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Title: Measles, diphtheria, scarlet fever, chicken pox, and whooping cough
Author: George H. Weaver
Editor: Morris Fishbein
E. Haldeman-Julius
Release date: March 10, 2026 [eBook #78158]
Language: English
Original publication: Girard: Haldeman-Julius Company, 1924
Other information and formats: www.gutenberg.org/ebooks/78158
Credits: Tim Miller, Franciszek Skawiński and the Online Distributed Proofreading Team at https://www.pgdp.net (This file was produced from images generously made available by The Internet Archive)
*** START OF THE PROJECT GUTENBERG EBOOK MEASLES, DIPHTHERIA, SCARLET FEVER, CHICKEN POX, AND WHOOPING COUGH ***
LITTLE BLUE BOOK NO. 136
Edited by E. Haldeman-Julius
Measles, Diphtheria, Scarlet
Fever, Chicken Pox and
Whooping Cough
George H. Weaver, M. D.
Professor of Pathology, Rush Medical College,
Chicago; Physician in Charge of Durand
Hospital of the John McCormick Institute
for Infectious Diseases, Chicago, Ill.
HALDEMAN-JULIUS COMPANY
GIRARD, KANSAS
LITTLE BLUE BOOK HEALTH SERIES.
EDITED BY MORRIS FISHBEIN, M. D.
Acting Editor, Journal of the American Medical
Association, and Associate Editor, Hygeia; a
Journal of Individual and Community Health.
Copyright, 1924
Haldeman Julius Company
PRINTED IN THE UNITED STATES OF AMERICA
MEASLES, DIPHTHERIA, SCARLET
FEVER, CHICKEN POX and
WHOOPING COUGH
PREFACE
It is generally recognized that the prevalence of contagious diseases,
and their associated injury to life and health, especially of children,
can only be satisfactorily limited if the full co-operation of those
who have the care of children is secured. This is dependent almost
entirely on general information. Scarcely any parent will willfully
endanger the health of the children of others. It is hoped that this
brief statement of facts, on which authorities agree, may be of some
use to those who are responsible for the health of children. It is not
intended to encourage the treatment of sick children without trained
advice, but rather to aid in securing intelligent aid to the doctor and
public health officer.
CONTENTS
Page
General Consideration 7
Measles 17
Causes and Mode of Spread 19
Symptoms 20
Complications 21
Prevention 23
Treatment 24
Diphtheria 26
Cause and How It Acts 27
Recognition of Diphtheria 29
How Diphtheria Is Spread 30
Treatment 30
Prevention of Diphtheria 33
Bad Effects of Serum 35
Suggestions of Measures Calculated to
Eliminate Diphtheria and Its Dangers 36
Scarlet Fever 38
Cause 39
Mode of Spreading 39
Effects of the Infection 40
Symptoms 40
Complications 42
Prevention of Scarlet Fever 44
Treatment 45
Chicken Pox 49
Symptoms 49
Complications 51
Different from Small Pox 52
Prevention 52
Treatment 53
Whooping Cough 54
Symptoms 55
Complications 56
Prevention 57
Treatment 58
MEASLES, DIPHTHERIA, SCARLET FEVER, CHICKEN POX and WHOOPING COUGH
GENERAL CONSIDERATION
Before beginning the consideration of the individual diseases
enumerated in the title, a review of some of the things which relate
to them in common may prevent subsequent repetition. The importance of
this group of diseases is realized when one remembers that during the
ten years ending in 1922, in a large city such as Chicago, more than
one person out of every seven of the population suffered from one of
these diseases and one out of every 150 died from one of them. Combined
these diseases cause about one-fourth of the deaths among children from
one to ten years of age. Not only are they responsible for abundant
deaths, but they also leave in those that recover a legacy of permanent
damage in the heart, lungs, ears, eyes and other parts of the body.
Statistics show that more than one-fifth of the cases of deaf-mutism
follow scarlet fever, measles and diphtheria. Chronic diseases of the
heart and of the kidneys may be due to earlier attacks of scarlet fever.
The diseases here considered constitute an important part of those
which are known as contagious. Contagious diseases are those which are
transmitted from one person to others by direct or indirect contact.
They are sometimes also designated “communicable diseases.”
CAUSES
Each of these diseases is caused by its own peculiar germ. We may
compare the germs causing contagious diseases to seeds of plants.
Each variety of seed will produce only the sort of plant from which
it came. Each of these diseases is due to the implantation of its own
peculiar germ in the body, and except in this way the disease never
occurs. Each case thus originates from a previous case of the same
sort. The old idea that contagious diseases are caused by sewer gas,
bad air, disturbances in the weather or similar things, is now known
to be untrue. The germs causing diphtheria, scarlet fever and whooping
cough and perhaps measles have been isolated and studied. They are all
bacteria, which are very small vegetable organisms. In order to be seen
by the human eye, they must be magnified about one thousand times by a
microscope.
As seeds must be placed in suitable soil if they are to grow and
produce plants, so disease germs must find a suitable soil in the body
in order to cause disease.
IMMUNITY AND SUSCEPTIBILITY
If disease germs are received by a person whose body acts as barren
soil no disease results, while if they reach a person whose body
furnishes suitable soil for growth, disease follows. The former
person is said to be immune to the disease. The latter is spoken of
as susceptible. It is well known that few persons ever have the same
contagious disease twice. One attack renders immune a person who
was susceptible. This explains why we have epidemics of contagious
diseases. During the epidemic most of the persons in a community who
are susceptible contract the disease. At the end of the epidemic most
of the suitable soil for the growth of the special germ has been
exhausted and the population of the community has become immune to the
disease. This causes the epidemic to cease. Another outbreak in the
same community of the same disease can only occur when susceptible
individuals have again accumulated, i. e., when children have been
born and reached a suitable age. Epidemics of contagious diseases are
naturally confined largely to children who have grown up after the
last epidemic occurred, the older members of the community having been
rendered immune by attack of the disease earlier in life. In isolated
situations where the germs of contagious diseases are not often
introduced persons may reach adult age without ever having been exposed
to them. Such adults may then become infected the same as children. In
the late world war large numbers of young men from rural communities
who had never had the usual contagious diseases were brought together
in training camps, and thus furnished fertile soil for many epidemic
diseases. In a study of over 30,000 native white children in 14
localities in the United States it was found that at 5 years of age
65% have had measles, 48% whooping cough, 22% chicken pox, 5% scarlet
fever, and 3.5% diphtheria. As age advanced the proportions increased
until at 15 years of age, 88% have had measles, 77.6% whooping cough,
51% chicken pox, 11.6% scarlet fever, and 8.7% diphtheria. By young
adult age most persons have had these diseases which are often spoken
of as children’s diseases, but some persons are affected later, some
adults at quite advanced age.
HOW NEW CASES ORIGINATE
The germs which cause these diseases are given off and escape from
the sick person in various secretions and discharges. This includes
discharges from the throat, nose, ears and eyes; pus from abscesses
in the neck; sputum or other excretions. The crusts from the skin
lesions of chicken pox contain the germs of the disease, but the scales
from the skin in measles and scarlet fever do not usually do so. The
amount of secretion or discharge required to carry enough germs to
cause infection is very minute. When the germs are once located on
suitable soil they multiply rapidly and enormous numbers are soon
produced from an original few. In originating new cases of disease the
secretion from the sick with its germs is deposited on some part of
the mucous membrane, or lining of the respiratory tract, as the lining
of the nose, throat or larynx; or enters through the mouth, and, being
swallowed, lodges in the stomach or intestine. At times the infecting
material enters through wounds and injuries of the skin, the intact
healthy skin usually forming a perfect protection against infection.
