Third, by liberal and regular feeding chiefly with some liquid or semi-liquid food, of which milk is the commonest form. The old attitude of mind represented by the proverb, "Feed a cold and starve a fever," has completely disappeared. One of the fathers of modern medicine asked on his death-bed, thirty years ago, that his epitaph should be, "He fed fevers."
Fourth. We respond to the other great thirst of fever patients, for coolness, by sponge baths and tub baths, whenever the temperature rises above a certain degree.
Simple as these methods sound, they are extremely troublesome to put into execution, and require thegreatest skill and judgment in their carrying out. But intelligent persistence in the careful elaboration of these methods of nature has resulted in already cutting the death-rate in two,—from fifteen or twenty per cent to less than ten per cent,—and where the full rigor of the tub bath is carried out it has been brought down to as low as five per cent.
Meanwhile the bacteriologists are steadily at work on a vaccine or antitoxin. Wright, of the English Army Medical Staff, has already secured a serum, which has given remarkable results in protecting regiments sent out to South Africa and other infected regions. Chantemesse has imported some six hundred successive cases treated with an antitoxin, whose mortality was only about a third of the ordinary hospital rate, and the future is full of promise.
That was a dark and stern saying, "Without the shedding of blood there is no remission," and, like all the words of the oracles, of limited application. But it proves true in some unexpected places outside of the realm of theology. Was there something prophetic in the legend that it was only by the sprinkling of the blood of the Paschal Lamb above the doorway that the plague of the firstborn could be stayed? To-day the guinea-pig is our burnt offering against a plague as deadly as any sent into Egypt.
Scarcely more than a decade ago, as the mother sat by the cradle of her firstborn, musing over his future, one moment fearfully reckoning the gauntlet of risks that his tiny life had to run, and the next building rosy air-castles of his happiness and success, there was one shadow that ever fell black and sinister across his tiny horoscope. Certain risks there were which were almost inevitable,—initiation ceremonies into life, mild expiations to be paid to the gods of the modern underworld, the diseases of infancy and of childhood. Most of these could be passed over with little more than a temporary wrinkle to break her smile. They were so trivial, so comparatively harmless: measles, a mere reddening of the eyelids and peppering of the throat, with a headache and purplish rash, dangerous only if neglected;chicken-pox, a child's-play at disease; scarlatina, a little more serious, but still with the chances of twenty to one in favor of recovery; diphtheria—ah! that drove the smile from her face and the blood from her lips. Not quite so common, not so inevitable as a prospect, but, as a possibility, full of terror, once its poison had passed the gates of the body fortress. The fight between the Angel of Life and the Angel of Death was waged on almost equal terms, with none daring to say which would be the victor, and none able to lift a hand with any certainty to aid.
Nor was the doctor in much happier plight. Even when the life at stake was not one of his own loved ones,—though from the deadly contagiousness of the disease it sadly often was (I have known more doctors made childless by diphtheria than by any other disease except tuberculosis),—he faced his cases by the hundred instead of by twos and threes. The feeling of helplessness, the sense of foreboding, with which we faced every case was something appalling. Few of us who have been in practice twenty years or more, or even fifteen, will ever forget the shock of dismay which ran through us whenever a case to which we had been summoned revealed itself to be diphtheria. Of course, there was a fighting chance, and we made the most of it; for in the milder epidemics only ten to twenty per cent of the patients died, and even in the severest a third of them recovered. But what "turned our liver to water"—as the graphic Oriental phrase has it—was the knowledge which, like Banquo's ghost, would not down, that while many cases would recover ofthemselves, and in many border-line ones our skill would turn the balance in favor of recovery, yet if the disease happened to take a certain sadly familiar, virulent form we could do little more to stay its fatal course than we could to stop an avalanche, and we never knew when a particular epidemic or a particular case would take that turn. "Black" diphtheria was as deadly as the Black Death of the Middle Ages.
The disease which caused all this terror and havoc is of singular character and history. It is not a modern invention or development, as is sometimes believed, for descriptions are on record of so-called "Egyptian ulcer of the throat" in the earliest centuries of our era; and it would appear to have been recognized by both Hippocrates and Galen. Epidemics of it also occurred in the Middle Ages; and, coming to more recent times, one of the many enemies which the Pilgrim Fathers had to fight was a series of epidemics of this "black sore throat," of particularly malignant character, in the seventeenth century. Nevertheless, it does not seem to have become sufficiently common to be distinctly recognized until it was named as a definite disease, and given the title which it now bears, by the celebrated French physician, Bretonneau, about eighty years ago. Since then it has become either more widely recognized or steadily more prevalent, and it is the general opinion of pathologists that the disease, up to some thirty or forty years ago, was steadily increasing, both in frequency and in severity.
So that we have not to deal with a disease which, like the other so-called diseases of childhood, has graduallybecome milder and milder by a sort of racial vaccination, with survival of the less susceptible, but one which is still full of virulence and of possibilities of future danger.
Unlike the other diseases of childhood, also, one attack confers no positive immunity for the future, although it greatly diminishes the probabilities; and, further, while adults do not readily or frequently catch the disease, yet when they do the results are apt to be exceedingly serious. Indeed, we have practically come to the conclusion that one of the main reasons why adults do not develop diphtheria so frequently as children, is that they are not brought into such close and intimate contact with other children, nor are they in the habit of promptly and indiscriminately hugging and kissing every one who happens to attract their transient affection, and they have outgrown that cheerful spirit of comradeship which leads to the sharing of candy in alternate sucks, and the passing on of slate-pencils, chewing-gum, and otherobjets d'artfrom hand to hand, and from mouth to mouth. Statistics show that of nurses employed in diphtheria wards, before the cause or the exact method of contagion was clearly understood, nearly thirty per cent developed the disease; and even with every modern precaution there are few diseases which doctors more frequently catch from their patients than diphtheria. It is a significant fact that the risk of developing diphtheria is greatest precisely at the ages when there is not the slightest scruple about putting everything that may be picked up into the mouth,—namely, from the second to thefifth year,—and diminishes steadily as habits of cleanliness and caution in this regard are developed, even though no immunity may have been gained by a mild or slight attack of the disease. The tendency to discourage and forbid the indiscriminate kissing of children, and the crusade against the uses of the mouth as a pencil-holder, pincushion, and general receptacle for odds and ends, would be thoroughly justified by the risks from diphtheria alone, to say nothing of tuberculosis and other infections.
In addition to being almost the only common disease of childhood which is not mild and becoming milder, diphtheria is unique in another respect, and that is its point of attack. Just as tuberculosis seizes its victims by the lungs, and typhoid fever by the bowels, diphtheria—like the weasel—grips at the throat. Its bacilli, entering through the mouth and gaining a foothold first upon the tonsils, the palate, or back of the throat (pharynx), multiply and spread until they swarm down into the larynx and windpipe, where their millions, swarming in the mesh of fibrin poured out by the outraged blood-vessels, grow into the deadly false membrane which fills the air-tube and slowly strangles its victim to death.
