The Mother's Manual of Children's Diseases Part 13

=Typhoid Fever.=--There is no question as to the place which should be occupied by typhoid fever, smallpox, measles, and scarlatina, for all belong to the cla.s.s of eruptive fevers. They are all specific diseases, each due to its own peculiar poison, and not capable of being produced by any mere unsanitary conditions, though such may aggravate their severity and facilitate their spread.

The belief in the special character of each of these diseases has received strong confirmation from the researches of the eminent Frenchman, M. Pasteur, and others who have followed in his track. They have discovered in the blood and other secretions, and in some of the tissues both of men and animals, minute microscopic organisms which differ in their characters in different diseases. Experiment has further shown that in some mysterious way these organisms are the cause of these diseases, for on inoculating animals with them the peculiar disease of which each was the accompaniment, and no other, was reproduced in the inoculated animal.

As far as our knowledge goes at present then, we are forced to regard each of these as a separate disease, measles never pa.s.sing into scarlatina, nor that into smallpox, but each, whether slight or severe, retaining throughout its distinct character.

We have already seen how, in the course of various diseases, the pulse is quickened, and the temperature raised, const.i.tuting that state which we commonly call fever, but as the local ailment subsides the fever disappears. There is, apart from smallpox, measles, and the other so-called eruptive fevers, only one real essential fever commonly met with in childhood, and that is what the doctors call _typhoid fever_.

The name, from the similarity of sound to _typhus_, from which, however, it is essentially different, has long been a name of terror in the nursery, and all sorts of epithets have been subst.i.tuted for it, as gastric fever, and infantile remittent fever, and so on. Name it as you may, the fever is one and the same with the typhoid fever, which one hears of as prevailing constantly in many continental cities, and proving dangerous and fatal in any district almost in direct relation to the neglect of drainage and of proper sanitary precautions.

It is extremely rare in infancy, though I saw it once in a babe eight months old, and is comparatively seldom met with before the age of five years. From five to ten years old it is more frequent than from ten to fifteen, but it is consolatory to know that it is less fatal in early childhood than at any subsequent time of life, and that cases of such exceedingly mild character that the child's condition can be more properly described as ailing rather than ill, are then far from uncommon. The symptoms, however, are in all instances similar in kind, though widely varying in degree, and the duration of the fever is, as nearly as may be, three weeks. By this it is not meant that at three weeks' end the child who has had typhoid fever is well again, but only that the temperature, which had hitherto been high, and always higher at night than in the morning, has subsided, that the skin has become less dry, the tongue slightly moist, the intelligence more clear, that the fever has run its course. For the first week or ten days, the symptoms have probably become every day more grave; and for the next ten the doctor could find no better consolation than the a.s.surance--happy if he could give it--that the condition was not worse, but that you must have patience, for the time for improvement had not yet arrived. If the attack has been severe, the child will be left greatly exhausted, sadly emaciated, and suffering from the effects of that ulceration of the bowels which accompanies the fever, and from which life may still be in imminent danger. But the fire is quenched; the question is no longer how to put out the conflagration, but how to repair the mischief it has caused.

When mild, the disease usually comes on very gradually, the child loses its cheerfulness, the appearance of health leaves it, the appet.i.te fails, and the thirst becomes troublesome; in the daytime it is listless and fretful, and drowsy towards evening, but the nights are often restless, and the slumber broken and unrefreshing. The skin is hotter, and almost always drier than natural, or if there is any perspiration, it comes on at irregular times, lasts but an hour or two and brings no refreshing. The thermometer will quite, in the early days, solve all doubt as to the nature of the case. In the morning the thermometer will be natural, or nearly so, but at seven o'clock in the evening it will have risen to 101 or 102, and will continue so during the early part of the unquiet night. After midnight it will begin to fall, and by six o'clock in the morning, or even earlier, will have regained its natural standard. There is no other disease but typhoid fever, and now and then some forms of galloping consumption, in which these oscillations of temperature take place regularly. Other symptoms attend typhoid fever besides these, and serve to stamp upon it its distinctive character. The bowels are usually loose, or if not, a moderate aperient acts on them excessively, the evacuations being loose, often watery, of a light yellow-ochrey colour. The abdomen is full, the bowels being more or less distended with wind, sometimes tender, especially at the right side, and both tender and painful in all cases where the disease is severe.

