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+*** START OF THE PROJECT GUTENBERG EBOOK 78158 ***
+
+
+
+
+    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.
+
+*** END OF THE PROJECT GUTENBERG EBOOK 78158 ***
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+    <title>
+      Measles, Diphtheria, Scarlet Fever, Chicken Pox and Whooping Cough | Project Gutenberg
+    </title>
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+<body>
+<div style='text-align:center'>*** START OF THE PROJECT GUTENBERG EBOOK 78158 ***</div>
+
+
+<p><span class="pagenum" id="Page_1">[Pg 1]</span></p>
+
+
+<table class="title-table title-small-margin">
+<tr>
+<td class="tdl">LITTLE BLUE BOOK NO.</td>
+<td rowspan="2" class="big-number">136</td>
+</tr>
+<tr>
+<td class="tdl title-editor">Edited by E. Haldeman-Julius</td>
+</tr>
+</table>
+
+
+<h1>
+Measles, Diphtheria, Scarlet<br>
+Fever, Chicken Pox and<br>
+Whooping Cough
+</h1>
+
+
+<p class="center title-author"><b>George H. Weaver, M. D.</b></p>
+
+<p class="center title-margin">Professor of Pathology, Rush Medical College,
+Chicago; Physician in Charge of Durand
+Hospital of the John McCormick Institute
+for Infectious Diseases, Chicago, Ill.</p>
+
+
+<p class="center"><b>HALDEMAN-JULIUS COMPANY</b></p>
+<p class="center"><b>GIRARD, KANSAS</b></p>
+
+<hr class="chap x-ebookmaker-drop">
+
+
+<p><span class="pagenum" id="Page_2">[Pg 2]</span></p>
+
+
+<div class=chapter>
+<p class="center">LITTLE BLUE BOOK HEALTH SERIES.</p>
+
+<p class="center">EDITED BY MORRIS FISHBEIN, M. D.</p>
+
+<p class="center title-small-margin">Acting Editor, Journal of the American Medical
+Association, and Associate Editor, Hygeia; a
+Journal of Individual and Community Health.</p>
+
+
+<p class="center">Copyright, 1924</p>
+<p class="center title-small-margin">Haldeman Julius Company</p>
+
+
+<p class="center">PRINTED IN THE UNITED STATES OF AMERICA</p>
+</div>
+
+
+<hr class="chap x-ebookmaker-drop">
+
+<p><span class="pagenum" id="Page_3">[Pg 3]</span></p>
+
+<div class=chapter>
+<p class="center"><b>MEASLES, DIPHTHERIA, SCARLET
+FEVER, CHICKEN POX and
+WHOOPING COUGH</b></p>
+</div>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_4">[Pg 4]</span></p>
+
+
+  <h2 class="nobreak">
+    PREFACE
+  </h2>
+</div>
+
+
+<p>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.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_5">[Pg 5]</span></p>
+
+
+  <h2 class="nobreak">
+    CONTENTS
+  </h2>
+</div>
+
+<table class="autotable">
+<tr>
+<td class="tdl"></td>
+<td class="tdr">Page</td>
+</tr>
+<tr>
+<td class="tdl">General Consideration</td>
+<td class="tdr"><a href="#GENERAL_CONSIDERATION">7</a></td>
+</tr>
+<tr>
+<td class="tdl">Measles</td>
+<td class="tdr"><a href="#MEASLES">17</a></td>
+</tr>
+<tr>
+<td class="tdl toc2row">Causes and Mode of Spread</td>
+<td class="tdr"><a href="#CAUSE_AND_MODE_OF_SPREAD">19</a></td>
+</tr>
+<tr>
+<td class="tdl toc2row">Symptoms</td>
+<td class="tdr"><a href="#SYMPTOMS">20</a></td>
+</tr>
+<tr>
+<td class="tdl toc2row">Complications</td>
+<td class="tdr"><a href="#COMPLICATIONS">21</a></td>
+</tr>
+<tr>
+<td class="tdl toc2row">Prevention</td>
+<td class="tdr"><a href="#PREVENTION">23</a></td>
+</tr>
+<tr>
+<td class="tdl toc2row">Treatment</td>
+<td class="tdr"><a href="#TREATMENT">24</a></td>
+</tr>
+<tr>
+<td class="tdl">Diphtheria</td>
+<td class="tdr"><a href="#DIPHTHERIA">26</a></td>
+</tr>
+<tr>
+<td class="tdl toc2row">Cause and How It Acts</td>
+<td class="tdr"><a href="#CAUSE_AND_HOW_IT_ACTS">27</a></td>
+</tr>
+<tr>
+<td class="tdl toc2row">Recognition of Diphtheria</td>
+<td class="tdr"><a href="#RECOGNITION_OF_DIPHTHERIA">29</a></td>
+</tr>
+<tr>
