Part 3

Inflammation inside the ear is a frequent complication of measles. The involvement of the ear follows the passage of infectious material from the throat through the Eustachian tube. There is first fever and pain in the ear, which may subside, or after a day or two, a discharge from the ear appears. The discharge at first is watery and may be tinged with blood, but it soon becomes thick and purulent. With the appearance of discharge the pain subsides and the fever disappears. As healing takes place the discharge again becomes thinner and finally stops. Sometimes the inflammation extends from the ear to the bone back of the ear and mastoid disease results. This is recognized by tenderness on pressing on the bone. When this develops fever returns and the child appears sicker. With mastoid disease there is always danger of extension of the inflammation through the bone and the production of meningitis. Children with measles often have small whitish ulcers in the mouth, on the lining of the cheek, along the gums and on the edges and tip of the tongue. These are apt to be sensitive, causing pain when eating, and associated with profuse flow of saliva. Very rarely these ulcers become black and there results an extensive ulceration of the entire face. This occurs only in poorly nourished children, especially in institutions.

Measles has the property of rendering the patient susceptible to other contagious diseases. Tuberculosis often progresses rapidly after measles. This should always be suspected if fever and cough continue after the rash fades. If diphtheria is contracted during or soon after measles it runs a particularly virulent course. On the other hand when measles follows other contagious diseases, especially whooping cough, it is more fatal. Children with whooping cough should be kept away from measles with special care.

PREVENTION

Prevention of measles is difficult because the most contagious period is that which precedes the eruption. At this time the child is usually supposed to have a cold and mixes freely with other children. To prevent the further spread, each patient must be isolated until fever has been absent two or three days. Children who have not had measles may be allowed to go about freely for a week after exposure, and then should be isolated until 15 days after exposure. Fortunately we are now able to prevent measles in young children even after exposure. This is accomplished by drawing a little blood from one who has recently recovered from the disease and injecting it into the exposed one. This usually prevents the disease entirely or at any rate renders it mild if it occurs. Blood drawn from a parent and injected into the child soon after exposure renders the disease mild. The drawing of the required amount of blood is devoid of any danger.

TREATMENT

Each person with measles should be put to bed and kept there until free of fever. Care must be taken to avoid exposure to drafts. Fluids are to be given freely, including cold water. Tepid baths should be given and add much to the comfort of the patient. If the fever is high it may often be lowered by frequent sponging with tepid water. Even quite warm water is grateful and the temperature of the bath may be determined by the feelings of the patient. When pain in the ear occurs it may often be relieved by applying heat, either wet or dry as most grateful. The pain is often relieved and the congestion reduced by putting in the ear a few drops of warm glycerine to which 5 to 10 per cent of carbolic acid has been added. When there is a discharge from the ear, the secretion must not be allowed to accumulate. The canal may be gently washed with warm boric acid solution, using no force, and then dried with little swabs of absorbent cotton. The canal must not be plugged with cotton, but the discharge allowed to drain freely. If the discharge is profuse a pad of gauze over the ear may be used to absorb it. Persistent discharge or tenderness about the ear demands attention by someone specially qualified.

The room should be moderately darkened to relieve the eyes. The eyes should be bathed with warm boric acid solution and sticking of the eye lids may be prevented by the application to the edges, especially before sleep, of a little vaseline. The diet at first may be largely milk, but general diet may be given as the appetite returns. In young children any intestinal disturbance should receive the attention of a doctor. The mouth should be kept clean by washing with boric acid solution or other mild washes. If there has been hoarseness in a child with measles and it tends to increase, especially if there are any croupy symptoms, a doctor should be consulted at once. Such cases are sometimes diphtheria of the larynx, engrafted upon measles.

At the termination of measles the measures for disinfection consist especially of thorough airing and sunning of room and contents.

DIPHTHERIA

Of all the contagious diseases diphtheria is most thoroughly understood. The cause is known, its method of spread understood, and the way in which it acts to bring about the disease has been clearly demonstrated. For its prevention and cure we have certain measures. In spite of this it continues to be one of the most dreaded and fatal diseases of children. Diphtheria is an ancient disease and has appeared in destructive epidemics in Europe and America for two hundred years. It caused the death of George Washington, and the empress Josephine and her grand-child, heir apparent to the French throne, died from it. As early as 1771 it was epidemic in New York and in 1856 an epidemic in San Francisco occurred in which few children attacked by it recovered. Before antitoxin came into use in 1894, of those attacked, one-third to one-quarter died, and in hospitals often 60 to 80 per cent of the cases terminated in death. After antitoxin came into use many more recovered, but for some years now little improvement in the prevalence and fatality from diphtheria has occurred. In Chicago from 1911 to 1920, there was an annual average of 7,358 cases and 813 deaths from diphtheria. Of those dying, 63 per cent were children below school age, and 90 per cent were children less than 10 years of age.