The horrors of a death like that can never fade from the memory of one who has once seen it, and will outweigh the lives of a thousand guinea-pigs. No wonder there was such a widespread and peculiar horror of the disease, as of some ghostly thug or strangler.
But not all of the dread of diphtheria went under its own name. Most of us can still remember when thecommonest occupant of the nursery shelf was the bottle of ipecac or soothing-syrup as a specific against croup. The thing that most often kept the mother or nurse of young children awake and listening through the night-watches was the sound of a cough, and the anxious waiting to hear whether the next explosion had a "croupy" or brassy sound. It was, of course, early recognized that there were two kinds of croup, the so-called "spasmodic" and the "membranous," the former comparatively common and correspondingly harmless, the latter one of the deadliest of known diseases. The fear that made the mother's heart leap into her mouth as she heard the ringing croup-cough was lest it might be membranous, or, if spasmodic, might turn into the deadly form later. To-day most young mothers hardly know the name of wine of ipecac or alum, and the coughs of young children awaken little more terror than a similar sound in an adult. Croup has almost ceased to be one of the bogies of the nursery. And why? Because membranous croup has been discovered to be diphtheria, and children will not develop diphtheria unless they have been exposed to the contagion, while, if they should be, we have a remedy against it.
He was a bold man who first ventured to announce this, and for years the battle raged hotly. It was early admitted that certain cases of so-called membranous croup in children occurred after or while other members of the family or household had diphtheria; and for a time the opposing camps used such words as "sporadic" or scattered croup, which was supposed to come ofitself, and "epidemic" or contagious croup, which was diphtheria. Now, however, these distinctions are swept away, and boards of health require isolation and quarantine against croup exactly as against any other form of diphtheria.
Cases of fatal croup still occasionally occur which cannot be directly traced to other cases of diphtheria, but the vast majority of them are clearly traceable to infection, usually from some case in another child, which was so mild that it was not recognized as diphtheria until the baby became "croupy" and search was made through the family throats for the bacilli.
For years we were in doubt as to the cause of diphtheria. Half a dozen different theories were advanced, bad sewerage, foul air, overcrowding; but it was not until shortly after the Columbus-like discovery, by Robert Koch, of the new continent of bacteriology, that the germ which caused it was arrested, tried, and found guilty, and our real knowledge of and control over the disease began. This was in 1883, when the bacteriologist Klebs discovered the organism, followed a few months later (in 1884) by Löffler, who made valuable additions to our knowledge of it; so that it has ever since been known as the Klebs-Löffler bacillus. This put us upon solid ground, and our progress was both sure and rapid: in ten years our knowledge of the causation, the method of spread, the mode of assault upon the body-fortress, and last, but not least, the cure, stood out clear cut as a die, a model and a prophecy of what may be hoped for in most other contagious diseases.
Great as is the credit to which bacteriologists are entitled for this splendid piece of scientific progress, there was another co-laborer, a silent partner, with them in all this triumph, an unsung hero and martyr of science who deserves his meed of praise—the tiny guinea-pig. He well deserves his niche in the temple of fame; and as other races and ages have worshiped the elephant, the snake, and the sacred cow, so this age should erect its temples to the guinea-pig. From one of the most trifling and unimportant,—kept merely as a pet and curiosity by the small boys of all ages,—he has become, after the horse, the cow, the pig, and the sheep, easily our most useful and important domestic animal. It may be urged that he deserves no credit, since his sacrifice—though of inestimable value—was entirely involuntary on his own part; but this should only make us the more deeply bound to acknowledge our obligation to him.
By a stern necessity of fate, which no one regrets more keenly than the laboratory workers themselves, the guinea-pig has had to be used as a stepping-stone for every inch of this progress. Upon it were conducted every one of the experiments whose results widened our knowledge, until we found that this bacillus and no other would cause diphtheria; that instead of getting, like many other disease-germs, into the blood, it chiefly limited itself to growing and multiplying upon a comparatively small patch of the body-surface, most commonly of the throat; that most of its serious and fatal results upon the body were produced, not by the entrance of the germs themselves into the blood, butby the absorption of the toxins or poisons produced by them on the moist surface of the throat, just as the yeast plant will produce alcohol in grape juice or sweet cider.
Here was a most important clew. It was not necessary to fight the germs themselves in every part of the body, but merely to introduce some ferment or chemical substance which would have the power of neutralizing their poison. Instantly attention was turned in this direction, and it was quickly found that if a guinea-pig were injected with a very small dose of the diphtheria toxin and allowed to recover, he would then be able to throw off a still larger dose, until finally, after a number of weeks, he could be given a dose which would have promptly killed him in the beginning of the experiments, but which he now readily resisted and recovered from. Evidently some substance was produced in his blood which was a natural antidote for the toxin, and a little further search quickly resulted in discovering and filtering out of his body the now famous antitoxin. A dose of this injected into another guinea-pig suffering from diphtheria would promptly save its life.
Could this antitoxin be obtained in sufficient amounts to protect the body of a human being? The guinea-pig was so tiny and the process of antitoxin-forming so slow, that we naturally turned to larger animals as a possible source, and here it was quickly found that not only would the goat and the horse develop this antidote substance very quickly and in large amounts, but that a certain amount of it, or a substance acting as an antitoxin, was present in their blood to begin with. Of thetwo, the horse was found to give both the stronger antitoxin and the larger amounts of it, so that he is now exclusively used for its production.
After his resisting power had been raised to the highest possible pitch by successive injections of increasing doses of the toxin, and his serum (the watery part of the blood which contains the healing body) had been used hundreds and hundreds of times to save the lives of diphtheria-stricken guinea-pigs, and had been shown over and over again to be not merely magically curative but absolutely harmless, it was tried with fear and trembling upon a gasping, struggling, suffocating child, as a last possible resort to save a life otherwise hopelessly doomed. Who could tell whether the "heal-serum," as the Germans call it, would act in a human being as it had upon all the other animals? In agonies of suspense, vibrating between hope and dread, doctors and parents hung over the couch. What was their delight, within a few hours, to see the muscles of the little one begin to relax, the fatal blueness of its lips to diminish, and its breathing become easier. In a few hours more the color had returned to the ashen face and it was breathing quietly. Then it began to cough and to bring up pieces of the loosened membrane that had been strangling it. Another dose was eagerly injected, and within twenty-four hours the child was sleeping peacefully—out of danger. And the most priceless and marvelous life-saving weapon of the century had been placed in the hand of the physician.
Of course there were many disappointments and failures in the earlier cases. Our first antitoxins weretoo weak and too variable. We were afraid to use them in sufficient doses. Often their injection would not be consented to until the case had become hopeless. But courage and industry have conquered these difficulties one after another, until now the fact that the prompt and intelligent use of antitoxin will effect a cure of from ninety to ninety-five per cent of all cases of diphtheria is as thoroughly established as any other fact in medicine. The mass of figures from all parts of the world in support of its value has become so overwhelming that it is neither possible nor necessary to specify them in detail. The series of Bayeaux, covering two hundred and thirty thousand cases of diphtheria, chiefly from hospitals and hence of the severest type, showing that the death-rate had been reduced from overfifty-fiveper cent to belowsixteenper cent already, and that this decrease was still continuing, will serve as a fair sample.
