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diff --git a/78158-0.txt b/78158-0.txt new file mode 100644 index 0000000..b6cd8a3 --- /dev/null +++ b/78158-0.txt @@ -0,0 +1,1526 @@ +*** 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 *** |