Towards the end of the first, or at the latest by the middle of the second week, small rose-red spots or pimples appear on the abdomen, sometimes also on the chest and back. They disappear for the moment if pressure is made on them, but reappear the moment the pressure is withdrawn. Now and then they are numerous, and sometimes two or three successive crops appear, the old ones fading as the others show themselves; but in childhood they are often scanty, though whether few or many, they are the external characteristic of the disease just as the rash is in scarlatina or measles.

Whenever a child of whatever age begins without obvious cause to lose appet.i.te and health, to become feverish, with marked increase of temperature towards evening for several days together, and more or less disposition to diarrh[oe]a, it is all but absolutely certain that the child has contracted typhoid fever.

When the disease comes on gradually, it seldom becomes dangerous, though until the end of the first week there is always considerable uncertainty on this point. The amount of diarrh[oe]a and the degree of disorder of the brain, as shown by restlessness, delirium, and stupor are the measure of the gravity of any case. There is, however, scarcely any disease from which even when most severe recovery so often takes place in childhood, and this not as persons so often imagine from some critical occurrence but by a process of gradual amendment. The first signs of amendment, too, may be taken as giving almost certain promise of complete recovery; but it is well to bear in mind that there is no disease of early life in which the mental faculties, though time brings them back at length uninjured, remain so long in a state of feebleness and torpor as in typhoid fever. Though the first signs of improvement, too, are very seldom deceptive, yet the patient's convalescence is almost always slow, and interrupted by many fluctuations.

Though contagious, still typhoid fever is far less directly contagious than measles or scarlatina. It seems as if with this disease, just as with cholera, the contagious element were present in its most active form in the discharges from the bowels. These should therefore be disinfected by carbolic acid or some other disinfectant immediately; and should never be emptied in a closet used by other members of the family, and more particularly by children. Special precautions also should be taken with the bed-linen, and night-dresses of the patient; and it must be remembered that wise precautions have nothing in common with exaggerated alarm. One more hint will not be out of place. In typhoid fever, and still more in the highly contagious measles and scarlatina, the person who sleeps in the patient's room is much more likely to contract the disease than she who sits up and watches at night keeping wide awake. Whoever takes charge of a fever patient during the night should therefore sit up and watch, not lie down and doze, and this not for the patient's sake only, but for her own.

It can scarcely be necessary to say that in every, even the mildest, attack of typhoid fever the attendance of the doctor is needed from first to last. He may come every day, and may daily do nothing but merely watch. The disease will run its course, the greatest skill cannot cut it short, though now and then instead of lasting for three or even four weeks it comes to an end spontaneously in fourteen days. Skilled watching is what the competent doctor gives. You would not despise or underestimate the pilot's skill, who steered your barque through a dangerous sea in smoothest water, because he knew each hidden rock or unseen quicksand on which but for his guidance you might have made shipwreck.

=Small-pox.=--At the present day, thanks to vaccination, and to re-vaccination, _small-pox_ is rarely met with in the well-to-do cla.s.ses of society, though it is not yet a century ago since it found its victims not only among the poor, but among the highest in the land. It does, however, occur sometimes after vaccination, and sometimes, though very rarely, an attack of small-pox fails to furnish an absolute guarantee against the occurrence of a second.

Small-pox, unmodified by previous vaccination, sets in in the child with violent sickness; vomiting, sometimes recurring frequently for forty-eight hours, with much depression, or even stupor; in some instances even actual convulsions, and fever; but neither with the sore-throat of scarlatina, nor with the sneezing, cough, and running at the nose of measles. At the end of from forty-eight to sixty hours, an eruption of pimples appears on the face, forehead, forearms and wrists, whence it extends to the body and the lower limbs. They are reddish in colour, rather pointed in form, and at first scarcely raised above the surface; so that the eruption looks at first like the very early eruption of measles; though the tiny pimples felt as if beneath the skin serve even then to distinguish the one disease from the other. In another forty-eight hours the character of the pimples has changed into that of little vesicles or pocks, depressed instead of pointed at their centre, and containing a little watery milky fluid. They next enlarge, and become once more prominent at their centre as they fill more and more with fluid, which becomes thicker, yellowish-white--looks like, and indeed is, matter. Four or five days are occupied with this process; the matter in the pocks then begins to dry, and scabs to form, which gradually by the end of another week drop off, and leave the skin spotted with red or even scarred if the pocks went deep enough to destroy the skin, and to leave the indelible marks, the so-called pitting of small-pox.

The danger of the disease is in childhood the nervous disorder at the outset, and then the exhaustion produced by the so-called maturation of the pocks when the thin watery fluid changes to the thicker matter, and depresses the patient in the same way as he would be depressed by an enormous abscess.

