Rural Hygiene Part 23

_Milk infection by typhoid._

Milk is responsible for perhaps 5 per cent of the cases of infection.

Although the infection is always foreign to the milk itself,--that is, enters the milk only after the milk is drawn from the cow,--milk frequently becomes infected because infected water has been added to it or because the cans have been washed in infected water, or because some persons in contact with a typhoid patient have had their hands infected and then handled the milk or the milk utensils. There are a number of epidemics which have been clearly traced to milk polluted in one of these ways. In Somerville, Ma.s.sachusetts, for example, in 1892, 32 cases occurred, 30 of which were on the route of a single milkman. It was found that the milkman had two sons, one of whom had typhoid fever just before the outbreak. This son washed the milk cans and mixed the milk in a milk house in the city, and the inference was that in some way this man infected the milk, probably in one of the mixing cans.

In Stamford, Connecticut, in 1895, an epidemic occurred which caused 386 cases and 22 deaths. Ninety-five per cent of all the cases occurred among those who took milk from one dealer, and it was probable that in this case the infection came from using a badly polluted water to wash the cans. In Montclair, in 1902, a small epidemic involving 28 cases occurred, where the health officers decided, after having found out that the cases were all among those customers taking milk in pint bottles, that the infection came from a house on the route, where typhoid fever had occurred. It appeared that this family infected the bottles left at their house, and since the milkman failed to sterilize the bottles before re-filling them, the infection was pa.s.sed on to others also taking milk in pint bottles.

_Infection by flies._

Flies also transmit typhoid fever chiefly because they are essentially such unclean insects. They are born in filth and they delight in living in filth, and if privies and cesspools and manure piles and garbage piles could be shut out from flies, the fly pestilence would be at an end. The feet of the flies are suction tubes, and when a fly lights on any object, it causes more or less of that material to stick to his feet, and then when he flies elsewhere, he may leave the particles on the object on which he alights. This has been proved by allowing a fly, caught in the house of a typhoid fever patient, to walk over a gelatine plate, leaving on the plate not merely his tracks, but the germs which his feet had carried. When the plate was exposed in an incubator, it was found that, within two or three days, millions of bacteria had grown from the number deposited by the one fly.

It is believed that the number of cases of typhoid which occurred in our Spanish-American War, at the military camps, and which were so disastrous, were due largely to flies. Among the 107,973 soldiers quartered in military camps at that time, there were 20,738 cases of typhoid fever, and the number of those which were fatal const.i.tuted 86 per cent of all the deaths from disease during this campaign. It was shown by the commission appointed to investigate the matter that the spread of the disease was not due to water or to food, but in most cases to the direct transmission of the germs through the agency of flies. In the j.a.panese and Russian war, where in the j.a.panese army of over a million men only 299 deaths from typhoid occurred, strict measures were taken to do away with all the breeding places of flies, and Major Seaman, who writes most interestingly on the success of the j.a.panese in avoiding typhoid, describes the ways in which the j.a.panese soldiers made flycatchers of themselves and waged war against flies quite as actively as against the Russians.

_Other sources of typhoid fever._

There are other sources of the disease; for instance, there have been a number of small epidemics undoubtedly caused by infected oysters. One of the unpleasant habits of the oystermen is to bring in oysters from the ocean and leave them for a few days in shallow water where they may plump up or fatten, and they have found by experience that this fattening occurs more rapidly in dirty water. If the oysters are fattened in sewage-polluted water, the typhoid germs get inside the sh.e.l.l in the oyster liquor and are thus transmitted to those persons who eat the oysters raw.

Some kinds of food may transmit the disease: lettuce and celery, for instance, if washed in contaminated water or handled by persons with unclean hands or perhaps fertilized with manure containing typhoid germs. Finally, it is possible to acquire the disease by direct contact--not that the germs of typhoid are in the air in the room where a typhoid fever patient is lying, but rather that the nurse in some way soils her hands and then infects herself by putting her fingers in her mouth, or handles dishes or food afterwards used by other people, and so infects those others. It is not uncommon, for example, to see food partly consumed by a sick person given to children, or it may be that a child in the sick room is fed dainties prepared for the use of the patient. The result of such division of food is very apt to be a division of the sickness to the injury of the child.