The passage of secretions from the sick person to others is
accomplished in numerous ways. Sometimes this is through direct
contact between two persons, as in kissing. More often the contact is
indirect, the secretion being carried on some object. Anything that
is contaminated by secretions may carry them to a second person. A
few of the most common carriers, such as hands, clothing, bedding,
eating utensils, cups, forks and spoons, toys and pet animals may
be mentioned. During forced expiratory efforts, such as coughing,
sneezing, hawking, stuttering, loud talking or crying, small particles
of secretions from the throat and mouth are thrown into the air in the
form of what is known as mouth spray. This may be inhaled by persons
who are near and be deposited in the throat or nose. This manner of
transferring contagious diseases is not so frequent as the others
mentioned, and only occurs at distances of a few feet. Secretions
which become dry and pulverized into dust outside the body soon lose
their power of infecting. Dust is not of much danger as a means of
transferring contagious diseases. Sometimes various foods which are
contaminated by disease discharges serve to carry them to well persons,
in which case they may be deposited in the throat or pass into the
stomach or intestines. This is specially true of milk, which has been
responsible for many outbreaks of scarlet fever and diphtheria. The
disease germs in the milk do not come from cows, but get into the milk
during or after milking from the hands, sputum and other means of
contact of the persons who handle the milk.
CARRIERS
In recent years persons who are known as disease carriers have been
looked on as important factors in the spread of many contagious
diseases. The part they play in diphtheria has been abundantly
demonstrated and is important. Carriers in this sense are persons who
are well, but who carry about disease germs in their throats or noses.
They may have recently passed through mild attacks of the disease whose
germs remain for a long time after recovery, or they may have received
the germs from sick persons, never having been sick. This condition of
carriage may persist a long time, and carriers are especially dangerous
because not usually suspected.
COMMON PECULIARITIES
Some common peculiarities of contagious diseases may be mentioned.
After exposure a definite period of incubation passes before any
symptoms develop; many of these diseases have characteristic skin
eruptions; they occur in epidemics, especially in children, and one
attack usually protects the individual during life.
PREVENTION
Because of the wide distribution of contagious disease and the large
number of deaths caused by them, attempts to prevent their spread have
been made from remote times. This has been largely concerned with
isolation or quarantine of sick persons. Doubtless these measures have
been useful, but that they have largely failed to accomplish what is
expected of them is not surprising if we bear in mind that many of
these diseases are most contagious early in their course before they
are recognized and before quarantine is begun, and if we consider
the important part which is played by healthy carriers who are not
suspected and go about freely.
An ideal condition would obtain if it were possible to render all
children, early in life, immune to these diseases. In vaccination
against smallpox we have a measure which has banished smallpox to a
large extent and which, if universally employed, would eradicate the
disease. Similar vaccination measures are now available for diphtheria
and scarlet fever. They are easily carried out, devoid of danger, and
rarely cause even slight discomfort. These will be again referred to in
discussing the individual diseases.
QUARANTINE AND DISINFECTION
The term quarantine was originally applied to the forty days during
which a ship suspected of being infected with a contagious disease was
held before those on board were allowed to come into contact with those
on shore. In present conditions a better term to use is isolation which
varies in length and severity in different diseases. The period of
isolation in diphtheria is until the person is free of the germs which
cause the disease. As it is possible to cultivate and recognize the
diphtheria germs the period of isolation can be accurately determined.
At times it is only a few days; at other times it must be extended to
weeks or even months. In the case of scarlet fever and diphtheria the
attendant who is liable to carry infectious materials is isolated with
the patient.
In scarlet fever the isolation is four or five weeks and until all
discharges have ceased. Discharges from the nose and ear after
scarlet fever are apt to contain the cause of the disease, and so are
dangerous. Epidemics of scarlet fever have been started in communities
by the coming of a child who still had a running ear following scarlet
fever many weeks previously.
The danger of transferring measles is quickly over, and patients may be
released after the fever has been absent two or three days.
In chicken pox the separation of all scabs is the measure of the
isolation period.
Whooping cough is released when the characteristic paroxyms cease.
If measles or whooping cough appears in a child in a family, other
children may be sent from home in hope that they have not been
infected. They must not be sent where there are children who may be
infected if the disease develops.
In diphtheria and scarlet fever the separation of the sick must be
absolute. No communication must be allowed between the sick and well.
The patient and attendant should be in a separate building, or in
a room which can be shut off from the rest of the house. Nothing
should pass from the sick room that is not sterilized at once. All
discharges should be collected on pieces of gauze, and these with
surgical dressings, portions of food, fruit or other material which
the patient may have handled may be placed in paper bags and burned
without opening. All sheets, towels, pillow covers and bed clothes
should be boiled in water before being washed. The same disinfection
should be used for eating utensils. After recovery the patient and
attendant should be given a thorough bath in warm water with soap. The
hair also is washed. In a clean room fresh clothing is to be put on.
After the isolation room is emptied of its occupants all its contents
are disinfected as thoroughly as possible. This can be accomplished by
boiling everything which can be treated in this way, by burning things
which have little value and which cannot be boiled such as books,
toys, mattresses and pillows contaminated by secretions, by thoroughly
washing with warm water and soap all wood work, floors and furniture,
and by thoroughly airing and sunning the bedding. The fumigation which
was formerly generally used has been largely discontinued. Much more
can be accomplished by washing, painting, and removal of paper and
replacing by new. A safe rule is to burn everything which can not be
boiled in water or thoroughly cleansed with warm water and soap. Fresh
air and sunshine are most efficient destroyers of germs. Children
recently relieved from isolation after diphtheria and especially after
scarlet fever should not sleep with well children for a week or two,
and should not be kissed.
The disinfection required after measles, whooping cough and chicken pox
is limited and consists of thorough airing and sunning.
It is not desirable to confine children with whooping cough. They
may be taken out of doors, but must not be allowed to play with well
children. Diphtheria carriers may also be allowed to be out of doors
provided provision is made for keeping them from well persons. Their
eating utensils, toys, etc., must always be treated as are those of
persons with active diphtheria.
The closing of schools at the times of outbreaks of the contagious
diseases is of doubtful value. It does not prevent contact between the
children when at play. Most favorable conditions for dissemination of
contagious diseases exist in Sunday schools since children too young to
attend school as well as older children are here brought together. If
closing of schools is to accomplish any good in controlling contagious
diseases it must be combined with separation of the families of
children at home, and the prevention of children coming together in
picture shows and other places.
It is hardly necessary to state that no child who is acutely sick
should be sent to school. So many contagious diseases are impossible
of recognition at the beginning that each case of sickness must be
considered suspicious until it is shown to be harmless.
MEASLES
Measles is one of the most contagious diseases, ranking in this respect
with small pox. It was apparently observed by the earliest medical
writers and has been known throughout the world for several hundred
years as a common epidemic disease. It is characteristic of measles
that it usually occurs in epidemics which vary much in severity, and
which appear especially in the spring months. At such times almost
every one in a community who has not had measles is affected. After
a longer or shorter interval when susceptible persons have again
accumulated, a new introduction results in another epidemic. In
cities a few cases occur every year and about every two or three
years epidemic outbreaks appear. Almost every person is susceptible
to measles until he contracts the disease after which there is almost
perfect immunity for life. Second attacks are very rare. As high as
98 or 99 per cent of people are originally susceptible. The disease
is usually contracted at the first exposure. If persons have escaped
in earlier life they may be affected in adult years, even at advanced
age. Among people who have never had measles, epidemics may take on
alarming proportions. When this disease was introduced into the Faroe
Islands in 1846, over 6,000 of the 7,782 inhabitants were attacked.