Three-quarters of even this sixteen per cent mortality is due to delay in the administration of the antitoxin, as is vividly shown in thousands of cases now on record, classified according to the day of the disease on which the antitoxin was given, of which MacCombie's "Report of the London Asylums Board" is a fair type. Of one hundred and eighty-seven cases treated the first day of the disease, none died; of eleven hundred and eighty-six injected on the second day of the disease, four and a half per cent died; of twelve hundred and thirty-three not treated until the third day of the disease, eleven per cent died; of nine hundred and sixty-three cases escaping treatment until the fourth day, seventeen per cent died; while of twelve hundred andsixty not seen until the fifth day, twenty per cent died. In other words, the chances for cure by the antitoxin are in precise proportion to the earliness with which it is administered, and are over four times as great during the first two days of the disease as they are after the fourth day. One "stick" in time saves five.
This brings us sharply to the fact that the most important factor in the cure of diphtheria, just as in the case of tuberculosis, is early recognition. How can this be secured? Here again the bacteriologist comes to our relief, and we needed his aid badly. The symptoms of a mild case of diphtheria for the first two, or even three, days are very much like those of an ordinary sore throat. As a rule, even the well-known membrane does not appear in sufficient amounts to be recognizable by the naked eye until the middle of the second, or sometimes even of the third, day. By any ordinary means, then, of diagnosis, we would often be in doubt as to whether a case were diphtheria or not, until it was both well advanced and had had time to infect other members of the family. With the help of the laboratory, however, we have a prompt, positive, and simple method of deciding at the very earliest stage. We merely take a sterilized swab of cotton on the end of a wire, rub it gently over the surface of the throat and tonsils, restore it to its glass tube, smearing it over the surface of some solidified blood-serum placed at the bottom of the tube, close the tube and send it to the nearest laboratory. The culture is put into an incubator at body heat, the germs sown upon the surface of theblood-serum grow and multiply, and in twelve hours a positive diagnosis can be made by examining this growth with a microscope. Often, just smearing the mucus swabbed out of the throat over the surface of a glass slide, staining this smear, and putting it under a microscope, will enable us to decide within an hour. These tubes are now provided by all progressive city boards of health, and can be had free of charge at depots scattered all over the city, for use in any doubtful case, within half an hour. Twelve hours later a free report can be had from the public laboratory. If every case of suspicious sore throat in a child were promptly swabbed out, and a smear from the swab examined at a laboratory, it would not be long before diphtheria would be practically exterminated, as smallpox has been by vaccination, and this is what we are working toward and looking forward to.
Our knowledge of the precise cause of diphtheria, the Klebs-Löffler bacillus, has furnished us not only with the cure, but also with the means of preventing its spread. While under certain circumstances, particularly the presence of moisture and the absence of light, this germ may live and remain virulent for weeks outside of the body, careful study of its behavior under all sorts of conditions has revealed the consoling fact that its vitality outside of the human or some other living animal body is low; so that it is relatively seldom carried from one case to another by articles of clothing, books, or toys, and comparatively seldom even through a third party, except where the latter has come into very close contact with the disease, like a doctor, anurse, or a mother, or—without disrespect to the preceding—a pet cat or dog.
More than this, the bacillus must chiefly be transmitted in the moist condition and does not float in the air at all, clinging only to such objects as may have become smeared with the mucus from the child's throat, as by being coughed or sneezed upon. As with most of our germ-enemies, sunlight is its deadliest foe, and it will not live more than two or three days exposed to sunshine. So the principal danger against which we must be on our guard is that of direct personal contact, as in kissing, in the use of spoons or cups in common, in the interchange of candy or pencils, or through having the hands or clothing sprayed by a cough or a sneeze.
The bacillus comparatively seldom even gets on the floor or walls of a room where reasonable precautions against coughing and spitting have been taken; but it is, of course, advisable thoroughly to disinfect and sterilize the room of a patient and all its contents with corrosive sublimate and formalin, as a number of cases are on record in which the disease has been carried through books and articles of clothing which had been kept in damp, dark places for several months. The chief method of spread is through unrecognized mild cases of the disease, especially of the nasal form. For this reason boards of health now always insist upon smears being made from the throats and noses of every other child in the family or house where a case of diphtheria is recognized. No small percentages of these are found to be suffering from a mild form of the disease,so slight as to cause them little inconvenience and no interference with their attending school. Unfortunately, a case caught from one of these mild forms may develop into the severest laryngeal type. If a child is running freely at the nose, keep it at home or keep your own child away from it. A profuse nasal discharge is generally infectious, in the case of influenza or other "colds," if not of diphtheria.
This also emphasizes the necessity for a thorough and expert medical inspection of school-children, to prevent these mild cases from spreading disease and death to their fellows. By an intelligent combination of the two methods, home examination of every infected family and strict school inspection, there is little difficulty in stamping out promptly a beginning infection before it has had time to reach the proportions of an epidemic.
One other step makes assurance doubly sure, and that is the prompt injection of all other children and young adults living in the family, where there is a case of diphtheria, with small doses of the antitoxin for preventive purposes. Its value in this respect has been only secondary to its use as a cure. There are now thousands of cases on record of children who had been exposed to diphtheria or were in hospitals where they were in danger of becoming exposed to it, with the delightful result that only a very small per cent of those so protected developed the disease, and of these not a single one died! This protective vaccination, however, cannot be used on a large scale, as in the case of smallpox, for the reason that the period of protection is a comparatively short one, probably not exceeding two or three weeks.
Suppose that, in spite of all our precautions, the disease has gained a foothold in the throat, what will be its course? This will depend, first of all, upon whether the invading germs have lodged in their commonest point of attack, the tonsils, palate, and upper throat, or have penetrated down the air-passages into the larynx or voice-organ. In the former, which is far the commoner case, their presence will cause an irritation of the surface cells which brings out the leucocyte cavalry of the body to the defense, together with squads of the serum or watery fluid of the blood containing fibrin. These, together with the surface-cells, are rapidly coagulated and killed by the deadly toxin; and their remains form a coating upon the surface, which at first is scarcely perceptible, a thin, grayish film, but which in the course of twenty-four to forty-eight hours rapidly thickens to the well-known and dreaded false membrane. Before, however, it has thickened in more than occasional spots or patches, the toxin has begun to penetrate into the blood, and the little patient will complain of headache, feverishness, and backache, often—indeed, usually—before any very marked soreness in the throat is complained of. Roughly speaking, attacks of sore throat, which begin first of all with well-marked soreness and pain in the throat, followed later by headache, backache, and fever, are not very likely to be diphtheria. The bacilli multiply and increase in their deadly mat on the surface of the throat, larger and larger amounts of the poison are poured intothe blood, the temperature goes up, the headache increases, the child often begins to vomit, and becomes seriously ill. The glands of the neck, in their efforts to arrest and neutralize the poison, become swollen and sore to the touch, the breath becomes foul from the breaking down of the membrane in the throat, the pulse becomes rapid and weak from the effect of the poison upon the heart, and the dreaded picture of the disease rapidly develops.