+<td class="tdl toc2row">How Diphtheria Is Spread</td>
+<td class="tdr"><a href="#HOW_DIPHTHERIA_IS_SPREAD">30</a></td>
+</tr>
+<tr>
+<td class="tdl toc2row">Treatment</td>
+<td class="tdr"><a href="#TREATMENT_1">30</a></td>
+</tr>
+<tr>
+<td class="tdl toc2row">Prevention of Diphtheria</td>
+<td class="tdr"><a href="#PREVENTION_OF_DIPHTHERIA">33</a></td>
+</tr>
+<tr>
+<td class="tdl toc2row">Bad Effects of Serum</td>
+<td class="tdr"><a href="#BAD_EFFECTS_OF_SERUM">35</a></td>
+</tr>
+<tr>
+<td class="tdl toc2row">Suggestions of Measures Calculated to Eliminate Diphtheria and Its Dangers</td>
+<td class="tdr"><a href="#SUGGESTIONS_OF_MEASURES_CALCULATED_TO">36</a></td>
+</tr>
+<tr>
+<td class="tdl">Scarlet Fever</td>
+<td class="tdr"><a href="#SCARLET_FEVER">38</a></td>
+</tr>
+<tr>
+<td class="tdl toc2row">Cause</td>
+<td class="tdr"><a href="#CAUSE">39</a></td>
+</tr>
+<tr>
+<td class="tdl toc2row">Mode of Spreading</td>
+<td class="tdr"><a href="#MODE_OF_SPREADING">39</a></td>
+</tr>
+<tr>
+<td class="tdl toc2row">Effects of the Infection</td>
+<td class="tdr"><a href="#EFFECTS_OF_THE_INFECTION">40</a></td>
+</tr>
+<tr>
+<td class="tdl toc2row">Symptoms</td>
+<td class="tdr"><a href="#SYMPTOMS_1">40</a></td>
+</tr>
+<tr>
+<td class="tdl toc2row">Complications</td>
+<td class="tdr"><a href="#COMPLICATIONS_1">42</a></td>
+</tr>
+<tr>
+<td class="tdl toc2row">Prevention of Scarlet Fever</td>
+<td class="tdr"><a href="#PREVENTION_OF_SCARLET_FEVER">44</a></td>
+</tr>
+<tr>
+<td class="tdl toc2row">Treatment</td>
+<td class="tdr"><a href="#TREATMENT_2">45</a></td>
+</tr>
+<tr>
+<td class="tdl">Chicken Pox</td>
+<td class="tdr"><a href="#CHICKEN_POX">49</a></td>
+</tr>
+<tr>
+<td class="tdl toc2row">Symptoms</td>
+<td class="tdr"><a href="#SYMPTOMS_2">49</a></td>
+</tr>
+<tr>
+<td class="tdl toc2row">Complications</td>
+<td class="tdr"><a href="#COMPLICATIONS_2">51</a></td>
+</tr>
+<tr>
+<td class="tdl toc2row">Different from Small Pox</td>
+<td class="tdr"><a href="#DIFFERENT_FROM_SMALL_POX">52</a></td>
+</tr>
+<tr>
+<td class="tdl toc2row">Prevention</td>
+<td class="tdr"><a href="#PREVENTION_1">52</a></td>
+</tr>
+<tr>
+<td class="tdl toc2row">Treatment</td>
+<td class="tdr"><a href="#TREATMENT_3">53</a></td>
+</tr>
+<tr>
+<td class="tdl">Whooping Cough</td>
+<td class="tdr"><a href="#WHOOPING_COUGH">54</a></td>
+</tr>
+<tr>
+<td class="tdl toc2row">Symptoms</td>
+<td class="tdr"><a href="#SYMPTOMS_3">55</a></td>
+</tr>
+<tr>
+<td class="tdl toc2row">Complications</td>
+<td class="tdr"><a href="#COMPLICATIONS_3">56</a></td>
+</tr>
+<tr>
+<td class="tdl toc2row">Prevention</td>
+<td class="tdr"><a href="#PREVENTION_2">57</a></td>
+</tr>
+<tr>
+<td class="tdl toc2row">Treatment</td>
+<td class="tdr"><a href="#TREATMENT_4">58</a></td>
+</tr>
+</table>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+
+<p><span class="pagenum"><a id="Page_6"></a><a id="Page_7"></a>[Pg 7]</span></p>
+
+
+  <h2 class="nobreak">
+    MEASLES, DIPHTHERIA, SCARLET
+    FEVER, CHICKEN POX and
+    WHOOPING COUGH
+  </h2>
+</div>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+  <h2 class="nobreak" id="GENERAL_CONSIDERATION">
+    GENERAL CONSIDERATION
+  </h2>
+</div>
+
+
+<p>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.</p>
+
+<p>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
+<span class="pagenum" id="Page_8">[Pg 8]</span>sometimes also designated “communicable
+diseases.”</p>
+
+
+<p>CAUSES</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+
+<p>IMMUNITY AND SUSCEPTIBILITY</p>
+
+<p>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
+<span class="pagenum" id="Page_9">[Pg 9]</span>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.