In 1775 measles was introduced into the Sandwich Islands and in four
months 40,000 of the population of 150,000 died. In 1875, measles
was carried to the Fiji Islands with the resulting death of one-fifth
of the population (20,000). In the late war many young men from rural
districts, who had never had measles, were brought together in military
camps. When measles gained entrance extensive epidemics resulted.
Because of the great contagiousness of measles, and its almost
universal susceptibility most persons are attacked early in life. While
it is especially a disease of childhood, it rarely occurs in infants
below six months of age. By the time 15 years has been reached about 90
per cent of children have had the disease.
Healthy children living in good hygienic surroundings usually pass
through measles without much trouble. Delicate, poorly nourished
children who live in institutions and in parts of cities where there is
overcrowding in unhygienic conditions often do badly and many of them
die. This is especially true of young children. As a cause of death
among children measles ranks third among the acute contagious diseases.
In the registration area of the United States in 1920, there were 7,712
deaths from measles of which 78 per cent were in children under 5 years
of age. In Chicago from 1917 to 1921, 718 deaths from measles occurred,
over 90 per cent of which were children under 5 years of age. In this
country 2 to 3 per cent of children in private families who have
measles die, but in institutions and hospitals the deaths may reach 6
to 10 per cent.
Emphasis has been placed on the fact that measles causes many deaths,
especially among young children, in order to draw attention to the
fact that young children, especially those not very strong, should be
kept away from this disease as long as possible. To willfully expose
young children to measles, as is sometimes done, is dangerous and open
to the severest criticism.
CAUSE AND MODE OF SPREAD
The germ which causes measles has not been certainly isolated but it
is known to be in the secretions from the respiratory mucous membrane.
It is there in the earliest stages of the disease, two or three days
before the skin eruption appears, and it disappears when the eruption
fades. The danger of spreading the disease is therefore present very
early, before the eruption develops, and it is soon over, having
passed when fever has been absent a couple of days. The germs pass
from the sick to others in the secretions from the respiratory tract.
In coughing and sneezing small particles of infected mucus are thrown
out into the air as mouth spray and the inhalation of these causes
infection. Outside the body the germs quickly die. They do not survive
drying and exposure to the sunlight. Transfer of the disease by a
third person or by any mechanical carrier can only occur if it is done
quickly. The particles of moist secretion which convey the infection
may be very small and may be carried several feet in the air. Thus
a susceptible individual may be infected by coming into a room with
a case of measles although never approaching very close. Similarly
a child coming down with measles while in school may sow the germs
widely among other pupils.
SYMPTOMS
The symptoms may be considered as they occur in three stages;
catarrhal, eruptive and convalescent. After infection no signs of
illness appear for several days. This is the period of incubation.
About eight to ten days after exposure, very fine, pin-point size spots
appear on the lining of the cheek opposite the molar teeth. These are
known as Koplik spots. They are bluish-white in color and seen only by
bright daylight. About the same time catarrhal symptoms appear, such
as a little fever, coryza, sneezing, hoarse cough, watery eyes. The
symptoms as they occur in this catarrhal stage of measles are usually
supposed to be due to a cold. After a further three, four or five days,
i. e.--12 to 13 days after exposure--the typical eruption appears.
It is first seen over the forehead at the border of the hair, behind
the ears and on the neck. This gradually spreads during two or three
days over the face, body and finally the arms and legs. The eruption
occurs as small red spots or blotches, round or oval in form. They
tend to become larger and finally run together, so that at the height
of the eruption the skin of the face and body is completely covered,
only small islands of pale skin appearing. The color of the eruption
is deeper red than that of scarlet fever, and is much coarser. During
the time the eruption is coming out the fever is often high and the
catarrhal symptoms are marked. Light hurts the eyes, and they become
bleary red, the secretions causing the lids to stick together during
sleep. The cough is often very troublesome. At first it is dry and
later looser. There is often hoarseness and sometimes the patient can
talk only in a whisper. When the eruption has reached its height it
soon begins to fade, but traces often remain for a week or more. As the
eruption begins to fade the fever falls, often very rapidly. A fine
branny scaling of the skin follows the fading of the eruption.
COMPLICATIONS
The danger from measles depends almost entirely on its complications.
In any case if fever persists after the rash fades and the patient
does not rapidly improve complications must be suspected. Sometimes
a looseness of the bowels occurs with the onset of measles, but it
usually stops as the eruption comes out. In babies the intestinal
disturbance may continue and grow worse as the disease progresses. This
may become a grave complication in young children. Most often dangerous
complications have to do with the respiratory tract. In small children
there is a special tendency for the inflammation to extend from the
bronchial tubes to the lungs with resulting pneumonia, which is the
most common cause of death. Sometimes the inflammation extends to the
covering of the lungs producing pleurisy. This may become purulent,
and then is known as empyema. In this condition pus collects in the
chest between the lung and the chest wall, causing compression of the
lung. When the pleurisy begins there is pain in the side, but as the
pus accumulates this stops. With the collection of pus in the side
breathing is interfered with and in children especially the side
affected may be seen to be enlarged and to move less than the other
side when the patient breathes. This condition is associated with fever
and sweats, and not infrequently has aroused suspicion of consumption.
Inflammation inside the ear is a frequent complication of measles. The
involvement of the ear follows the passage of infectious material from
the throat through the Eustachian tube. There is first fever and pain
in the ear, which may subside, or after a day or two, a discharge from
the ear appears. The discharge at first is watery and may be tinged
with blood, but it soon becomes thick and purulent. With the appearance
of discharge the pain subsides and the fever disappears. As healing
takes place the discharge again becomes thinner and finally stops.
Sometimes the inflammation extends from the ear to the bone back of
the ear and mastoid disease results. This is recognized by tenderness
on pressing on the bone. When this develops fever returns and the
child appears sicker. With mastoid disease there is always danger of
extension of the inflammation through the bone and the production of
meningitis. Children with measles often have small whitish ulcers in
the mouth, on the lining of the cheek, along the gums and on the edges
and tip of the tongue. These are apt to be sensitive, causing pain when
eating, and associated with profuse flow of saliva. Very rarely these
ulcers become black and there results an extensive ulceration of the
entire face. This occurs only in poorly nourished children, especially
in institutions.
Measles has the property of rendering the patient susceptible to other
contagious diseases. Tuberculosis often progresses rapidly after
measles. This should always be suspected if fever and cough continue
after the rash fades. If diphtheria is contracted during or soon after
measles it runs a particularly virulent course. On the other hand when
measles follows other contagious diseases, especially whooping cough,
it is more fatal. Children with whooping cough should be kept away from
measles with special care.
PREVENTION
Prevention of measles is difficult because the most contagious period
is that which precedes the eruption. At this time the child is usually
supposed to have a cold and mixes freely with other children. To
prevent the further spread, each patient must be isolated until fever
has been absent two or three days. Children who have not had measles
may be allowed to go about freely for a week after exposure, and then
should be isolated until 15 days after exposure. Fortunately we are now
able to prevent measles in young children even after exposure. This
is accomplished by drawing a little blood from one who has recently
recovered from the disease and injecting it into the exposed one. This
usually prevents the disease entirely or at any rate renders it mild if
it occurs. Blood drawn from a parent and injected into the child soon
after exposure renders the disease mild. The drawing of the required
amount of blood is devoid of any danger.
