A system of practical medicine. By American authors. Vol. 1

by Unknown

⁷ Virch. Archiv, Bd. 28.

⁸ Trans. of Amer. Derm. Ass., Aug., 1879.

First appear circumscribed patches of hyperæmia, in which the papillary layer of the corium is concerned, and which is followed by some thickening of the rete, the epithelia involved becoming coarsely granular. This granular condition is due to an increase of living matter within the protoplasmic bodies, evident at the points of intersection of the reticulum of which they are composed, the nuclei becoming solid and shining, and the threads traversing this cement-substance between them becoming also increased in thickness. The papillæ beneath increase in size in consequence of their vascular engorgement, and in consequence of the change experienced by the connective-tissue bundles, which are partly transformed into protoplasm, while the protoplasm between them increases also. There is, in brief, a liquefaction of the glue-giving basis-substance, which makes visible the reticulum of living matter formerly hidden within it. In this way the epidermis is raised into the flat solid papules which are the early lesions of the disease.

Then follows an exudation of a serous fluid at one or more points in the papule, the meshes of the reticulum being so stretched and torn that small chambers are formed filled with the liquid exudate containing granules. Between these chambers the separating strata of epithelia are compressed so as to form septa or partition walls. The neighboring epithelia become granular, divested of their cement envelope, and transformed into protoplasmic clusters still connected with the living reticulum by slender threads. An irregular cavity is thus formed in the thickened rete traversed by septa, the contained exudation being filled with granules, coagulated fibrin, and lymph. A few protoplasmic bodies are here also distinguishable, which Heitzmann regards as either débris of destroyed epithelia or colorless blood-corpuscles.

In these changes the connective-tissue beneath participates. The papillæ eventually disappear, the superior portion of the corium being replaced by clusters of medullary or inflammatory elements uninterruptedly connected by threads of living matter.

The pus-corpuscles which eventually appear originate mainly from transformed epithelia. In the process of transformation the increased protoplasm of the epithelia first exhibits shining homogeneous lumps, which, after an intermediate stage of vacuolation, undergo an endogenous metamorphosis into nucleated bodies with a reticulum in each. To the number of these there is possibly an addition by the immigration from below (diapedesis) of leucocytes.

The question of repair with or without the production of cicatrices rests upon the behavior of the connective-tissue elements. If these are not torn asunder, but remain in connection with each other, the re-formation of a glue-giving basis-substance is possible, and new bundles of fibrous connective-tissue take the place of the old. If, on the contrary, the latter are completely destroyed, their place is filled with the cicatricial new growth. The pigmentation, which is such a common transitory sequela of the skin lesions, is due both to the imbibition of the coloring matter of the blood by the epithelia and by direct hemorrhagic exudation into both the rete and derma.

The umbilication of the mature pock is doubtless due to the situation of such lesions at the orifices of the excretory ducts of the skin-glands. The epidermis, in one or more of its strata, dips downward to form a living investment for such glands, and in this situation ties down the centre of the roof-wall of the pustules. Eventually, it too, as a result of the maceration and tension incidental to the complete filling of the pock with pus-elements, is ruptured or stretched, and the umbilication of the pustule disappears.

The anatomy of the exanthematous lesions in hemorrhagic variola is not different from that described above. The pocks in such cases are merely filled with blood instead of with pus or sero-pus. In some forms of hemorrhagic variola, as indeed would be suggested by their clinical observation, there is hemorrhage directly into the tissues of the integument, or, more probably in severe cases, a mere passive leaking of the sanguineous fluid with its coloring matter through the relaxed and weakened vascular walls.

The morbid changes occurring in the viscera are described by Curschmann as follows: The mucous surfaces may be the seat of pustules, diffuse purulent infiltration, and catarrhal, croupous, or diphtheritic inflammation. As regards the extent of diffusion of the pustular lesions, they occur, according to Wagner, in bronchi of the second and even of the third order, rarely in the stomach and intestines, and in the rectum only in its lowest portion. The bladder, urethra, and serous surfaces are always exempt. The lungs, breast, liver, spleen, brain, and spinal medulla are variously involved. Often the tissues of these organs are quite unchanged as regards their macroscopical appearance. At other times the tissues appear swollen, granular, and undergo a fatty degeneration. In purpura variolosa the spleen and walls of the heart, however, are seen to be firm, dark-red, and more or less indurated.