CAUSE AND HOW IT ACTS

The cause of diphtheria, discovered in 1883-84 by Klebs and Loeffler, two German scientists, is the diphtheria bacillus. It is a minute rod shaped vegetable organism sometimes spoken of as a germ. If it is taken into the throat and lodges and grows upon the tonsils two results may follow. If the person is susceptible diphtheria occurs. If the person is immune no local changes occur and the individual becomes a carrier. Both may transfer the germs to other persons. We may compare what occurs here to what happens when persons come in contact with certain higher plants. The poison ivy vine has in its leaves a specific poison which causes an inflammation of the skin of some persons who are susceptible to it, but has no effect upon others who are immune. So the diphtheria plant as it grows in the throat produces soluble poisons or toxins which cause the changes we call diphtheria in a susceptible person, but is without effect on the immune person. The immune person is protected by an antidote or antitoxin which is in the blood, while the susceptible person has none. After the diphtheria bacilli have localized on the tonsil the events which follow may be briefly stated. In their growth the bacilli produce poisons and as a result the tonsils become red and swollen. On the surface of the tonsil, where the injury is greatest, white spots appear, and, as they enlarge, they run together to form the membrane which is characteristic of the disease. The name diphtheria means in its derivation a pellicle or skin. This membrane often extends beyond the tonsils, spreading over the throat, up to the roof of the mouth, over the palate. Sometimes it goes from the throat upward into the back of the nose or downward into the larynx. Wherever the membrane spreads the tissues below are swollen. In the nose the nostrils become occluded and the patient cannot breathe through the nose; in the throat the tonsils become very large interfering with swallowing and breathing. In the larynx the swelling causes hoarseness, croupy cough, and finally difficulty in breathing which may terminate in death from strangulation unless relieved. This is what was formerly called membranous croup. The membrane in the throat is first white, but as it thickens it becomes grayish-yellow, like buck skin, and finally may be black. It is closely adherent and not readily wiped off. When the disease extends to the larynx it tends to go further along the windpipe until it reaches the lungs with resulting pneumonia. When the changes in the throat are severe, there is external swelling of the neck. This may be extreme and is sometimes mistaken for mumps.

While the things we have spoken of are going on poisons are being taken by the blood to all parts of the body. In this way they reach and injure the muscle of the heart, and this injury is of such a degree in severe cases that it causes death. The poisons in the blood also profoundly injure the nervous system with resulting paralysis, so that the eyes are turned to the side, swallowing becomes difficult or impossible, and the muscles of the body and limbs become weak. These paralyses appear as late as six to eight weeks after the beginning of the disease. The symptoms as described are as they occur at the present time in cases untreated by antitoxin. Some cases are mild and never reach an extreme degree. In some the laryngeal symptoms develop early and death from obstruction to breathing may occur before much is seen in the throat. Sometimes a child who has what appears as a tonsilitis for several days shows a sudden extension to the larynx. The onset of diphtheria is insidious. The child acts “dopey”, has a little fever, and does not usually complain of pain in the throat. A child with acute tonsilitis is at first apparently much sicker, has more fever and complains more of soreness in the throat.

RECOGNITION OF DIPHTHERIA

Many cases of diphtheria may be recognized with considerable certainty by the appearance of the membrane in the throat, but there is only one way by which diphtheria of all degrees can be certainly recognized especially at the onset; that is by the detection of the germ. The making of cultures for diphtheria bacilli by a doctor is easily performed, and the materials for such cultures and their examination are provided for by local and state health laboratories. It would be desirable to have cultures made from every sore throat at the beginning. In this way much valuable time would be gained and many lives saved by the early use of antitoxin.

HOW DIPHTHERIA IS SPREAD

The general discussion of the ways in which contagious diseases are spread at the beginning of this article covers also diphtheria. The germs are in the secretions from the throat and nose. About one person out of every ten who is about a case of diphtheria becomes a carrier. Carriers play a large part in the spread of this disease. When an outbreak occurs in a school, it can usually be traced to one or more healthy carriers among the pupils or even the teachers. This is determined by making cultures from all the throats and noses. Diphtheria may be introduced into a community by a carrier who comes from outside.

TREATMENT

The sovereign remedy for diphtheria is antitoxin. If given early and in sufficient amount practically every case could be cured. Diphtheria antitoxin was first used in Berlin in 1891. It came into general use about 1894. Like most new remedies it met much opposition at first but is now recognized throughout the civilized world as the one essential means of cure. Cases given antitoxin on the first day practically always recover, only a little over 1 per cent die. Each day of delay is shown in the results. When given the second day, a little over 3 per cent die; the third day, over 6 per cent die; the fourth day, nearly 11 per cent, the fifth day, 15 per cent. In hospitals where many cases come late under treatment, about 10 per cent of the cases of diphtheria now die. This is in marked contrast to the 50 to 80 per cent of deaths in preantitoxin days. The patients who receive antitoxin early not only have greater chance of recovery but they get well promptly after a very brief illness, while those that come late under treatment, even if they recover, do so after a tedious illness and protracted period of convalescence.