+<span class="pagenum" id="Page_10">[Pg 10]</span>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.</p>
+
+
+<p>HOW NEW CASES ORIGINATE</p>
+
+<p>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.</p>
+
+<p>The passage of secretions from the sick person
+<span class="pagenum" id="Page_11">[Pg 11]</span>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.</p>
+
+<p><span class="pagenum" id="Page_12">[Pg 12]</span></p>
+
+
+<p>CARRIERS</p>
+
+<p>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.</p>
+
+
+<p>COMMON PECULIARITIES</p>
+
+<p>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.</p>
+
+
+<p>PREVENTION</p>
+
+<p>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
+<span class="pagenum" id="Page_13">[Pg 13]</span>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.</p>
+
+<p>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.</p>
+
+
+<p>QUARANTINE AND DISINFECTION</p>
+
+<p>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
+<span class="pagenum" id="Page_14">[Pg 14]</span>and diphtheria the attendant who is liable
+to carry infectious materials is isolated with
+the patient.</p>
+
+<p>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.</p>
+
+<p>The danger of transferring measles is quickly
+over, and patients may be released after the
+fever has been absent two or three days.</p>
+
+<p>In chicken pox the separation of all scabs is
+the measure of the isolation period.</p>
+
+<p>Whooping cough is released when the characteristic
+paroxyms cease.</p>
+
+<p>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.</p>
+
+<p>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
+<span class="pagenum" id="Page_15">[Pg 15]</span>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 cannot 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.</p>
+
+<p>The disinfection required after measles,
+whooping cough and chicken pox is limited
+and consists of thorough airing and sunning.</p>
+
+<p><span class="pagenum" id="Page_16">[Pg 16]</span></p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_17">[Pg 17]</span></p>
+
+
+  <h2 class="nobreak" id="MEASLES">
+    MEASLES
+  </h2>
+</div>
+
+
+<p>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
+<span class="pagenum" id="Page_18">[Pg 18]</span>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.</p>
+
+<p>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.</p>
+
+<p>Emphasis has been placed on the fact that
+measles causes many deaths, especially among
+<span class="pagenum" id="Page_19">[Pg 19]</span>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.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+  <h2 class="nobreak" id="CAUSE_AND_MODE_OF_SPREAD">
+    CAUSE AND MODE OF SPREAD
+  </h2>
+</div>
+
+
+<p>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
+<span class="pagenum" id="Page_20">[Pg 20]</span>while in school may sow the germs widely
+among other pupils.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+  <h2 class="nobreak" id="SYMPTOMS">
+    SYMPTOMS
+  </h2>
+</div>
+
+
+<p>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
+<span class="pagenum" id="Page_21">[Pg 21]</span>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.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+  <h2 class="nobreak" id="COMPLICATIONS">
+    COMPLICATIONS
+  </h2>
+</div>
+
+
+<p>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
+<span class="pagenum" id="Page_22">[Pg 22]</span>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.</p>
+
+<p>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.</p>
+
+<p><span class="pagenum" id="Page_23">[Pg 23]</span></p>
+
+<p>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.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+  <h2 class="nobreak" id="PREVENTION">
+    PREVENTION
+  </h2>
+</div>
+
+
+<p>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.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_24">[Pg 24]</span></p>
+
+
+  <h2 class="nobreak" id="TREATMENT">
+    TREATMENT
+  </h2>
+</div>
+
+
+<p>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.</p>
+
+<p>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
+<span class="pagenum" id="Page_25">[Pg 25]</span>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.</p>
+
+<p>At the termination of measles the measures
+for disinfection consist especially of thorough
+airing and sunning of room and contents.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_26">[Pg 26]</span></p>
+
+
+  <h2 class="nobreak" id="DIPHTHERIA">
+    DIPHTHERIA
+  </h2>
+</div>
+
+
+<p>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.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_27">[Pg 27]</span></p>
+
+
+  <h2 class="nobreak" id="CAUSE_AND_HOW_IT_ACTS">
+    CAUSE AND HOW IT ACTS
+  </h2>
+</div>
+
+
+<p>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
