Part 4

BAD EFFECTS OF SERUM

Antitoxin is contained in the blood serum of horses, which have been injected with diphtheria toxins, and cannot be entirely separated from other parts of the serum. The antitoxin itself probably produces no disturbances, but the serum sometimes causes hives and other inconveniences which quickly pass away. Probably no person with diphtheria has been permanently harmed by antitoxin. A few instances of death have followed the use of small immunizing doses in persons who were not sick and were subject to “horse asthma”. Such cases can be counted on the fingers of the hands and appear insignificant when contrasted with the hundreds of thousands of injections given during the same time. Diphtheria in one week causes five to ten times as many deaths as antitoxin serum in thirty years. In our large cities as many children are killed daily by motor vehicles as have died from antitoxin serum in thirty years. In the presence of the enormous danger from diphtheria, we can ignore the infinitesimal danger from the serum.

SUGGESTIONS OF MEASURES CALCULATED TO ELIMINATE DIPHTHERIA AND ITS DANGERS

1. Teaching children to have their throats examined when they are well, and the examination of the throat whenever a child is not well.

2. Call a doctor immediately when a child has a sore throat, swelling of the neck, or any croupy condition with hoarseness.

3. Taking cultures at the first visit of the doctor.

4. Giving antitoxin at once whenever there is any exudate in the throat or any condition resembling diphtheria.

5. Protection of children with antitoxin when they are intimately associated with others who have diphtheria.

6. Immunization of all children over six months of age with toxin-antitoxin.

7. Pasteurization or heating of all milk used by children.

SCARLET FEVER

Quite accurate descriptions of scarlet fever have existed for over three hundred years. One of the best of the early descriptions was written by William Douglass, a doctor in Boston, at the time when the first epidemic of this disease on this continent occurred in 1735-1736. From the Atlantic Coast the disease gradually extended westward and ever since has appeared at intervals in all parts of this country, following the settlers into the new regions and often causing many deaths among their children. A very striking peculiarity of scarlet fever is the great variation in virulence at different times. Sometimes it is so mild that scarcely any deaths are associated with it; at other times it takes on such a high degree of virulence that it wipes out whole families of children. In cities isolated cases are always present, and at intervals of a few years epidemic outbreaks occur. For many years in this country scarlet fever has gradually become less severe and while the total cases of the disease have not been much reduced, deaths have become much fewer. In recent years the proportion of deaths in scarlet fever has varied from 1.5 to 10 per cent. The death rate is highest in infancy and decreases with advancing age. Few cases of scarlet fever occur in children under one year of age, the largest number is observed in children up to 10 years. The disease is not so infrequent in young adults, and occasional instances appear in persons of quite advanced age. In these respects it resembles diphtheria. The disease is most prevalent in late autumn and winter.

CAUSE

The cause of scarlet fever is a small round bacterium known as the streptococcus of scarlet fever. This germ is in the secretion from the throat, and nose, in discharges from the ears, in pus from abscesses in the neck and in the discharges from infected wounds. The germ is very tenacious of life. In dried secretions it may remain alive for a long time. Instances are known where clothing, worn by children when sick with the disease, has been put away in a dark place. When this clothing was brought out many years later and given healthy children to wear they contracted scarlet fever.

MODE OF SPREADING

The germs of the disease pass from the sick person to others in particles of the secretions already mentioned. This transfer is usually accomplished by direct contact or by the agency of some carrier such as infected hands, eating utensils, toys, etc. In the manner of its dissemination scarlet fever resembles diphtheria very closely. This disease does not often pass from one person to another through the air as occurs in measles. Like diphtheria it is sometimes spread through milk which has been handled by someone who has recently had the disease or has been in close contact with it. Many epidemics of scarlet fever have been traced to contaminated milk. Usually the germs first lodge in the throat, often on the tonsils. Sometimes they enter through wounds.

EFFECTS OF THE INFECTION

The results of the location of the germs in the throat or in wounds depend on whether the individual is susceptible or immune. One attack of scarlet fever is followed by immunity which usually lasts through life. A second attack is very rare. Many persons probably are immune because they have sometime passed through very mild forms of the disease which were not recognized as scarlet fever at all. If the germs have secured a footing in a susceptible person they grow and produce their poisons or toxines. These cause inflammation of the tonsils, and other parts of the throat and as the toxines enter the blood and are carried to all parts of the body they cause fever, an eruption of the skin, and injury to various organs, especially the heart and kidneys.

SYMPTOMS

The period of incubation, i.e., the time between exposure or infection and the appearance of signs of illness--is very short in scarlet fever. It may be only a day or two and is almost always less than a week. The onset is very sudden. A child goes to school as usual in the morning and during the day becomes acutely sick, or he goes to bed at night in apparent health and by morning is virulently ill. At the beginning there is fever, which may quickly rise very high, sore throat and often vomiting. The throat is so sore that the patient usually complains very much of it, and acute pain is caused by swallowing. Vomiting once or several times in the early part of the disease is very common. Whenever a child is suddenly taken with fever, a sore throat and vomiting, scarlet fever should be suspected. Soon the eruption appears. This usually is present within 24 hours, but may be delayed 2 or 3 days in rare instances. It is first seen upon the neck and chest, rapidly extends to the body, then to the arms and legs. It is absent on the face. The skin about the mouth is paler than natural. The rash consists of very small red points closely set upon the skin which shows a uniform bright red flush. The skin looks much like that seen after severe sunburn. The color is bright scarlet. If one looks at the throat it is bright red, and often small white spots are seen upon the swollen tonsils. The tongue is coated white through which bright red points may project giving the appearance spoken of as “strawberry tongue.” At the sides of the neck the glands are swollen and tender. In size they may correspond to a marble, or may attain the size of a hen’s egg or larger. While the eruption is coming out, the throat remains very sore, and the fever is high. Especially at night, children in this acute stage of scarlet fever are apt to show delirium and may try to get out of bed. After two to four days the fever begins to fall, the throat becomes less sore, and the rash fades. As the rash fades the skin is roughened and peels in small flakes. About three weeks from the onset the thick skin of the palms of the hands and soles of the feet peels off. The detached pieces may be large, or only small delicate pieces may come from the fingers and toes. This late peeling is very characteristic. The case to which the preceding description applies is one of average severity. Many mild cases have little fever and slight rashes which last but a few hours. The sore throat is constant even in mild cases.

COMPLICATIONS

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