This process in from sixty to eighty per cent of cases will continue for from three to seven days, when a check will come and the condition will gradually improve. This is a sign that the defensive tissues of the body have succeeded in rallying their forces against the attack, and have poured out sufficient amounts of their natural antitoxin to neutralize the poisons poured in by the invaders. The membrane begins to break down and peel off the throat, the temperature goes down, the headache disappears, the swelling in the glands of the neck may either subside or go on to suppuration and rupture, but within another week the child is fairly on the way to recovery.
Should the invaders, however, have secured a foothold in the larynx, then the picture is sadly different. The child may have even less headache, temperature, and general sense of illness; but he begins to cough, and the cough has a ringing, brassy sound. Within forty-eight, or even twenty-four, hours he begins to have difficulty in respiration. This rapidly increases as the delicate tissues of the larynx swell under the attack of the poison, and the very membrane which iscreated in an attempt at defense becomes the body's own undoing by increasing the blocking of the air-passages. The difficulty of breathing becomes greater and greater, until the little victim tosses continually from side to side in one constant, agonizing struggle for breath. After a time, however, the accumulation of carbon dioxide in the blood produces its merciful narcotic effect, and the struggles cease. The breathing becomes shallower and shallower, the lips become first blue, then ashy pale, and the little torch of life goes out with a flicker. This was what we had to expect, in spite of our utmost effort, in from seventy to ninety per cent of these laryngeal cases, before the days of the blessed antitoxin. Now we actually reverse these percentages, prevent the vast majority of cases from developing serious laryngeal symptoms at all, and save from seventy to eighty per cent of those who do.
Our only resource in this form of the disease used to be by mechanical or surgical means, opening the windpipe below the level of the obstruction and inserting a curved silver tube—the so-called tracheotomy operation; or later, and less heroic, by pushing forcibly down into the larynx, and through and past the obstruction at the vocal cords, a small metal tube through which the child could manage to breathe. This was known as intubation. But these were both distressing and painful methods, and, what was far worse, pitifully broken reeds to depend upon. In spite of the utmost skill of our surgeons, from fifty to eighty per cent of cases that were tracheotomized, and from forty to sixty per cent of those that were intubated, died.In many cases they were enabled to breathe, their attacks of suffocation were relieved—but still they died.
This leads us to the most important single fact about the course of the disease, and that is that the chief source of danger is not so much from direct suffocation as from general collapse, and particularly failure of the heart.
This has given us two other data of great importance and value, namely, that while the immediate and greatest peril is over when the membrane has become loosened and the temperature has begun to subside, in both ordinary throat and in laryngeal forms of the disease, the patient is by no means out of danger. While the antitoxins poured out by his body have completely defeated the invading toxins in the open field of the blood, yet almost every tissue of the body is still saturated with these latter and has often been seriously damaged by them before their course was checked. For instance, nearly two-thirds of our diphtheria cases, which are properly examined, will show albumin in the urine, showing that the kidney-cells have been attacked and poisoned by the toxin. This may go on to a fatal attack of uremia; but fortunately, not commonly, far less so than in scarlet fever. The kidneys usually recover completely, but this may take weeks and months. Again, many cases of diphtheria will show a weak and rapid pulse, which will persist for weeks after the patient has apparently recovered; and if the little ones are allowed to sit up too soon, or to indulge in any sudden movements or muscular strains, thisweak and rapid pulse will suddenly change into an attack of heart failure and, possibly, fatal collapse. This, again, illustrates the saturation of the poison, as these effects are now known to be due in part to a direct poisoning of the muscle of the heart itself, and later to serious damage done to the nerves controlling the heart, chiefly the pneumo-gastric. Moral: Keep the little patient in bed for at least two weeks or, better, three. He will have to spend a month or more in quarantine, anyway.
Last of all, and by no means least interesting, are the effects which are produced upon the nervous system. One day, while the child is recovering, and is possibly beginning to sit up in bed, a glass of milk is handed to him. The little one drinks it eagerly and attempts to swallow, but suddenly it chokes, half strangles, and back comes the milk, pouring out through the nostrils. Paralysis of the soft palate has occurred from poisoning of the nerves controlling it, caused by direct penetration of the toxin. Sometimes the muscles of the eye become paralyzed and the little one squints, or can no longer see to read.
Fortunately, most of these alarming results go only to a certain degree, and then gradually fade away and disappear; but this may take months or even longer. In a certain number, however, the nerves of respiration, or those controlling the heart-beat, become affected, and the patient dies suddenly from heart failure.
This strange after-effect upon the nervous system, which was first clearly noticed in diphtheria and syphilis, has now been found to occur in lesserdegree in a large number of our infectious diseases, so that many of our most serious paralyses and other diseases of the nervous system are now traceable to such causes.
These effects of the diphtheria toxin are also of interest for a somewhat unexpected reason, since it has been claimed that they are effects of the antitoxin, by those who are opposed to its use. Every one of them was well recognized as a possible result of diphtheria long before the antitoxin was discovered, and every one of them can be readily produced by injections of diphtheria bacilli or their toxin into animals.
It is quite possibly true that there are more cases of nerve-poisoning (neuritis) and of paralysis following diphtheria than there were before the use of antitoxin, but that is for the simple and sufficient reason that there are more children left alive to display them! And between a child with a temporary squint and a dead child few mothers would hesitate long in their choice.
Why is a disease a disease of childhood? First and fundamentally, because that is the earliest period at which a human being can have it. But the problem goes deeper than this. There is no more interesting and important group of diseases in the whole realm of pathology than those which we calmly dub "the diseases of childhood," and thereby dismiss to the limbo of unavoidable accidents and discomforts, like flies, mosquitoes, and stubbed toes, which are best treated with a shrug of the shoulders and such stoic philosophy as we can muster. They are interesting, because the moment we begin to study them intelligently we stumble upon some of the profoundest and most far-reaching problems of resistance to disease; important, because, trifling as we regard them, and indeed largely just because we so regard them, they kill, or handicap for life, more children in civilized communities than the most deadly pestilence. Measles, for instance, according to the last United States census, causes yearly nearly thirteen thousand deaths, while smallpox causes so few that it is not listed among the important causes of death. Scarlet fever causes sixty-three hundred and thirty-three deaths, as comparedwith barely five thousand from appendicitis and the same number from rheumatism. Whooping-cough causes ninety-nine hundred and fifty-eight deaths, more than double the mortality from diabetes and nearly equal to that of malarial fever.