TREATMENT
Each person with measles should be put to bed and kept there until
free of fever. Care must be taken to avoid exposure to drafts. Fluids
are to be given freely, including cold water. Tepid baths should be
given and add much to the comfort of the patient. If the fever is high
it may often be lowered by frequent sponging with tepid water. Even
quite warm water is grateful and the temperature of the bath may be
determined by the feelings of the patient. When pain in the ear occurs
it may often be relieved by applying heat, either wet or dry as most
grateful. The pain is often relieved and the congestion reduced by
putting in the ear a few drops of warm glycerine to which 5 to 10 per
cent of carbolic acid has been added. When there is a discharge from
the ear, the secretion must not be allowed to accumulate. The canal may
be gently washed with warm boric acid solution, using no force, and
then dried with little swabs of absorbent cotton. The canal must not be
plugged with cotton, but the discharge allowed to drain freely. If the
discharge is profuse a pad of gauze over the ear may be used to absorb
it. Persistent discharge or tenderness about the ear demands attention
by someone specially qualified.
The room should be moderately darkened to relieve the eyes. The eyes
should be bathed with warm boric acid solution and sticking of the
eye lids may be prevented by the application to the edges, especially
before sleep, of a little vaseline. The diet at first may be largely
milk, but general diet may be given as the appetite returns. In young
children any intestinal disturbance should receive the attention of
a doctor. The mouth should be kept clean by washing with boric acid
solution or other mild washes. If there has been hoarseness in a child
with measles and it tends to increase, especially if there are any
croupy symptoms, a doctor should be consulted at once. Such cases are
sometimes diphtheria of the larynx, engrafted upon measles.
At the termination of measles the measures for disinfection consist
especially of thorough airing and sunning of room and contents.
DIPHTHERIA
Of all the contagious diseases diphtheria is most thoroughly
understood. The cause is known, its method of spread understood, and
the way in which it acts to bring about the disease has been clearly
demonstrated. For its prevention and cure we have certain measures.
In spite of this it continues to be one of the most dreaded and fatal
diseases of children. Diphtheria is an ancient disease and has appeared
in destructive epidemics in Europe and America for two hundred years.
It caused the death of George Washington, and the empress Josephine and
her grand-child, heir apparent to the French throne, died from it. As
early as 1771 it was epidemic in New York and in 1856 an epidemic in
San Francisco occurred in which few children attacked by it recovered.
Before antitoxin came into use in 1894, of those attacked, one-third
to one-quarter died, and in hospitals often 60 to 80 per cent of the
cases terminated in death. After antitoxin came into use many more
recovered, but for some years now little improvement in the prevalence
and fatality from diphtheria has occurred. In Chicago from 1911 to
1920, there was an annual average of 7,358 cases and 813 deaths from
diphtheria. Of those dying, 63 per cent were children below school age,
and 90 per cent were children less than 10 years of age.
CAUSE AND HOW IT ACTS
The cause of diphtheria, discovered in 1883-84 by Klebs and Loeffler,
two German scientists, is the diphtheria bacillus. It is a minute rod
shaped vegetable organism sometimes spoken of as a germ. If it is taken
into the throat and lodges and grows upon the tonsils two results may
follow. If the person is susceptible diphtheria occurs. If the person
is immune no local changes occur and the individual becomes a carrier.
Both may transfer the germs to other persons. We may compare what
occurs here to what happens when persons come in contact with certain
higher plants. The poison ivy vine has in its leaves a specific poison
which causes an inflammation of the skin of some persons who are
susceptible to it, but has no effect upon others who are immune. So the
diphtheria plant as it grows in the throat produces soluble poisons or
toxins which cause the changes we call diphtheria in a susceptible
person, but is without effect on the immune person. The immune person
is protected by an antidote or antitoxin which is in the blood, while
the susceptible person has none. After the diphtheria bacilli have
localized on the tonsil the events which follow may be briefly stated.
In their growth the bacilli produce poisons and as a result the tonsils
become red and swollen. On the surface of the tonsil, where the injury
is greatest, white spots appear, and, as they enlarge, they run
together to form the membrane which is characteristic of the disease.
The name diphtheria means in its derivation a pellicle or skin. This
membrane often extends beyond the tonsils, spreading over the throat,
up to the roof of the mouth, over the palate. Sometimes it goes from
the throat upward into the back of the nose or downward into the
larynx. Wherever the membrane spreads the tissues below are swollen.
In the nose the nostrils become occluded and the patient cannot
breathe through the nose; in the throat the tonsils become very large
interfering with swallowing and breathing. In the larynx the swelling
causes hoarseness, croupy cough, and finally difficulty in breathing
which may terminate in death from strangulation unless relieved. This
is what was formerly called membranous croup. The membrane in the
throat is first white, but as it thickens it becomes grayish-yellow,
like buck skin, and finally may be black. It is closely adherent and
not readily wiped off. When the disease extends to the larynx it tends
to go further along the windpipe until it reaches the lungs with
resulting pneumonia. When the changes in the throat are severe, there
is external swelling of the neck. This may be extreme and is sometimes
mistaken for mumps.
While the things we have spoken of are going on poisons are being taken
by the blood to all parts of the body. In this way they reach and
injure the muscle of the heart, and this injury is of such a degree
in severe cases that it causes death. The poisons in the blood also
profoundly injure the nervous system with resulting paralysis, so
that the eyes are turned to the side, swallowing becomes difficult or
impossible, and the muscles of the body and limbs become weak. These
paralyses appear as late as six to eight weeks after the beginning of
the disease. The symptoms as described are as they occur at the present
time in cases untreated by antitoxin. Some cases are mild and never
reach an extreme degree. In some the laryngeal symptoms develop early
and death from obstruction to breathing may occur before much is seen
in the throat. Sometimes a child who has what appears as a tonsilitis
for several days shows a sudden extension to the larynx. The onset of
diphtheria is insidious. The child acts “dopey”, has a little fever,
and does not usually complain of pain in the throat. A child with acute
tonsilitis is at first apparently much sicker, has more fever and
complains more of soreness in the throat.
RECOGNITION OF DIPHTHERIA
Many cases of diphtheria may be recognized with considerable certainty
by the appearance of the membrane in the throat, but there is only one
way by which diphtheria of all degrees can be certainly recognized
especially at the onset; that is by the detection of the germ. The
making of cultures for diphtheria bacilli by a doctor is easily
performed, and the materials for such cultures and their examination
are provided for by local and state health laboratories. It would
be desirable to have cultures made from every sore throat at the
beginning. In this way much valuable time would be gained and many
lives saved by the early use of antitoxin.
HOW DIPHTHERIA IS SPREAD
The general discussion of the ways in which contagious diseases are
spread at the beginning of this article covers also diphtheria. The
germs are in the secretions from the throat and nose. About one
person out of every ten who is about a case of diphtheria becomes a
carrier. Carriers play a large part in the spread of this disease.
When an outbreak occurs in a school, it can usually be traced to one
or more healthy carriers among the pupils or even the teachers. This
is determined by making cultures from all the throats and noses.
Diphtheria may be introduced into a community by a carrier who comes
from outside.
TREATMENT
The sovereign remedy for diphtheria is antitoxin. If given early and
in sufficient amount practically every case could be cured. Diphtheria
antitoxin was first used in Berlin in 1891. It came into general use
about 1894. Like most new remedies it met much opposition at first but
is now recognized throughout the civilized world as the one essential
means of cure. Cases given antitoxin on the first day practically
always recover, only a little over 1 per cent die. Each day of delay
is shown in the results. When given the second day, a little over 3
per cent die; the third day, over 6 per cent die; the fourth day,
nearly 11 per cent, the fifth day, 15 per cent. In hospitals where
many cases come late under treatment, about 10 per cent of the cases
of diphtheria now die. This is in marked contrast to the 50 to 80 per
cent of deaths in preantitoxin days. The patients who receive antitoxin
early not only have greater chance of recovery but they get well
promptly after a very brief illness, while those that come late under
treatment, even if they recover, do so after a tedious illness and
protracted period of convalescence.
