Part 12 (1/2)
Suppose that, in spite of all our precautions, the disease has gained a foothold in the throat, what will be its course? This will depend, first of all, upon whether the invading germs have lodged in their commonest point of attack, the tonsils, palate, and upper throat, or have penetrated down the air-pa.s.sages into the larynx or voice-organ. In the former, which is far the commoner case, their presence will cause an irritation of the surface cells which brings out the leucocyte cavalry of the body to the defense, together with squads of the serum or watery fluid of the blood containing fibrin. These, together with the surface-cells, are rapidly coagulated and killed by the deadly toxin; and their remains form a coating upon the surface, which at first is scarcely perceptible, a thin, grayish film, but which in the course of twenty-four to forty-eight hours rapidly thickens to the well-known and dreaded false membrane. Before, however, it has thickened in more than occasional spots or patches, the toxin has begun to penetrate into the blood, and the little patient will complain of headache, feverishness, and backache, often--indeed, usually--before any very marked soreness in the throat is complained of. Roughly speaking, attacks of sore throat, which begin first of all with well-marked soreness and pain in the throat, followed later by headache, backache, and fever, are not very likely to be diphtheria. The bacilli multiply and increase in their deadly mat on the surface of the throat, larger and larger amounts of the poison are poured into the blood, the temperature goes up, the headache increases, the child often begins to vomit, and becomes seriously ill. The glands of the neck, in their efforts to arrest and neutralize the poison, become swollen and sore to the touch, the breath becomes foul from the breaking down of the membrane in the throat, the pulse becomes rapid and weak from the effect of the poison upon the heart, and the dreaded picture of the disease rapidly develops.
This process in from sixty to eighty per cent of cases will continue for from three to seven days, when a check will come and the condition will gradually improve. This is a sign that the defensive tissues of the body have succeeded in rallying their forces against the attack, and have poured out sufficient amounts of their natural ant.i.toxin to neutralize the poisons poured in by the invaders. The membrane begins to break down and peel off the throat, the temperature goes down, the headache disappears, the swelling in the glands of the neck may either subside or go on to suppuration and rupture, but within another week the child is fairly on the way to recovery.
Should the invaders, however, have secured a foothold in the larynx, then the picture is sadly different. The child may have even less headache, temperature, and general sense of illness; but he begins to cough, and the cough has a ringing, bra.s.sy sound. Within forty-eight, or even twenty-four, hours he begins to have difficulty in respiration.
This rapidly increases as the delicate tissues of the larynx swell under the attack of the poison, and the very membrane which is created in an attempt at defense becomes the body's own undoing by increasing the blocking of the air-pa.s.sages. The difficulty of breathing becomes greater and greater, until the little victim tosses continually from side to side in one constant, agonizing struggle for breath. After a time, however, the acc.u.mulation of carbon dioxide in the blood produces its merciful narcotic effect, and the struggles cease. The breathing becomes shallower and shallower, the lips become first blue, then ashy pale, and the little torch of life goes out with a flicker. This was what we had to expect, in spite of our utmost effort, in from seventy to ninety per cent of these laryngeal cases, before the days of the blessed ant.i.toxin. Now we actually reverse these percentages, prevent the vast majority of cases from developing serious laryngeal symptoms at all, and save from seventy to eighty per cent of those who do.
Our only resource in this form of the disease used to be by mechanical or surgical means, opening the windpipe below the level of the obstruction and inserting a curved silver tube--the so-called tracheotomy operation; or later, and less heroic, by pus.h.i.+ng forcibly down into the larynx, and through and past the obstruction at the vocal cords, a small metal tube through which the child could manage to breathe. This was known as intubation. But these were both distressing and painful methods, and, what was far worse, pitifully broken reeds to depend upon. In spite of the utmost skill of our surgeons, from fifty to eighty per cent of cases that were tracheotomized, and from forty to sixty per cent of those that were intubated, died. In many cases they were enabled to breathe, their attacks of suffocation were relieved--but still they died.
This leads us to the most important single fact about the course of the disease, and that is that the chief source of danger is not so much from direct suffocation as from general collapse, and particularly failure of the heart.