In medicine, as in war, the gravest and deadliest mistake that you can make is to despise your enemy. These trivial disorders, these trifling ailments, which every one takes as a matter of course, and expects to go through with, like teething, tight shoes, and learning to smoke, sweep away every year in these United States the lives of from forty to fifty thousand children, reaching the bad eminence of fifth upon our mortality lists, only consumption, pneumonia, heart disease, and diarrhœal diseases ranking above them. Of course, it is obvious that these diseases outrank many other more serious ones among the "captains of the men of death," largely upon the familiar principle of the old riddle, whereby the white sheep eat more grass than the black, "because there are more of them."
While only a relatively small percentage of us ever have the bad luck to be attacked by typhoid fever, rheumatism, or appendicitis, to say nothing of cholera and smallpox, the vast majority of us have gone through two or more of these diseases of childhood; so that, though the death-rate of each and all of them is low, yet the number of cases is so enormous that the absolute total mounts high. But the pity and, at the same time, the practical importance of this heavy death-roll is thatat least two-thirds of it is absolutely preventable, and by the exercise of only a very moderateamount of intelligence and vigilance. It is, of course, obvious that in a group of diseases which numbers its victims literally by the million every year there will inevitably occur a certain minute percentage of fatal results due to what might be termed unavoidable causes, like a badly nourished condition of the child attacked, unusual circumstances preventing proper shelter or nursing, or an exceptional virulence of the disease, such as will occur in two or three cases of every thousand in even the most trifling infectious malady. But even after making liberal allowance for what might be termed the unavoidable fatalities, at least two-thirds, and more probably nine-tenths, of the deaths from children's diseases might be prevented upon two grounds:—
First, that they are contagious and absolutely dependent upon a living germ, whose spread can be prevented; and secondly, and practically even more important, that more than half the deaths from them are due, not to the disease itself, but to complications occurring during the period of recovery, caused, for the most part, by gross carelessness on the part of the mother or nurse. A large majority, for instance, of the nearly thirteen thousand deaths attributed to measles are due to bronchitis, caught by letting the child go out-of-doors too soon after recovery, which means, of course, either a chill falling upon the irritated and weakened bronchial mucous membrane, or an infection by one of the score of disease-germs, such as those of influenza, pneumonia, bronchitis, and even tuberculosis, which are continually lying in wait for justsuch an emergency as this—just such a weakening of the vital resistance.
It is a sadly familiar statement in the history of fatal cases of tuberculosis that the trouble "began with an attack of measles," or whooping-cough, or a bad cold, and was mistaken for a mere "hanging on" of one of these milder maladies until it had gained a foothold that there was no dislodging. As breakers of the wall of the hollow square of the body-cells, drawn up to resist the cavalry charges of tuberculosis, pneumonia, and rheumatism, few can be compared in deadliness with the diseases of childhood and "common colds."
Further, while all of them except scarlet fever have a mortality so low that it might almost be described as what the French delicately termune quantité négligeable, yet a surprisingly large number of the survivors do not escape scot-free, but bear scars which they may carry to their graves, or which may even carry them to that bourne later. Again, the actual percentage of the survivors who are marked in this fashion is small, but such milliards of children are attacked every year that, on the old familiar principle, "if you throw plenty of mud some of it will stick," quite a serious number are more or less handicapped by these remainders. For instance, quite a noticeable percentage of cases of chronic eye troubles, particularly of the lids and conjunctiva, such as "granulated" lids, styes, ulcers of the cornea, date from an attack of measles or even whooping-cough. Many cases of nasal catarrh or chronic throat trouble or bronchitis in children date from the same source. A large group of chronic discharges fromthe ear and perforations of the ear-drum are a direct after-result of scarlet fever; and the frequency with which this disease causes serious disturbances of the kidneys is almost a household word. Less definitely traceable, but even more serious in their entirety, are the large group of chronic depression of vigor, loss of appetite, various forms of indigestion and of bowel trouble, which are left behind after the visitation of one of these minor pests, particularly among the children of the poorer classes, who are unable to obtain the highly nutritious, appetizing, and delicately cooked foods which are so essential to the full recovery of the little invalids.
One of the English commissions which was investigating the alleged physical deterioration of city and town populations stumbled upon a singularly interesting and significant fact in this connection, while plotting the curves of the rate of growth of the children in a given district in Scotland during a series of years. They were struck with the fact that children born in certain years in the same families, neighborhoods, and presumably the same circumstances, grew more rapidly and had a lower death-rate than those born in other years; and that, on the other hand, children born in other years fell almost as far below the normal in their rate of growth. The only factor which they found to coincide with these differences was that in the years in which those children who made the slowest growth were born there had been unusually heavy epidemics of children's diseases and a high mortality; while, on the other hand, those years whose "crop" of children made the bestgrowth had been unusually free from such epidemics and had a correspondingly low mortality, showing clearly that even the survivors of children's diseases were not only not benefited, but distinctly handicapped and set back in their growth by the energy, so to speak, wasted in resisting the onslaught.
This brings us to an aspect of these diseases which from both a philosophic and a practical point of view is most interesting and profoundly significant; and that is the question with which we opened: Why is a disease a disease of childhood? The old, primitive view was as guileless and as simple as the age in which the diseases occurred. They were regarded not merely by the laity but by grave and reverend physicians of the Dark Ages as a sort of necessary vital crisis peculiar and appropriate to each particular age of life,—a sort of sweating out and erupting of "peccant humors" of the blood, which must be got rid of or else the individual would not thrive. Incredible as it may seem, so far was this idea extended, that the great Arabian physician-philosopher, Rhazes, actually included smallpox in this group, as the last of the "crises of growth" which had to appear and have its way in young manhood or womanhood. Quaint little echoes of this simple faith still ring in the popular mind, as, for instance, in the widespread notion about the dangerousness of doing anything to check the eruption in measles and cause it to "strike in." Any mother in Israel will tell you, the first time you propose a bath or a wet pack to reduce the temperature in measles, that if you so much as touch water to the skin of that childit will "drive the rash in" and cause it to die in convulsions. And, of course, one of the commonest of a physician's memories is the expression of relief from the mother or aunt in any of these mild eruptive fevers, where the skin was well reddened and spotted: "Well, anyway, doctor, it is a splendid thing to get the rash so well out!" Until within the last ten or fifteen years it was no uncommon thing to hear the expression: "Well, I suppose we might just as well let Willie and Susie go on to school and get the measles and have done with it. It seems to be a real mild sort this time." Of course this view was scientifically shattered two or more decades ago by our recognition of the infectious nature of these diseases, but practically its hold on the public mind constitutes one of the most serious and vital obstacles in the way of the health-officer when he endeavors to attack and break up an epidemic of measles, whooping-cough, or chicken-pox.
It cannot be too strongly emphasized that, mild and in their immediate results trifling, as most of these "little diseases" are, they are genuine members of that class of pathologic poison-snakes, the germ-infections; that when they bite, they bite to kill; that two to five times in every hundred they do kill; that, like all other infections, they are capable of inflicting serious and permanent damage upon the great vital organs, the heart, the kidneys, the liver, and the brain; and that they are the very jackals of diseases, tracing down and pointing out the prey to the lions that work in partnership with them. With whatever we may treat measles and whooping-cough,nevertreat them with contempt!
