Chapter II: Part 2

Complications of scarlet fever are common and it is in these that most of the danger lies. In the throat ulcers may form on the tonsils and elsewhere resulting in extensive destruction of tissues. Secondary to such conditions the glands in the neck may become swollen and may break down with resulting abscesses. The inflammation in the throat may extend to the nose and nasal sinuses with associated purulent discharge from the nostrils. Extension of the inflammation from the throat along the Eustachian tubes to the middle ear is frequent, and occurs most often when the illness has lasted a week or so. Many times this causes only transient pain, but often there develops a discharge of purulent material from the external ear. Sometimes the destruction within the ear is so severe and extensive that deafness results. Scarlet fever is responsible for a considerable number of instances of acquired deaf-mutism. Inflammation in the ear is indicated by pain which may be severe. After a few hours or sometimes only after days perforation of the drumhead is followed by a discharge from the ear. At first this is watery, sometimes tinged with blood, and soon becomes thick and purulent. With healing it again becomes thinner and finally stops. Most of such ears, after recovery have the hearing but little dulled. Fever is apt to recur or become higher when the trouble in the ear starts, and when perforation occurs the pain stops and the fever falls. Mastoid disease may be caused by extension of the inflammation from the ear to the bone behind the ear. This is recognized by pain, tenderness and swelling back of the ear. This is always dangerous.

It is quite common for patients with scarlet fever to have joint pains about 4 to 10 days after being taken sick. A few or many joints are involved, and as the pain disappears from one joint it appears in another. After a few days this disturbance comes to an end without leaving any permanent damage. The poisons of scarlet fever circulating in the blood, sometimes cause severe and even fatal damage to the heart. Injury to the kidneys is common with resulting acute Bright’s disease. This develops early or late in scarlet fever. The late cases, which come after the child has been sick for about three weeks, are most characteristic. Attention is often directed to this condition by a high colored, smoky urine, and by a puffy swelling of the eyelids. Later the swelling, due to the accumulation of water, becomes more extensive and general dropsy may result. With the dropsy and scanty, highly-colored urine, there may be associated disturbances of sight, headaches, vomiting and convulsions. Under appropriate treatment recovery from nephritis usually occurs, but in a few instances death results. While usually the heart and kidneys apparently return to normal after recovery from scarlet fever, there is much evidence which indicates that heart and kidney diseases later in life may be dependent upon damage done during this disease.

PREVENTION OF SCARLET FEVER

Effort to prevent scarlet fever may take two directions; the first is directed toward limiting the spread from the sick individual and consist of isolation and disinfection; the second concerns itself with the production of immunity in susceptible children. Similar to the Schick test in diphtheria, we have the Dick test in scarlet fever. If a very small quantity of the toxins of scarlet fever is injected into the skin of a person the result will vary according to whether the person is susceptible or immune to the disease. In the susceptible person a redness of the skin appears where the injection was made, while in the immune person this does not occur. In this way it is possible to pick out the children who will not contract scarlet fever if exposed. Those who give a positive reaction with the Dick test, i.e.--show a redness of the skin at the point of injection of the toxin--may be rendered immune by a process of vaccination. This consists of three injections at intervals of a week of small quantities of scarlet fever toxins or poisons. Little or no disturbance follows the administration of suitable amounts of the toxins, but usually an immunity results. There is every reason to believe that the immunity produced in this manner will be permanent as is that which follows an attack of the disease.

Children who have been exposed to scarlet fever should be kept away from other children for 10 days after the last exposure. To prevent spread of the disease the sick child must be isolated and this must be continued for four or five weeks, and in every case until all discharges from the nose and ears have stopped. The throat must also have become normal before the child is released. Removal of the tonsils does not appear to render children less susceptible to scarlet fever, but diseased tonsils when scarlet fever occurs add to the gravity of the case by favoring severe throat and nasal complications and especially extension to the ear. The details of isolation and terminal disinfection are discussed in detail in connection with their use in these diseases as a group.

Proper pasteurization of milk will prevent the spread of scarlet fever through this common food of children.

TREATMENT

The patient should be kept in bed for three weeks and chilling of the skin prevented. This is important in even the mildest cases in order to avoid kidney complications.

Skillful management and careful nursing does much good in scarlet fever. In the acute stage when fever is high much relief is afforded by baths. Small children may be placed in a bath of warm water and left there for 15 to 20 minutes. The temperature of the water must not be below that which is comfortable to the child, but it may be gradually lowered by adding cold water. While in the bath the head should be kept cool with wet cloths. The bath lowers the fever, quiets the nervous symptoms and favors sleep. In older children and adults the same results may be secured by sponging the body and by packing in wet sheets. In any case the temperature of the water used should be adapted to the sensibility of the patient. He should not be chilled, and quite warm water is often most grateful and followed by the most beneficial results.