The important things in treating diphtheria with antitoxin are early
administration and sufficient amounts. The earlier given the smaller
the dose required. The doctor from experience is able to estimate
the dose needed in each case. A moderate dose is 5 to 10 thousand
units, a full dose is from 20 to 30 thousand units. A small fire may
be extinguished by a little water, but when it has spread much more
is needed. The damage done by the diphtheria poisons before antitoxin
is given cannot be undone by any amount of antitoxin. Antitoxin only
prevents further injury. If sufficient injury to the heart and kidneys
has occurred death will follow. Lost time cannot be regained. The
antitoxin must be injected with a hypodermic needle. It cannot be given
by mouth as it is destroyed and rendered useless in the stomach.
A few hours after enough antitoxin to control the disease has been
given marked improvement occurs. The restlessness subsides, the
swelling begins to grow less and the membrane separates at the edges
and begins to peel off, the color reappears in the pasty cheeks, the
pale lips become red again, and the child which has been blue and
struggling for breath falls into quiet sleep. The change in a short
time is one of the most remarkable observed in sick persons.
Local treatment is of little value. We no longer gargle, spray and swab
the throat. We only try to keep the mouth and throat as clean as we can
with cleansing washes but this is not done with the idea of influencing
the disease.
If the obstruction to breathing from diphtheria in the larynx becomes
extreme this must be relieved by making an opening in the windpipe or
by passing a small rigid tube into the larynx through the mouth.
If antitoxin has been given late the complications which have developed
must receive appropriate treatment. The duration of confinement to bed
will depend on the time antitoxin was given. If given early the patient
may be up in a few days. Serious damage to the heart and kidneys may
require confinement to bed for several weeks. When there are heart
disturbances perfect quiet in a horizontal position is imperative.
Even rising to a sitting position or moderate exertion may be quickly
fatal. Such accidents are most apt to occur about the 5th to the 14th
day. Recovery from the paralysis is usually complete, but may require
several weeks or months. These paralyses may continue to extend for two
months, and during this time the weakened muscles must not be used. If
unable to swallow the patient must be fed with a rubber tube through
the nose or mouth.
PREVENTION OF DIPHTHERIA
Efforts to prevent diphtheria take two main directions. In one the
object is to prevent the infection of new persons; in the other the
measures employed are used to render well persons immune to the
disease so that they will not become sick even if the germs reach
them. Prevention of the infection of other persons is accomplished by
isolation or quarantine of the sick individual and his attendant. To be
effective quarantine must be carried out with conscientious attention
to the smallest details. When a member of a family develops diphtheria,
other members of the household may permanently leave the house if they
are free of diphtheria germs as shown by cultures. The way in which
quarantine is carried on has been described as it relates to all the
diseases under discussion. In the case of diphtheria quarantine can
only be terminated when repeated cultures from the throat and nose
have shown that the diphtheria bacilli have disappeared. This may
require several weeks and in exceptional cases even months. Carriers
must be placed in quarantine as well as active cases. As recovery from
diphtheria progresses the germs tend to die out and often are no longer
present after a few days. Sometimes the germs persist and the patient
becomes a persistent carrier. In the persistent carrier usually some
abnormal condition in the nose and throat interferes with the efforts
of nature to destroy the germs. When such are corrected the germs often
quickly disappear. Most often diseased adenoids and tonsils are the
offending conditions. In this case the removal of abnormal adenoids
and tonsils is usually followed by prompt disappearance of the germs.
Persistence of bacilli in the nose of children has sometimes been
dependent on the presence of foreign bodies such as shoe buttons.
Aside from the measures outlined which have for their purpose the
prevention of extension of the germs to other persons, important steps
may be taken to render persons immune to diphtheria so that they will
not be affected by the germs. This is accomplished in two ways. In the
presence of immediate danger, small doses of antitoxin at intervals of
three to four weeks procure protection. This is to be selected when
children in a family cannot be protected from infection by quarantine.
When immediate danger is absent an immunity which lasts for years may
be secured by a sort of vaccination. This consists of three hypodermic
injections at intervals of a week of a mixture of diphtheria toxin
and antitoxin. The amount injected is very small and produces little
or no inconvenience, but it is followed in a few weeks by a lasting
protection against future infections. Almost all persons become immune
after such injections. Such vaccinations have been used in a large
scale among school children in New York City. Among 90,000 school
children thus treated only one-fourth as many cases of diphtheria
occurred last year as among the same number who refused the treatment.
Injections are advised in children as early as possible after six
months of age is reached. If this were uniformly employed children
would be protected against diphtheria during the most susceptible
years, and the disease would largely disappear. It is not too much to
hope that this vaccination measure against this most fatal disease of
children will accomplish corresponding favorable results to those which
have followed vaccination against small pox.
It is not desirable or necessary to use such injections in children
who are already immune. By a simple harmless test it is possible to
determine if susceptibility exists in the individual. This is known
as the Schick test. It is easily given and is devoid of all danger
and discomfort. Such tests have shown that the proportion of persons
susceptible to diphtheria varies with age. Few infants under six
months are susceptible. From one to three years about 60 per cent are
susceptible. As age advances the proportion gradually decreases so
that by 20 years only about 20 per cent are liable to be infected if
opportunity occurs. The children in the families of the well-to-do are
susceptible in larger proportions than are those living in crowded
parts of cities, and in country districts the proportion of susceptible
children is very high.
BAD EFFECTS OF SERUM
Antitoxin is contained in the blood serum of horses, which have been
injected with diphtheria toxins, and cannot be entirely separated
from other parts of the serum. The antitoxin itself probably produces
no disturbances, but the serum sometimes causes hives and other
inconveniences which quickly pass away. Probably no person with
diphtheria has been permanently harmed by antitoxin. A few instances
of death have followed the use of small immunizing doses in persons
who were not sick and were subject to “horse asthma”. Such cases can
be counted on the fingers of the hands and appear insignificant when
contrasted with the hundreds of thousands of injections given during
the same time. Diphtheria in one week causes five to ten times as many
deaths as antitoxin serum in thirty years. In our large cities as many
children are killed daily by motor vehicles as have died from antitoxin
serum in thirty years. In the presence of the enormous danger from
diphtheria, we can ignore the infinitesimal danger from the serum.
SUGGESTIONS OF MEASURES CALCULATED TO ELIMINATE DIPHTHERIA AND ITS
DANGERS
1. Teaching children to have their throats examined when they are well,
and the examination of the throat whenever a child is not well.
2. Call a doctor immediately when a child has a sore throat, swelling
of the neck, or any croupy condition with hoarseness.
3. Taking cultures at the first visit of the doctor.
4. Giving antitoxin at once whenever there is any exudate in the throat
or any condition resembling diphtheria.
5. Protection of children with antitoxin when they are intimately
associated with others who have diphtheria.
6. Immunization of all children over six months of age with
toxin-antitoxin.
7. Pasteurization or heating of all milk used by children.
SCARLET FEVER
Quite accurate descriptions of scarlet fever have existed for over
three hundred years. One of the best of the early descriptions was
written by William Douglass, a doctor in Boston, at the time when the
first epidemic of this disease on this continent occurred in 1735-1736.