The first outbreak of the eruption is followed always by a most remarkable abatement in the disturbance of the const.i.tution, and for three or four days, even though the eruption is abundant, the patient may seem so well that it is almost impossible to realise the imminent peril to which he will be exposed in a few days' time.

=Inoculation and Vaccination.=--The danger of small-pox is in direct proportion to the abundance of the eruption; and the great advantage of inoculation for the small-pox consisted in the much scantier eruption which followed it, as compared with that which commonly took place in the natural small-pox.

The same advantage in a greater degree is obtained by vaccination, even in the exceptional instances in which it fails to render the person altogether insusceptible to the disease.

The great advantage which inoculation secured was counterbalanced in great measure by the fact that it always maintained small-pox rife throughout the whole country, and that consequently all who either had neglected inoculation, or young children on whom, on account of their tender age, it had not yet been practised, were more than ever exposed to constant risk of infection.

This very real danger led to the almost unanimous welcome which the practice of vaccination received towards the end of the last century, since it was hoped that by it not only would the risk attending small-pox be lessened, and the disease when it did occur be even milder in character than inoculated small-pox, but that small-pox itself would eventually be extirpated.

These antic.i.p.ations have not hitherto been fully realised; but the good effected by vaccination has been such as to render it, in the opinion of nearly everyone qualified to form an opinion on the subject, one of the greatest boons ever conferred on the human race.

Small-pox, like other eruptive fevers, has the peculiarity of occurring for the most part only once in a person's life. We do not know in the least on what this protecting influence depends. We know the fact, but are the less able to offer an explanation, since there are other const.i.tutional diseases, such as gout and rheumatism, in which the local symptoms are equally the outcome of previous const.i.tutional disorder, where exactly the opposite rule obtains, and in which their occurrence does but increase the liability to their return.

The protective power is apparently possessed by the mild form of the disease communicated by inoculation as much as by the severer form of small-pox which is contracted by direct contagion or infection. This knowledge has been applied in the treatment of some of the diseases of animals, and it has been found in the case of the so-called small-pox in sheep (a disease which, however, is quite distinct from human small-pox) that while one in two of the animals who contracted it in the ordinary way died, death took place in only three per cent, or not one in thirty, of those in whom it was produced by inoculation; and the inoculated sheep were thereby safeguarded from subsequent attacks as completely as the others.

This knowledge was more recently applied by the distinguished Frenchman whom I have already mentioned, M. Pasteur, in the case of a fatal pestilence among sheep in many parts of France, known by the name of _charbon_. The inoculated sheep died, however, in such large numbers, though in a somewhat smaller proportion than those who had been directly infected, that he found it necessary to weaken the matter which he employed by admixture with other innocuous materials. This experiment, however, again yielded unsatisfactory results; slight symptoms of the disease were produced, but the protection thus afforded was inadequate and uncertain. Some few resisted the disease, but others contracted it and died. With that clear insight which const.i.tutes genius, M. Pasteur next tried the experiment of inoculating the sheep first with a weak matter which produced but slight symptoms, but at the same time enabled the animal to support a second inoculation with a stronger matter; and this second inoculation enabled them to bear, unharmed, subsequent exposure to the disease. A grateful country has given a pension, and conferred well-merited honours on the man who has preserved their flocks from pestilence, but whom the silly sentimentality of the anti-vivisectionists in England would have mulcted in a fine, and, if possible, have sent to prison.

That weakening of the poisonous element which Pasteur strove to attain by art, is already provided by nature in the cow-pox. The cow-pox is nothing else than small-pox modified in character, diminished in severity by pa.s.sing through the system of the animal; but giving, when introduced into the system, a safeguard against natural small-pox at least as complete as that furnished by the inoculated disease.

More than 70,000 children have come under my observation, either in hospital or in private practice; and I need not say that a physician having much consulting practice sees far more than the average of unusual and severe cases. Twice, and only twice, I have seen infants die from vaccination, and in both instances death took place from erysipelas beginning at the puncture. The one case I saw twice in consultation with the family pract.i.tioner. The other which I watched throughout was that of a little boy, the fifth child of a n.o.bleman of high rank, both his parents being perfectly healthy. He was vaccinated by the family doctor in the country, direct from the arm of another perfectly healthy infant, from whom ten other infants were vaccinated immediately afterwards. The little boy was seized with convulsions within twenty-four hours, and almost at the same time erysipelas appeared on the punctured arm. The erysipelas extended rapidly, convulsions returned more than once, and on the fourth day from the vaccination the child died. One of the other children vaccinated at the same time died in the country in the same manner; all the others pa.s.sed through vaccination regularly, and without a single bad symptom. I have no explanation to offer; this case stands by itself just as do those of death from the sting of a bee or death from cutting a corn.

