Part 2

In recent years persons who are known as disease carriers have been looked on as important factors in the spread of many contagious diseases. The part they play in diphtheria has been abundantly demonstrated and is important. Carriers in this sense are persons who are well, but who carry about disease germs in their throats or noses. They may have recently passed through mild attacks of the disease whose germs remain for a long time after recovery, or they may have received the germs from sick persons, never having been sick. This condition of carriage may persist a long time, and carriers are especially dangerous because not usually suspected.

COMMON PECULIARITIES

Some common peculiarities of contagious diseases may be mentioned. After exposure a definite period of incubation passes before any symptoms develop; many of these diseases have characteristic skin eruptions; they occur in epidemics, especially in children, and one attack usually protects the individual during life.

PREVENTION

Because of the wide distribution of contagious disease and the large number of deaths caused by them, attempts to prevent their spread have been made from remote times. This has been largely concerned with isolation or quarantine of sick persons. Doubtless these measures have been useful, but that they have largely failed to accomplish what is expected of them is not surprising if we bear in mind that many of these diseases are most contagious early in their course before they are recognized and before quarantine is begun, and if we consider the important part which is played by healthy carriers who are not suspected and go about freely.

An ideal condition would obtain if it were possible to render all children, early in life, immune to these diseases. In vaccination against smallpox we have a measure which has banished smallpox to a large extent and which, if universally employed, would eradicate the disease. Similar vaccination measures are now available for diphtheria and scarlet fever. They are easily carried out, devoid of danger, and rarely cause even slight discomfort. These will be again referred to in discussing the individual diseases.

QUARANTINE AND DISINFECTION

The term quarantine was originally applied to the forty days during which a ship suspected of being infected with a contagious disease was held before those on board were allowed to come into contact with those on shore. In present conditions a better term to use is isolation which varies in length and severity in different diseases. The period of isolation in diphtheria is until the person is free of the germs which cause the disease. As it is possible to cultivate and recognize the diphtheria germs the period of isolation can be accurately determined. At times it is only a few days; at other times it must be extended to weeks or even months. In the case of scarlet fever and diphtheria the attendant who is liable to carry infectious materials is isolated with the patient.

In scarlet fever the isolation is four or five weeks and until all discharges have ceased. Discharges from the nose and ear after scarlet fever are apt to contain the cause of the disease, and so are dangerous. Epidemics of scarlet fever have been started in communities by the coming of a child who still had a running ear following scarlet fever many weeks previously.

The danger of transferring measles is quickly over, and patients may be released after the fever has been absent two or three days.

In chicken pox the separation of all scabs is the measure of the isolation period.

Whooping cough is released when the characteristic paroxyms cease.

If measles or whooping cough appears in a child in a family, other children may be sent from home in hope that they have not been infected. They must not be sent where there are children who may be infected if the disease develops.

In diphtheria and scarlet fever the separation of the sick must be absolute. No communication must be allowed between the sick and well. The patient and attendant should be in a separate building, or in a room which can be shut off from the rest of the house. Nothing should pass from the sick room that is not sterilized at once. All discharges should be collected on pieces of gauze, and these with surgical dressings, portions of food, fruit or other material which the patient may have handled may be placed in paper bags and burned without opening. All sheets, towels, pillow covers and bed clothes should be boiled in water before being washed. The same disinfection should be used for eating utensils. After recovery the patient and attendant should be given a thorough bath in warm water with soap. The hair also is washed. In a clean room fresh clothing is to be put on. After the isolation room is emptied of its occupants all its contents are disinfected as thoroughly as possible. This can be accomplished by boiling everything which can be treated in this way, by burning things which have little value and which cannot be boiled such as books, toys, mattresses and pillows contaminated by secretions, by thoroughly washing with warm water and soap all wood work, floors and furniture, and by thoroughly airing and sunning the bedding. The fumigation which was formerly generally used has been largely discontinued. Much more can be accomplished by washing, painting, and removal of paper and replacing by new. A safe rule is to burn everything which can not be boiled in water or thoroughly cleansed with warm water and soap. Fresh air and sunshine are most efficient destroyers of germs. Children recently relieved from isolation after diphtheria and especially after scarlet fever should not sleep with well children for a week or two, and should not be kissed.

The disinfection required after measles, whooping cough and chicken pox is limited and consists of thorough airing and sunning.

It is not desirable to confine children with whooping cough. They may be taken out of doors, but must not be allowed to play with well children. Diphtheria carriers may also be allowed to be out of doors provided provision is made for keeping them from well persons. Their eating utensils, toys, etc., must always be treated as are those of persons with active diphtheria.

The closing of schools at the times of outbreaks of the contagious diseases is of doubtful value. It does not prevent contact between the children when at play. Most favorable conditions for dissemination of contagious diseases exist in Sunday schools since children too young to attend school as well as older children are here brought together. If closing of schools is to accomplish any good in controlling contagious diseases it must be combined with separation of the families of children at home, and the prevention of children coming together in picture shows and other places.

It is hardly necessary to state that no child who is acutely sick should be sent to school. So many contagious diseases are impossible of recognition at the beginning that each case of sickness must be considered suspicious until it is shown to be harmless.