The next conception of the "whyness" of children's diseases was that as one star differs from another in glory, so does one germ differ from another in virulence; that the germs of these particular diseases just happened to be from the beginning unusually mild and at the same time highly contagious, so that they remained permanently scattered about throughout the community, and attacked each successive brood of newborn children as quickly as they could conveniently get at them. Being so mild and so comparatively seldom fatal, little or no alarm was excited by them and few efforts made to check their spread, so that they continued to flourish, generation after generation. Upon this theory the germs of measles, chicken-pox, whooping-cough, mumps, would be in something like the same class as the numerous species of bacteria and other germs that normally inhabit the human mouth, stomach, and intestines; for the most part, comparatively harmless parasites, or what are technically now known as "symbiotes" (from two Greek words,bios, "life," andsyn, "with"), a sort of little partners or non-paying boarders, for the most part harmless, but occasionally capable of making trouble. There are scores of species of such germs in our food-canals, some of which may be even slightly helpful in the process of digestion. Only a very small per cent of the bacilli of any sort in the world are harmful; the vast majority are exceedingly helpful.
There is evidently some truth in this view of children's diseases, especially so far as the reason for their steady persistence and undiminished spread is concerned, namely, the comparative carelessness and indifference with which they are regarded and treated. But some rather striking developments of recent years have raised grave doubts in our minds as to whether they were always the mild and inoffensive "house cats" that they pass for at present. These are the astonishing and almost incredible developments that occur when for the first time these mild and harmless "diseaselets" are introduced to a savage or half-civilized tribe. Like an Arabian Nights' transformation, our sleepy, purring, but still able to scratch, "pussy cat" flashes out as a ravenous man-eating tiger, killing and maiming right and left. Measles—harmless, tickly, snuffly, "measly" little measles—kills from thirty to sixty per cent of whole villages and tribes of Indians and cripples half the remainder!
My first direct experience with this feature of our "household pets" was on the Pacific Coast. All the old settlers told me of a dread pestilence which had preceded the coming of the main wave of invading civilization, sweeping down the Columbia River. Not merely were whole clans and villages swept out of existence, but the valley was practically depopulated; so that, as one of the old patriarchs grimly remarked, "It made it a heap easier to settle it up quietly." So swift and so fatal had been its onslaught that villages would be found deserted. The canoes were rotting on the river bank above high-water mark. The curtains of the lodges were flapped and blown into shreds. The weapons and garments of the dead lay about them, rusting and rotting. The salmon-nets were still standing inthe river, worn to tatters and fringes by the current. Yet, from the best light that I was able to secure upon it, it appeared to have been nothing more than an epidemic of the measles, caught from the child of some pioneer or trapper and spreading like wildfire in the prairie grass. A little later I had an opportunity to see personally an epidemic of mumps in a group of Indians, and I have seldom seen fever patients, ill of any disease, who were more violently attacked and apparently more desperately ill than were sturdy young Indian boys attacked by this trifling malady. Their temperatures rose to one hundred and five or one hundred and six degrees, they became delirious, their faces were red and swollen, they ached in every limb, and the complications that occasionally follow mumps even in civilized patients were frequent and exceedingly severe. In like manner, influenza will slay its hundreds in a tribe of less than a thousand members. Chicken-pox will become so virulent as to be mistaken for smallpox. Several of the epidemics of alleged smallpox that have occurred among Indians and other savage tribes are now known to have been only measles. At first, pathologists were inclined to receive these reports with some degree of skepticism, and to regard them either as travelers' tales, or as instances of exceptional and accidental virulence in that particular tribe, the high death-rate due to bad nursing or horrible methods of voodoo treatment.
But from all over the world came ringing in the same story, not merely from scores of travelers, but also from army surgeons, medical missionaries, and medical explorers, until it has now become a definitely established fact that the mild, trifling diseases of infancy, "colds" and influenzas of civilized races, leap to the proportions of a deadly pestilence when communicated to a savage tribe. Whether that tribe be the Eskimo of the Northern ice-sheet or the Terra del Fuegian of the Southern, the Hawaiian of the islands of the Pacific or the Aymarás of the Amazon, all fall like grain before the scythe under the attack of a malady which is little more than the proverbial "little 'oliday" of three days in bed to civilized man. Evidently civilized man has acquired a degree and kind of immunity that uncivilized man has not. Either the disease has grown milder or civilized man tougher with the ages.
The probability is that both of these explanations are true. These diseases may originally have been comparatively severe and serious; but as generation after generation has been submitted to their attack, those who were most susceptible died or were so crippled as to be seriously handicapped in the race of life and have left fewer and less vigorous offspring. So that, by a gradual process of weeding out the more susceptible, the more resisting survived and became the resistant civilized races of to-day.
On the other hand, any disease which kills its victim so quickly that it has not time to make sure of its transmission to another one before his death, will not have so many chances of survival as will a milder and more chronic disorder. Hence, the milder and less fatal strains of germs would stand the better chance of survival. This, of course, is a very crude outline, but itprobably represents something of the process by which almost all known diseases, except a few untamable hyenas, like the Black Death, the cholera, and smallpox, have gradually grown milder with civilization. If we escape the attack of these attenuated diseases of infancy until fifteen or sixteen years of age, we can usually defy them afterward; though occasionally an unusually virulent strain will attack an adult, with troublesome consequences.
At all events, whatever explanation we may give, the consoling fact stands out clearly that civilized man is decidedly more resistant to these pests of civilization than is any half-civilized race, and there is good reason to believe that this is a typical instance of his comparative vigor and endurance all along the line.
If this view of the original character and taming of these diseases be correct, it also accounts for the extraordinary and otherwise inexplicable cases where they suddenly assume the virulence of cholera, or yellow fever, and kill within forty-eight or ninety-six hours, not merely in children but also in adults.
To group these three diseases together simply because they all happen to occur in children would appear scarcely a rational principle of classification. Yet, practically, widely different as they are in their ultimate results and, probably, in their origin, they have so many points in common as to their method of spread, prevention, and general treatment, that what is said of one will with certain modifications apply to all.
I said "probably" of widely different origin, because, by one of those strange paradoxes which so often confront us in real life, though the infectiousness and the method of spread of all these diseases is as familiar as the alphabet and as firmly settled, the most careful study and innumerable researches have failed to identify positively the germ in any one of them. There are a number of "suspects" against which a great deal of circumstantial evidence exists: a streptococcus in scarlet fever, a bacillus in whooping-cough, and a protozoan in measles; but none of these have been definitely convicted. The principal reason for our failure is a very common one in bacteriological research, whose importance is not generally known, and that is, that there is not a single species of the lower animals that is subject to the diseases or can be inoculated with them. This unfortunate condition is the greatest barrier which can now exist to our discovery of the causation of any disease. We were absolutely blocked, for instance, by it in smallpox and syphilis until we discovered that our nearest blood relatives, the ape and the monkey, are susceptible to them; and then theCytoryctes Variolæand theTreponema pallidawere discovered within comparatively a few months. Some lucky day, perhaps, we may stumble on the animal or bird which will take measles, scarlet fever, or whooping-cough, and then we will soon find out all about them.
