1496 



COSMOPOLITAN FEVERS 



duced by perfectly pure calf -lymph and by a satisfactory technique in persons 

 suffering from any form of latent constitutional disturbance of severe nature, and 

 that the severity of the local signs is caused by the lowered resistance of the 

 tissues due to this latent infection, which, judging from this and other cases, 

 makes itself sufficiently evident in the course of the illness which follows 

 the vaccination. 



Treatment. — At first the area should be merely protected from septic infec- 

 tion by pieces of sterilized lint lightly held in position by pieces of bandage. 

 When the inflammatory symptoms appear, antiseptic dressings in the form of 

 I in 80 carbolic lotion may be applied on lint, while the whole area is covered 

 with cotton-wool, loosely held in position bj^ first a bandage and then a hand- 

 kerchief. 



Closed dressings are not indicated, and the afiected area should be simply 

 exposed to the air in an elevated position, and treated at first by dry powders, 

 later by lead and opium lotion, and finally by calamine lotion. 



. Papulo-Vesicular Vaccinia (Synonym, Vaccine Lichen). — This rash, which 

 was first described by Crocker as vaccine lichen, has been observed in a number 

 of cases by Chalmers and Byam in the Anglo-Egyptian Sudan, Some seven 

 or eight days after vaccination the patient suffers from a mild attack of fever, 

 which may reach 102° F., and may be attended with a slight sensation of itching 

 in various parts of the body. The febrile symptoms subside as the rash appears . 

 and do not return ; but during the fever some of the patients suffer from a dry 

 cough, which becomes worse as the eruption develops, and then slowly dis- 

 appears. There is no vomiting or diarrhoea or other symptom worthy of 

 record, while the vaccination pursues a normal course. 



With regard to the rash, it appears, as already stated, some seven to nine 

 days after vaccination in the form of dark-coloured maculae, which quickly 

 become papules or papulo-vesicles, because, although no actual vesicles can 

 be seen by the naked eye, still they produce a hard shotty sensation on palpa- 

 tion, and on microscopical examination show minute vesicles in the epidermis. 

 A fully developed papule is about the size of a large pin's head, dome-shaped, 

 and projects above the surrounding skin, which, as a rule, is quite normal, 

 though in some cases it maybe distinctly congested and may even be swollen. 

 They appeared firstly upon the back of the hands and forearms, then on the 

 back of the neck, then on the face, chiefly on the forehead, and then on the 

 chest and back, and varied considerably in number from a few dozen to 

 several hundreds. 



The blood showed no parasites, but there was a leucocytosis and a marked 

 relative increase of mononuclear and eosinophile leucocytes. 



After lasting some four or five days, the rash slowly disappears, and is 

 followed by a well-marked desquamation. 



With regard to its aetiology, it was associated with vaccination because it 

 occurred in two quite distinct detachments of Nuers and Nubas. The first 

 detachment of twenty-four were vaccinated on February 10, 1914, and the 

 eruption developed in eight, while the second detachment of thirty-six was 

 vaccinated on February 23, 1914, and three developed the rash. It is to be 

 noted that the vaccination in all was performed with lymph from one and the 

 same calf. In every case the vaccination took well and developed normally, 

 and in no case was there any sign of septicity or infection. No fungi or bacteria 

 could be found in or cultivated from the papules; on the other hand, bodies 

 which bore a resemblance to Guarnieri bodies were found in the vesicles. 



The chief diagnostic points are : — 



A papular or papulo-vesicular eruption beginning about eight days after 

 vaccination and heralded by slight or no constitutional disturbance, but with 

 moderate itching, and usually commencing on the arms, is most probably 

 this eruption, which maybe called a vaccine lichen, but which would be better 

 termed a papulo-vesicular vaccinia. 



The diagnosis should be confirmed by attempts at vaccination of a monkey 

 from a papule or a vesicle. 



The differential diagnosis may be made from : — 



Lichen acuminatus by the fact that the hair follicles are not attacked. 