MEASLES

Measles is one of the most contagious diseases, ranking in this respect with small pox. It was apparently observed by the earliest medical writers and has been known throughout the world for several hundred years as a common epidemic disease. It is characteristic of measles that it usually occurs in epidemics which vary much in severity, and which appear especially in the spring months. At such times almost every one in a community who has not had measles is affected. After a longer or shorter interval when susceptible persons have again accumulated, a new introduction results in another epidemic. In cities a few cases occur every year and about every two or three years epidemic outbreaks appear. Almost every person is susceptible to measles until he contracts the disease after which there is almost perfect immunity for life. Second attacks are very rare. As high as 98 or 99 per cent of people are originally susceptible. The disease is usually contracted at the first exposure. If persons have escaped in earlier life they may be affected in adult years, even at advanced age. Among people who have never had measles, epidemics may take on alarming proportions. When this disease was introduced into the Faroe Islands in 1846, over 6,000 of the 7,782 inhabitants were attacked. In 1775 measles was introduced into the Sandwich Islands and in four months 40,000 of the population of 150,000 died. In 1875, measles was carried to the Fiji Islands with the resulting death of one-fifth of the population (20,000). In the late war many young men from rural districts, who had never had measles, were brought together in military camps. When measles gained entrance extensive epidemics resulted. Because of the great contagiousness of measles, and its almost universal susceptibility most persons are attacked early in life. While it is especially a disease of childhood, it rarely occurs in infants below six months of age. By the time 15 years has been reached about 90 per cent of children have had the disease.

Healthy children living in good hygienic surroundings usually pass through measles without much trouble. Delicate, poorly nourished children who live in institutions and in parts of cities where there is overcrowding in unhygienic conditions often do badly and many of them die. This is especially true of young children. As a cause of death among children measles ranks third among the acute contagious diseases. In the registration area of the United States in 1920, there were 7,712 deaths from measles of which 78 per cent were in children under 5 years of age. In Chicago from 1917 to 1921, 718 deaths from measles occurred, over 90 per cent of which were children under 5 years of age. In this country 2 to 3 per cent of children in private families who have measles die, but in institutions and hospitals the deaths may reach 6 to 10 per cent.

Emphasis has been placed on the fact that measles causes many deaths, especially among young children, in order to draw attention to the fact that young children, especially those not very strong, should be kept away from this disease as long as possible. To willfully expose young children to measles, as is sometimes done, is dangerous and open to the severest criticism.

CAUSE AND MODE OF SPREAD

The germ which causes measles has not been certainly isolated but it is known to be in the secretions from the respiratory mucous membrane. It is there in the earliest stages of the disease, two or three days before the skin eruption appears, and it disappears when the eruption fades. The danger of spreading the disease is therefore present very early, before the eruption develops, and it is soon over, having passed when fever has been absent a couple of days. The germs pass from the sick to others in the secretions from the respiratory tract. In coughing and sneezing small particles of infected mucus are thrown out into the air as mouth spray and the inhalation of these causes infection. Outside the body the germs quickly die. They do not survive drying and exposure to the sunlight. Transfer of the disease by a third person or by any mechanical carrier can only occur if it is done quickly. The particles of moist secretion which convey the infection may be very small and may be carried several feet in the air. Thus a susceptible individual may be infected by coming into a room with a case of measles although never approaching very close. Similarly a child coming down with measles while in school may sow the germs widely among other pupils.

SYMPTOMS

The symptoms may be considered as they occur in three stages; catarrhal, eruptive and convalescent. After infection no signs of illness appear for several days. This is the period of incubation. About eight to ten days after exposure, very fine, pin-point size spots appear on the lining of the cheek opposite the molar teeth. These are known as Koplik spots. They are bluish-white in color and seen only by bright daylight. About the same time catarrhal symptoms appear, such as a little fever, coryza, sneezing, hoarse cough, watery eyes. The symptoms as they occur in this catarrhal stage of measles are usually supposed to be due to a cold. After a further three, four or five days, i. e.--12 to 13 days after exposure--the typical eruption appears. It is first seen over the forehead at the border of the hair, behind the ears and on the neck. This gradually spreads during two or three days over the face, body and finally the arms and legs. The eruption occurs as small red spots or blotches, round or oval in form. They tend to become larger and finally run together, so that at the height of the eruption the skin of the face and body is completely covered, only small islands of pale skin appearing. The color of the eruption is deeper red than that of scarlet fever, and is much coarser. During the time the eruption is coming out the fever is often high and the catarrhal symptoms are marked. Light hurts the eyes, and they become bleary red, the secretions causing the lids to stick together during sleep. The cough is often very troublesome. At first it is dry and later looser. There is often hoarseness and sometimes the patient can talk only in a whisper. When the eruption has reached its height it soon begins to fade, but traces often remain for a week or more. As the eruption begins to fade the fever falls, often very rapidly. A fine branny scaling of the skin follows the fading of the eruption.

COMPLICATIONS

The danger from measles depends almost entirely on its complications. In any case if fever persists after the rash fades and the patient does not rapidly improve complications must be suspected. Sometimes a looseness of the bowels occurs with the onset of measles, but it usually stops as the eruption comes out. In babies the intestinal disturbance may continue and grow worse as the disease progresses. This may become a grave complication in young children. Most often dangerous complications have to do with the respiratory tract. In small children there is a special tendency for the inflammation to extend from the bronchial tubes to the lungs with resulting pneumonia, which is the most common cause of death. Sometimes the inflammation extends to the covering of the lungs producing pleurisy. This may become purulent, and then is known as empyema. In this condition pus collects in the chest between the lung and the chest wall, causing compression of the lung. When the pleurisy begins there is pain in the side, but as the pus accumulates this stops. With the collection of pus in the side breathing is interfered with and in children especially the side affected may be seen to be enlarged and to move less than the other side when the patient breathes. This condition is associated with fever and sweats, and not infrequently has aroused suspicion of consumption.