripheral portion, de­
pressed. Umbilication, therefore, while not a common feature as thus
described, is not infrequent in several or more marked or maturing
lesions.

As a rule, the individual lesions reach full development in several
hours to one or two days, by which time desiccation has already set
in, drying to thin, film-like crusts. The contents, at first clear, soon
become milky, and later may be slightly puriform. This latter probably
results usually from accidental irritation or inoculation; it is chiefly in
such lesions, particularly when scratched and made more inflammatory
and sometimes impetiginous, that slight scarring results. This is uncom­
mon, however, and when occurring is usually in some lesions on the face.
Subjective symptoms are rarely complained of, but occasionally there
is itching, and in extensive cases, some tenderness. The eruption is
commonly scanty, and chiefly seated upon the trunk, more numerous
usually upon the back; the scalp also generally shows some vesicles, but
the face and extremities relatively few. Sometimes they are also ob­
served on the adjoining mucous surfaces, more especially in the mouth
and throat; the covering is soon broken or rubbed off, and superficial
abrasions result. Exceptionally the eruption may be quite extensive,
but with no tendency to confluence, grouping, or bunching; in such
instances the constitutional disturbance, generally slight, usually con­
tinues until the height of the malady is reached. The process is, as a
rule, ended, and the crusts fallen off in from seven to twelve days after
the inception of the disease.

Exceptionally the vesicles are somewhat large, exceeding the size
of small or medium-sized peas; or such pemphigoid development is
noticed to follow the ordinary sized lesions, developing from the latter
or arising independently. In such rare instances, as doubtless in the
4 cases reported by Pye-Smith,¹ it seems probable that the bleb eruption
is not necessarily a part of the varicella, but is due to some accidental
and subsequent infection. The seriousness of this development or com­
plication would also support this belief. To accidental infection is also
to be attributed that condition known as varicella gangrænosa (q. v.),
in which gangrenous development, in rare instances, follows upon vari-
cellous and other eruptive lesions.

Etiology and Pathology.—The malady is contagious, and, ac­
cording to Hutchinson and LeGendre, it is inoculable, although Smith²
failed to produce it in his experimental attempts. One attack is usually
protective—it is rarely observed twice in the same individual. Nor
does an attack protect against small­pox, as would be the fact were the

¹Pye-Smith, “Four Cases of Bullous Varicella,” Brit. Jour. Derm., 1897, p. 148.
² J. Lewis Smith, Diseases of Children, 189ó edition, p. 326.

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1NFLAMMATIONS

two diseases at all related.¹ It has been alleged that it occurs most
frequently immediately before, during, and after small­pox epidemics,
but this will not bear the test of investigation. The period of incubation
doubtless varies somewhat from ten to seventeen or eighteen days—
Smith's observations indicate between fifteen and seventeen days.
Young children are its usual subjects. In an analysis by Baader (quoted
by Smith, loc. cit.) of 584 cases, 382 occurred between the ages of one and
five, 191 between six and ten, 7 between eleven and fifteen, 2 between
sixteen and twenty, and 2 between twenty-one and forty. I have ob­
served an instance of its occurrence in a man past sixty. The most
common age is about three.

The pathologic changes are superficial, rarely extending below the
middle layers of the rete, in this respect differing from variola, in which
the process is most pronounced in the lowest layers and the papillary
body. The vesicle cavity is, in the earliest stages at least, divided by
septa, as in the latter disease, but, according to Unna,² in varicella the
septa join on the covering wall, whereas in the small­pox lesion at the
center of the base. The cavity proper occupies only the upper part of
the much widened prickle layer. Fibrinoid degeneration of the epithe­
lium takes place, and to which process Unna gives the name of “reticulat­
ing colliquation,” in view of the most frequently recognizable stage of the
fibrinous reticulum.

Diagnosis.—The diagnostic points in varicella are the absence or
lightness of the systemic disturbance, the distribution of the eruption,
usually most pronounced on trunk, and often on scalp, the superficial
nature of the lesion, its thin, easily ruptured wall, and the irregular,
crop-like appearance of the eruption. The disease with which it is most
likely to be confounded is small­pox, more especially in the earlier stage.
Morrow³ states that in an analysis of 38 cases of error reported to the
New York Health Board at a certain period for small­pox, 17 were cases
of chicken-pox. It is true that urticaria bullosa, impetigo contagiosa, and
a few other diseases have occasionally been confounded with varicella,
but such mistakes are usually the result of hasty and imperfect exam­
ination, and readily avoidable, as the features of these several affections
(q. v.) are sufficiently distinctive.

