THE HERODS OF OUR DAY: SCARLET FEVER, MEASLES, AND WHOOPING-COUGH
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 compared with 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 diarrh[oe]al
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 that _at
least two-thirds of it is absolutely preventable_, and by the exercise
of only a very moderate amount 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 just such 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 term
_une 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 from the 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 best
growth 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 child it 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, _never_ treat
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," and _syn_, "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 in the 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 it probably 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 the _Cytoryctes
Variolæ_ and the _Treponema pallida_ were 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 for the 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 distinguish them 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 tongue parched, 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
steadily improves 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. These _flakes 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 of
_recovery_ that is the period of _greatest danger_ in 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 first
symptoms; 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 child_ that 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 and of 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 the numerous 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 thousand deaths 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.