_Treatment of typhoid fever._

So far as present knowledge extends, the disease is one best treated by being let alone, with some moderate modification. When germs have been swallowed and when the vitality of the individual is such that the disease is contracted (happily, as has already been said, only about 10 per cent of those into whom the germ effects an entrance are inoculated), the first stage in the disease is a multiplication of the germs. This const.i.tutes what is known as the incubation period, and lasts about ten days. During this time, the individual feels uneasy, has more or less headache and backache, and loses mental energy. The typhoid bacillus during this time spreads into almost every organ and tissue of the body, and towards the end of the period, when the resisting forces of the body have been proved unable to counteract the attack and the fever is well developed, the condition of the patient is deplorable. The bacteria are everywhere throughout the system, although they are especially active in the small intestines. This inflammation may produce ulceration and the blood vessels may be attacked, so that hemorrhages or even peritonitis may occur. A slight rash appears on the body, and a peculiar appearance of the tongue is to be found in severe cases. In from two to four weeks, the battle has been decided, and if the resisting forces prevail, the fever stops, and the patient begins to get well. This means probably, not that the bacilli are all dead, but that the patient has developed in his blood a sufficient antidote to the poison, so that the effects of the latter are no longer noticeable. The period of recovery, if the patient does recover, is most tedious, since the condition of the alimentary ca.n.a.l is such that great care must be exercised lest serious disorders there occur, and, although the patient is excessively hungry and really in great need of nourishing food, no greater folly can be committed than in allowing his desire for food to lead to indiscretion.

Injudicious exposure or fatigue will also cause a relapse, and while recovery is usually a simple matter, it is only so when under the eye of a judicious and careful nurse. The only treatment required is plenty of water for drinking, to make up for the enormous loss by perspiration from the skin, which helps to wash out the poisons from the body. Then baths, where such methods of treatment can be used, as in hospitals, are also used both to lower the skin temperature and to add water to the surface. Sponge baths in water or alcohol are valuable and in some cases tub baths with the temperature as low as 40 degrees are used. Then a proper diet to keep up the strength of the patient, liquids always, and usually milk, forms the only other treatment possible. No drug is of any avail, and uninterrupted watchful care is the only way of combating the disease.

In concluding this chapter, it may be mentioned that certain army officers interested in medical work have discovered what they believe to be an ant.i.toxin for typhoid fever, and they have inoculated hundreds of soldiers as a preventative. The results are not yet conclusive, but there seems to be great promise. It is hoped that the time may come soon when people will be so educated that there will be no opportunity of the germs escaping from the sick room, and that food and drink will be so cared for that there will be no possibility of infection. The writer feels that it is in these last two methods of prevention rather than in the use of ant.i.toxin that the hope of the future lies.

CHAPTER XVIII

_CHILDREN'S DISEASES_

There are four diseases, scarlet fever, measles, whooping cough, and chicken pox, which are recognized as belonging preeminently to the period of childhood and which are supposed to be the result of bacterial contagion, although, curiously, the specific bacteria concerned in any one of these four diseases has not been detected. They may be rationally grouped together for two reasons. First, because of their attacking, in the majority of cases, children under the age of fifteen years, and second, because the first stages of these diseases are very similar, so that the recognition of them is not easy except for the practiced physician. It must not be thought, however, that because these are diseases of childhood and because a majority of children have them at one time or another, without great suffering and without serious after effects, they are on that account to be despised. Scarlet fever, for instance, is to-day probably the most dreaded of children's diseases, not because so many children die of it,--although the death-rate is large, about 20 per cent of the cases finally succ.u.mbing,--but because of the large number of complications and consequences which are directly due to this disease. Measles, also, though not to the same extent, is frequently followed by serious after results. In the United States, about 13,000 children die every year of measles and about half as many die of scarlet fever. It is a significant fact that the death-rate is much higher among younger children, so that if, by carefully keeping children from the possibility of infection, the disease can be postponed until they are well along in years, the danger of fatal termination is much reduced.

The following table, for instance, shows the number of deaths from measles and scarlet fever at different ages, and it is very evident from this table that if the former disease is contracted by a child under five years old, the danger of death is four times as great as if it were postponed until the child were ten years old:--

TABLE XIX. TABLE SHOWING DEATHS AND PERCENTAGES FROM MEASLES AND SCARLET FEVER FOR DIFFERENT AGES IN UNITED STATES REGISTRATION AREA FOR 1907

