Part 18
Many physicians are still under the grave error that diphtheria can always be recognised without the aid of the microscope, and that membranous croup commonly kills. All scientific writers upon diphtheria agree that it is caused by the Klebs-Loeffler bacillus. They also hold that there is a disease called membranous croup, as distinct from diphtheria as typhoid is, but that membranous croup is a comparatively harmless and non-contagious disease. Two per centum is a liberal mortality in membranous croup, yet a certain class of physicians are constantly reporting deaths from this disease. In a series of 286 cases (not deaths) diagnosed as membranous croup by physicians of New York {188} City a few years ago, Park found the diphtheria bacillus in 229, or 80 per centum. I have never examined the throat of a child dead from so-called membranous croup in which I did not find the diphtheria bacillus. This is the experience of almost every bacteriologist who has had to do with diphtheria. Some men report deaths from diphtheria as thrush! These deaths might just as truthfully be attributed to the wearing of linen collars.
On the other hand, according to Baginsky of Berlin, Martin of Paris, Park of New York, and Morse of Boston, from 20 to 50 per centum of the cases admitted even to diphtheria hospitals have not diphtheria at all. Bacteriologists find that about 35 per centum of the cases reported by physicians to be diphtheria are really nothing but tonsilitis or pharyngitis, with now and then a case of membranous croup. Without a bacteriological diagnosis, therefore, 35 families in each 100 quarantined (where quarantine laws exist) are unjustly quarantined and subjected to the trouble and expense of useless disinfection. The suffering this can cause to a poor family, whose small business is often ruined by quarantine, is a matter for very serious consideration. Again, no matter what experience a physician may have had, he can not in many cases differentiate diphtheria in its early stages, or in children of good resisting power, from comparatively harmless throat affections. The extraordinary resisting power against diphtheria shown by some children and adults has been described by Wassermann (_Zeitschrift f. Hyg._, 19 B., 3 H.). He found one series of 17 children, from one and a half to eleven years of age, and 34 adults, in which 11 children and 28 adults were not only immune to diphtheria, but some of them had enough antitoxin in their blood to neutralise a tenfold fatal dose of diphtheria toxin. This explains many mysterious outbreaks of diphtheria: such immune persons are infected and they carry about the disease unconsciously because they are not ill themselves. I have seen a mother kiss a child dying of malignant diphtheria and the woman did not get even a sore throat, but I know of another case exactly like this in which the mother died from the infection.
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There are bad cases of diphtheria which the experienced physician can diagnose as soon as he enters the patient's room without even looking at the throat, but the lighter cases that are dangerous are not easily recognised. I have seen two children of a family in Washington attacked with a slight throat soreness after one child had died of diphtheria in the house. The cases of these two children would never even suggest diphtheria if that first child had not had the disease. Both these patients died within ten days of syncope without the formation of any membrane, but the diphtheria bacillus was present microscopically. To the moment of death there was nothing in the symptoms of these two children to show diphtheria to the naked eye. From a personal experience with more than 800 cases of diphtheria in hospitals and as a medical inspector, I feel certain that light attacks of diphtheria can not be diagnosed without the aid of the microscope.
The immunity mentioned above explains the fact that the Klebs-Loeffler bacillus is sometimes found in healthy throats, and the person that has such a throat is really more dangerous than a patient that is ill with diphtheria, because we cannot guard ourselves against him. School-children at times have what appears to be mere sore throat but which is really diphtheria in the naturally immune.
All cases of sore throat in school-children should be examined bacteriologically, but unfortunately the bacteriological examination for diphtheria is a complicated process which requires an expert bacteriologist and a laboratory. The cost of a laboratory fitted for this diagnosis alone is not great, but it is not easy to persuade small city governments that they need such plants.
The only resource, then, is to treat every suspicious case of sore throat as if the disease were really diphtheria, until a diagnosis is established as near the truth as possible. Children that are afflicted with throat inflammations should be kept from school. The people should be taught the necessity of isolation and disinfection; they should be warned against patent disinfectants, and told to ask competent physicians to advise them in disinfection.
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Diphtheria is not directly caused by unhygienic surroundings. A disregard for hygiene disposes a child for infection if the child is exposed to the bacillus. The specific germ must be introduced into the patient's mouth or nostrils. When a child is infected with diphtheria the breath is not a medium of contagion. The sputum, spat out or coughed out, is a means whereby the disease is spread. The bacillus is in the patient's mouth and nostrils; it gets upon his hands by contact, upon eating utensils, upon whatever touches the mouth of the sick person. The bacillus does not float in the air of even the sick-room, except in those cases where dried sputum is stirred up by sweeping or attrition of other kinds.