The important things in treating diphtheria with antitoxin are early administration and sufficient amounts. The earlier given the smaller the dose required. The doctor from experience is able to estimate the dose needed in each case. A moderate dose is 5 to 10 thousand units, a full dose is from 20 to 30 thousand units. A small fire may be extinguished by a little water, but when it has spread much more is needed. The damage done by the diphtheria poisons before antitoxin is given cannot be undone by any amount of antitoxin. Antitoxin only prevents further injury. If sufficient injury to the heart and kidneys has occurred death will follow. Lost time cannot be regained. The antitoxin must be injected with a hypodermic needle. It cannot be given by mouth as it is destroyed and rendered useless in the stomach.

A few hours after enough antitoxin to control the disease has been given marked improvement occurs. The restlessness subsides, the swelling begins to grow less and the membrane separates at the edges and begins to peel off, the color reappears in the pasty cheeks, the pale lips become red again, and the child which has been blue and struggling for breath falls into quiet sleep. The change in a short time is one of the most remarkable observed in sick persons.

Local treatment is of little value. We no longer gargle, spray and swab the throat. We only try to keep the mouth and throat as clean as we can with cleansing washes but this is not done with the idea of influencing the disease.

If the obstruction to breathing from diphtheria in the larynx becomes extreme this must be relieved by making an opening in the windpipe or by passing a small rigid tube into the larynx through the mouth.

If antitoxin has been given late the complications which have developed must receive appropriate treatment. The duration of confinement to bed will depend on the time antitoxin was given. If given early the patient may be up in a few days. Serious damage to the heart and kidneys may require confinement to bed for several weeks. When there are heart disturbances perfect quiet in a horizontal position is imperative. Even rising to a sitting position or moderate exertion may be quickly fatal. Such accidents are most apt to occur about the 5th to the 14th day. Recovery from the paralysis is usually complete, but may require several weeks or months. These paralyses may continue to extend for two months, and during this time the weakened muscles must not be used. If unable to swallow the patient must be fed with a rubber tube through the nose or mouth.

PREVENTION OF DIPHTHERIA

Efforts to prevent diphtheria take two main directions. In one the object is to prevent the infection of new persons; in the other the measures employed are used to render well persons immune to the disease so that they will not become sick even if the germs reach them. Prevention of the infection of other persons is accomplished by isolation or quarantine of the sick individual and his attendant. To be effective quarantine must be carried out with conscientious attention to the smallest details. When a member of a family develops diphtheria, other members of the household may permanently leave the house if they are free of diphtheria germs as shown by cultures. The way in which quarantine is carried on has been described as it relates to all the diseases under discussion. In the case of diphtheria quarantine can only be terminated when repeated cultures from the throat and nose have shown that the diphtheria bacilli have disappeared. This may require several weeks and in exceptional cases even months. Carriers must be placed in quarantine as well as active cases. As recovery from diphtheria progresses the germs tend to die out and often are no longer present after a few days. Sometimes the germs persist and the patient becomes a persistent carrier. In the persistent carrier usually some abnormal condition in the nose and throat interferes with the efforts of nature to destroy the germs. When such are corrected the germs often quickly disappear. Most often diseased adenoids and tonsils are the offending conditions. In this case the removal of abnormal adenoids and tonsils is usually followed by prompt disappearance of the germs. Persistence of bacilli in the nose of children has sometimes been dependent on the presence of foreign bodies such as shoe buttons.

Aside from the measures outlined which have for their purpose the prevention of extension of the germs to other persons, important steps may be taken to render persons immune to diphtheria so that they will not be affected by the germs. This is accomplished in two ways. In the presence of immediate danger, small doses of antitoxin at intervals of three to four weeks procure protection. This is to be selected when children in a family cannot be protected from infection by quarantine. When immediate danger is absent an immunity which lasts for years may be secured by a sort of vaccination. This consists of three hypodermic injections at intervals of a week of a mixture of diphtheria toxin and antitoxin. The amount injected is very small and produces little or no inconvenience, but it is followed in a few weeks by a lasting protection against future infections. Almost all persons become immune after such injections. Such vaccinations have been used in a large scale among school children in New York City. Among 90,000 school children thus treated only one-fourth as many cases of diphtheria occurred last year as among the same number who refused the treatment. Injections are advised in children as early as possible after six months of age is reached. If this were uniformly employed children would be protected against diphtheria during the most susceptible years, and the disease would largely disappear. It is not too much to hope that this vaccination measure against this most fatal disease of children will accomplish corresponding favorable results to those which have followed vaccination against small pox.

It is not desirable or necessary to use such injections in children who are already immune. By a simple harmless test it is possible to determine if susceptibility exists in the individual. This is known as the Schick test. It is easily given and is devoid of all danger and discomfort. Such tests have shown that the proportion of persons susceptible to diphtheria varies with age. Few infants under six months are susceptible. From one to three years about 60 per cent are susceptible. As age advances the proportion gradually decreases so that by 20 years only about 20 per cent are liable to be infected if opportunity occurs. The children in the families of the well-to-do are susceptible in larger proportions than are those living in crowded parts of cities, and in country districts the proportion of susceptible children is very high.