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-•ruTE OF Child HEALin
A MANUAL OF INFECTIOUS DISEASES
OCCURRING IN SCHOOLS
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in 2014
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CANCELLED L
A MANUAL OF
INFECTIOUS DISEASES
OCCURRING IN SCHOOLS
(Issued by the Association of Preparatory Schools),
BY
H. G. ARMSTRONG, M.R.C.S., L.S.A.
' Medical Officer to Wellington College;
AND
J. M. FORTESCUE-BRICKDALE, M.A., M.D
Physician to Clifton College; Assistant Physician, Royal Infirmary, Bristol;
Clinical Lecturer, University of Bristol
CAN
WITH CHAPTERS ON
INFECTIOUS EYE DISEASES
By R. W. DOYNE, M.A., F.R.C.S.
Margaret Ogilvy Reader in Ojihthabnology, University of Oxjord
AND
RINGWORM
By H. ALDERSMITH, M.B., F.R.C.S.
Medical Officer to Christ's Hospital
BRISTOL: JOHN WRIGHT AND SONS LTD.
LONDON : SIMPKIN, MARSHALL, HAMILTON, KENT AND CO. LTD.
191 2
I CLASS 2mJ aJIccx
JOHN WRIGHT AND SONS LTD.,
PRINTERS AND PUBLISHERS, BRISTOL.
LlbKAKY
.vsTm!T= Of Child heali
PREFACE.
This manual of Infectious Diseases has been written
for, and is being issued by the Association of Prepara-
tory Schools.
The assemblage of large numbers of young persons
under one roof leads to the introduction and ready
spread of the infectious diseases to which they are
specially Hable. The Association feels that a manual,
setting forth the characteristics of each disease, will
be of assistance to the masters and mistresses of
schools in dealing with them. Intended primarily
for their use, the effort of the authors has been to give
a cHnical picture, as complete as possible, of the
features of the various diseases ; questions of
pathology have been only Ughtly touched on and
treatment has been dealt with only in a general way,
the special treatment of each individual case being
the province of the medical man in charge. Though
written primarily for laymen, it is hoped, however,
that the manual may be found to be of some assist-
ance to doctors in their school practices.
For its compilation the Council obtained the ser-
vices of medical men, who, being in charge of large
Public Schools, were able to write from their
vi
PREFACE
personal experience. Although the authors have, in
the main, depended on their own experiences, ample
use has been made of the writings of others ; but,
in a work of this scope and object, it has not been
found possible to give many bibliographical references.
The chapter on Infectious Ophthalmia has been
contributed by Mr. R. W. Doyne, the Margaret
Ogilvy Reader in Ophthalmology in Oxford Univer-
sity.
It has been found difficult to avoid altogether the
use of medical and scientific terms, but these have,
as far as possible, been placed in foot notes. A
glossary has been appended of those employed in
the text.
CONTENTS.
I. — The Specific Infectious Diseases . r
IJ. — The Acute Exanthemata .... 23
III. — ^Measles ....... 29
IV. — Rubella. German Measles ... 42
V. — Scarlet Fever. Scarlatina . . .46
VI. — Chicken Pox . . . . . .58
VII. — ^MuMPS ....... 62
VIII. — Whooping Cough ..... 66
IX. — Glandular Fever ..... 70
X. — Diphtheria ...... 72
XI. — Typhoid Fever, Enteric Fever . . 85
XII. — Cerebro-spinal Meningitis ... 97
XIII. — Epidemic Poliomyelitis .... 104
XIV. — Infectious Diseases of the Eye . .107
XV. — Ringworm . . . . . . .117
XVI. — Impetigo ....... 135
XVII. — School Epidemiology .... 137
Glossary ....... 142
Index 143
A MANUAL OF INFECTIOUS/^
DISEASES OCCURRING IN SCHOtXi:-S j^^V'
CHAPTER I.
THE SPECIFIC INFECTIOUS DISEASES.
THE group of diseases known as the " specific
infections " comprises a large number of
complaints varying greatly in their symptoms,
course, and geographical distribution. Some last
for a few days or weeks, others, it may be, for a life-
time ; some are limited to certain regions, such as
the tropics, others occur wherever man makes his
habitation ; some are severe and dangerous, others
almost invariably mild, others again vary in the
severity of their symptoms in different races,
chmates and circumstances. But in spite of these
diverse characteristics, one fact serves as a basis of
classification and unites the whole group, and this
fact is that the diseases in question are directly
or indirectly communicable from one individual to
another, and that in no case can any one disease give
rise to another different one ; in other words, the
specific infections always " breed true." The word
" specific " is apphed to the group to denote this
fact.
