Part 5

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