+<span class="pagenum" id="Page_28">[Pg 28]</span>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.</p>
+
+<p>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
+<span class="pagenum" id="Page_29">[Pg 29]</span>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.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+  <h2 class="nobreak" id="RECOGNITION_OF_DIPHTHERIA">
+    RECOGNITION OF DIPHTHERIA
+  </h2>
+</div>
+
+
+<p>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.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_30">[Pg 30]</span></p>
+
+
+  <h2 class="nobreak" id="HOW_DIPHTHERIA_IS_SPREAD">
+    HOW DIPHTHERIA IS SPREAD
+  </h2>
+</div>
+
+
+<p>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.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+  <h2 class="nobreak" id="TREATMENT_1">
+    TREATMENT
+  </h2>
+</div>
+
+
+<p>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,
+<span class="pagenum" id="Page_31">[Pg 31]</span>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.</p>
+
+<p>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.</p>
+
+<p>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
+<span class="pagenum" id="Page_32">[Pg 32]</span>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_33">[Pg 33]</span></p>
+
+
+  <h2 class="nobreak" id="PREVENTION_OF_DIPHTHERIA">
+    PREVENTION OF DIPHTHERIA
+  </h2>
+</div>
+
+
+<p>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
+<span class="pagenum" id="Page_34">[Pg 34]</span>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.</p>
+
+<p>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
+<span class="pagenum" id="Page_35">[Pg 35]</span>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.</p>
+
+<p>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.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+  <h2 class="nobreak" id="BAD_EFFECTS_OF_SERUM">
+    BAD EFFECTS OF SERUM
+  </h2>
+</div>
+
+
+<p>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
+<span class="pagenum" id="Page_36">[Pg 36]</span>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.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+  <h2 class="nobreak" id="SUGGESTIONS_OF_MEASURES_CALCULATED_TO">
+    SUGGESTIONS OF MEASURES CALCULATED TO
+    ELIMINATE DIPHTHERIA AND ITS DANGERS
+  </h2>
+</div>
+
+
+<ol>
+<li>Teaching children to have their throats
+examined when they are well, and the examination
+of the throat whenever a child is not well.</li>
+
+<li>Call a doctor immediately when a child
+has a sore throat, swelling of the neck, or any
+croupy condition with hoarseness.</li>
+
+<li>Taking cultures at the first visit of the
+doctor.</li>
+
+<li>Giving antitoxin at once whenever there
+is any exudate in the throat or any condition
+resembling diphtheria.
+</li>
+
+<li>Protection of children with antitoxin
+when they are intimately associated with others
+who have diphtheria.
+<span class="pagenum" id="Page_37">[Pg 37]</span>
+</li>
+
+<li>Immunization of all children over six
+months of age with toxin-antitoxin.</li>
+
+<li>Pasteurization or heating of all milk used
+by children.</li>
+</ol>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_38">[Pg 38]</span></p>
+
+
+  <h2 class="nobreak" id="SCARLET_FEVER">
+    SCARLET FEVER
+  </h2>
+</div>
+
+
+<p>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
+<span class="pagenum" id="Page_39">[Pg 39]</span>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.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+  <h2 class="nobreak" id="CAUSE">
+    CAUSE
+  </h2>
+</div>
+
+
+<p>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.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+  <h2 class="nobreak" id="MODE_OF_SPREADING">
+    MODE OF SPREADING
+  </h2>
+</div>
+
+
+<p>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
+<span class="pagenum" id="Page_40">[Pg 40]</span>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.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+  <h2 class="nobreak" id="EFFECTS_OF_THE_INFECTION">
+    EFFECTS OF THE INFECTION
+  </h2>
+</div>
+
+
+<p>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.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+  <h2 class="nobreak" id="SYMPTOMS_1">
+    SYMPTOMS
+  </h2>
+</div>
+
+
+<p>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.
+<span class="pagenum" id="Page_41">[Pg 41]</span>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.
+<span class="pagenum" id="Page_42">[Pg 42]</span>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.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+  <h2 class="nobreak" id="COMPLICATIONS_1">
+    COMPLICATIONS
+  </h2>
+</div>
+
+
+<p>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
+<span class="pagenum" id="Page_43">[Pg 43]</span>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.</p>
+
+<p>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.