Various subdivisions of this large and important
class have been made. In these pages only a very
few of the specific infections will be considered —
1
INFECTIOUS DISEASES IN SCHOOLS
namely, those which ran a short and more or less
definite course usually accompanied by fever, and in
which the infection is readily passed from one person
to another ; they are therefore known as the " acute
specific fevers," or "infectious fevers." Owing to
the fact that a prominent symptom in many cases
is the appearance of a rash or eraption upon the skin,
the term " eraptive fevers " is also used, while their
infectious character is indicated in the general term
"communicable diseases," "which is applied to the
whole group. The term " zymotic diseases," which
is still not infrequently used, is intended to give
expression to the opinion now widely held as to their
real cause or causes ; the word having been scientifi-
cally applied to the so-called "living ferments"
(zymo!) which are now more usually known as germs,
microbes or bacteria. This name may conveniently
lead us on to consider the origin of the specific
infections.
According to the view now generally held, all
these diseases are due to the invasion of the body
by minute living organisms, each disease being
produced by its own particular germ. These micro-
scopical particles of living matter belong to various
groups, but are all of them, as far as is known,
unicellular, that is consisting of a single ceU or unit
of living matter (or protoplasm) which is able to
perform all the vital functions of nutrition, excretion,
reproduction, and in some cases the function of
locomotion. Some of these belong to the class
known as bacteria which lies on the confines of the
animal and vegetable kingdoms, but is usually held
to belong to the latter. The bacteria themselves
are subdivided into famihes according to their shape,
round ones being known as cocci, straight, rod-shaped
THE SPECIFIC INFECTIOUS DISEASES 3
ones as bacilli, wavy rod-shaped ones as spirilla,
vibriones, or vibrios.
Other classes of unicellular organisms, however,
also contribute to the army of disease producers;
these are of a rather more highly organized and
more definitely animal type ; they belong to the
group known as protozoa or primitive organisms,
and the exact classification of the species within
the group is still, in the imperfect condition of
our knowledge, a matter of great difficulty and
not a little dispute. All these germs are called
" pathogenic," that is to say, disease producing,
and it must be clearly understood that a much
larger number of both bacteria and other unicel-
lular organisms are known, which are apparently
quite incapable of producing disease either in man
or other animals ; others affect particular classes
of animals only, and others again are injurious to
plants.
Organisms producing disease do so by living and
growing in the body of the animal affected, and are
thus called parasitic. But in many cases they are
quite capable of leading an independent existence
to which the term saprophytic has been applied.
Thus three modes of life are known among germs :
the purely parasitic, the purely saprophytic, and that
which at one time is parasitic and at another sapro-
phytic according to circumstances. In many cases
very Httle is known of the Hfe history of germs outside
the body of man or animal, but it is obvious that
this is an important branch of knowledge in relation
to the prevention of disease.
One fact, however, is of importance in this con-
nexion, though it apphes only to a certain number
of cases. Some bacteria have the power of forming
4 INFECTIOUS DISEASES IN SCHOOlS
what are called spores, minute rounded bodies which
are remarkably resistant to adverse environment,
and can live in a quiescent state for long periods
and under circumstances in which their parent
organisms would certainly and speedily succumb.
The following diseases are known to be caused by
bacteria : typhoid fever (or enteric fever), diphtheria,
cerebro-spinal meningitis, impetigo, besides others
not dealt with in this book. Whooping cough is
probably due to a bacillus somewhat resembling
the so-called influenza bacillus of Pfeiffer ; scarlet
fever is possibly due to a protozoon, though a special
form of streptococcus (one of the bacteria) has also
been considered the causal agent by several high
authorities. Smallpox is very probably produced
by an organism of the same class as that which
causes malaria.*
There is at present no evidence that chicken pox
is produced by any allied protozoon, and with regard
to this disease, as well as measles, rubella, and certain
others, we can only say at present that the presump-
tion is very strongly in favour of their being due to
some form of minute organism the characteristics
and history of which have not yet been discovered.
Organisms may enter the animal body in various
ways. A shght abrasion of the skin may allow the
coccus of impetigo or the more deadly streptococcus of
erysipelas to make its entry ; the mucous membrane
of the mouth, throat, and nose may similarly allow
the entry of organisms through some sHght local
lesion. This very Ukely occurs in diphtheria, and
* It is called the Cytoryctes Variolas, and probably passes
through several phases of existence, one of wliich produces
the disease.