====================================+===================================== MEASLES SCARLET FEVER ------------+----------+------------+-------------+----------+------------ Per cent of Per cent of Age Period Number of Total Age Period Number of Total Deaths Deaths Deaths Deaths ------------+----------+------------+-------------+----------+------------ All ages 4302 100 All ages 4309 100 Under 1 yr. 1058 24 Under 1 yr. 175 4 1-2 yr. 1315 31 1-2 yr. 474 11 2-3 yr. 626 14 2-3 yr. 639 15 3-4 yr. 343 8 3-4 yr. 640 15 4-5 yr. 189 4 4-5 yr. 511 12 5-9 yr. 350 8 5-9 yr. 1213 30 10-14 yr 89 2 10-14 yr. 315 8 Under 5 yr. 3531 82 Under 5 yr. 2439 58 Under 15 yr. 3970 92 Under 15 yr. 3967 92 Over 5 yr. 771 18 Over 5 yr. 1870 42 Over 15 yr. 332 8 Over 15 yr. 342 8 ============+==========+============+=============+==========+============

The table shows also that the dangerous age period for scarlet fever is later than for measles. It indicates that while 82 per cent of all deaths from measles are of children under five years of age, only 58 per cent of the deaths from scarlet fever are in that period; but that the number of deaths of the latter between five and nine years is so great that the percentage of deaths under fifteen is the same in both cases.

The moral is plain, namely, that a child should be carefully protected from infection by measles until he is five years old and from scarlet fever until fifteen, if the danger to the child's life is to be reduced to a minimum.

_After effects of scarlet fever and measles._

In themselves, these diseases may not be severe, children often having mild attacks of scarlet fever, called scarletina, and apparently suffering only from a cold, but exposure, by which a cold is developed either during or after the disease, may lead to serious troubles.

Inflammation of the kidneys often occurs, which may develop into chronic Bright's disease and ultimately cause death. Inflammation of the ear is another incident of scarlet fever, in which abscesses are formed, resulting not infrequently in permanent deafness.

The consequences of measles are not so serious usually, and a more common after effect is trouble with the lungs or bronchial tubes.

Pneumonia, croup, and bronchitis very often follow measles, due, as already indicated, to exposure before the body has regained its normal condition. In both scarlet fever and measles the eyes are apt to be affected, and it is very important in both diseases to keep the patient in a darkened room and to forbid use of the eyes in reading or other close work. On account of the complications following scarlet fever and measles, as well as for their greater death-rate, these diseases are more serious than the other two included in this discussion,--whooping cough and chicken pox.

_Preliminary symptoms._

The beginning of each of these four diseases is much the same, and the symptoms are likely to be mistaken for those of an ordinary cold. In all of them, the first indication of illness is redness and itching on the inside of the nose and throat with snuffling and discharging from both eyes and nose. Sometimes the throat is affected, and the patient complains of sore throat. Then the cheeks become flushed, headache may follow, and fever begins, so that the patient is in a sort of stupor, unwilling to do anything and glad to lie in bed. In severe cases vomiting may accompany or precede the outbreak of fever.

At the outset, the probable reason for the similarity of these four diseases as well as their likeness to a common cold is that the germs responsible for all of them enter the body through the nose and throat and begin their attack upon the membranes there. The action of the germ is followed by the formation of poisons or toxins which are distributed by the blood through the body, causing the fever and what are known as "general symptoms." At the beginning it is not possible to determine to which particular germ the distress of the patient is due, and probably the continued prevalence of these diseases is chiefly owing to the fact that in the early stages and in mild cases throughout, the sufferer is allowed to be at large with every opportunity for spreading the disease.

_Contagiousness._

If, whenever a child has a cold accompanied by a fever, the mother would promptly put him in bed in a room by himself, keeping the other children of the family away from the sick room and the invalid under restraint until all possibility of transmitting the disease is over, the number of cases would be greatly diminished. Unfortunately, there seems to be a general impression that such precautions are useless, and that sooner or later every child must have these children's diseases. This is a mistaken notion, and the table already referred to is sufficient evidence to prove the error of this way of thinking.

All these diseases are affections of the whole body, caused by poisons generated by germs, for which so far scientists have found no antidote.

The reason is plain. The germ itself is not known, and no animal has been discovered on which scientists can experiment. If we could only produce measles in a rabbit, for instance, we could very soon detect the germ and would no doubt be able to procure an antidote to the measles poison. But this has not been done, and therefore in measles and in the other diseases mentioned we can only hope that the sick person will be able to generate in his own body sufficient antidote to secure his own recovery. Physicians therefore are almost helpless in treating these diseases. They keep the patient in bed in order that all his strength may be kept for fighting the disease. They insist on ventilation in abundance, so that oxygen may be applied to the lungs in large quant.i.ties in order to neutralize the poison. They advise sponge baths in cold water and alcohol to allay the fever, and they prescribe nourishing, easily digested food, such as milk, eggs, fruit, and plenty of water to drink. In the hope of diminishing the chances of infection, particularly in measles and scarlet fever, they recommend antiseptic sprays for the nose and throat and antiseptic ointments, such as carbolized vaseline for the skin when peeling or desquamation is going on.

