ON THE 
DIFFERENTIAL DIAGNOSIS 
OF 
VARICELLA and VARIOLA, 
WITH THE REPORT OF A CASE IN POINT.- 
By ISADORE DYER, M. D., Xew Orleans, La. 
Reprinted, from the January, i8qb, number of the Nevi Orleans Medical and Surgical Journal. ON THE 
DIFFERENTIAL DIAGNOSIS 
OF 
VARICELLA and VARIOLA, 
WITH THE REPORT OF A CASE IN POINT.* 
ISADORE DYER, M. D., New Orleans, La. 
Reprinted from the January, 189b, number of the Nevi Orleans Medical and Surgical Journal, 
In studying the eruption of diseases which affect the skin, 
there are certain essential points of consideration. These 
apply to all skin diseases and to the exanthemata as well. 
Before going into the details of these points of diagnosis, 
I wish to make the general propositions: first, do variola and 
varicella differ, and, second, if so, in what do they differ? 
In all eruptions, then, the location, the distribution, and the 
arrangements of the eruption are important, while the charac- 
teristics of the component lesions determine the disease. 
The duration, course, history and attendant symptoms are 
important, but secondary considerations. 
In considering variola and varicella along these lines, we 
see at a glance important differences. 
Location. 
Variola-face and extremities, particularly. 
Varicella-trunk, particularly; face and extremities, un- 
usually. 
* Read before the Orleans Parish Medical Society, December 14, 1S95. 2 
A rra ng emen t. 
Variola-closely aggregated lesions, often confluent, par- 
ticularly in the vesicular stage, clusters frequently seen. 
Varicella-either single, widely separated lesions, never 
inclined to confluence, or in groups of two or three, maintain- 
ing throughout the integrity of shape and form. 
Characteristics of the Individual Lesions. 
Variola begins as a hard, shot-like papule, as an efllores- 
ence, even-involving the mucous membranes. After a distinct 
period, these change to vesicles, all lesions undergoing this 
change-umbilication customary. Lesions not umbilicated un- 
usual in variola-vesicles change altogether into pustules, 
always deep seated, beginning always in the papillae them- 
selves, heal as scars, or pits after a long period of time. 
Varicella lesions large, irregular in shape, spherical in 
form, globular at times, superficial always, rubbing off the skin 
easily. Papular stage indefinite, so short as often to be missed, 
and lesions seem to begin as vesicles. Often dry as vesicles, 
pustulating uncommon, umbilication rare, exceptional when it 
does occur, and then only in a few of a number of lesions. 
Eruption of lesions heals by drying, or peeling, leaving, at most, 
only a slight pigmentation-never scars, unless abscess from 
secondary pus infection. Pitting is never seen. 
Course of the Eruption. 
Variola-slow, periodic changes in eruption from papular 
to vesicular or pustular; never find pustules and papules to- 
gether. Never under three weeks, even in mild cases (Hebra, 
Liveing, Kaposi, Morrow). Usually four weeks or longer. 
Varicella-rapid and irregular course, recurrent crops. 
May begin to heal on second day of eruption; find papules, 
pustules and vesicles side by side. No periodic change ; 
usually completed in fourteen days. Sometimes less, rarely 
more. 
History and Attendant Symptoms. 
Variola has prodromata more or less severe, but always 
present characteristic fever, angina common, headaches, fever 3 
marked by exacerbation as the eruption becomes pustular. 
Depression throughout, more pronounced as the disease ad- 
vances, and at the pustular change. 
Finally varicella is not an uncommon disease, occurring 
independent of season and place. 
Variola is epidemic and not concurrent otherwise, and is 
not a common disease. Is occurrent most in colder weather. 
Varicella does not protect against variola. 
Variola protects against variola, and recurrent cases of 
variola are rare, and occurring, occur in a modified form. 
There is no case on record of a relapsing variola. 
I have presented these different points, to the more sa- 
liently bring out the main features of the case I am about to 
report. 
That there is some reasonable purpose in this report will 
likely appear to all, and. I wish to ask the free discussion of the 
case as one of importance, not only in its own clinical 
features, but as exercising some direct reflection upon the in- 
dividual physician's position in his relation to the official 
health authorities. 
There may perhaps be some who believe that the patient 
deserves consideration also. 
On November 8, I was requested by the visiting physician 
of one of the wards of the Charity Hospital to see a case of 
skin disease, to express an opinion upon it and to prescribe. 
On entering the ward of the hospital, I met one of the 
house officers, who additionally invited me to see the case. 
With the house officer and Dr. Menage, my associate at 
the hospital, I made a careful clinical examination, with the 
following result: 
The patient was a negress, about 20 years of age, in good 
physical condition, with the following skin manifestations : 
!•-The eruption was distributed in discrete lesions over 
the chest, abdomen and back. On the face, there were a 
number of lesions, single, and widely separated. On the arms 
and legs, the lesions were fewer and sparsely located. On the 
tongue and over the hard palate, there were likewise discrete 
lesions. 4 
II.- The eruption consisted of irregular-sized vesicles on 
the body and face, while the lesions on the tongue and the 
mouth were for the most part pustular. I called the attention 
of the gentleman with me to this phase of the eruption, and 
also to the fact that there was an absence of any other evidence 
of inflammation in the mouth and throat. 