From the Atlantic Coast the disease gradually extended westward and
ever since has appeared at intervals in all parts of this country,
following the settlers into the new regions and often causing many
deaths among their children. A very striking peculiarity of scarlet
fever is the great variation in virulence at different times. Sometimes
it is so mild that scarcely any deaths are associated with it; at
other times it takes on such a high degree of virulence that it wipes
out whole families of children. In cities isolated cases are always
present, and at intervals of a few years epidemic outbreaks occur. For
many years in this country scarlet fever has gradually become less
severe and while the total cases of the disease have not been much
reduced, deaths have become much fewer. In recent years the proportion
of deaths in scarlet fever has varied from 1.5 to 10 per cent. The
death rate is highest in infancy and decreases with advancing age. Few
cases of scarlet fever occur in children under one year of age, the
largest number is observed in children up to 10 years. The disease is
not so infrequent in young adults, and occasional instances appear
in persons of quite advanced age. In these respects it resembles
diphtheria. The disease is most prevalent in late autumn and winter.
CAUSE
The cause of scarlet fever is a small round bacterium known as the
streptococcus of scarlet fever. This germ is in the secretion from the
throat, and nose, in discharges from the ears, in pus from abscesses in
the neck and in the discharges from infected wounds. The germ is very
tenacious of life. In dried secretions it may remain alive for a long
time. Instances are known where clothing, worn by children when sick
with the disease, has been put away in a dark place. When this clothing
was brought out many years later and given healthy children to wear
they contracted scarlet fever.
MODE OF SPREADING
The germs of the disease pass from the sick person to others in
particles of the secretions already mentioned. This transfer is usually
accomplished by direct contact or by the agency of some carrier such
as infected hands, eating utensils, toys, etc. In the manner of its
dissemination scarlet fever resembles diphtheria very closely. This
disease does not often pass from one person to another through the air
as occurs in measles. Like diphtheria it is sometimes spread through
milk which has been handled by someone who has recently had the disease
or has been in close contact with it. Many epidemics of scarlet fever
have been traced to contaminated milk. Usually the germs first lodge in
the throat, often on the tonsils. Sometimes they enter through wounds.
EFFECTS OF THE INFECTION
The results of the location of the germs in the throat or in wounds
depend on whether the individual is susceptible or immune. One attack
of scarlet fever is followed by immunity which usually lasts through
life. A second attack is very rare. Many persons probably are immune
because they have sometime passed through very mild forms of the
disease which were not recognized as scarlet fever at all. If the germs
have secured a footing in a susceptible person they grow and produce
their poisons or toxines. These cause inflammation of the tonsils, and
other parts of the throat and as the toxines enter the blood and are
carried to all parts of the body they cause fever, an eruption of the
skin, and injury to various organs, especially the heart and kidneys.
SYMPTOMS
The period of incubation, i.e., the time between exposure or infection
and the appearance of signs of illness--is very short in scarlet fever.
It may be only a day or two and is almost always less than a week. The
onset is very sudden. A child goes to school as usual in the morning
and during the day becomes acutely sick, or he goes to bed at night in
apparent health and by morning is virulently ill. At the beginning
there is fever, which may quickly rise very high, sore throat and often
vomiting. The throat is so sore that the patient usually complains very
much of it, and acute pain is caused by swallowing. Vomiting once or
several times in the early part of the disease is very common. Whenever
a child is suddenly taken with fever, a sore throat and vomiting,
scarlet fever should be suspected. Soon the eruption appears. This
usually is present within 24 hours, but may be delayed 2 or 3 days in rare
instances. It is first seen upon the neck and chest, rapidly extends
to the body, then to the arms and legs. It is absent on the face. The
skin about the mouth is paler than natural. The rash consists of very
small red points closely set upon the skin which shows a uniform bright
red flush. The skin looks much like that seen after severe sunburn.
The color is bright scarlet. If one looks at the throat it is bright
red, and often small white spots are seen upon the swollen tonsils.
The tongue is coated white through which bright red points may project
giving the appearance spoken of as “strawberry tongue.” At the sides of
the neck the glands are swollen and tender. In size they may correspond
to a marble, or may attain the size of a hen’s egg or larger. While the
eruption is coming out, the throat remains very sore, and the fever
is high. Especially at night, children in this acute stage of scarlet
fever are apt to show delirium and may try to get out of bed. After two
to four days the fever begins to fall, the throat becomes less sore,
and the rash fades. As the rash fades the skin is roughened and peels
in small flakes. About three weeks from the onset the thick skin of the
palms of the hands and soles of the feet peels off. The detached pieces
may be large, or only small delicate pieces may come from the fingers
and toes. This late peeling is very characteristic. The case to which
the preceding description applies is one of average severity. Many mild
cases have little fever and slight rashes which last but a few hours.
The sore throat is constant even in mild cases.
COMPLICATIONS
Complications of scarlet fever are common and it is in these that most
of the danger lies. In the throat ulcers may form on the tonsils and
elsewhere resulting in extensive destruction of tissues. Secondary
to such conditions the glands in the neck may become swollen and may
break down with resulting abscesses. The inflammation in the throat may
extend to the nose and nasal sinuses with associated purulent discharge
from the nostrils. Extension of the inflammation from the throat along
the Eustachian tubes to the middle ear is frequent, and occurs most
often when the illness has lasted a week or so. Many times this causes
only transient pain, but often there develops a discharge of purulent
material from the external ear. Sometimes the destruction within the
ear is so severe and extensive that deafness results. Scarlet fever
is responsible for a considerable number of instances of acquired
deaf-mutism. Inflammation in the ear is indicated by pain which may
be severe. After a few hours or sometimes only after days perforation
of the drumhead is followed by a discharge from the ear. At first this
is watery, sometimes tinged with blood, and soon becomes thick and
purulent. With healing it again becomes thinner and finally stops. Most
of such ears, after recovery have the hearing but little dulled. Fever
is apt to recur or become higher when the trouble in the ear starts,
and when perforation occurs the pain stops and the fever falls. Mastoid
disease may be caused by extension of the inflammation from the ear to
the bone behind the ear. This is recognized by pain, tenderness and
swelling back of the ear. This is always dangerous.
It is quite common for patients with scarlet fever to have joint pains
about 4 to 10 days after being taken sick. A few or many joints are
involved, and as the pain disappears from one joint it appears in
another. After a few days this disturbance comes to an end without
leaving any permanent damage. The poisons of scarlet fever circulating
in the blood, sometimes cause severe and even fatal damage to the
heart. Injury to the kidneys is common with resulting acute Bright’s
disease. This develops early or late in scarlet fever. The late cases,
which come after the child has been sick for about three weeks, are
most characteristic. Attention is often directed to this condition by
a high colored, smoky urine, and by a puffy swelling of the eyelids.
Later the swelling, due to the accumulation of water, becomes more
extensive and general dropsy may result. With the dropsy and scanty,
highly-colored urine, there may be associated disturbances of sight,
headaches, vomiting and convulsions. Under appropriate treatment
recovery from nephritis usually occurs, but in a few instances death
results. While usually the heart and kidneys apparently return to
normal after recovery from scarlet fever, there is much evidence which
indicates that heart and kidney diseases later in life may be dependent
upon damage done during this disease.
PREVENTION OF SCARLET FEVER
Effort to prevent scarlet fever may take two directions; the first
is directed toward limiting the spread from the sick individual and
consist of isolation and disinfection; the second concerns itself with
the production of immunity in susceptible children. Similar to the
Schick test in diphtheria, we have the Dick test in scarlet fever. If a
very small quantity of the toxins of scarlet fever is injected into the
skin of a person the result will vary according to whether the person
is susceptible or immune to the disease. In the susceptible person a
redness of the skin appears where the injection was made, while in the
immune person this does not occur. In this way it is possible to pick
out the children who will not contract scarlet fever if exposed. Those
who give a positive reaction with the Dick test, i.e.--show a redness
of the skin at the point of injection of the toxin--may be rendered
immune by a process of vaccination. This consists of three injections
at intervals of a week of small quantities of scarlet fever toxins
or poisons. Little or no disturbance follows the administration of
suitable amounts of the toxins, but usually an immunity results. There
is every reason to believe that the immunity produced in this manner
will be permanent as is that which follows an attack of the disease.
