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A CASE OF CONFLUENT HÆMORRHAGIC ERUPTION IN VARICELLA.
1359
f thp apparatus for washing a double cylinder, with
out the colon. This consists methods is both rational and successful and that it is destined a float in the lower cylinder, to become an essential part in the treatment of many cases. which regulates the escape of water from the upper, so that The same kind of treatment has been carried out at Plombières the same pressure is maintained throughout. The cylinder and Chatel-Guyon for several years. "’ Careful dieting during and after the course of douching glides on two graduated uprights which mark the height and are a is imperative. Foods which are easily digested and leaving pressure and is moved to the height prescribed. There thermometer attached to the cylinder and a gauge to register only a small and unirritating residuum are best. In my exthe quantity of water, both sufficiently large for the patients perience the diet advocated by von Noorden proves unsuitshould be instructed to eat only to observe for themselves whilst lying on the couch. One of able. Further, the The quantity a small amount of animal food, since it is a fruitful source of the sulphur waters is used for irrigation. prescribed may be from 10 to 40 or more ounces for each putrefactive material. They require to be warmly clothed, douche and is usually repeated. The temperature varies and be careful to avoid chills, which are apt to increase the from 96° up to 104° F. or more, depending on the condi- catarrh of the colon. Warm bright sunshine is a valuable tion of the bowel. A long tube is passed per rectum aid to treatment and sometimes is indispensable. Moderateinto the sigmoid flexure and the sulphur water gradually exercise should be regularly taken in the fresh air, that of This is retained an upland or mountainous character being especially benepasses through it into the colon. several minutes by the patient and is then ejected into a ficial. Moderation is essential in food, drink, exercise, and flat-bottomed receptacle. The douche is always given by a pursuits. In short, the scriptural injunction : " Be ye skilled attendant, who examines the ejecta and reports to moderate in all things," applies more to patients affected with the medical attendant. Immediately after the internal colitis than perhaps to any others. douching the patient goes into an adjoining room and steps Harrogate. into a warm sulphur bath. Whilst reclining in this a hot douche is directed through the water to the abdominal wall. It is delivered through a large nozzle with numerous fine A CASE OF CONFLUENT HÆMORRHAGIC perforations and moved slowly over the site of the colon. ERUPTION IN VARICELLA. There are several therapeutic actions produced by this internal and external treatment besides the mechanical one By CHARLES R. PORTER, M.R.C.S.ENG., L.R C.P.LOND. of cleaning out the intestine. The internal douche acts as a warm bath upon the intestine, the heat of this soothing THE fact that varicella is usually such a mild disease no it and the neighbouring organs. Then the sulphur water brought in contact with the mucous membrane produces its doubt accounts for the scarcity of literature found relating well-known action of diminishing catarrh and restoring the to its complications. Medical advice is often nor, sought at mucosa to a healthy condition. Again, Sir William Ramsay all, and there is no doubt that many cases occur which are has found that the stronger of the sulphur waters used is radio- not even recognised by parents of children who have the active, and doubtless this property is beneficial, producing a disease. Among the uneducated if the disease is recognised sedative effect upon the bowel and the body generally. it is looked upon as a harmless affection called "the Another important action of the internal douche is free blisters " and no further notice is taken of it, the child in diuresis. This arises partly from the kidney being stimulated question being probably allowed to go to school as usual. by the hot internal douche, though chiefly from the absorp- There are, however, a few authentic illustrations of the fact tion from the bowel of some of the sulphur water, part of that varicella can assume a serious and even dangerous which is retained and subsequently secreted. This flushes character from the intensity of its infection. The following case appears to me to be worth wbileout the liver, kidneys, and tissues, and carries away some of the toxins already absorbed. putting on record for the following reasons. In the first When we come to examine the effects of the external place because confluence with basmorrbage into the vesicles treatment we find the warm sulphur bath soothes the nervous is apparently so rare ; secondly, because it emphasises the system and induces a sense of comfort in the patient. It fact that diagnosis is made so much easier by being allowed determines an increased flow of blood to the skin, stimulating to observe the disease from its onset; and, thirdly, because its glands and improving its nutrition. This in turn has a a skin lesion occurring during the incubation period seems healthy influence upon the colon as there is undoubtedly a to favour an extensive eruption-in fact, in this c:4-,e it seems close relationship between the skin and