The lesions were rounded, hemispherical, and irregular 
in shape. It was only after a careful search that any umbilica- 
tion was found. This could be seen only on two or three 
lesions on the right side just below the region of the floating 
ribs. 
On questioning and cross-questioning the patient, it was 
discovered that she had experienced no prodromic symptoms 
whatsoever, and felt at the time of examination in excellent 
health. 
The eruption had been out, she said, only two days, and 
had come out gradually. The lesions were more carefully ex- 
amined, and were found to be loose walled, some even flabby. 
In touching one, on the belly, the walls gave way under my 
finger, the top slipped off, leaving a smooth, reddened spot be- 
hind, when the exudate was wiped away. 
An unqualified diagnosis of varicella was made by me, 
which was concurred in by the house officer and by Dr. Men- 
age. 
The case was received by the hospital and admitted. 
On the morning following I again saw the patient. There 
was plain evidence of resolution of the condition. Fully half 
the lesions on the face had dried. Those on the body had in 
many places been reabsorbed, leaving behind the little 
crumpled epidermis, which is customary after the resolution of 
a vesicle. 
The general condition of the patient had not changed. 
I advised treatment, and said that the case needed no 
especial watching, giving a prognosis of a few days. 
The same night I learned that the patient had been sent by 
the Board of Health Inspectors to the small-pox hospital. 
At the invitation of the President of the Board of Health, 
who had resented my repeated expressions of opinion in the 
case, namely: " that a case of varicella had been sent to the 5 
small-pox hospital," I visited the pest-house on the 12th of 
November. 
I found the patient in bed, in a room with another, sick 
with small-pox, I conclude. 
She rose with ease at my request, and I for the third time 
made a careful examination. 
I found the following state of affairs: 
i. There were no lesions on the face. Some pigmented 
spots, dark or whitish red, marked on the site of the desiccated 
lesions. 
2. There were no lesions of any sort in the mouth and no 
evidences of eruption except a little red spot on the right 
underside of the tip of the tongue, where a lesion might have 
been. 
3. The body presented both vesicles and pustules in stages 
of disintegration, some flabby, some half peeled, some already 
dried and some having peeled, leaving whitish, smooth spots 
behind. 
All the lesions on the arms and legs had dried. 
4. There were no constitutional symptoms. In spite of 
repeated questioning and cross-questioning, the patient denied 
sore throat at any stage or time of the disease, and at this 
examination there was still no evidence of it. 
I reiterated my expression of opinion in the case and 
passed the comment that such aclinical picture on the sixth or 
seventh day confirmed beyond peradventure my original diag- 
nosis of varicella. I insisted that a case of varicella had been 
sent to the small-pox hospital, where she was confined. 
The case remained at the pest-house notwithstanding. 
On November 24 the patient applied at the Charity Hos- 
pital for admission in another service. On the following day 
the patient was the second time transferred to the small-pox 
hospital with a diagnosis of variola. 
A few days subsequently I learned she was in the hospital 
with confluent small-pox. Within the past few days I was told 
that this patient had died of small-pox. 
I might dismiss this subject without further comment, but 
I prefer, if not trespassing too much upon your time, to draw 
a few conclusions. 6 
I would call your attention for consideration to the follow- 
ing points: 
i. The character of the eruption in the case when I saw 
her. 
2. The history and course of the eruption. 
3. The date of admission and discharge from the small- 
pox hospital (November 9, November 18). 
4. The date of readmission to the small-pox hospital 
(November 26). 
5. The more than improbability of a recurrent attack of 
variola. 
First. Because the patient was discharged from the pest- 
house not later than the 18th (if earlier, all the more argument, 
for variola even in varioloid types never runs a course of less 
than three weeks). 
Second. The small-pox was manifested on the 23d, or 
just seven days after the discharge from the pest-house, and 
just sixteen days from the date of first admission to the pest- 
house. 
The period of incubation of small-pox is from ten to four- 
teen days. 
6. This suggests that small-pox was contracted in the pest- 
house. 
7. It would be an unique case in medical literature to find 
a "mild case of varioloid," as diagnosed by the sanitary in- 
spector, followed within a week or eight days by a typical case 
of true variola, confluent in type, and malignant in its history 
and outcome. 
Gentlemen, we are entitled to differences of opinion, and 
the weight of proof rests with those who have the weaker side. 
I believe I have made a fair presentation of this case and its 
history. 
When there is a reasonable doubt in such an instance 
much harm may result to the patient, and much discredit reflect 
upon the health authorities if a mistake is made in sending one 
with a similar disease to a hospital for small-pox, where death 
may be the forfeit of the patient. 
124- Baronne St.