Children who have been exposed to scarlet fever should be kept away
from other children for 10 days after the last exposure. To prevent
spread of the disease the sick child must be isolated and this must
be continued for four or five weeks, and in every case until all
discharges from the nose and ears have stopped. The throat must also
have become normal before the child is released. Removal of the tonsils
does not appear to render children less susceptible to scarlet fever,
but diseased tonsils when scarlet fever occurs add to the gravity
of the case by favoring severe throat and nasal complications and
especially extension to the ear. The details of isolation and terminal
disinfection are discussed in detail in connection with their use in
these diseases as a group.
Proper pasteurization of milk will prevent the spread of scarlet fever
through this common food of children.
TREATMENT
The patient should be kept in bed for three weeks and chilling of the
skin prevented. This is important in even the mildest cases in order to
avoid kidney complications.
Skillful management and careful nursing does much good in scarlet
fever. In the acute stage when fever is high much relief is afforded
by baths. Small children may be placed in a bath of warm water and
left there for 15 to 20 minutes. The temperature of the water must
not be below that which is comfortable to the child, but it may be
gradually lowered by adding cold water. While in the bath the head
should be kept cool with wet cloths. The bath lowers the fever, quiets
the nervous symptoms and favors sleep. In older children and adults the
same results may be secured by sponging the body and by packing in wet
sheets. In any case the temperature of the water used should be adapted
to the sensibility of the patient. He should not be chilled, and quite
warm water is often most grateful and followed by the most beneficial
results.
Throughout the disease liberal amounts of water should be taken. This
is given cold. In young children this can be accomplished by giving
small quantities at frequent intervals. Water increases the elimination
of the poisons, and its administration is one of the most important
measures in the management of the disease. If the stomach is disturbed
with a tendency to vomit cold water, small amounts of weak tea, taken
as hot as possible, will sometimes help settle the stomach.
The diet during the early period will be principally milk. As the fever
falls and the appetite returns cereals, toast, fruits and vegetables
may be added. Eggs and meats are best withheld until three weeks from
the onset. In septic cases with prolonged course, liberal feeding
with easily digested foods is of the greatest importance. The mouth
and throat should be kept as clean as possible. In persons who are
large enough frequent use of bland gargles are desirable. For this
purpose a tablespoonful of table salt or baking soda to a pint of
water is suitable. Rubber bags filled loosely with finely cracked ice
and applied to the neck, relieve the soreness of the throat. They are
specially useful when the neck is swollen, and tend to prevent the
formation of abscesses in the glands of the neck.
Pain in the ear is treated by the application of heat. A few drops of
warm glycerine, to which carbolic acid in the proportion of five to ten
per cent is added when dropped into the ear is very useful in relieving
pain and reducing inflammation. When a discharge from the ear occurs,
it must be collected on gauze which is burned. The canal must be kept
as clean as possible and secretion not allowed to accumulate. If it
is thick and does not run out freely the ear may be gently washed out
with a saturated solution of boric acid in water. The ear must not be
plugged with cotton but drainage must be facilitated. As the discharge
becomes less the ear should be cleansed with boric acid dissolved in
alcohol and then dried carefully with small pledgets of absorbent
cotton.
Pain and tenderness back of the ear always calls for expert advice.
Such cases often come to operation which must not be too long deferred
if results are to be satisfactory. Also when signs of kidney disease
appear, such as swelling of the eyelids, vomiting, etc., medical
advice should be sought as quickly as possible.
The painful joints which occur in some cases are usually relieved by
hot applications.
Until recently the treatment of scarlet fever has been entirely
symptomatic, and directed toward conserving the strength of the child
and toward preventing complications until nature cured the disease.
Natural recovery occurs when the individual who is sick makes his
own antidote for the poisons of the disease. We may assist nature
by injecting into the acutely sick person, some blood drawn from an
individual recently recovered from the disease. The convalescent blood,
containing the antidote or antitoxin, serves to destroy the poison
in the blood of the acutely sick child, and so aids recovery. Marked
improvement often follows the use of convalescent serum. Such serum is
not always at hand, but if an older child or adult who has had scarlet
fever is available, his blood may be drawn and injected into the sick
child. There is reason to believe that we may soon have a scarlet fever
antitoxin, produced from horses in a manner similar to that in use in
making antitoxin for diphtheria.
The successful treatment of scarlet fever with its many complications
demands great skill. There is no disease in which the outcome depends
more on judicious medical management and careful persistent nursing
than in scarlet fever.
CHICKEN POX
Corresponding to measles in its degree of contagiousness, chicken pox
occurs in extensive epidemics. In cities occasional cases appear at any
time, but at intervals epidemic outbreaks occur. Most children have
the disease during early years, but adults may also have it if they
have not come in contact with it in childhood. This disease is entirely
different from small pox and has no relationship to chickens. The cause
is unknown, but doubtless is a living germ. The crusts from the skin
have usually been blamed for the transferring of the disease from one
person to others. The disease however is contagious before the crusts
from the body have separated, and it is likely that the infectious
agent may be in the respiratory secretions early in the disease. One
attack protects for life. Second attacks are practically unknown.
The period of incubation which passes between the time of exposure and
the appearance of signs of the disease is quite long, being about three
weeks, varying in individuals between twelve and twenty-two days.
SYMPTOMS
As in all of these contagious diseases there is much variation in the
severity of the individual case. Most cases of chicken pox are mild
affairs. There is no fever or general disturbance, only the eruption
of a mild or moderate sort. In a few individuals the disease assumes a
severe form, in which case, fever, headache, backache and chilliness
precede the eruption for a day. This is especially apt to occur in
adults, but children may have some fever, and be generally unwell for
a day or so before the eruption appears. Preceding the characteristic
eruption there sometimes appears a day or so earlier a redness of
the skin which has often been looked upon as scarlet fever until the
typical eruption has developed.
The individual lesions of the chicken pox eruption pass through an
evolution which is often very rapid. There is first a pink blotch or
spot which soon is a little elevated above the skin, and disappears
when pressed upon. Soon this is replaced by a vesicle or water blister.
The vesicles are very near the surface of the skin and have a very
thin covering, so that they often look like drops of water lying on
the skin. The covering is soon broken, the fluid escapes, and as
drying occurs a little crust or scab is left. This separates after
several days. There is great variation in the number of these lesions.
Sometimes only two or three develop. In severe cases the lesions are
very closely placed on the body so that the finger can hardly be
placed at any point between them. In the average case the lesions lie
two or three inches apart. The distribution upon the body is quite
characteristic. Most lesions are located on the parts of the body
covered by clothing. In mild and moderate cases the eruption is almost
confined to the trunk, but some lesions are also seen upon the arms,
legs and forehead. In severe cases rather abundant eruption appears on
the face, arms and legs. The lesions develop in the scalp, palms of
the hands and soles of the feet in limited numbers especially in more
severe cases. In such instances also, vesicles appear in the mucous
membrane of the mouth, especially on the palate, and as they rupture
they leave very sensitive points which are painful when food is taken.
One of the most characteristic things of the chicken pox eruption is
that the lesions appear in crops. By the time the first lesions have
reached the crusting stage others are present which are still vesicles,
and still younger ones appear as pink spots. New lesions continue to
appear for 3 or 4 days. In parts of the body where the skin is thick as
on the palms of the hands, soles of the feet and forehead, the vesicles
may remain unruptured for some time in which case the contents becomes
yellowish and the surrounding skin reddened. If the skin has been
rendered specially susceptible by any cause, the eruption is apt to be
more severe. When chicken pox follows upon scarlet fever the eruption
is apt to be profuse. Upon parts of the body which have been recently
burned by the sun or subject to irritation under a surgical dressing,
cast, or diaper, the eruption is more abundant than on other portions
of the body.