That some people die of other diseases since the introduction of vaccination, is undoubtedly true, for many of those who would have died in early infancy of small-pox are cut off later by measles or bronchitis, or die during teething; since it is obvious that vaccination does not protect against any other disease than small-pox.

That protection, indeed, is not absolute, nor was the protection afforded by inoculation absolute; but small-pox after vaccination, even when it does occur, is very rarely severe, and still more seldom fatal.

There seems good reason for believing that the protecting power of vaccination tends to diminish with the lapse of time; though apparently this is not always the case, nor can any direct statement be made as to the conditions which favour this in one case, or prevent it in another.

As a matter of fact, however, we do know that such a tendency does exist, and that this tendency calls for the repet.i.tion of vaccination from time to time; such re-vaccination carefully performed being as nearly as possible an absolute guarantee against small-pox. All persons engaged as nurses or attendants at the Small-Pox Hospital during the past thirty-two years, have been vaccinated or re-vaccinated before entering on their duties, and during this period not a single case of the disease has occurred among the whole staff. The experience of other small-pox hospitals for a shorter period is identical. As far as we know, every seventh year is a reasonable interval at which re-vaccination should be performed.

One great cause of the failure of the protective power of vaccination is the unintelligent and careless manner in which it is too often performed, especially among the poor. To this same cause it is also due that in some cases of almost infinite rarity one special const.i.tutional disease has been known to be communicated. I have never seen such a case, but I know there are such. They are, however, no more a reason against vaccination than the occasional death from an overdose of opium is a reason against the use of that drug.

To avoid any risk of this kind, and also with the idea that the power of the vaccine matter may have become weakened by transmission through many thousands of persons, vaccination direct from the calf has been introduced of late years, especially in America and on the Continent.

The time, however, that has as yet elapsed is scarcely sufficient to test the comparative preservative power of this as compared with vaccination from the human subject. Its immediate local effects are somewhat more severe; I do not know any reason why its influence should not be equally abiding.

There is absolutely no foundation for the idea that scrofula, consumption, or any similar disease can be transmitted by vaccination.

In some infants, whose skin is very delicate, and especially in those, some members of whose family have been liable to eruptions on the skin, vaccination has seemed to act as an irritant, and to give occasion to an eruption, or aggravate an eruption already existing. Such cases, however, are not frequent, and the eruption is not more troublesome than those which often appear in teething children. The occurrence of actual erysipelas around the puncture, while very dangerous, is, as I have already stated, of excessive rarity.

A thoroughly dispa.s.sionate review of the whole subject appears to me to warrant the following conclusions:--

1st. That vaccination, though not a perfect guarantee against small-pox, diminishes immensely the risk of its occurrence; and that by periodical revaccination, this guarantee is rendered all but absolute.

2nd. That a very large proportion of the failures of vaccination are due to its careless and imperfect performance.

3rd. That to such careless performance and to the introduction of the blood and not of the vaccine matter alone, from one child to another are due the extremely rare instances in which one special disease has been transmitted by vaccination.

4th. That there is absolutely no evidence of the transmission of scrofula, consumption, or any similar disease by vaccination.

5th. That vaccination direct from the calf appears to present some decided advantages; but it has not yet been practised for a sufficient time to admit of a comparison between its preservative power and that of vaccination from one child to another.

6th. That in either case it is expedient that vaccination be performed within the first three months after birth, so as to avoid the irritation of teething which is unfavourable to successful vaccination, and also because the disposition to those skin diseases which vaccination tends to aggravate is never so considerable before the age of three months as it becomes subsequently.

Even when vaccination fails to protect against small-pox it tends to produce a modified and so much milder form of the disease, that while one patient died out of every two in the Homerton Small Pox Hospital who had the disease naturally, the deaths were only one in four of those who had been imperfectly vaccinated, and one in forty-three of those whose arms bore evidence of perfectly good and successful vaccination.

The influence of previous vaccination often scarcely shows itself in the stage which precedes the appearance of the eruption of small-pox, the fever being often just as intense, and the general symptoms just as severe as in the unmodified disease. The difference, however, becomes at once obvious with the appearance of the rash. The pocks are always much fewer than even in mild small-pox, sometimes even not more than twenty.