THE SPECIFIC INFECTIOUS DISEASES 5
possibly in cerebro-spinal meningitis, though some
think that in the latter case the organisms enter by
the intestinal mucous membrane. In typhoid fever
the Hning membrane of the bowel is most probably
the portal of entry for the bacillus.
When once the germ has gained a hold on the
animal body, one of two things may happen. It
may, in the first place, pass into the blood stream
or the small channels called the lymph vessels, which
everywhere help to convey fluid to the tissues, and
by this means become widely distributed through-
out the body ; or it may, in the second place, remain
close to the site of invasion, and there grow and
multiply. In either case it is probable that many,
if not all the symptoms of disease are produced by
certain products formed by the germs and known
generally as toxins or poisons. These toxins are
sometimes excreted by the germs during their life,
and pass into aU the tissues of the body ; this will
happen even when the actual organisms only live
and thrive in a small restricted area, such as the
throat in the case of diphtheria. Other organisms
appear to retain their toxins within their own
bodies, but are thought to yield them up when
they die and become disintegrated, so that the
ultimate effect is similar in either case. This
distinction, however, is of considerable practical
importance with regard to the means at our disposal
for combating the disease caused by any particular
germ.
Now it is a well known and generally recog-
nized fact that aU persons who are exposed to an
infectious disease do not develop the symptoms
with the same degree of severity, and that in some
cases individuals appear to escape infection altogether.
6 INFECTIOUS DISEASES IN SCHOOLS
This has been expressed by saying that in all
infections there are two factors, the "seed" and
the " soil." The seed is represented of course by the
germ, the soil by the tissues of the person in whom
the germ is located. The seed may be strong and
healthy, but there may be some characteristic in the
soil which prevents its growth and development,
so that instead of thriving and multiplying till it
produces the symptoms of disease, it remains in a
passive condition or dies out altogether. When an
individual is insusceptible to any given disease of
this nature, he is said to be " immune."
The question of immunity is indeed a vast and
difficult one, and although it has been largely in-
vestigated by a great number of able men, it is
still in considerable confusion, so complex and
difficult of interpretation are the facts, and so
elaborate are the experiments and deductions which
have been devised to explain them. This at least
is known ; immunity may be of two sorts, natural
or acquired. Natural immunity is exemplified in
certain animals ; thus fowls are naturally immune
to the disease known as anthrax, and tortoises to
the disease known as tetanus or lockjaw. Acquired
immunity is exemplified in the case of individuals
who have passed through an attack of infectious
disease, and are then protected for a longer or
shorter period from a second attack of the same
character. These two conditions probably differ
essentially in the way in which they are produced.
In the first case it is possible that the animal
fails to acquire the disease because its tissues are
incapable of being affected by the poison or toxin
produced by the invading germ ; the toxin is pos-
sibly formed, but is, for that animal or individual,
THE SPECIFIC INFECTIOUS DISEASES 7
innocuous. In the second case it is possible that
the infected animal has, as a result of the previous
attack, produced within itself an antidote to the
poison or toxin, which neutrahzes it as soon as it is
formed. This form of immunity can be artificially
induced in the case of some diseases by injecting
into a susceptible animal small quantities of the
germ causing the disease or its toxin, and gradually
increasing the dose as the animal becomes more and
more immune. In diphtheria, to take the best
known and most conspicuous instance, it is possible
by injecting repeated and increasing quantities of
the bacterial toxins into a large animal (such as the
horse) to produce a condition of immunity, so that
very large doses, much greater than those which
would ordinarily be fatal, fail to produce any reaction.
The animal is then said to possess active immunity.
The serum or fluid portion of its blood can be shown
experimentally to be capable of neutralizing the
toxins or poisons produced by the bacillus when
artificially cultivated. When injected into the body
of a patient suffering from diphtheria the same
result occurs ; much of the poison is immediately
neutraHzed, and the patient is thereby considerably
helped on towards recovery.