Throughout the disease liberal amounts of water should be taken. This is given cold. In young children this can be accomplished by giving small quantities at frequent intervals. Water increases the elimination of the poisons, and its administration is one of the most important measures in the management of the disease. If the stomach is disturbed with a tendency to vomit cold water, small amounts of weak tea, taken as hot as possible, will sometimes help settle the stomach.

The diet during the early period will be principally milk. As the fever falls and the appetite returns cereals, toast, fruits and vegetables may be added. Eggs and meats are best withheld until three weeks from the onset. In septic cases with prolonged course, liberal feeding with easily digested foods is of the greatest importance. The mouth and throat should be kept as clean as possible. In persons who are large enough frequent use of bland gargles are desirable. For this purpose a tablespoonful of table salt or baking soda to a pint of water is suitable. Rubber bags filled loosely with finely cracked ice and applied to the neck, relieve the soreness of the throat. They are specially useful when the neck is swollen, and tend to prevent the formation of abscesses in the glands of the neck.

Pain in the ear is treated by the application of heat. A few drops of warm glycerine, to which carbolic acid in the proportion of five to ten per cent is added when dropped into the ear is very useful in relieving pain and reducing inflammation. When a discharge from the ear occurs, it must be collected on gauze which is burned. The canal must be kept as clean as possible and secretion not allowed to accumulate. If it is thick and does not run out freely the ear may be gently washed out with a saturated solution of boric acid in water. The ear must not be plugged with cotton but drainage must be facilitated. As the discharge becomes less the ear should be cleansed with boric acid dissolved in alcohol and then dried carefully with small pledgets of absorbent cotton.

Pain and tenderness back of the ear always calls for expert advice. Such cases often come to operation which must not be too long deferred if results are to be satisfactory. Also when signs of kidney disease appear, such as swelling of the eyelids, vomiting, etc., medical advice should be sought as quickly as possible.

The painful joints which occur in some cases are usually relieved by hot applications.

Until recently the treatment of scarlet fever has been entirely symptomatic, and directed toward conserving the strength of the child and toward preventing complications until nature cured the disease. Natural recovery occurs when the individual who is sick makes his own antidote for the poisons of the disease. We may assist nature by injecting into the acutely sick person, some blood drawn from an individual recently recovered from the disease. The convalescent blood, containing the antidote or antitoxin, serves to destroy the poison in the blood of the acutely sick child, and so aids recovery. Marked improvement often follows the use of convalescent serum. Such serum is not always at hand, but if an older child or adult who has had scarlet fever is available, his blood may be drawn and injected into the sick child. There is reason to believe that we may soon have a scarlet fever antitoxin, produced from horses in a manner similar to that in use in making antitoxin for diphtheria.

The successful treatment of scarlet fever with its many complications demands great skill. There is no disease in which the outcome depends more on judicious medical management and careful persistent nursing than in scarlet fever.

CHICKEN POX

Corresponding to measles in its degree of contagiousness, chicken pox occurs in extensive epidemics. In cities occasional cases appear at any time, but at intervals epidemic outbreaks occur. Most children have the disease during early years, but adults may also have it if they have not come in contact with it in childhood. This disease is entirely different from small pox and has no relationship to chickens. The cause is unknown, but doubtless is a living germ. The crusts from the skin have usually been blamed for the transferring of the disease from one person to others. The disease however is contagious before the crusts from the body have separated, and it is likely that the infectious agent may be in the respiratory secretions early in the disease. One attack protects for life. Second attacks are practically unknown.

The period of incubation which passes between the time of exposure and the appearance of signs of the disease is quite long, being about three weeks, varying in individuals between twelve and twenty-two days.

SYMPTOMS

As in all of these contagious diseases there is much variation in the severity of the individual case. Most cases of chicken pox are mild affairs. There is no fever or general disturbance, only the eruption of a mild or moderate sort. In a few individuals the disease assumes a severe form, in which case, fever, headache, backache and chilliness precede the eruption for a day. This is especially apt to occur in adults, but children may have some fever, and be generally unwell for a day or so before the eruption appears. Preceding the characteristic eruption there sometimes appears a day or so earlier a redness of the skin which has often been looked upon as scarlet fever until the typical eruption has developed.