_Quarantine for scarlet fever._

Scarlet fever, while the most violent, is also the shortest lived, in the majority of cases not more than three or four days, although the full period of recovery is much longer. The peculiarity of this disease lies in the abundant peeling which takes place usually from the entire body and particularly from the hands and feet; in fact, in a number of cases where the disease is light, the peeling from the hands and feet is the only positive proof that the malady has been scarlet fever. During this process of peeling contagion seems most active; therefore, although recovery seems entire so far as the fever is concerned, the patient should remain strictly isolated during this time. It is a slow process, lasting from two to five weeks, and is very tiresome for the child who feels perfectly well; yet, in the interests of other children, the child must be kept strictly at home until at least a week after the last sign has disappeared. It is also for the child's own sake very desirable to observe this quarantine, since it is during this period of recovery that most of the complications of scarlet fever occur, and if the patient is kept under observation, either in his sick room or on some porch where atmospheric exposure is not too great and where the child is certain to eat nothing harmful, the chances for avoiding lung troubles and digestive disturbances are minimized.

There is such a striking difference in the severity of cases of scarlet fever that the name "scarletina" was for a long time applied to mild cases with the feeling that possibly it represented an altogether different disease. At the present time the disease is more intelligently diagnosed, and while there is vast difference in the severity of the sickness, it is all the same thing. Of the ordinary cases, about 5 per cent terminate fatally; that is, in a village or a community where a hundred cases occur, there would be five deaths. If the epidemic, however, is of the severe form, a larger percentage of deaths occur, often reaching 20 per cent of those affected. It has been noted that as an epidemic progresses, the disease becomes more serious, and a death-rate of only 5 per cent may, in the course of an epidemic lasting several months, gradually increase to one of 20 or 25 per cent. For this reason strong efforts ought to be made to stamp out an epidemic while it is in the first stages.

Besides the possibility of contagion from the skin as it comes off, to prevent which the antiseptic ointment is used, contagion also occurs through clothing used in the sick room. In fact, the contagiousness of scarlet fever is probably as malignant as any other infectious disease.

It has been observed that a year after a case of scarlet fever in a house, the unpacking of a trunk or the unrolling of a bundle would set free the contagion and would result in new cases of the disease. The writer learned recently of a family in which a child had died of scarlet fever and some of its clothing had been packed away in the attic. A younger sister grew up, married, moved away, and some twenty years after the death of the child, came back to her former home on a visit with her own little girl. The grandmother, visiting the attic, found the clothing packed away so long before, gave it to her grand-daughter to wear, and in ten days the child was dead with the same disease.

There are a number of cases where scarlet fever seems to have been carried by infected milk, and great care must be taken on dairy farms to avoid any possibility of this kind of infection. To prevent the disease being transmitted after apparent recovery, thorough disinfection should be practiced. The patient's body should be very carefully and completely and continuously covered with antiseptic ointment which prevents the distribution of the contagion in small particles of skin. The sick room, after the patient's recovery, should be thoroughly disinfected, and all bedding steamed or boiled. All the surfaces in the room should be washed with a solution of carbolic acid, 1 in 50, or corrosive sublimate, 1 in 1000.

_Measles._

If the disease is measles, one may expect a general epidemic, since its power of direct contagion is nearly equal to scarlet fever, although the fatality is much less. It is unfortunate that so little pains are taken to prevent the spread of this disease and fortunate that, except in the case of very young children, the effect of the illness is only a temporary inconvenience. Curiously, however, if measles attacks savage tribes where it has been before unknown, the severity of the disease is very great. Cases are on record where measles have broken out on the frontier and whole villages were wiped out; where the insignificant measles, so innocuous in civilized communities, became a plague similar to a scourge of the Middle Ages. It apparently has been modified by its pa.s.sage through generations of individuals, just as any bacterial disease germ is modified by successive transmission through the bodies of different animals. When, however, the disease breaks out in a community which has not suffered from the disease for many years, it is, on that account, likely to appear in a far more virulent form.