The neutrahzing agents in the blood serum are
known as " antitoxins," and belong to a large class
of substances which are produced by the injection
of foreign substances into the blood stream of an
animal and by other means also, and which are
collectively known by the barbarous name of " anti-
bodies." Thus the antitoxin of diphtheria is an
antibody to the toxin of the diphtheria bacillus ;
the serum recently introduced for cerebro-spinal
meningitis is not a definitely antitoxic serum ; it is
8 INFECTIOUS DISEASES IN SCHOOLS
stated by some to be an anti-bacterial serum which
weakens or kills the bacteria themselves. Sera
have also been prepared to act against typhoid,
pneumonia, and other diseases, but they have not
as a rule been very successful, partly perhaps
because they cannot be produced in a sufficiently
concentrated form, and partly owing to variations
in the toxins they are designed to combat.
The immunity produced by the injection of anti-
toxin (which is also used to a certain extent to
protect those likely to be attacked) is what is called
a passive immunity, and from the blood of those so
immunized no curative serum can be obtained.
In the case of other diseases, immunity can be
produced by the injection of an artificial preparation
containing the dead bodies of the causal organism.
There have been many technical difficulties to over-
come before this method could be practically applied
to medicine ; sometimes by means of an elaborate
technique the actual number of organisms to be
injected is counted, in order to obtain an appropriate
dosage ; in others the dose has been determined by
special observations on the animal into which they
are injected. These preparations are known as
" vaccines " — again an unfortunate name, as they
differ essentially from the smallpox vaccine. Vaccines
have been employed successfully in curing a number
of conditions, mainly those produced by various
cocci, and associated with the formation of pus, or
matter, such as boils, abscesses and the like. A
successful vaccine has also been prepared as a pro-
tective against typhoid fever (see page 95).
The ordinary " vaccination " against smallpox
differs from the above described vaccines, for here
the organism (which is almost certainly not a
THE SPECIFIC INFECTIOUS DISEASES 9
bacterium) is not artificially grown and then killed,
but is naturally modified by its passage through
the living body of another animal, namely the
calf, which so alters its virulence that it can no
longer set up the train of symptoms known as
variola or smallpox ; it is still able, however, to
produce immunity in the person into whom it is
passed. Before use the vaccine is in this case sub-
jected to many processes which effectually prevent
the introduction of other possibly harmful bodies,
and the finished product is really a highly artificial
substance suspended in glycerine.
We can now consider the various ways in which
infectious diseases are passed on from one person
to another under the actual conditions of life. A
distinction is sometimes drawn between infectious
and contagious diseases, the former being those in
which very close contact is not necessary for the
transmission of the infection, and the latter being
those in which something like actual contact is
required. The distinction is not really of much
value, and is also somewhat artificial. It is per-
haps better to drop it altogether and to speak of
all these diseases as infectious or communicable.
The following are the chief methods of transmis-
sion : —
(i) Direct. — ^That is from one person to another.
In a disease hke diphtheria, when the germs are in
the throat, they may easily be ejected by coughing,
and, becoming mixed with the fine almost invisible
dust of the air, be inhaled by another person.
Probably measles, scarlet fever and other diseases
are spread from one person to another in a similar
manner. In smallpox, the causal organism is
contained in the pustules on the skin, m typhoid
10 INFECTIOUS DISEASES IN SCHOOLS
fever it is in the excretions from the bowel, and in
these diseases may easily spread on to the persons
generally of those who are suffering from an attack.
In some diseases, however, it is now quite well known
that persons may harbour the causal germs without
themselves presenting any symptoms of iUness. In
diphtheria and typhoid this has repeatedly been
shown to occur. Apparently healthy children may
have diphtheria germs for many months in their
throats, and adults may carry typhoid germs in their
intestines. These persons are called " carriers,"
and as the germs are in many cases virulent, these
carriers may set up the disease in others with whom
they are in contact.
(2) Indirect. — ^That is by means of some inter-
mediary person, object, or animal. Germs may be
carried on the clothes or hands of those attending
on the sick, or on inanimate objects, such as books,
bedding, food, or feeding utensils. The degree in
which this is possible varies in different diseases. In
some the genn causing the disease is capable of
surviving for a long time outside the human body,
in others, especially if exposed to air and sunshine,
it very quickly dies.
Inanimate objects which are infected by a sick
person are often called fomites, because they may
set up a wide-spread epidemic, as a spark may
kindle a conflagration. Dust, either the palpable
dust such as we aU know in dry windy weather,
or those fine particles which occur in the air of
most houses but are only seen as "sunbeams,"
may be impregnated with the germs of disease and
assist in spreading infection. This occurred in the
South African war when dust charged with typhoid
germs carried the disease to great distances, but,
THE SPECIFIC INFECTIOUS DISEASES 11
on the whole, the theory of air-borne infection is now
held to have only a very limited application.