the intestine, a state to have been the determining factor in the severity of the frequently demonstrated in colitis. The external douche local lesions. The patient, a girl, aged 13 years, was first seen onapplied to the abdominal walls has an extremely soothing effect upon the colon, relieving pain and spasm when it August 8th, 1906, and was then suffering from a somewhat exists. Further, the impact of the tiny jets of the douche irritable papular eczema of the face and the backs of stimulates the intestine and promotes muscular contractility both hands. The forehead, nose, and cheeks were espeThis She was otherwise quite well. It is an interesting fact that the cially irritable. in the distended portions. relief of spasm in one part of the intestine and increase of condition quite cleared up within two days under an contractility in another will take place at the same time, application containing oxide of zinc. It should be mentioned probably from the irritation of the intestine being allayed. that when an infant the patient had been unsuccessfully After four or five weeks of such treatment a marked ameliora- vaccinated three times, and when revaccinated in 1902 tion is produced in the patient’s condition. The catarrh is it was successful in two places only. The only serious lessened, pain and spasm are alleviated, and constipation is acute illness previous to the present attack was acute anterior poliomyelitis when the child was aged four years, relieved. Coming to the general symptoms the first thing noticed is from which very slight deformity results. On August 10th the improvement in the appearance of the skin. In a few in the evening she complained of headache, latitude, and days it becomes clearer and brighter. Next, if there is pains in the limbs and a few spots were noticed on glycosuria it usually quickly disappears, as does also the the chest. She played tennis that evening and was stool pallor. Soon the patient feels better and becomes somewhat restless that night. On the llth she was out and brighter and happier. The neuroses, which are generally the about and one or two more spots were noticed on the chest. most troublesome features in severe cases, improve slowly, She was restless again that night. I was called to see her though in the milder forms of the affection they are soon on the morning of the 12tb, as a rash had appeared on the ameliorated. One remarkable circumstance is the effect of face. The temperature was 101° F. and the pulse was 80. treatment on a loose kidney. After some months of effective There was the typical rash of varicella present on the chest, treatment it becomes much less moveable, and in some cases face, and limbs, and one or two typical vesicles on the when recovery from colitis has taken place the kidney ’, buccal mucous membrane and soft palate. The rash was in becomes practically fixed. In severe cases of colitis one different stages of eruption, showing papule, vesicle, and crust course of colon irrigation is not sufficient. It must be re- on the chest. There were no papules at the roots of the hairs peated once or oftener after an interval, depending on the on the forehead, and the wrists, back and front, were quite state of the patient at the end of the course and subsequently clear. The patient was quite comfortable and the irritation to it. was practically nil. On the 13th the temperature was During the last three or four years this treatment has 101’6° and the pulse was 80. The eruption had further been employed at Harrogate in several hundred cases of developed, especially on the face, the vesicles varying in size colitis. The excellent results which have been achieved from a pin’s head to a quarter of an inch in diameter. The have exceeded expectations. The results prove that the rash was then so plentiful on the face that it would have-
ef
patient
___
____
1360
impossible to find a free area of the size of a developed typical varicella, which ran a severe course, with sixpence. The roots of the hairs were, however, still abundance of rash and high pyrexia. It might be practically free, though there were, of course, many mentioned in addition that there have been no cases of vesicles on the scalp. The chest and back were literally small-pox in the neighbourhood for the past 10 or 15 years covered and the eruption was very plentiful on both to my knowledge. The general condition The subsequent course of the case was quite uneventful. arms and legs, back and front. was good, the patient being quite bright and cheerful and On August 16th the temperature fell to 99 ’5°, and many of free from discomfort. On the 14th the vesicles on the face the vesicles had changed to crusts. No mora haemorrhage had become confluent in three places-viz., five on the fore- occurred and the patient made an uninterrupted recovery. head, three over the course of the right temporal artery on (The photograph reproduced was taken on August 16th, the forehead, *and four on the right side of the neck over the the sixth day of the disease.) The last scabs to come off sterno-mastoid muscle; the latter are well shown in the were those into which hasmorrbage had occurred, and this accompanying figure. The temperature was 101’ 6° and the took place just four weeks from the onset of the first symptoms. The local treatment employed was a mask of been
pulse
was
84.