In a boarding-school or family when a diphtheria patient is found, select a room set off as far as possible from the rooms commonly used, and before putting the patient into this room remove all curtains, upholstered furniture and carpets from it that are not so cheap or so worn that they may be destroyed after the patient's convalescence, or which are of such texture that they will not be destroyed by water or disinfection by heat. In any case the less there is in the room the easier the disinfection will be.
Use the mattress upon which the patient had slept before you discovered the nature of the disease. Books should be removed, because an infected book can not be disinfected except upon the outside. The room is not to be swept while the patient is in it,--dust may be wiped up with a damp cloth. The cloth is to be disinfected before it is sent out of the room.
The popular notions regarding sulphur as a disinfectant after diphtheria are erroneous. Sulphur fumes in certain definite quantities will disinfect after smallpox, scarlet fever, measles, and some other diseases; these fumes will also kill the diphtheria bacillus, if the bacillus is wet and exposed directly; but if it is buried in sputum or in clothing the fumes will have no effect whatever upon it. The disinfectants to use are acid bichloride of mercury and heat. Formaldehyde does not penetrate well enough to be reliable in diphtheria.
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When the patient is taken to the room prepared, let a mixture of one ounce of bichloride of mercury in the powdered form, in two ounces of common hydrochloric acid (not the dilute hydrochloric acid used in medicine), be obtained. This is a violent poison, and it must be kept out of the reach of children and careless persons. Two teaspoonfuls of this solution in an ordinary wooden bucket filled with water to within two inches of the rim makes the disinfecting mixture. A wooden washtub nearly filled with this disinfectant, mixed in the bucket as directed, should be kept near the door of the room, and all towels, sheets, and soiled linen must be soaked in this tub for twenty-four hours. After that any one may handle these articles with perfect safety. The articles that have been soaked for twenty-four hours should be rinsed in ordinary water to remove the acid, and they may then be washed. The nurse should not touch the outside of the tub with infected articles while putting these in the disinfectant. Do not make the disinfectant stronger than directed here, or it will destroy the articles soaked in it, and for the same reason do not leave them in it longer than twenty-four hours.
If the attendant can be kept isolated with the patient there will be less liability of carrying the infection through the house. In a majority of cases in families, however, the mother is obliged to care for the patient and to attend also to her household duties. In the last case, let her keep near the door of the room a cotton wrapper which can be put on over her dress whenever she enters the room. She had better tie a towel over her hair. In the room a china-stone basin should be kept, containing a gallon of water, in which there is a teaspoonful of the acid bichloride. Every time the attendant touches the patient let her wash her hands in this mixture, using no soap. She should remove her finger rings or they will be blackened. The patient should not be handled except when absolutely necessary, to avoid needless exposure to infection; it is also injurious to a child ill with diphtheria to lift it up. The nurse's covering wrapper should be soaked in the tub as often as possible. Some ignorant persons give as an excuse for a lack of care in {192} handling patients having contagious diseases like diphtheria, that they are not afraid of the infection. Fear has nothing to do with the matter.
Food is to be taken to the door of the sick-room by some one other than the attendant. The tray should not be carried into the room. After the meal, take to the door a pan containing water, and let the attendant set the dishes, knives and forks, and the food handled by the child, under the water without touching the rim or sides of the dish-pan. Then any one may carry the pan to the kitchen, where it is to be set upon the stove, and the water holding the dishes and the rejected food is boiled for an hour. After that process the contents of the pan are safe, and they may be handled for washing. Cloths used in wiping the mouth of the patient are to be wrapped in paper and burned. Dejecta should be covered with fresh chlorinated lime, one part to two of water.
After the patient begins to convalesce the danger of infection grows greater. When the membrane has disappeared, and the child is able to run about the room, the attendant ceases commonly to use the throat-spray because the process is troublesome. In such cases the diphtheria bacillus remains in the patient's mouth for some time--from a few days to weeks. During the most of this time the child is as dangerous to others as it was while it was ill. In one case in my own experience, the bacillus remained present for eleven weeks from the date of diagnosis, and I then lost sight of the child. In the tenth week the bacillus present when in pure culture killed a guinea-pig in thirty-six hours. This is, of course, an exceptional occurrence; but the routine practice is to keep the patient isolated for three weeks after the membrane has disappeared, unless a bacteriological examination shows that the bacillus is absent. The bacillus remains after the use of antitoxin just as if antitoxin had not been used.
When a child is to be released from the sick-room, bathe it carefully with soaped warm water, washing out the hair and under the finger-nails carefully. Then wet a towel with the disinfectant (the acid bichloride of mercury,--a {193} teaspoonful to a gallon of water) and go over the body with it; afterward rinse with ordinary water. Do not let the disinfectant enter the child's mouth or eyes. Next, without allowing the child to touch anything in the room, especially avoiding the door-knob, send it to another room and dress it in clothing that has not been near the sick-room. If, after this process, other children are infected, the explanation is that the child had been released too soon--before the bacillus had disappeared.