Insects may also carry germs. The common house-
fly is a notorious offender in this respect ; he walks
upon contaminated material, or even feeds upon it,
and then, in the course of his peregrinations, alights
on articles of food on which he deposits virulent
germs. Hence the importance of clearing out dust-
bins, manure heaps, and refuse of aU sorts, which are
the usual breeding ground for these creatures. Milk,
and water may, as is well known, carry disease germs
and set up an epidemic. The diseases most commonly
propagated in this manner are typhoid fever, scarlet
fever, and to a lesser extent diphtheria. Butter and
cream may act, of course, in the same way as milk.
It will be noticed that in this account of the
way infective diseases are spread no mention has
been made of defective drainage as a cause of
epidemic disease. Practically the only disease in
this country which is likely to occur in epidemic
form owing to defects in drainage is typhoid fever.
If the discharges from a patient containing the
typhoid germs are carelessly emptied into the drains,
and owing to some leak or defects the contaminated
sewage gets into the water supply, obviously fresh
cases of disease are likely, if not certain, to occur in
those drinking the polluted water. But the popular
idea that if a case of diphtheria or scarlet fever
occurs in a house, something must be wrong with the
drains, is for the most part erroneous. It is true
that expert investigation will often detect faults in
any drainage system, but this does not prove that
the disease in question was caused by the defect
which has been discovered, and the hasty assumption
that when the drains are set right all has been done
12 INFECTIOUS DISEASES IN SCHOOLS
that is needful may prove an absolute danger, because
it tends to divert attention from the true cause of
the infection, which is possibly to be found in a
" carrier " or some mild and consequently un-
diagnosed case,
A house into which sewer gas is constantly escaping
is, of course, not a desirable residence from the point
of view of health, and may have a deleterious effect
on the general condition of those living in it. Under
these circumstances they may be less able to resist
the attacks of disease-producing germs, so that bad
drainage, as may any unhealthy environment, may
pave the way to epidemic disease, though it is not
the actual cause.
The next point with which we must deal is the
general course of an infectious fever. After the
germ or organism causing the disease has found a
lodgment in the body, or as we may say, the patient
has taken the infection, a more or less definite period
elapses before any symptoms occur. This is called
the " incubation period," and is perhaps partly
occupied by the multiphcation of the germs and
partly by the elaboration of their poisons and the
fixing of these poisons on to the tissues and cells of
the body. This period is succeeded by the period
of invasion, when the characteristic symptoms of
the disease are suddenly or gradually manifested.
As with the period of incubation, the stage of invasion
is more or less definitely self limited in each disease ;
that is to say, most cases pass into the developed
acute stage and then into the fourth stage of defer-
vescence ; or else they die within a period which
may be roughly forecast. During the last penod
(defervescence) the symptoms gradually abate and
the patient becomes convalescent.
THE SPECIFIC INFECTIOUS DISEASES 13
The period of invasion is in most cases character-
ized by " fever," a term which connotes a group of
symptoms, and not, as is popularly thought, a rise
of temperature alone. These symptoms are : a rise
of temperature, a rapid pulse and respiration, a hot
dry skin, a furred tongue and sometimes shivering
fits or " rigors." Appetite is lost and digestion much
impaired ; the urine is usually scanty and high
coloured, and on standing may show a thick red
deposit. The bowels are constipated, and the
patient complains of thirst, headache, pains about
the body, nausea, and a general sensation of dis-
comfort or illness, which has been summed up in
the word " malaise." Often the febrile condition
is ushered in by vomiting.
A few words may now be said on the general
management of fever patients. The temperature
itself, unless it rises to an abnormally high degree or
continues an unusually lengthy period, is not usually
treated. In some cases patients are thought to do
better when their temperature is high, rather than
below what is the usual average for the disease. In
any case the rise in temperature is very hkely a
protective reaction ; that is, it is one of nature's
methods of combating the invading germs, and
should not be unnecessarily checked. A fever
patient should be nursed in a large airy room ;
where several are nursed together 144 square feet of
floor space should be allowed to each bed,* and the
room should be fairly lofty, adequately ventilated,
and well supplied with sunHght. The patient's
* In practice it is not always possible to give so large a
floor space to each bed, though all authorities consider that
this is the proper amount to allow. At any rate the floor
space should not be less than 100 square feet to each bed.