They never attain above half the size of the ordinary small-pox pustules; they run their course and dry off in half the time, and consequently the dangerous fever which accompanies their development in the natural disease is almost or altogether absent in the vast majority of instances.

If vaccination did no more than this it would be hard to overestimate its value, or to praise as it deserves the merit of its discoverer.

=Chicken-Pox= is an ailment of such slight importance that it would scarcely call for notice if it were not that the resemblance of the eruption to that of small-pox sometimes leads to its being mistaken for that disease.

It is highly contagious, and for this reason perhaps it is usually met with in infancy and early childhood. Sometimes, though by no means constantly, the eruption is preceded for twenty-four or thirty-six hours by slight feverishness; but oftener the appearance of the rash is the first indication of anything being the matter. It shows itself in the form of small pimples, which in a few hours change into small circular pocks containing a little slightly turbid fluid. They appear on the forehead, face, and body, but very rarely on the limbs; they enlarge for some two or at most three days, then shrivel and dry up; and at the end of a week the crusts or scabs fall off, scarcely ever causing any permanent pitting of the skin. They are usually not above twenty or thirty in number, though every now and then they are much more numerous without any obvious reason. Their distinction from the small-pox eruption consists not only in the smaller size of the pocks, and in the entirely different course which they run, but also in the fact that two or three successive crops of the eruption appear in the course of five or six days, so that new ones, those at maturity, and those on which the crusts have already formed, or from which they have already fallen, may be seen on the child at the same time. This is sufficient of itself to establish the difference between the two diseases, and also to distinguish between chicken-pox and the milder variety of small-pox which is sometimes observed in children who have been already vaccinated.

=Measles= is a disease with which almost everyone is familiar, and one which with proper care is not generally attended with danger. Its great risks are twofold; first, that of its being complicated with bronchitis, or inflammation of the lungs during its progress, and next of its being followed by an imperfect recovery, and by the awakening into activity any tendency to scrofulous or consumptive disease. On these two accounts the disease is not to be made light of, and special watchfulness is to be exercised during the whole time of convalescence. It is also unwise when one child in a family is attacked by measles to expose the others, as is often done, to its contagion, in order, as people say, 'to get it over;' for its mildness in one case furnishes no guarantee of its mildness in another, and the danger of the disease is almost in exact proportion to the tender age of those who are attacked by it.

The early symptoms of measles are those of a bad feverish cold; the eyes grow red, weak, and watery, and are unable to bear the light, the child sneezes very frequently, sometimes almost every five minutes, and is troubled by a constant short dry cough. About the fourth day, a rash makes its appearance on the face, forehead, and behind the ears, and in the course of the next forty-eight hours travels downwards over the body and limbs, and then in another forty-eight hours it fades in the same way, being at its height on the body when it has already begun to disappear from the face. It first shows itself in the form of small red circular spots, not unlike fleabites, but very slightly raised above the somewhat reddened skin, and looking for a few hours not unlike the very early stages of small-pox, before the eruption has lost the character of minute pimples. On the face the spots sometimes run together, and then form irregular blotches about a third of an inch long by half that breadth; while elsewhere they present an irregular crescentic arrangement. As the rash fades it puts on a dirty yellowish red appearance; the surface of the skin often becomes slightly scurfy, and it continues somewhat stained of a reddish hue for some days after the eruption has disappeared.

The only other point on which it is necessary to dwell is this, that the symptoms do not, as in small-pox, become less severe immediately on the appearance of the eruption, but continue just as troublesome as before for twenty-four hours or more, the voice being hoa.r.s.e, the cough even more incessant, and the throat often slightly sore and red. Soon, however, improvement becomes apparent, the fever lessens, the cough grows looser; and in less than a fortnight the patient is usually convalescent.

The above is pretty nearly the ordinary course of measles, for we do not meet with that extreme variation in its severity which is observed in scarlatina, where one child will seem scarcely to ail at all, while its brother or sister may be in a state of extreme peril. It is not wise, however, to trust a case even of apparently mild measles to domestic management, for while the cough is troublesome in almost every case, the ear of the experienced doctor is needed to ascertain whether it is merely the cough of irritation which attends the measles, or the graver cough due to bronchitis.

One other caution will not be out of place. The danger of exposure to cold is very real, but that does not necessitate the loading the child with excessive covering, or the abstaining from washing its hands and face. The child should be kept moderately cool; and sponging its hands and face frequently with tepid water soothes it and relieves the painful irritation and itching.