The individual lesions of the chicken pox eruption pass through an evolution which is often very rapid. There is first a pink blotch or spot which soon is a little elevated above the skin, and disappears when pressed upon. Soon this is replaced by a vesicle or water blister. The vesicles are very near the surface of the skin and have a very thin covering, so that they often look like drops of water lying on the skin. The covering is soon broken, the fluid escapes, and as drying occurs a little crust or scab is left. This separates after several days. There is great variation in the number of these lesions. Sometimes only two or three develop. In severe cases the lesions are very closely placed on the body so that the finger can hardly be placed at any point between them. In the average case the lesions lie two or three inches apart. The distribution upon the body is quite characteristic. Most lesions are located on the parts of the body covered by clothing. In mild and moderate cases the eruption is almost confined to the trunk, but some lesions are also seen upon the arms, legs and forehead. In severe cases rather abundant eruption appears on the face, arms and legs. The lesions develop in the scalp, palms of the hands and soles of the feet in limited numbers especially in more severe cases. In such instances also, vesicles appear in the mucous membrane of the mouth, especially on the palate, and as they rupture they leave very sensitive points which are painful when food is taken.

One of the most characteristic things of the chicken pox eruption is that the lesions appear in crops. By the time the first lesions have reached the crusting stage others are present which are still vesicles, and still younger ones appear as pink spots. New lesions continue to appear for 3 or 4 days. In parts of the body where the skin is thick as on the palms of the hands, soles of the feet and forehead, the vesicles may remain unruptured for some time in which case the contents becomes yellowish and the surrounding skin reddened. If the skin has been rendered specially susceptible by any cause, the eruption is apt to be more severe. When chicken pox follows upon scarlet fever the eruption is apt to be profuse. Upon parts of the body which have been recently burned by the sun or subject to irritation under a surgical dressing, cast, or diaper, the eruption is more abundant than on other portions of the body.

COMPLICATIONS

There are few deaths following chicken pox and many of these cannot be properly blamed on the disease. There occur occasionally in poorly nourished children, gangrenous processes in the skin which may cause death. Blood poisoning may rarely follow the introduction of ordinary wound infections into the open lesions. The itching associated with the drying stage is very troublesome, and children sometimes in scratching, break the deeper layers of the skin, and small ulcers are produced which heal with scars or pits. One most often sees these scars on the forehead of children. Usually no permanent pits follow recovery.

DIFFERENT FROM SMALL POX

In the presence of small pox in a community its differentiation from some cases of chicken pox is important but sometimes difficult. One of the most striking differences between the two diseases is that in chicken pox the lesions occur in crops, all the stages of the eruption being present at the same time, while in small pox the lesions are all the same sort at any time. Another difference consists in the distribution of the eruption, in chicken pox most is on the covered parts of the body while in small pox the eruption is most abundant on the exposed parts of the skin, the face, wrists and hands. The presence of a fairly recent vaccination scar is always strong evidence against small pox.

PREVENTION

The only means of prevention is the isolation of the sick person until all the scabs have separated.

TREATMENT

Little treatment is required. Scratching of the skin is to be avoided. During the acute stage it is best to keep the skin dry. When the crusts have become dry baths may be given, and they probably hasten the separation of the scabs.

WHOOPING COUGH

Whooping cough is a very contagious disease which is contracted by most children during early years. Occasional persons who have escaped it in childhood are affected in adult life. Second attacks are rare. Sometimes a mother or nurse, who has had whooping cough in childhood, will again contract the disease when caring for children who are suffering from it. In distinction to most of the contagious diseases, whooping cough frequently occurs in infants less than a year of age, and the mortality associated with it is due largely to this fact. In Chicago from 1911 to 1922, out of 39,233 cases of whooping cough 1,630 were fatal. This represents one death out of every 24 patients, and corresponds very closely to the death rate in scarlet fever during the same period and is about three times as high as that in measles. Of 97 deaths from whooping cough in Chicago during 1922, 58 were in children under 1 year of age, and all but one were in children under 5 years. This serves to emphasize the importance of protecting young children from the disease as long as possible.

The cause of whooping cough appears to be a very minute bacillus which is found in the secretions from the upper respiratory tract. The action of this germ seems to be through poisons which it produces. The disease is transferred from one person to others through small particles of the secretions which are thrown out into the air during coughing. These moist particles being inhaled, gain a lodgement in the throat and thus cause another case. The time after exposure before symptoms appear is indefinite. Exact dates are hard to fix, but the incubation period is often very short. It may vary from five to fifteen days.