14 INFECTIOUS DISEASES IN SCHOOLS
skin should be well sponged over with tepid water
once or twice daily, he should be aUowed plenty of
water to drink, the bowels should be kept acting,
and the diet be confined to fluid and easily digested
substances, of which the principal example is milk.
The temperature of the room should be kept at about
60° Fahrenheit and should not vary more than two
or three degrees ; and though protected from draught
and chills, the patient should not be overloaded
with bed clothes. Quiet must be enforced, both in
the sick room and outside it, as undue noise may
often prevent that sleep which is so important to
the well-being of the invahd.
We will conclude this general account of the
infections by a few words on the subject of the
prevention, or, as it is called, " prophylaxis " of
disease. The measures at our disposal may be
classified under the following headings : —
I. Preventive inoculations and antitoxins. — ^These,
the best of all known methods of prevention, can
unfortunately only be applied to a few diseases,
owing to the imperfect state of our knowledge.
Foremost, of course, comes smallpox, which by a
thorough system of vaccination and revaccination
can be practically abolished, or at any rate reduced
to inconsiderable dimensions. Next, with regard
to typhoid fever, it seems fairly certain that protec-
tive injections of antityphoid vaccine are of consider-
abe value, but at present their application cannot,
for reasons too technical to be gone into in this place,
be so widespread as is possible in the case of vaccina-
tion for smallpox. In any given case expert opinion
must decide whether this measure is applicable or not.
The same may be said of protective injections of
anti-diphtheric serum, which, though for different
THE SPECIFIC INFECTIOUS DISEASES 15
reasons, cannot always be carried out, although in
many cases they may be found very advisable.
Against the other infectious diseases common in
this country, we have at present no means of this
kind on which we can rely.
2. Isolation. — ^The isolation of the patient is the
chief measure on which we rely for the prevention
of the spread of the disease, and this therefore should
be carried out as thoroughly and at as early a moment
as is possible. In schools, infectious cases should
be nursed in a separate building, or where this is
not possible on a separate floor, preferably at the
top of the house, or in a wing into which the other
inhabitants do not enter. It has been suggested
that the infective agent being a material body will
tend to faU downwards by the law of gravitation,
and that therefore patients should not be isolated
at the top of a house. This seems to be a somewhat
academic point. Practically, isolation at the top
of a house is more convenient and likely to be more
thorough, and owing to their lightness infective
organisms are just as likely to be carried upwards by
draughts as downwards by gravitation.
The room or ward should contain no unnecessary
furniture ; boards should be bare, and there should
be no hangings or curtains except what may be neces-
sary for darkening the room. The nurses should not
mix with the other inhabitants of the house, and
when going out for exercise should change their
outer garments. Visitors should only be allowed in
the room under conditions to be determined by the
medical man in charge. In cases of scarlet fever it
is usual and advisable for the doctor, and any other
person allowed to visit the patients, to wear a wash-
able overall, which is kept in the infected quarters.
16 INFECTIOUS DISEASES IN SCHOOLS
Nothing should be taken out of the sick room or sick
quarters without thorough disinfection; all slops,
remains of food, and refuse of all descriptions should
be disinfected before they are emptied into the drains,
and, wherever possible, sohd articles, such as ragsi
bandages, etc., should be burnt immediately after
use. No papers, books, or other articles of per-
manent value should be allowed in the sick room,
as all such things are better burnt at the end of the
illness, and are Hable to damage if attempts are made
to disinfect them. When patients are sufficiently
convalescent to go out of doors, they should only be
allowed to do so if they can go straight from the sick
room into the open air, without passing through the
house. During their walks they should be accom-
panied by a nurse, who will see that they do not
come in contact with other persons.
With regard to isolation it is only fair to say,
however, that at present it has more practical utility
than theoretical justification. It is no doubt possible
to nurse a great many of the infectious diseases in
the same ward with other patients, or at any rate
in a ward in which the different patients are only
partially separated by such physical barriers as walls
and solid partitions. Typhoid is often nursed in
the general wards of hospitals, and until recently
diphtheria was so treated in many institutions
without bad results ; many other infections such as
measles, mumps, and scarlet fever may be similarly
managed. But the degree of care necessary for the
successful carrying out of such an arrangement is
great, and under the present conditions the isolation
of infectious patients is simpler and less Ukely to
break down in ordinary practice.
3. Disinfection. — ^This is apphed to the patient, at
THE SPECIFIC INFECTIOUS DISEASES 17
the end of his attack, to the room or building in which
he has been nursed, and to various articles which
have been used by him or by those nursing him
during the attack of infectious disease.