_Characteristic eruptions of measles._

Measles, like scarlet fever and chicken pox, is an eruptive disease; that is, is accompanied with a rash, differing slightly in the three diseases of which the presence of the rash and its progress over the body is one of the distinguishing features. In scarlet fever, for instance, the rash appears first on the neck and chest or back and spreads outward to the extremities. In measles, the rash appears on the extremities, beginning on the face usually, and spreads to the chest and trunk. In scarlet fever, this rash appears as fine scarlet pin points scattered around on the reddened skin, and on the second or third day the entire body may look like a boiled lobster. In measles, the rash appears as blotches, while the skin is not flushed but retains its natural color. In chicken pox, the rash appears generally on the body first and consists of small red pimples which develop into whitish blisters about as large as a pea and well separated. They are much more distinct and separated than the rash of scarlet fever and measles, and are much more likely to be mistaken for smallpox pustules than for an ordinary eruptive rash.

One of the old-time fancies connected with these eruptive diseases is the belief that an abundant eruption is a sort of guarantee against the severity of the disease. The old nurse was careful to keep the child in bed, well covered, steamed in fact, until the eruption appeared, and it was commonly thought that nothing should be done to check the rash or to prevent its coming out. This is not sustained by later science, and the appearance of the rash, whether it strikes in or strikes out, has nothing to do with either the disease or with its severity. No possible connection can be traced between the dissemination of the poison through the system by the action of the bacteria and the appearance of the skin, which is a minor factor in the disease. It may be worth while to repeat that the greatest danger from measles consists in the possibility of lung complications, and infinite care should be taken to keep the patient shielded from drafts and free from overexertion until recovery is complete. Like scarlet fever, the skin peels off, although not to the same extent, and the small particles are capable of transmitting the disease. Probably, also, the secretion from the nose and throat will transmit the disease, so that it is the height of folly to allow a sick person to use a handkerchief, for example, and then to use the same handkerchief to wipe the baby's nose when he comes into the sick room.

All dishes and clothing of every sort should be boiled or steamed, and to be rendered harmless they should be soaked in a disinfecting solution before being taken from the sick room. The room itself, after being vacated, should be disinfected and the walls washed, as already prescribed.

_Whooping cough._

Whooping cough is unlike the other three diseases in that it is a nervous trouble, and probably the germ or the poison formed by the germ attacks the nervous system, and particularly one great nerve connecting the lungs and stomach. This is why the spasm of coughing is frequently followed by vomiting, and the only remedy which is of value in whooping cough is a nerve depressant which will diminish the activity of the nervous system without at the same time interfering with the strength or vigor of the patient. On account of this connection between the lungs, whose spasmodic ejection of air seems to threaten the entire collapse of the little patient, and the stomach, so alarming do the repeated fits of vomiting appear that often this feature of the disease is even more serious than the coughing, pathetic as it is with younger children. In some cases the stomach cannot retain nourishment long enough to feed the body, and the child literally wastes away unless the period of the disease runs out before the child starves to death.

It is often weeks instead of days before the disease can be recognized.

Then, if it develops in its usual form, begins the coughing so characteristic of the malady and the hard straining whoop so painful to listen to. Occasionally this coughing may be severe enough to cause a rupture of a blood vessel; but ordinarily, unless the stomach is affected by sympathy, no great danger need be feared. Fresh air, moderate exercise, good food, and some mild nerve depressant is all that can be done. The disease is very contagious and is usually transmitted directly from the sick person to the well person. It may, however, be carried in clothing, particularly in handkerchiefs and towels. Like measles, if it gains a foothold in an uncivilized community, it attains the size of an epidemic or plague with very fatal results. It seems to have a great power over girls and children, particularly those whose vitality is below the normal. Like measles, one does not generally have two attacks of this disease. In the winter, and this is the time when the whooping cough is most common, it is often followed by lung troubles, such as bronchitis and pneumonia. The death-rate from whooping cough is as large as from scarlet fever and measles combined, but chiefly because the disease is common among the smallest children. It is not unusual for babies under a year old to have whooping cough, and when their vitality is low, they scarcely ever recover.

_Precautions against spread of whooping cough._

Probably the disease does not become contagious until the cough starts, and there is no reason why the disease should not be arrested in the first victim, provided proper isolation is practiced. The idea of a child with whooping cough, even when he whoops only once or twice a day, being allowed to attend school and mingle with the other scholars and to distribute the disease among them seems in these days of sanitary knowledge almost criminal. As soon as the first whoop occurs the child should be put in a room by himself and kept there until the last whoop has been whooped, and no other child should be allowed to go into the room, and the nurse or mother who is in charge should be careful about contact with other children after coming from the sick room until she has changed her outer garment. A big ap.r.o.n with long sleeves, fitted closely around the neck, which may be slipped on and off easily, is an admirable protection. The same precautions about disinfecting dishes, napkins, towels, handkerchiefs, and bedding should be observed here as already referred to.