But, fortunately, our knowledge of these little diseases, like Mercutio's wound, is "not so deep as a well, nor so wide as a church door; but 't is enough" for all practical purposes. The general plan of treatment in all of them might be roughly summed up as, rest in bed in a well-ventilated room; sponge-baths and packs forthe fever; milk, eggs, bread, and fruit diet, with plenty of cool water to drink, either plain, or disguised as lemonade or "fizzy" mixtures; mild local antiseptic washes for nose and throat, and mild internal antiseptics, with laxatives, for the bowels and kidneys. There is no known drug which is specific in any one of them, though their course may be made milder and the patient more comfortable by the intelligent use of a variety of remedies, which assist nature in her fight against the toxin. Not knowing the precise cause, we have as yet no reliable antitoxin for any.
Now very briefly as to the earmarks of each particular member of this children's group. It may be said in advance that the "openings" of all of them (as chess-players call the first moves) are very much alike. All of them are apt to begin with a little redness and itching of the mucous membranes of the nose, the throat, and the eyes, with consequent snuffling and blinking and complaints of sore throat. These are followed, or in severe, swift cases may be preceded, by flushed cheeks, complaints of headache or heaviness in the head, fever, sometimes rising very quickly to from one hundred and four to one hundred and five degrees, backache, pains in the limbs, and, in very severe cases, vomiting. In fact, the symptoms are almost identical with those of an attack of that commonest of all acute infections, a bad cold, and probably for the same reason, namely, that the germs, whatever they may be, attack and enter the system by way of the nose and throat.
One of the most difficult practical points about the beginning of this group of diseases is to distinguishthem from one another, or from a common cold. The important thing to remember is that, theoretically important as it may be to make this distinction, practically it isn't necessary at all, as they should all be treated exactly alike in the beginning. The only vital thing is to recognize that you are dealing with an infection of some sort, isolate promptly the little patient, put him to bed, and make your diagnosis later as the disease develops. Fortunately neither scarlet fever nor measles usually becomes acutely infectious until the rash appears, and as neither is particularly dangerous to adults, especially to such as have had them already, a one-room quarantine is sufficient for the first few days of any of these diseases. We will lose nothing and gain enormously by adopting this routine plan in all cases of snuffling noses, sore throats, headache, and fever in children, for these are the early symptoms of all their febrile diseases, from colds to diphtheria; all alike are infectious and all, even to the mildest, benefited by a few days of rest and seclusion.
After this first general blare of defiance on the part of the system to the enemy, whoever he may be, the battle begins to take on its characteristic form according to the nature of the invader. We will take first the campaign of scarlet fever, since this is the swiftest and first to disclose itself. After the preliminary snuffles and headache have lasted for a few hours, the temperature usually begins to rise; and when it does, by leaps and bounds often reaching one hundred and four or one hundred and five degrees within twelve hours, the skin becomes dry and hot, the throat sore, the tongueparched, and the little patient drowsy and heavy-eyed. Within from twenty-four to forty-eight hours a bright red or pinkish rash appears, first on the neck and chest, and then rapidly spreading all over the surface of the body within another twenty-four hours.
Meanwhile the throat becomes sore and swollen, ranging, according to the severity of the case, from a slight reddening and swelling to a furious ulcerative inflammation, with the formation of a thick membrane-like exudate, which sometimes is so severe as to raise a suspicion of possible diphtheria. The tongue becomes red and naked, with the papillæ showing light against a red ground, so as to give rise to what has been known as "the strawberry tongue." The temperature is usually high, and the little patient when he drowses off to sleep is quite apt to become more or less delirious. In the vast majority of cases, after two to four days of this, the temperature goes down almost as swiftly as it came up, the rash begins to fade, the throat gets less sore, and the rebound toward recovery sets in. About this time the daily examination of the urine will begin to show traces of albumin, but this, under strict rest in bed and careful diet, will usually diminish and ultimately disappear. In the event of a relapse, however, or setback from any cause, the kidneys may become violently attacked, and a considerable per cent of the fatal cases die from suppression of the urine. After this crisis has occurred, however, in ninety-nine per cent of all cases it is comparatively plain sailing; the throat is still sore and troublesome, the skin itches and tickles, and the eyes smart, but the little patient steadilyimproves day by day. Anywhere from three to five days after the break in the fever the skin begins to get rough and scaly, and gradually peels off, until in some cases the entire coating of the body is shed, having been killed, as it were, by the violence of the eruption. Theseflakes and scales of the skin are exceedingly contagious, and no case should be regarded as fit to be released from isolation until every particle has been shed and got rid of. This constitutes one of the most tiresome and annoying periods of the disease, as complete shedding is seldom finished before two weeks, and sometimes may last from three to five.
However, this long period of contagiousness has been found to be really a blessing in disguise, inasmuch as we now know that even more strikingly than in the other children's diseases it is the period ofrecoverythat is the period ofgreatest dangerin scarlet fever. Like the Parthians of Greek history it is most dangerous when in retreat. Keeping the child at rest for the greater part of the time, in bed or on a lounge, in a well-ventilated room, or later on a porch or terrace, for five weeks from the beginning of the disease, is well worth all the trouble and inconvenience that it causes, for the sake of the almost absolute protection it gives against dangerous and even fatal complications, particularly of the kidneys, heart, or lungs.
This is a fair description of what might be termed an average case of the disease. We also have the sadly familiar type described as the fulminant or, literally, "lightning-stroke" variety. The child goes down as if struck by an invisible hand; vomiting is one of the firstsymptoms; delirium follows within ten or twelve hours; the eruption becomes not merely scarlet but purplish from hemorrhage under the skin, giving the name of "black" scarlet fever to this type. The throat becomes furiously swollen, the urine is absolutely suppressed, the child goes into convulsions, and dies within forty-eight hours from the beginning of the attack. Fortunately, this type is rare, but the important thing to remember is that it may develop in a child who caught the disease from one of the mildest of all possible cases! Hence every case should be treated with the strictest isolation, as if it were itself of the most malignant type.
Naturally, the mortality of scarlet fever varies according to the type. Not only may it assume a malignant form in individual cases, but whole epidemics may be of this character, with a mortality of from twenty to thirty per cent. Generally speaking, however, the death-rate is about one in twelve, ranging from as low as one in twenty-five to as high as one in five.
As in the case of diphtheria, the greatest danger and most powerful means of spread of the disease is through the mild, unrecognized cases, which are supposed to have nothing but a cold and are allowed to continue in school or play with other children. We have no antitoxin and no bacteriologic means of positive diagnosis. But one method will stop the spread and within ten or fifteen years exterminate every one of these infections—isolate at once every childthat shows symptoms of a cold, sore throat, or feverishness, both for its own sake and for that of the community!