This has given us two other data of great importance and value, namely, that while the immediate and greatest peril is over when the membrane has become loosened and the temperature has begun to subside, in both ordinary throat and in laryngeal forms of the disease, the patient is by no means out of danger. While the ant.i.toxins poured out by his body have completely defeated the invading toxins in the open field of the blood, yet almost every tissue of the body is still saturated with these latter and has often been seriously damaged by them before their course was checked. For instance, nearly two-thirds of our diphtheria cases, which are properly examined, will show alb.u.min in the urine, showing that the kidney-cells have been attacked and poisoned by the toxin. This may go on to a fatal attack of uremia; but fortunately, not commonly, far less so than in scarlet fever. The kidneys usually recover completely, but this may take weeks and months. Again, many cases of diphtheria will show a weak and rapid pulse, which will persist for weeks after the patient has apparently recovered; and if the little ones are allowed to sit up too soon, or to indulge in any sudden movements or muscular strains, this weak and rapid pulse will suddenly change into an attack of heart failure and, possibly, fatal collapse. This, again, ill.u.s.trates the saturation of the poison, as these effects are now known to be due in part to a direct poisoning of the muscle of the heart itself, and later to serious damage done to the nerves controlling the heart, chiefly the pneumo-gastric. Moral: Keep the little patient in bed for at least two weeks or, better, three. He will have to spend a month or more in quarantine, anyway.
Last of all, and by no means least interesting, are the effects which are produced upon the nervous system. One day, while the child is recovering, and is possibly beginning to sit up in bed, a gla.s.s of milk is handed to him. The little one drinks it eagerly and attempts to swallow, but suddenly it chokes, half strangles, and back comes the milk, pouring out through the nostrils. Paralysis of the soft palate has occurred from poisoning of the nerves controlling it, caused by direct penetration of the toxin. Sometimes the muscles of the eye become paralyzed and the little one squints, or can no longer see to read.
Fortunately, most of these alarming results go only to a certain degree, and then gradually fade away and disappear; but this may take months or even longer. In a certain number, however, the nerves of respiration, or those controlling the heart-beat, become affected, and the patient dies suddenly from heart failure.
This strange after-effect upon the nervous system, which was first clearly noticed in diphtheria and syphilis, has now been found to occur in lesser degree in a large number of our infectious diseases, so that many of our most serious paralyses and other diseases of the nervous system are now traceable to such causes.
These effects of the diphtheria toxin are also of interest for a somewhat unexpected reason, since it has been claimed that they are effects of the ant.i.toxin, by those who are opposed to its use. Every one of them was well recognized as a possible result of diphtheria long before the ant.i.toxin was discovered, and every one of them can be readily produced by injections of diphtheria bacilli or their toxin into animals.
It is quite possibly true that there are more cases of nerve-poisoning (neuritis) and of paralysis following diphtheria than there were before the use of ant.i.toxin, but that is for the simple and sufficient reason that there are more children left alive to display them! And between a child with a temporary squint and a dead child few mothers would hesitate long in their choice.
CHAPTER XI
THE HERODS OF OUR DAY: SCARLET FEVER, MEASLES, AND WHOOPING-COUGH
Why is a disease a disease of childhood? First and fundamentally, because that is the earliest period at which a human being can have it.
But the problem goes deeper than this. There is no more interesting and important group of diseases in the whole realm of pathology than those which we calmly dub ”the diseases of childhood,” and thereby dismiss to the limbo of unavoidable accidents and discomforts, like flies, mosquitoes, and stubbed toes, which are best treated with a shrug of the shoulders and such stoic philosophy as we can muster. They are interesting, because the moment we begin to study them intelligently we stumble upon some of the profoundest and most far-reaching problems of resistance to disease; important, because, trifling as we regard them, and indeed largely just because we so regard them, they kill, or handicap for life, more children in civilized communities than the most deadly pestilence. Measles, for instance, according to the last United States census, causes yearly nearly thirteen thousand deaths, while smallpox causes so few that it is not listed among the important causes of death. Scarlet fever causes sixty-three hundred and thirty-three deaths, as compared with barely five thousand from appendicitis and the same number from rheumatism. Whooping-cough causes ninety-nine hundred and fifty-eight deaths, more than double the mortality from diabetes and nearly equal to that of malarial fever.
In medicine, as in war, the gravest and deadliest mistake that you can make is to despise your enemy. These trivial disorders, these trifling ailments, which every one takes as a matter of course, and expects to go through with, like teething, tight shoes, and learning to smoke, sweep away every year in these United States the lives of from forty to fifty thousand children, reaching the bad eminence of fifth upon our mortality lists, only consumption, pneumonia, heart disease, and diarrh[oe]al diseases ranking above them. Of course, it is obvious that these diseases outrank many other more serious ones among the ”captains of the men of death,” largely upon the familiar principle of the old riddle, whereby the white sheep eat more gra.s.s than the black, ”because there are more of them.”
