Preventable Diseases

by Woods Hutchinson

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.