It commonly happens that a child has been going about the house for some days before a physician has been called in. In that event you have the house to disinfect. You must then wet with bichloride everything the child has touched, and boil all eating utensils.
As to the disinfection of the room and its contents: the irritation of diphtheria causes a large quantity of saliva to flow from the patient's mouth; this infected saliva runs down upon the pillows and soaks into them. It may also soak into the mattress. If a town has a steam disinfecting plant, there is no trouble in dealing with bedding and carpets after diphtheria and other contagious diseases; such a plant, however, costs at the least $6000. It is safer, in the absence of steam disinfection, to destroy pillows by fire; but if these are opened and the filling put into tubs or barrels containing two teaspoonfuls of the acid bichloride of mercury to each gallon of water and soaked for about two days they will be safe. The ticking in this case should be boiled in a wash-boiler, and the filling is to be rinsed before drying. The mattress is less liable to infection but it may be infected. If a piece of oil-cloth or rubber sheeting is spread beneath the bed-clothes under the patient and the mattress is kept well covered during the course of the disease, the filling of the tick will most probably be not infected. The loss of a good feather or hair mattress is considerable in the house of a poor man, and these often may be saved. To disinfect the surface of a mattress place it on chairs in a small room or in a closet and pour upon a cloth under it 500 cc. of formalin for each 1000 cubic feet of air-space in the room or closet--multiply the length by the height by {194} the width of the room or closet to get the cubic feet of air-space. Leave the room or closet shut tightly for twenty-four hours. The Trenner-Lee formaldehyde disinfector is a good apparatus for disinfecting. The smaller size costs twenty-five dollars.
If anything is to be sent out of a room to be burned, spread a piece of old carpet, bagging, or similar useless cloth outside the room door, set on this the articles to be destroyed, wrap them carefully in the fabric, tying all with cords; then take the bundle outside the town in a covered wagon, pour kerosene oil on the package without opening it, and set it afire. Afterward wash the wagon with the acid bichloride.
Wet the furniture and floors of the room with the acid bichloride. Do not merely sprinkle the solution about, flood everything with it, because the germ is killed only by direct contact; and remember that a diphtheria bacillus magnified 800 times is not larger than the eye of a needle. The bichloride will spoil gilt picture-frames, therefore use a 10 per centum solution of pure carbolic acid on these and all other metallic surfaces. Coins should be boiled, and paper money should be dipped in the 10 per centum carbolic acid solution and dried at a stove. Money is frequently found in smallpox rooms under the patient's pillow.
Formalin is the best disinfectant for wall-paper unless the child has spat upon it--then use the bichloride. Sometimes the bichloride will not injure the wall-paper, but if there are gilt figures upon it these will be blackened. Sulphur fumes are no better than formalin--not so good, and they injure and blacken tinted and gilded wall-paper, silks, satins, and other fabrics. If you determine to have the room repapered, wet it with bichloride before you bring in the workmen.
It is difficult to disinfect a carpet except by steam, and on this account the carpet should be removed from the room before the patient is brought into it. If it has been kept in the room, wet it thoroughly with the bichloride, when you are disinfecting, if you can not have it disinfected by hot steam. The wetting commonly spoils the carpet, consequently it may be necessary to bum it.
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Keep cats, dogs, and especially kittens, out of a diphtheria room. Kittens will take the disease easily, and cats and dogs will carry about the contagion. If a valuable dog should get into the room, disinfect its hair thoroughly with the acid bichloride and then rinse the hair. Be careful to disinfect its feet.
While using the bichloride do not forget the window-panes, the door-knobs, and that part of the chair-legs which touches the floor. After you have used the bichloride expose the room to the gas from formalin. Hang up sheets wet with 500 c.c. of formalin for each 1000 cubic feet of air-space, and close all keyholes and cracks; then leave the room shut for twenty-four hours.
As to the use of antitoxin as a preventive and cure for diphtheria, too much praise cannot be given to that wonderful discovery. Reliable diphtheria antitoxin, used in proper quantity and early enough, is almost an absolute cure. Where it fails it has been used too late or not in the proper dose. In any case its only evil effect may be an attack of nettle-rash or hives. The few deaths that have occurred in its use were caused by an ignorant use of the syringe. If you find a physician opposed to the use of antitoxin this simply means that he is a quack. One serious disadvantage in the use of antitoxin is that it leaves the dangerous bacillus in the throat of the patient about as long as an unaided convalescence would leave it. The membrane often will disappear in twenty-four hours where antitoxin has been used, and the child will be playing about the floor. Then the mother will say the child never had diphtheria; she will not disinfect, and she will let the child run about the house.