arms
and
even
There were more crops out on the legs and on the soles of the feet and palms of the hands. One single vesicle in the left mammary region just above the left nipple had attained a diameter ofhalf an inch (? " varicella bullosa"). The general condition was quite satisfactory, the intellect was clear, and the patient was cheerful with a fair appetite. On the 15th, after a somewhat restless night, the morning temperature was 103°. The tongue was furred but moist. The pulse was 100 and of good volume. The heart sounds were clear. The urine was of specific gravity 1020 ; it contained The eruption was, if anything, more no sugar or albumin. exaggerated than on the previous day. The face was swollen, especially under the eyes, and had the appearance of being inflated. Hemorrhage had taken place into the three regions where the eruption had become confluent; the surface of the pocks in these regions being somewhat flattened but intact and the pocks were dark purplish-black in colour. The eruption was present on both pinns and between the toes and fingers. The patient at this stage certainly presented an alarming appearance, but even on this day (August 15th) was quite cheerful and expressed herself as feeling "much more comfortable." The only complaint had been that the "face felt very stiff all over." Had she been seen for the first time at this stage there might have been some reasonable doubt as to the diagnosis. The following seemed to be the chief points in the differential diagnosis between variola and varicella : 1. There was an epidemic of varicella in the neighbourhood and the patient had been exposed to infection. 2. After the first day or so of the disease there were no pains or other symptoms giving rise to discomfort (such as acute pain in the back) and the intellect remained clear throughout except for occasional wandering at night. 3. The eruption came out in definite crops and the papules had never at any time the shotty feel of small-pox papules. 4. The wrists and roots of the hairs at the forehead were the only parts of the body that were particularly free from the eruption throughout. 5. The great abundance of rash present on the trunk and the character of the vesicles which 6. The never had any deeply infiltrated areola about them. absence of any prolonged period of invasion (the patient was out and about with the rash present on the chest). 7. Successful vaccination within four years. 8. The fact that 16 days after contact with the patient her sister
carbolated vaseline for the face and occasional sponging of the rest of the body and limbs with a 1 in 60 carbolic acid lotion. The room was kept darkened throughout the acute stage of the eruption. There was at no time any evidence of marks of scratching, and as the patient had had her hands bound up as a precaution and had been very carefully watched night and day the element of traumatism as a cause of the haemorrhage could be quite excluded. It was indeed a notable fact that there was very little irritation of the face, this being mostly confined to the trunk and limbs where no haemorrhage took place. Unfortunately there has resulted considerable scarring where the rash was confluent. It is an interesting point that keloid has developed in two placesviz., where the rash was confluent and hsemorrhagic over the right sterno-mastoid, and also where the largest pock occurred, over the left nipple. The only references I can find to the occurrence of a hasmorrhagic eruption in varicella are : 1. in an article by Dr. J. MacCombie in Allbutt’s " System of Medicine," Vol. II., p. 181, where he says : " This form is very rare [i.e., hasmorrhagic varicella, to which he is referring], and the vesicles are usually few in number. Large and small ecchymoses appear with hasmorrhages into the cutis under the vesicle, accompanied by hsematemesis and melasna." 2. Osler in his "Principles and Practice of Medicine," p. 70, says, "Cases have been described by Andrew of bsemorrbagic varicella with cutaneous ecchymoses and bleeding from the mucous membranes." On referring to Andrew’s paper in the Transactions of the Clinical Society of London, 1890, it will be found that the cases described are very similar to Dr. MacCombie’s description, being complicated by basmorrhage from the mucous membranes. Savill1 says : " Untoward symptoms such as gangrene and hasmorrhage into the vesicles are rarely met with." With regard to cicatrices Osler says: "Indeed, I cicatrices after chicken-pox are not so very uncommon. They are" in my experience more common than after varioloid." Since writing the above, further information with regard to the literature has come under my notice, viz., E. W. Goodall, in an article on varicella in the .1lfedioal Annual for 1907, -I quotes three cases, by Rundle,2 Neech,3 and J. D. Rolleston was In Rundle’s there from case b2amorrhage respectively. the mucous and cutaneous surfaces but no confluence. In Neech’s case there was confluence but no haemorrhage. In Rolleston’s case there were both. In the British Medical Journal of May 4th, 1907, p. 1051, there is an article on accidental rashes of varicella by J. D. Rolleston, to which i. appended a very extensive and complete bibliography, in which the above cases are quoted. Great Berkhamsted.