In measles we have to deal with a much more harmless and more nearly domesticated "beast of prey," but one of a prevalence to correspond. Though probably (exact data being as yet lacking) not more than one-third of all individuals are attacked by scarlet fever, it would be safe to say that not more than one-third, and possibly not more than one-fifth, of us escape measles. Hence, though its mortality is scarcely one-fourth that of scarlet fever, it more than holds its own in the Herod class, as grimly shown by its total death-roll of over twelve thousand, compared with only a little over six thousand to the credit of scarlet fever.
After the preliminary disturbances of snuffles, hot throat, headache, and feverishness, which it shares with all the other "little fevers," the first thing to mark off measles is usually that the itching and running at the nose and eyes become more prominent, the child begins to turn its face away from the light because it makes its eyes smart, and complains not so much of soreness as of a peppery, burning, itching sensation in its nose and throat. The tongue is coated, the stomach mildly upset; the little patient is more uncomfortable and fretful than seriously ill. This condition drags on, without apparently getting anywhere, for from two to four days, during which time it is often very difficult even for the most experienced physician to say positively what the sufferer has. But about the fourth day a rash begins to appear, typically first upon the cheeks or forehead in the shape of little widely separated dull-red blotches. These grow larger and deeper in color, rising in the middle and spreading at their edges, so that shortly the whole skin becomes puffed and swollen andof a mottled, pinkish-purple color. If the child's lower lip be pulled down, little red spots will be seen scattered over the lining membrane of the mouth, showing that the eruption is not confined to the skin. Indeed, these Koplik's spots (as they are called, after their discoverer) in the mouth will often appear a day or more before the eruption upon the skin and give the first clew to the nature of the disease. These are significant, because they probably illustrate the process of eruption, or, at least, irritation, which is taking place, not merely upon the skin, but also upon the mucous membranes of the eyes, nose, and throat, the windpipe and the bronchial tubes, and which is the cause of the burning, running, and, later, occasional serious inflammatory symptoms in all these regions.
When you look at the hot, angry-looking, swollen skin of the little victim of measles, the weeping eyes and running nose, and remember that this same sort of process is either going on or is likely to occur all over his entire lining, so to speak, from lungs to bowels, you can easily grasp how important it is to keep him absolutely at rest and protected from every possible risk in the way of chill, over-exertion, or injudicious feeding, until the whole process has completely subsided and been forgotten. Neglect of these precautions is the reason why so many cases of measles, on the least and most trifling exposure and overstrain during the two or three weeks following the disease, will blaze up into a fatal bronchitis or pneumonia.
The rash takes about two or three days to get out, then it begins to fade and the skin to peel off in tiny,branny scales, so small and thin as to be almost invisible—unlike the huge flakes of scarlet fever. At the same time all the other symptoms recede.
But, as in scarlet fever, all cases should be treated alike, by rest, sponging and packing for the fever, light diet with plenty of milk and fruit, and confinement to the room for at least ten days after the disappearance of the fever. The very mildest and most insignificant of attacks may be followed, through carelessness or exposure, by a fatal bronchitis. Indeed, in view of the distressing frequency with which our histories of tuberculosis in children contain the words, "Came on after measles," it is highly advisable to watch carefully every child as regards abundant feeding, avoidance of overwork or overstrain, and of all unnecessary exposure to infection, wind, or wet, for two months after an attack of measles instead of the customary two weeks. As the disease is acutely infectious, the little victim should be isolated for at least three weeks after the disappearance of the fever; but this again, as in the case of scarlet fever, is emphatically a blessing in disguise from his point of view, as well as a protection to the rest of the community.
Should the "little fever" prove to be whooping-cough, it will be later still in positively declaring its definite intentions. The cold or catarrhal stage will be much milder, the fever lower, the cough a trifle more marked, but will drag on for from a week to ten days before anything definite happens. Usually the child is supposed to be suffering with a slight cold, hence the prevailing impression that colds run into whooping-cough,if neglected. Then one day the child is suddenly seized with a coughing fit, consisting of from ten to fifteen short coughs in rapid succession of increasing intensity, until all the air seems literally pumped out of the lungs of the poor little patient; then, with a tremendous whoop, the youngster gets his breath again and the diagnosis is made. This distressing performance may occur only four or five times a day, or it may be repeated every half-hour or so. So violent is the paroxysm that the eyes of the child protrude, it becomes literally black in the face, and runs to its mother or nurse, or clutches a chair, to keep from falling.
As the same great nerves which supply the lungs supply the stomach, the irritation frequently "radiates," or spills over, from one division of it to the other, and the coughing fit is frequently followed by vomiting. Unexpectedly enough this may often become the most serious practical symptom of the disease, inasmuch as the stomach is emptied so frequently that the poor little victim is unable to retain any nourishment long enough to absorb it, and may waste away frightfully, and even literally starve to death, or have its resisting power so greatly lowered that an attack of bronchial trouble or bowel disturbance will prove rapidly fatal.
So serious are the disturbances of the circulation all over the body by these spasmodic suffocation-fits, that rupture of small blood-vessels may occur in the eyes, the brain, in the lungs, and on the surface of the skin. The heart becomes distended, and if originally weakened may be seriously dilated or overstrained; the lungs become congested and inflamed, and any of thenumerous accidental germs which may be present will set up a broncho-pneumonia, which is the commonest cause of death in this disease, as in measles.
Strangely enough, while, as we do not positively know the germ, and hence cannot state definitely either the cause or the principal seat of the trouble, it is not generally believed that the condition of the lungs or the throat has much to do with the cough.
At all events, it is perfectly idle to treat the disease with cough mixtures or expectorants. The view toward which the majority of intelligent observers are inclined is that whooping-cough is an infection, the germ or toxin of which attacks the nervous system, and particularly the great "lung-stomach" (pneumo-gastric) nerve. At all events, the only remedies which appear to have any effect upon the disease are, in the early stages, mild local antiseptics in the nose and throat, and later those which diminish the irritability of the nerves without upsetting the appetite or depressing the general vigor. The disease is, for all its mildness, one of the most obstinate known.
A small percentage of cases run a violent course, in spite of the most intelligent and anxious care, both medical and household; but the vast majority of such complications as occur are either caused by carelessness or become serious only if neglected. Treating all children with whooping-cough as emphatically sick children, entitled to every care and excuse from exertion, every exemption and privilege that can be given them until the last whoop has been whooped, would prevent at least two-thirds of the almost ten thousanddeaths from whooping-cough that yearly disgrace the United States.
To sum up in fine: intelligent, effective isolation of all cases, the mild no less than the severe, would stamp out these Herods of the twentieth century within ten years. In the meantime, six weeks' sick-leave, with all the privileges and care appertaining thereto, will rob them of two-thirds of their terrors.