While only a relatively small percentage of us ever have the bad luck to be attacked by typhoid fever, rheumatism, or appendicitis, to say nothing of cholera and smallpox, the vast majority of us have gone through two or more of these diseases of childhood; so that, though the death-rate of each and all of them is low, yet the number of cases is so enormous that the absolute total mounts high. But the pity and, at the same time, the practical importance of this heavy death-roll is that _at least two-thirds of it is absolutely preventable_, and by the exercise of only a very moderate amount of intelligence and vigilance. It is, of course, obvious that in a group of diseases which numbers its victims literally by the million every year there will inevitably occur a certain minute percentage of fatal results due to what might be termed unavoidable causes, like a badly nourished condition of the child attacked, unusual circ.u.mstances preventing proper shelter or nursing, or an exceptional virulence of the disease, such as will occur in two or three cases of every thousand in even the most trifling infectious malady. But even after making liberal allowance for what might be termed the unavoidable fatalities, at least two-thirds, and more probably nine-tenths, of the deaths from children's diseases might be prevented upon two grounds:--
First, that they are contagious and absolutely dependent upon a living germ, whose spread can be prevented; and secondly, and practically even more important, that more than half the deaths from them are due, not to the disease itself, but to complications occurring during the period of recovery, caused, for the most part, by gross carelessness on the part of the mother or nurse. A large majority, for instance, of the nearly thirteen thousand deaths attributed to measles are due to bronchitis, caught by letting the child go out-of-doors too soon after recovery, which means, of course, either a chill falling upon the irritated and weakened bronchial mucous membrane, or an infection by one of the score of disease-germs, such as those of influenza, pneumonia, bronchitis, and even tuberculosis, which are continually lying in wait for just such an emergency as this--just such a weakening of the vital resistance.
It is a sadly familiar statement in the history of fatal cases of tuberculosis that the trouble ”began with an attack of measles,” or whooping-cough, or a bad cold, and was mistaken for a mere ”hanging on”
of one of these milder maladies until it had gained a foothold that there was no dislodging. As breakers of the wall of the hollow square of the body-cells, drawn up to resist the cavalry charges of tuberculosis, pneumonia, and rheumatism, few can be compared in deadliness with the diseases of childhood and ”common colds.”
Further, while all of them except scarlet fever have a mortality so low that it might almost be described as what the French delicately term _une quant.i.te negligeable_, yet a surprisingly large number of the survivors do not escape scot-free, but bear scars which they may carry to their graves, or which may even carry them to that bourne later.
Again, the actual percentage of the survivors who are marked in this fas.h.i.+on is small, but such milliards of children are attacked every year that, on the old familiar principle, ”if you throw plenty of mud some of it will stick,” quite a serious number are more or less handicapped by these remainders. For instance, quite a noticeable percentage of cases of chronic eye troubles, particularly of the lids and conjunctiva, such as ”granulated” lids, styes, ulcers of the cornea, date from an attack of measles or even whooping-cough. Many cases of nasal catarrh or chronic throat trouble or bronchitis in children date from the same source. A large group of chronic discharges from the ear and perforations of the ear-drum are a direct after-result of scarlet fever; and the frequency with which this disease causes serious disturbances of the kidneys is almost a household word. Less definitely traceable, but even more serious in their entirety, are the large group of chronic depression of vigor, loss of appet.i.te, various forms of indigestion and of bowel trouble, which are left behind after the visitation of one of these minor pests, particularly among the children of the poorer cla.s.ses, who are unable to obtain the highly nutritious, appetizing, and delicately cooked foods which are so essential to the full recovery of the little invalids.
One of the English commissions which was investigating the alleged physical deterioration of city and town populations stumbled upon a singularly interesting and significant fact in this connection, while plotting the curves of the rate of growth of the children in a given district in Scotland during a series of years. They were struck with the fact that children born in certain years in the same families, neighborhoods, and presumably the same circ.u.mstances, grew more rapidly and had a lower death-rate than those born in other years; and that, on the other hand, children born in other years fell almost as far below the normal in their rate of growth. The only factor which they found to coincide with these differences was that in the years in which those children who made the slowest growth were born there had been unusually heavy epidemics of children's diseases and a high mortality; while, on the other hand, those years whose ”crop” of children made the best growth had been unusually free from such epidemics and had a correspondingly low mortality, showing clearly that even the survivors of children's diseases were not only not benefited, but distinctly handicapped and set back in their growth by the energy, so to speak, wasted in resisting the onslaught.