Before describing in detail the methods of disinfec-
tion usually adopted, I should like to make a few
general remarks on the rationale of this procedure.
In the first place, we must remember that of the
common acute infectious diseases of this country
the causal germ is known in only a few Thus they
may be divided into three groups, —
(i) Those in which the causal agent is well known :
diphtheria, a bacillus
typhoid fever, a bacillus
impetigo, cocci
cerebro-spinal
menmgitis
a coccus.
(2) Those in which the causal agent is known with
some degree of certainty :
whooping cough, a bacillus
mumps, a coccus (?)
smallpox, a protozoon (?)
(3) Those in which the causal agent is not known :
scarlet fever, chicken pox, measles, rubella, epidemic
poHomyehtis, glandular fever.
I. In the first of these groups, disinfection can be
scientifically carried out. Special methods can be
adopted to ascertain whether the patient is free
from the organism or not, and definite measures
taken to rid him of it in the latter eventuality. It is
known on what articles, used by or for the patient
the organism is likely to be found, and what mean^
will effectually destroy it. The secretions of the
throat and nose in diphtheria and cerebro-spinal
menmgitis, the stools and urine in typhoid, and the
2
18 INFECTIOUS DISEASES IN SCHOOLS
skin lesions in impetigo can all contaminate things
brought near to them, but on these objects the
organisms do not long survive, especially in a dry
state ; probably the most long lived are the cocci
causing impetigo.
The disinfection of rooms has very little place in
these diseases, nor would antiseptic baths have any
appreciable effect in diminishing the infectivity of
a patient in whom the germs still existed. Diph-
theria bacilli have been found on the walls of rooms
in which diphtheria patients have been nursed, but
they are mostly deposited in the earlier stages of
the disease, and die before the patient is con-
valescent. In the larger proportion of cases they
are not found at all on walls. Typhoid bacilli, when
due care is taken in nursing the patient, should
not be present on the waUs or floors of rooms, and
the wards of general hospitals are not disinfected
after typhoid patients are discharged.
2. With regard to the second group, our know-
ledge is less certain. It is only, however, in the case
of smaUpox that the virus is capable of marked
dissemination into the air surrounding the patient,
and is able to survive for any considerable time. In
a well known case the virus of whooping cough
survived on a third person for at least twenty-four
hours.
3. With regard to the third group, we are practi-
cally fighting in the dark against an unknown
enemy. The virus of epidemic pohomyehtis is
smaller than any organism which can be observed
under the microscope. A number of such organisms
are now known ; one which produces yellow fever
is transmitted by a species of mosquito, or by the
blood of an infected person, but not otherwise.
THE SPECIFIC INFECTIOUS DISEASES 19
When, therefore, we adopt a number of disinfecting
methods in the diseases of this group, we are going on
the shot-gun principle, hoping that one of the many
small pellets will hit the mark. What we know,
however, of the diseases in which the organism can
be traced, makes it probable that, in time, many of
these methods will be discarded as superfluous. The
virus will be shown in many cases to be incapable
of long survival outside the body when exposed to
light and air ; and very likely special methods for
its transmission will be definitely determined in each
case. In the meantime the elaboration with which
disinfection should be carried out must be determined
by the seriousness of the disease. In scarlet fever
and diphtheria, for instance, which are the most
serious of all common infections in schools, no
precaution should be omitted. In chicken pox and
rubella a very ordinary degree of care and cleanliness
will suffice.
(«). The patient is usually disinfected by means
of one or more warm baths, with plenty of scrubbing
and soap, followed by sponging over with an anti-
septic solution, such as Izal i in 200.
After the last bath the patient puts on entirely
fresh non-infected clothes, those he had worn during
his convalescence being removed from the bathroom
before he is out of the bath. He then leaves the
infected quarters immediately.
{b). The disinfection of the ward or building is, in
large towns, usually carried out by the sanitary
authority. Thorough scrubbing and cleaning of
floors and walls should be carried out after all cases
of infectious disease, and in the more serious ones
the full routine is necessary. After articles to be
otherwise dealt with, such as bedding, crockery,
20 INFECTIOUS DISEASES IN SCHOOLS
etc., have been removed, the room is first fumigated
with sulphur or formahn. Sulphur can be merely
pounded up and burnt in an iron saucer suspended
over a bucket of water to obviate the danger of fire,
or the more convenient sulphur candles may be
employed. In any case all cracks and orifices should
be sealed up as securely as possible, and all cupboards,
etc. opened, before fumigation begins. The walls
and floors should be wetted and the air rendered
thoroughly moist. The presence of curtains and
hangings m a room considerably impairs the efficacy
of this form of fumigation. Two or three pounds of
sulphur must be allowed for every i,ooo cubic feet
of air-space. Often the room is left for twenty-four
hours, by which time it will usually be possible to
enter it, but after three hours the windows may be
opened if the person entering the room protects his
face with a towel soaked in a solution of washing
soda.