+<span class="pagenum" id="Page_44">[Pg 44]</span>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.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+  <h2 class="nobreak" id="PREVENTION_OF_SCARLET_FEVER">
+    PREVENTION OF SCARLET FEVER
+  </h2>
+</div>
+
+
+<p>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
+<span class="pagenum" id="Page_45">[Pg 45]</span>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.</p>
+
+<p>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.</p>
+
+<p>Proper pasteurization of milk will prevent
+the spread of scarlet fever through this common
+food of children.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+  <h2 class="nobreak" id="TREATMENT_2">
+    TREATMENT
+  </h2>
+</div>
+
+
+<p>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.</p>
+
+<p>Skillful management and careful nursing
+<span class="pagenum" id="Page_46">[Pg 46]</span>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.</p>
+
+<p>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.</p>
+
+<p>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
+<span class="pagenum" id="Page_47">[Pg 47]</span>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.</p>
+
+<p>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.</p>
+
+<p>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
+<span class="pagenum" id="Page_48">[Pg 48]</span>swelling of the eyelids, vomiting, etc., medical
+advice should be sought as quickly as possible.</p>
+
+<p>The painful joints which occur in some cases
+are usually relieved by hot applications.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_49">[Pg 49]</span></p>
+
+
+  <h2 class="nobreak" id="CHICKEN_POX">
+    CHICKEN POX
+  </h2>
+</div>
+
+
+<p>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.</p>
+
+<p>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.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+  <h2 class="nobreak" id="SYMPTOMS_2">
+    SYMPTOMS
+  </h2>
+</div>
+
+
+<p>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,
+<span class="pagenum" id="Page_50">[Pg 50]</span>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.</p>
+
+<p>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
+<span class="pagenum" id="Page_51">[Pg 51]</span>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.</p>
+
+<p>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.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+  <h2 class="nobreak" id="COMPLICATIONS_2">
+    COMPLICATIONS
+  </h2>
+</div>
+
+
+<p>There are few deaths following chicken pox
+<span class="pagenum" id="Page_52">[Pg 52]</span>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.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+  <h2 class="nobreak" id="DIFFERENT_FROM_SMALL_POX">
+    DIFFERENT FROM SMALL POX
+  </h2>
+</div>
+
+
+<p>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.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+  <h2 class="nobreak" id="PREVENTION_1">
+    PREVENTION
+  </h2>
+</div>
+
+
+<p>The only means of prevention is the isolation
+<span class="pagenum" id="Page_53">[Pg 53]</span>of the sick person until all the scabs have
+separated.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+  <h2 class="nobreak" id="TREATMENT_3">
+    TREATMENT
+  </h2>
+</div>
+
+
+<p>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.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_54">[Pg 54]</span></p>
+
+
+  <h2 class="nobreak" id="WHOOPING_COUGH">
+    WHOOPING COUGH
+  </h2>
+</div>
+
+
+<p>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.</p>
+
+<p>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
+<span class="pagenum" id="Page_55">[Pg 55]</span>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.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+  <h2 class="nobreak" id="SYMPTOMS_3">
+    SYMPTOMS
+  </h2>
+</div>
+
+
+<p>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
+<span class="pagenum" id="Page_56">[Pg 56]</span>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.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+  <h2 class="nobreak" id="COMPLICATIONS_3">
+    COMPLICATIONS
+  </h2>
+</div>
+
+
+<p>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
+<span class="pagenum" id="Page_57">[Pg 57]</span>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.</p>
+
+<p>In infants disturbances of digestion are frequent,
+and intestinal disorders in them are
+grave and add materially to the danger of the
+disease.</p>
+
+<p>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.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+  <h2 class="nobreak" id="PREVENTION_2">
+    PREVENTION
+  </h2>
+</div>
+
+
+<p>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,
+<span class="pagenum" id="Page_58">[Pg 58]</span>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.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter">
+  <h2 class="nobreak" id="TREATMENT_4">
+    TREATMENT
+  </h2>
+</div>
+
+
+<p>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
+<span class="pagenum" id="Page_59">[Pg 59]</span>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.</p>
+
+<hr class="chap x-ebookmaker-drop">
+
+<div class="transnote">
+    <p class="center"><b>Transcriber’s Notes</b></p>
+    <p class="center">Obvious errors and omissions in punctuation have been fixed.</p>
+</div>
+
+<div style='text-align:center'>*** END OF THE PROJECT GUTENBERG EBOOK 78158 ***</div>
+</body>
+</html>
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+Project Gutenberg (https://www.gutenberg.org) public repository for eBook #78158
+(https://www.gutenberg.org/ebooks/78158)