SYMPTOMS

The onset of whooping cough is gradual and for some time the child is usually supposed to be suffering from a cold or bronchitis. This first or catarrhal stage has nothing which is characteristic. There is a cough which gradually increases in severity. As the cough becomes more severe it assumes also more of a paroxysmal character with a tendency to recur at certain intervals. After about two weeks with the appearance of typical paroxysms the second or paroxysmal stage is entered upon. This lasts about six weeks on an average. The number of paroxysms varies greatly. There may be but one or two in 24 hours, or one may occur every hour. On an average about 10 to 15 are observed during 24 hours. They are apt to be most severe at night. When a paroxysm of coughing begins the child sits up and if old enough tries to get hold of something for support. The paroxysms consists of a series of expiratory coughs following in such rapid succession that the child is unable to get its breath. These have been compared to the explosions of a motor cycle, or those of a machine gun. At the height of a severe paroxysm the face is red or blue as in choking, saliva flows from the mouth, the tongue protrudes and is blue, the child struggles for breath, when finally, maybe only after several seconds, the spasm relaxes somewhat and air is drawn through the narrowed opening in the larynx with a peculiar crowing sound which is known as the whoop and has given the name of the disease. Such a series of events often is repeated several times in quick succession. Finally the end comes with vomiting which not only gets rid of the mucus in the throat but also empties the mucus from the air tubes. The child now falls down on the bed exhausted, the skin wet with sweat and it often falls to sleep. The struggle of the little patient in its efforts to get its breath cannot fail to awaken the sympathy of anyone who witnesses it. In older children the paroxysms are better borne and the general strength is not much affected. In young children with frequent paroxysms and loss of food from vomiting much depression and weakness develops. When there are frequent severe seizures the face in the intervals has a woe-begone expression, the skin is dusky and the eyes dull.

COMPLICATIONS

Occasionally a child dies in a severe paroxysm from strangulation. Most deaths are, however, dependent upon complications. Of these the most frequent is pneumonia, which is not uncommon in infants. Convulsions also cause many deaths. They may occur during the paroxysms of coughing and if repeated are very dangerous. The great congestion of the blood vessels of the head during the paroxysms sometimes leads to rupture of blood vessels, so, that nose-bleed is not infrequent. Hemorrhage into the brain may occur. Bleeding beneath the conjunctiva of the eye-ball results in red blotches over the white of the eye. These may be small or the blood may spread over the entire white portion of the eye-ball causing a most striking appearance. Bleeding into the loose tissues of the eye-lid may occur, producing a “black eye”. This has been mistaken as due to injury and should be remembered as something which may occur spontaneously during whooping cough.

In infants disturbances of digestion are frequent, and intestinal disorders in them are grave and add materially to the danger of the disease.

After recovery permanent damage to the heart may remain. The condition brought about by the disease also favors the rapid progress of any tubercular disease which otherwise might be of little moment.

PREVENTION

It is important that small children be kept away from this disease as long as possible. It is particularly difficult to limit the spread of the disease by isolation because the period of greatest contagiousness is that in the beginning when the child is supposed to have a cold. An older child in a family contracts the disease at school or in play with other children, and before he is suspected of having the disease, the younger members of the family have been infected. A vaccine has been prepared from the bacillus of whooping cough which appears to have some value in preventing and rendering milder the disease. As this is harmless it ought to be given to young children as soon after exposure as possible in the hope that it may prevent the disease or make it milder if it develops. After the paroxysms have been established the vaccine seems to be less useful.

TREATMENT

Many cases, especially in older healthy children, require little treatment. When paroxysms are frequent and severe, remedies to reduce them are desirable, and of these paregoric seems to do as well as any. If vomiting occurs frequently the loss of food is of importance. In such cases easily digested food should be given as soon after a paroxysm as possible so as to allow time for digestion and absorption before another paroxysm occurs. The feeding is of great importance in infants. A simple mechanical appliance is of considerable use to these children. It consists of a firm binder fastened snugly about the entire abdomen. It should come up over the lower ribs, and be held in place by straps over the shoulders. This gives support to the abdomen during coughing, enables the child to endure the paroxysms easier, and also supports the weaker points of the abdominal wall and so prevents the development of hernias or ruptures. Of all measures used in the treatment of whooping cough the most important is the furnishing of fresh air. In suitable weather the children should be kept out of doors all day, and at night should have plenty of fresh air. This is equally the case when pneumonia complicates whooping cough.

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TRANSCRIBER’S NOTES

Obvious errors and omissions in punctuation have been fixed.