The disease differs from variola in many particulars, although the
differences are much less recognizable when it concerns mild cases of
small­pox or varioloid and severe cases of chicken-pox. The most im­
portant differential points in my judgment are the distribution, the
manner of appearance, the character of the lesion and its thin covering
or wall, and the nature of the constitutional symptoms. In chicken-

¹ See a suggestive and, for the patient, extremely unfortunate, exemplification of
this fact reported by Dyer “On the Differential Diagnosis of Varicella and Variola,”
New Orleans Med. and Surg. Jour., Jan., 1896. The patient, according to Dyer‘s
opinion, presented varicella, but was placed in the small­pox hospital by the municipal
authorities, who considered the case variola; the patient made the usual course of aver­
age varicella and was discharged; a few days subsequently he presented small­pox of
confluent form, was again taken to the hospital where he had contracted the disease,
and died.

² Unna, Histopathology, p. 635.

³ Morrow, “On the Diagnosis of Small­pox,” Jour. Cutan. Dis., 1886, p. 72.

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479

pox the trunk presents the most lesions, and the face, hands, and ex­
tremities are comparatively, or in some cases wholly, free; whereas in
variola the hands and face and extremities are generally most markedly
involved. In chicken-pox the eruption rarely, if ever, comes out at
once, but there are irregular or crop-like outbreaks for two or three days,
although the largest number appear with the first outbreak; the lesions
are, therefore, to be found in all stages of evolution. They begin as
hyperemic spots from the center of which a vesicle develops, or they
begin as vesicles; the beginning spot or lesion is never hard or shotty. In
small­pox, on the contrary, the lesions usually appear at one time or
within several hours or a day, and their evolution and course are, there­
fore, uniform, although naturally some lesions may be larger than others;
they are distinctly hard and shotty in the beginning. The lesions of
varicella are discrete and usually scattered, with no tendency to close
grouping, bunching, or confluence. In variola closely set grouping or
crowding together and confluence are quite common. The lesion of
varicella is relatively rapid, often beginning to crust over in a few days,
whereas that of variola is slow and much longer in its course. The
character of the lesions in the two diseases is often strikingly different.
The varicella vesicle is extremely superficial, thin-walled, translucent,
often of irregular or irregularly rounded shape, and easily broken, acci­
dentally or intentionally; whereas that of variola is deep-seated, often
markedly globular; the covering is thick and tough, with little if any
tendency to break, even if roughly handled, and with a yellowish cast,
but not translucent, owing to the thickness of the walls. Umbilication
is not an essential feature of varicella, and is generally seen only in few
lesions, and these the larger and usually the relatively slow-developing
vesicles, and it frequently results from a beginning desiccation of the
central or earliest formed part; the lesions rarely become pustular; as a
rule, only slightly cloudy or milky, and are not distinctly multilocular.
In variola a sinking-in of the central part is a common feature of all cases
and all lesions, and is observed long before the actual desiccating stage
has been reached, being, in fact, a part of the advanced vesicular stage,
the lesions becoming globular as they develop into pustules, and again
slightly umbilicated as desiccation takes place; the lesions all become
purulent, and are, except in the very latest stage, clearly multilocular.
Scarring is the rule in variola, and rare in varicella, and then usually
due to accidental irritation. The constitutional disturbance in varicella
is slight or wanting, except in the extensive cases, and the eruption is
often the first evidence of the malady. Even in severe cases it usually
subsides rapidly after the eruption has appeared or reached full develop­
ment, and does not reappear; in variola, on the other hand, there are
almost always distinct prodromal symptoms for several days—headache,
backache, general rheumatic pains, some gastric uneasiness, and febrile
action, especially developing with the eruption, upon the full appearance
of which it partially subsides, to become marked again when the pustular
stage approaches.

Prognosis and Treatment.—The disease is benign and runs a
quick, favorable course, recovery ensuing in one to two weeks. Rare

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instances of fatal ending are, in all probability, purely accidental, and
due to some complication wholly independent of the varicella exanthem.
Treatment is purely hygienic and expectant. As a matter of precaution,
the patient should be kept housed, and if the eruption is at all extensive,
in bed. A mild antiseptic dusting-powder, such as boric acid, can be
used to lessen the chances of accidental infection. For the same reason
scratching should be cautioned against, and if there is sufficient irritation
or itching present to lead to this, a saturated solution of boric acid with
\ dram (2.) of carbolic acid to the pint (500.) can be used.

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