This brings us to an aspect of these diseases which from both a philosophic and a practical point of view is most interesting and profoundly significant; and that is the question with which we opened: Why is a disease a disease of childhood? The old, primitive view was as guileless and as simple as the age in which the diseases occurred. They were regarded not merely by the laity but by grave and reverend physicians of the Dark Ages as a sort of necessary vital crisis peculiar and appropriate to each particular age of life,--a sort of sweating out and erupting of ”peccant humors” of the blood, which must be got rid of or else the individual would not thrive. Incredible as it may seem, so far was this idea extended, that the great Arabian physician-philosopher, Rhazes, actually included smallpox in this group, as the last of the ”crises of growth” which had to appear and have its way in young manhood or womanhood. Quaint little echoes of this simple faith still ring in the popular mind, as, for instance, in the widespread notion about the dangerousness of doing anything to check the eruption in measles and cause it to ”strike in.” Any mother in Israel will tell you, the first time you propose a bath or a wet pack to reduce the temperature in measles, that if you so much as touch water to the skin of that child it will ”drive the rash in” and cause it to die in convulsions. And, of course, one of the commonest of a physician's memories is the expression of relief from the mother or aunt in any of these mild eruptive fevers, where the skin was well reddened and spotted: ”Well, anyway, doctor, it is a splendid thing to get the rash so well out!” Until within the last ten or fifteen years it was no uncommon thing to hear the expression: ”Well, I suppose we might just as well let Willie and Susie go on to school and get the measles and have done with it. It seems to be a real mild sort this time.” Of course this view was scientifically shattered two or more decades ago by our recognition of the infectious nature of these diseases, but practically its hold on the public mind const.i.tutes one of the most serious and vital obstacles in the way of the health-officer when he endeavors to attack and break up an epidemic of measles, whooping-cough, or chicken-pox.
It cannot be too strongly emphasized that, mild and in their immediate results trifling, as most of these ”little diseases” are, they are genuine members of that cla.s.s of pathologic poison-snakes, the germ-infections; that when they bite, they bite to kill; that two to five times in every hundred they do kill; that, like all other infections, they are capable of inflicting serious and permanent damage upon the great vital organs, the heart, the kidneys, the liver, and the brain; and that they are the very jackals of diseases, tracing down and pointing out the prey to the lions that work in partners.h.i.+p with them.
With whatever we may treat measles and whooping-cough, _never_ treat them with contempt!
The next conception of the ”whyness” of children's diseases was that as one star differs from another in glory, so does one germ differ from another in virulence; that the germs of these particular diseases just happened to be from the beginning unusually mild and at the same time highly contagious, so that they remained permanently scattered about throughout the community, and attacked each successive brood of newborn children as quickly as they could conveniently get at them. Being so mild and so comparatively seldom fatal, little or no alarm was excited by them and few efforts made to check their spread, so that they continued to flourish, generation after generation. Upon this theory the germs of measles, chicken-pox, whooping-cough, mumps, would be in something like the same cla.s.s as the numerous species of bacteria and other germs that normally inhabit the human mouth, stomach, and intestines; for the most part, comparatively harmless parasites, or what are technically now known as ”_symbiotes_” (from two Greek words, _bios_, ”life,” and _syn_, ”with”), a sort of little partners or non-paying boarders, for the most part harmless, but occasionally capable of making trouble. There are scores of species of such germs in our food-ca.n.a.ls, some of which may be even slightly helpful in the process of digestion. Only a very small per cent of the bacilli of any sort in the world are harmful; the vast majority are exceedingly helpful.
There is evidently some truth in this view of children's diseases, especially so far as the reason for their steady persistence and undiminished spread is concerned, namely, the comparative carelessness and indifference with which they are regarded and treated. But some rather striking developments of recent years have raised grave doubts in our minds as to whether they were always the mild and inoffensive ”house cats” that they pa.s.s for at present. These are the astonis.h.i.+ng and almost incredible developments that occur when for the first time these mild and harmless ”diseaselets” are introduced to a savage or half-civilized tribe. Like an Arabian Nights' transformation, our sleepy, purring, but still able to scratch, ”p.u.s.s.y cat” flashes out as a ravenous man-eating tiger, killing and maiming right and left.