A NOTE ON THE ALBUMINOUS BODIES PRESENT IN PATHOLOGICAL
EFFUSIONS. BY W. CECIL
BOSANQUET, M.A., M.D. OXON., F.R.C.P. LOND.,
ASSISTANT PHYSICIAN TO CHARING CROSS HOSPITAL AND TO THE BROMPTON HOSPITAL FOR CONSUMPTION AND DISEASES OF THE CHEST.
THE
note does not profess to add anything the nature and proportions of the different albuminous bodies which occur in pathological effusions, but is written merely in the hope that it may save
to
our
following brief knowledge of
1 System2 of Clinical Medicine, 4
vol. i., p. 591, 1905 edition. THE LANCET, June 16th, 1906, p. 1692. 3 THE LANCET, Feb. 24th, 1906, p. 515. British Journal of Children’s Diseases, January, 1906.
f thp apparatus for washing a double cylinder, with
out the colon. This consists methods is both rational and successful and that it is destined a float in the lower cylinder, to become an essential part in the treatment of many cases. which regulates the escape of water from the upper, so that The same kind of treatment has been carried out at Plombières the same pressure is maintained throughout. The cylinder and Chatel-Guyon for several years. "’ Careful dieting during and after the course of douching glides on two graduated uprights which mark the height and are a is imperative. Foods which are easily digested and leaving pressure and is moved to the height prescribed. There thermometer attached to the cylinder and a gauge to register only a small and unirritating residuum are best. In my exthe quantity of water, both sufficiently large for the patients perience the diet advocated by von Noorden proves unsuitshould be instructed to eat only to observe for themselves whilst lying on the couch. One of able. Further, the The quantity a small amount of animal food, since it is a fruitful source of the sulphur waters is used for irrigation. prescribed may be from 10 to 40 or more ounces for each putrefactive material. They require to be warmly clothed, douche and is usually repeated. The temperature varies and be careful to avoid chills, which are apt to increase the from 96° up to 104° F. or more, depending on the condi- catarrh of the colon. Warm bright sunshine is a valuable tion of the bowel. A long tube is passed per rectum aid to treatment and sometimes is indispensable. Moderateinto the sigmoid flexure and the sulphur water gradually exercise should be regularly taken in the fresh air, that of This is retained an upland or mountainous character being especially benepasses through it into the colon. several minutes by the patient and is then ejected into a ficial. Moderation is essential in food, drink, exercise, and flat-bottomed receptacle. The douche is always given by a pursuits. In short, the scriptural injunction : " Be ye skilled attendant, who examines the ejecta and reports to moderate in all things," applies more to patients affected with the medical attendant. Immediately after the internal colitis than perhaps to any others. douching the patient goes into an adjoining room and steps Harrogate. into a warm sulphur bath. Whilst reclining in this a hot douche is directed through the water to the abdominal wall. It is delivered through a large nozzle with numerous fine A CASE OF CONFLUENT HÆMORRHAGIC perforations and moved slowly over the site of the colon. ERUPTION IN VARICELLA. There are several therapeutic actions produced by this internal and external treatment besides the mechanical one By CHARLES R. PORTER, M.R.C.S.ENG., L.R C.P.LOND. of cleaning out the intestine. The internal douche acts as a warm bath upon the intestine, the heat of this soothing THE fact that varicella is usually such a mild disease no it and the neighbouring organs. Then the sulphur water brought in contact with the mucous membrane produces its doubt accounts for the scarcity of literature found relating well-known action of diminishing catarrh and restoring the to its complications. Medical advice is often nor, sought at mucosa to a healthy condition. Again, Sir William Ramsay all, and there is no doubt that many cases occur which are has found that the stronger of the sulphur waters used is radio- not even recognised by parents of children who have the active, and doubtless this property is beneficial, producing a disease. Among the uneducated if the disease is recognised sedative effect upon the