COMPLICATIONS
There are few deaths following chicken pox and many of these cannot
be properly blamed on the disease. There occur occasionally in poorly
nourished children, gangrenous processes in the skin which may cause
death. Blood poisoning may rarely follow the introduction of ordinary
wound infections into the open lesions. The itching associated with the
drying stage is very troublesome, and children sometimes in scratching,
break the deeper layers of the skin, and small ulcers are produced
which heal with scars or pits. One most often sees these scars on the
forehead of children. Usually no permanent pits follow recovery.
DIFFERENT FROM SMALL POX
In the presence of small pox in a community its differentiation from
some cases of chicken pox is important but sometimes difficult. One
of the most striking differences between the two diseases is that in
chicken pox the lesions occur in crops, all the stages of the eruption
being present at the same time, while in small pox the lesions are
all the same sort at any time. Another difference consists in the
distribution of the eruption, in chicken pox most is on the covered
parts of the body while in small pox the eruption is most abundant on
the exposed parts of the skin, the face, wrists and hands. The presence
of a fairly recent vaccination scar is always strong evidence against
small pox.
PREVENTION
The only means of prevention is the isolation of the sick person until
all the scabs have separated.
TREATMENT
Little treatment is required. Scratching of the skin is to be avoided.
During the acute stage it is best to keep the skin dry. When the crusts
have become dry baths may be given, and they probably hasten the
separation of the scabs.
WHOOPING COUGH
Whooping cough is a very contagious disease which is contracted by
most children during early years. Occasional persons who have escaped
it in childhood are affected in adult life. Second attacks are rare.
Sometimes a mother or nurse, who has had whooping cough in childhood,
will again contract the disease when caring for children who are
suffering from it. In distinction to most of the contagious diseases,
whooping cough frequently occurs in infants less than a year of age,
and the mortality associated with it is due largely to this fact. In
Chicago from 1911 to 1922, out of 39,233 cases of whooping cough 1,630
were fatal. This represents one death out of every 24 patients, and
corresponds very closely to the death rate in scarlet fever during the
same period and is about three times as high as that in measles. Of 97
deaths from whooping cough in Chicago during 1922, 58 were in children
under 1 year of age, and all but one were in children under 5 years.
This serves to emphasize the importance of protecting young children
from the disease as long as possible.
The cause of whooping cough appears to be a very minute bacillus which
is found in the secretions from the upper respiratory tract. The action
of this germ seems to be through poisons which it produces. The disease
is transferred from one person to others through small particles of
the secretions which are thrown out into the air during coughing. These
moist particles being inhaled, gain a lodgement in the throat and thus
cause another case. The time after exposure before symptoms appear is
indefinite. Exact dates are hard to fix, but the incubation period is
often very short. It may vary from five to fifteen days.
SYMPTOMS
The onset of whooping cough is gradual and for some time the child
is usually supposed to be suffering from a cold or bronchitis. This
first or catarrhal stage has nothing which is characteristic. There is
a cough which gradually increases in severity. As the cough becomes
more severe it assumes also more of a paroxysmal character with a
tendency to recur at certain intervals. After about two weeks with
the appearance of typical paroxysms the second or paroxysmal stage is
entered upon. This lasts about six weeks on an average. The number of
paroxysms varies greatly. There may be but one or two in 24 hours, or
one may occur every hour. On an average about 10 to 15 are observed
during 24 hours. They are apt to be most severe at night. When a
paroxysm of coughing begins the child sits up and if old enough tries
to get hold of something for support. The paroxysms consists of a
series of expiratory coughs following in such rapid succession that
the child is unable to get its breath. These have been compared to the
explosions of a motor cycle, or those of a machine gun. At the height
of a severe paroxysm the face is red or blue as in choking, saliva
flows from the mouth, the tongue protrudes and is blue, the child
struggles for breath, when finally, maybe only after several seconds,
the spasm relaxes somewhat and air is drawn through the narrowed
opening in the larynx with a peculiar crowing sound which is known
as the whoop and has given the name of the disease. Such a series of
events often is repeated several times in quick succession. Finally
the end comes with vomiting which not only gets rid of the mucus in
the throat but also empties the mucus from the air tubes. The child
now falls down on the bed exhausted, the skin wet with sweat and it
often falls to sleep. The struggle of the little patient in its efforts
to get its breath cannot fail to awaken the sympathy of anyone who
witnesses it. In older children the paroxysms are better borne and the
general strength is not much affected. In young children with frequent
paroxysms and loss of food from vomiting much depression and weakness
develops. When there are frequent severe seizures the face in the
intervals has a woe-begone expression, the skin is dusky and the eyes
dull.
COMPLICATIONS
Occasionally a child dies in a severe paroxysm from strangulation.
Most deaths are, however, dependent upon complications. Of these
the most frequent is pneumonia, which is not uncommon in infants.
Convulsions also cause many deaths. They may occur during the paroxysms
of coughing and if repeated are very dangerous. The great congestion
of the blood vessels of the head during the paroxysms sometimes leads
to rupture of blood vessels, so, that nose-bleed is not infrequent.
Hemorrhage into the brain may occur. Bleeding beneath the conjunctiva
of the eye-ball results in red blotches over the white of the eye.
These may be small or the blood may spread over the entire white
portion of the eye-ball causing a most striking appearance. Bleeding
into the loose tissues of the eye-lid may occur, producing a “black
eye”. This has been mistaken as due to injury and should be remembered
as something which may occur spontaneously during whooping cough.
In infants disturbances of digestion are frequent, and intestinal
disorders in them are grave and add materially to the danger of the
disease.
After recovery permanent damage to the heart may remain. The condition
brought about by the disease also favors the rapid progress of any
tubercular disease which otherwise might be of little moment.
PREVENTION
It is important that small children be kept away from this disease as
long as possible. It is particularly difficult to limit the spread of
the disease by isolation because the period of greatest contagiousness
is that in the beginning when the child is supposed to have a cold. An
older child in a family contracts the disease at school or in play with
other children, and before he is suspected of having the disease, the
younger members of the family have been infected. A vaccine has been
prepared from the bacillus of whooping cough which appears to have
some value in preventing and rendering milder the disease. As this is
harmless it ought to be given to young children as soon after exposure
as possible in the hope that it may prevent the disease or make it
milder if it develops. After the paroxysms have been established the
vaccine seems to be less useful.
TREATMENT
Many cases, especially in older healthy children, require little
treatment. When paroxysms are frequent and severe, remedies to reduce
them are desirable, and of these paregoric seems to do as well as
any. If vomiting occurs frequently the loss of food is of importance.
In such cases easily digested food should be given as soon after a
paroxysm as possible so as to allow time for digestion and absorption
before another paroxysm occurs. The feeding is of great importance
in infants. A simple mechanical appliance is of considerable use to
these children. It consists of a firm binder fastened snugly about the
entire abdomen. It should come up over the lower ribs, and be held in
place by straps over the shoulders. This gives support to the abdomen
during coughing, enables the child to endure the paroxysms easier, and
also supports the weaker points of the abdominal wall and so prevents
the development of hernias or ruptures. Of all measures used in the
treatment of whooping cough the most important is the furnishing of
fresh air. In suitable weather the children should be kept out of doors
all day, and at night should have plenty of fresh air. This is equally
the case when pneumonia complicates whooping cough.
------------------------------------------------------------------------
TRANSCRIBER’S NOTES
Obvious errors and omissions in punctuation have been fixed.
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