The free book system that prevails in some schools is a prolific source of infection. Books are infected at home or by children from infected houses, and mixed with other books in the school. The diphtheria bacillus will cling to a book for at least a year. If books are given to the children, give them outright; do not let the books be mixed in the schoolroom.
Drinking-cups used in common are another source of {196} infection. Let each child have its own tin cup. The clothes-rack in a school also spreads infection. Room enough should be given to each hook to keep the hat and coat of one child from touching those of another, and a wooden partition standing out from the wall about eight inches should separate hook from hook. The janitor should wash the clothes-racks with the acid bichloride solution every time he sweeps.
Suppose a child having diphtheria is found in school, or one is discovered as coming from a house where he was in contact with diphtheria. The discovery is made commonly after the child has been spreading infection for some days. Do not frighten the youngster, but find out from him what parts of the school-building he has been visiting. Then send him and the other children home. Rooms in which the child has not been are not infected, and only that which he has touched is infected in any case. Wet everything in the building and outhouses with which he possibly could have come in contact with the acid bichloride. Burn his books and papers, or, if this action may cause difficulty with parents, let him take his books home and inform the health officer of that fact. When he returns to school be sure of the history of his books. Use formalin or sulphur in the infected rooms, and classes may be begun again the next day. If within the week any child shows signs of sore throat send it home immediately.
Sulphur must be burned when used as a disinfectant, and to be effectual four pounds should be burned for every 1000 cubic feet of air-space in the room. A teaspoonful of sulphur when burned will fill a house with choking, dangerous fumes, but two pounds of sulphur burned in an ordinary bedroom will have no effect whatever on the diphtheria bacillus and very little on any other disease. Sprinkling disinfectants about a house, and setting saucers containing disinfectants in rooms is nonsense--the quantity must be sufficient and be in actual contact with the contagion. A deodorant does not disinfect because it removes a stench.
To burn sulphur set a coal-hod or an old tin pan on two bricks in the middle of the room, but see that there are no {197} holes in the bottom of the hod or pan through which burning sulphur could drip to the floor. For a like reason see that the pan is not too narrow nor too shallow. It is safer to set the bricks in a tub filled with water up to the top of the bricks. Use powdered sulphur in preference to the cakes sold by the druggists, and fire this sulphur with a red coal. The room should be moist with steam when the sulphur is set afire so that the fumes will act effectually. Leave it shut tightly for twenty-four hours.
In the Northern States diphtheria is most prevalent in October, November, and December; scarlet fever is an April disease, but it may occur at any time. It is easier to spread the infection of scarlet fever and measles than that of diphtheria, but it is not so difficult to disinfect after scarlet fever and measles as after diphtheria. The contagion of scarlet fever does not resist the fumes of sulphur or formalin. Disinfect a room after scarlet fever as for diphtheria but be sure to use also either sulphur or formalin because the contagion can float about a room. Eruptive contagious diseases like scarlet fever, smallpox, and measles so affect the skin that during convalescence the cuticle scales off. In severe cases of smallpox and scarlet fever the entire outer skin of the hand may peel off like a glove. The contagion is always found in the scaling skin. As the patient grows stronger the scales become finer, until at last they lie as mere mealy dust in the hollows of the elbows or other parts of the body. Down to the very last these scales are infectious, and they will retain the infection for months, probably for a year or more. The scales float in the air of a sick-room, fall on the clothing of visitors, are carried away by the shoes of those that leave the room. The scaling may continue for three weeks--it commonly does. These three diseases are infectious before the scaling begins, sometimes before the rash is well out. A very light attack of any of these diseases in one child may infect another fatally. Insist upon keeping a scarlet fever or measles patient out of school until all scaling has ceased.
Chickenpox is almost a harmless disease, but it is more infectious than even measles. Be cautious with it because {198} nearly every epidemic of smallpox begins through some one mistaking smallpox for chickenpox, although there is little or no similarity between the diseases.
A child with tuberculosis of the lungs or a child infected with acute syphilis should not be permitted to go to school under any circumstance.
In the chapter on The Priest in Infectious Diseases will be found an account of the necessity of vaccination as a precaution against smallpox.
Tinea Favosa, or favus, is a contagious and a very stubborn disease of the skin, caused by the fungus _Achorion Schoenleinii_. It produces yellowish crusts about the hairs of the scalp and other parts of the body, and it destroys the hair. It attacks also the finger-nails and the skin that is without hair. In the later stages of the disease there is a foul odour. It is one of the most difficult of the scalp-diseases to cure; months and sometimes years are required to get rid of it.
A child with tinea should be kept away from school; and his desk and what he touches should be washed with the bichloride of mercury solution. Burn his books and papers.