bowel and the body generally. it is looked upon as a harmless affection called "the Another important action of the internal douche is free blisters " and no further notice is taken of it, the child in diuresis. This arises partly from the kidney being stimulated question being probably allowed to go to school as usual. by the hot internal douche, though chiefly from the absorp- There are, however, a few authentic illustrations of the fact tion from the bowel of some of the sulphur water, part of that varicella can assume a serious and even dangerous which is retained and subsequently secreted. This flushes character from the intensity of its infection. The following case appears to me to be worth wbileout the liver, kidneys, and tissues, and carries away some of the toxins already absorbed. putting on record for the following reasons. In the first When we come to examine the effects of the external place because confluence with basmorrbage into the vesicles treatment we find the warm sulphur bath soothes the nervous is apparently so rare ; secondly, because it emphasises the system and induces a sense of comfort in the patient. It fact that diagnosis is made so much easier by being allowed determines an increased flow of blood to the skin, stimulating to observe the disease from its onset; and, thirdly, because its glands and improving its nutrition. This in turn has a a skin lesion occurring during the incubation period seems healthy influence upon the colon as there is undoubtedly a to favour an extensive eruption-in fact, in this c:4-,e it seems close relationship between the skin and the intestine, a state to have been the determining factor in the severity of the frequently demonstrated in colitis. The external douche local lesions. The patient, a girl, aged 13 years, was first seen onapplied to the abdominal walls has an extremely soothing effect upon the colon, relieving pain and spasm when it August 8th, 1906, and was then suffering from a somewhat exists. Further, the impact of the tiny jets of the douche irritable papular eczema of the face and the backs of stimulates the intestine and promotes muscular contractility both hands. The forehead, nose, and cheeks were espeThis She was otherwise quite well. It is an interesting fact that the cially irritable. in the distended portions. relief of spasm in one part of the intestine and increase of condition quite cleared up within two days under an contractility in another will take place at the same time, application containing oxide of zinc. It should be mentioned probably from the irritation of the intestine being allayed. that when an infant the patient had been unsuccessfully After four or five weeks of such treatment a marked ameliora- vaccinated three times, and when revaccinated in 1902 tion is produced in the patient’s condition. The catarrh is it was successful in two places only. The only serious lessened, pain and spasm are alleviated, and constipation is acute illness previous to the present attack was acute anterior poliomyelitis when the child was aged four years, relieved. Coming to the general symptoms the first thing noticed is from which very slight deformity results. On August 10th the improvement in the appearance of the skin. In a few in the evening she complained of headache, latitude, and days it becomes clearer and brighter. Next, if there is pains in the limbs and a few spots were noticed on glycosuria it usually quickly disappears, as does also the the chest. She played tennis that evening and was stool pallor. Soon the patient feels better and becomes somewhat restless that night. On the llth she was out and brighter and happier. The neuroses, which are generally the about and one or two more spots were noticed on the chest. most troublesome features in severe cases, improve slowly, She was restless again that night. I was called to see her though in the milder forms of the affection they are soon on the morning of the 12tb, as a rash had appeared on the ameliorated. One remarkable circumstance is the effect of face. The temperature was 101° F. and the pulse was 80. treatment on a loose kidney. After some months of effective There was the typical rash of varicella present on the chest, treatment it becomes much less moveable, and in some cases face, and limbs, and one or two typical vesicles on the when recovery from colitis has taken place the kidney ’, buccal mucous membrane and soft palate. The rash was in becomes practically fixed. In severe cases of colitis one different stages of eruption, showing papule, vesicle, and crust course of colon irrigation is not sufficient. It must be re- on the chest. There were no papules at the roots of the hairs peated once or oftener after an interval, depending on the on the forehead, and the wrists, back and front, were quite state of the patient at the end of the course and subsequently clear. The patient was quite comfortable and the irritation to it. was practically nil. On the 13th the temperature was During the last three or four years this treatment has 101’6° and the pulse was 80. The eruption had further been employed at Harrogate in several hundred cases of developed, especially on the face, the vesicles varying in size colitis. The excellent results which have been achieved from a pin’s head to a quarter of an inch in diameter. The have exceeded expectations. The results prove that the rash was then so plentiful on the face that it would have-
ef
patient
___
____
1360
impossible to find a free area of the size of a developed typical varicella, which ran a severe course, with sixpence. The roots of the hairs were, however, still abundance of rash and high pyrexia. It might be practically free, though there were, of course, many mentioned in addition that there have been no cases of vesicles on the scalp. The chest and back were literally small-pox in the neighbourhood for the past 10 or 15 years covered and the eruption was very plentiful on both to my knowledge. The general condition The subsequent course of the case was quite uneventful. arms and legs, back and front. was good, the patient being quite bright and cheerful and On August 16th the temperature fell to 99 ’5°, and many of free from discomfort. On the 14th the vesicles on the face the vesicles had changed to crusts. No mora haemorrhage had become confluent in three places-viz., five on the fore- occurred and the patient made an uninterrupted recovery. head, three over the course of the right temporal artery on (The photograph reproduced was taken on August 16th, the forehead, *and four on the right side of the neck over the the sixth day of the disease.) The last scabs to come off sterno-mastoid muscle; the latter are well shown in the were those into which hasmorrbage had occurred, and this accompanying figure. The temperature was 101’ 6° and the took place just four weeks from the onset of the first symptoms. The local treatment employed was a mask of been
pulse
was
84.
arms
and
even
There were more crops out on the legs and on the soles of the feet and palms of the hands. One single vesicle in the left mammary region just above the left nipple had attained a diameter ofhalf an inch (? " varicella bullosa"). The general condition was quite satisfactory, the intellect was clear, and the patient was cheerful with a fair appetite. On the 15th, after a somewhat restless night, the morning temperature was 103°. The tongue was furred but moist. The pulse was 100 and of good volume. The heart sounds were clear. The urine was of specific gravity 1020 ; it contained The eruption was, if anything, more no sugar or albumin. exaggerated than on the previous day. The face was swollen, especially under the eyes, and had the appearance of being inflated. Hemorrhage had taken place into the three regions where the eruption had become confluent; the surface of the pocks in these regions being somewhat flattened but intact and the pocks were dark purplish-black in colour. The eruption was present on both pinns and between the toes and fingers. The patient at this stage certainly presented an alarming appearance, but even on this day (August 15th) was quite cheerful and expressed herself as feeling "much more comfortable." The only complaint had been that the "face felt very stiff all over." Had she been seen for the first time at this stage there might have been some reasonable doubt as to the diagnosis. The following seemed to be the chief points in the differential diagnosis between variola and varicella : 1. There was an epidemic of varicella in the neighbourhood and the patient had been exposed to infection. 2. After the first day or so of the disease there were no pains or other symptoms giving rise to discomfort (such as acute pain in the back) and the intellect remained clear throughout except for occasional wandering at night. 3. The eruption came out in definite crops and the papules had never at any time the shotty feel of small-pox papules. 4. The wrists and roots of the hairs at the forehead were the only parts of the body that were particularly free from the eruption throughout. 5. The great abundance of rash present on the trunk and the character of the vesicles which 6. The never had any deeply infiltrated areola about them. absence of any prolonged period of invasion (the patient was out and about with the rash present on the chest). 7. Successful vaccination within four years. 8. The fact that 16 days after contact with the patient her sister
carbolated vaseline for the face and occasional sponging of the rest of the body and limbs with a 1 in 60 carbolic acid lotion. The room was kept darkened throughout the acute stage of the eruption. There was at no time any evidence of marks of scratching, and as the patient had had her hands bound up as a precaution and had been very carefully watched night and day the element of traumatism as a cause of the haemorrhage could be quite excluded. It was indeed a notable fact that there was very little irritation of the face, this being mostly confined to the trunk and limbs where no haemorrhage took place. Unfortunately there has resulted considerable scarring where the rash was confluent. It is an interesting point that keloid has developed in two placesviz., where the rash was confluent and hsemorrhagic over the right sterno-mastoid, and also where the largest pock occurred, over the left nipple. The only references I can find to the occurrence of a hasmorrhagic eruption in varicella are : 1. in an article by Dr. J. MacCombie in Allbutt’s " System of Medicine," Vol. II., p. 181, where he says : " This form is very rare [i.e., hasmorrhagic varicella, to which he is referring], and the vesicles are usually few in number. Large and small ecchymoses appear with hasmorrhages into the cutis under the vesicle, accompanied by hsematemesis and melasna." 2. Osler in his "Principles and Practice of Medicine," p. 70, says, "Cases have been described by Andrew of bsemorrbagic varicella with cutaneous ecchymoses and bleeding from the mucous membranes." On referring to Andrew’s paper in the Transactions of the Clinical Society of London, 1890, it will be found that the cases described are very similar to Dr. MacCombie’s description, being complicated by basmorrhage from the mucous membranes. Savill1 says : " Untoward symptoms such as gangrene and hasmorrhage into the vesicles are rarely met with." With regard to cicatrices Osler says: "Indeed, I cicatrices after chicken-pox are not so very uncommon. They are" in my experience more common than after varioloid." Since writing the above, further information with regard to the literature has come under my notice, viz., E. W. Goodall, in an article on varicella in the .1lfedioal Annual for 1907, -I quotes three cases, by Rundle,2 Neech,3 and J. D. Rolleston was In Rundle’s there from case b2amorrhage respectively. the mucous and cutaneous surfaces but no confluence. In Neech’s case there was confluence but no haemorrhage. In Rolleston’s case there were both. In the British Medical Journal of May 4th, 1907, p. 1051, there is an article on accidental rashes of varicella by J. D. Rolleston, to which i. appended a very extensive and complete bibliography, in which the above cases are quoted. Great Berkhamsted.
A NOTE ON THE ALBUMINOUS BODIES PRESENT IN PATHOLOGICAL
EFFUSIONS. BY W. CECIL
BOSANQUET, M.A., M.D. OXON., F.R.C.P. LOND.,
ASSISTANT PHYSICIAN TO CHARING CROSS HOSPITAL AND TO THE BROMPTON HOSPITAL FOR CONSUMPTION AND DISEASES OF THE CHEST.
THE
note does not profess to add anything the nature and proportions of the different albuminous bodies which occur in pathological effusions, but is written merely in the hope that it may save
to
our
following brief knowledge of
1 System2 of Clinical Medicine, 4
vol. i., p. 591, 1905 edition. THE LANCET, June 16th, 1906, p. 1692. 3 THE LANCET, Feb. 24th, 1906, p. 515. British Journal of Children’s Diseases, January, 1906.