Sulphur has the disadvantage of damaging cer-
tain articles, notably pohshed metals, such as gas
fittings, window fasteners, etc. In its place formal-
dehyde gas (the commercial solution of which is
known as formahn) may be employed. The Alformant
lamp is a convenient way of fumigation by formahn
in small rooms. Thirty tablets are used for every
1,000 cubic feet. The air must be moist and the
temperature not under 60° Fahrenheit. The usual
period of fumigation is 4 hours. For large rooms
the apparatus known as Trillet's, or the more con-
venient Lingner's, must be employed. The former
method at any rate, can only be carried out by
sanitary authorities. After any form of fumigation
thorough ventilation of the room must take place,
in itself a valuable proceeding. The floors, etc.,
THE SPECIFIC INFECTIOUS DISEASES 21
are then scrabbed with a disinfectant solution, such
as I in 100 Izal, CylHn, or Cresol. Papers should
be scraped off the walls, the ceilings hme-washed, and
the walls if unpapered sprayed with 2 per cent
formalin solution or washed with one of the disin-
fectants used for the floors. In Germany the walls
are first rubbed over with breadcrumbs, which are
subsequently swept up and burnt, and then sprayed
with carbolic acid solution i in 100.
(c). Bedding, clothes and materials generally must
be disinfected by steam generated under pressure in
a special apparatus. Leather articles, such as boots,
which are damaged by steam, must be exposed to
sulphur or formahn when the room is fumigated.
Sheets and Hnen articles may be disinfected by
soaking in carbolic acid solution i in 25 to i in 50,
Izal I in 100 to i in 200, or Cyllin i in 150 to i in 300
for an hour. They may then be wrung out and sent
to the wash. Crockery, glass ware and enamelled
metal ware may be placed in water and boiled for
fifteen minutes. In some cases it is necessary to dis-
infect the stools of patients. This is done by pouring
on to them i or 2 pints of i in 40 carbohc acid, Lysol
or Cresol. The mass is thoroughly mixed, covered
up and allowed to stand for at least one hour. It
may then be disposed of in the usual way. Urine
may be similarly treated, being mixed with an equal
bulk of the disinfectant solution.
4. Quarantine.— Omng to the fact that infectious
fevers present no symptoms till after the " incubation
period " proper to each has elapsed, it is impossible
to say whether a person exposed to infection will
develop the disease or not until a certain time has
expired and the characteristic features begin to
appear. When therefore definite exposure to an
22 INFECTIOUS DISEASES IN SCHOOLS
infectious disease has occurred, those who may
develop it should be prevented from mixing with
others until it becomes known whether or not they
have taken the infection. In practice it is usual to
allow a few days over the longest incubation period,
in order to give a margin for safety, and this is called
the quarantine period. The term quarantine there-
fore should not be applied to a patient who is isolated
because he has an infectious complaint ; it should be
used only to denote the time during which suspected
persons are isolated and watched to see if they are
going to develop symptoms. A child is usually
placed in quarantine, and not allowed to attend
school if a case of infectious disease has occurred in
the house in which he lives, and the period is reckoned
either from the day the patient is removed from the
house or otherwise completely isolated, or from the
day on which the suspected individual is removed
from the house in which the case is being nursed.
The various periods of quarantine will be stated
under their respective diseases in the subsequent
chapters of this book.
5. Certificates— These will be dealt with later
(see pp. 139-140).
J. M. F.-B.
23
CHAPTER II.
THE ACUTE EXANTHEMATA
THE acute exanthemata belong to that group of
infectious diseases in which the poison is
generated within the human body, and in the
course of which there is developed on the skin
and mucous membranes a rash characteristic of
each of them.
The poison is transmitted from one individual to
another, generally by proximity, but also, in some
of them, by fomites or articles of food such as
milk or water. Direct contact or inoculation is
not necessary.
An individual who has been attacked by one of
them is not, as a rule, subject to a second attack of
the same disease. The exceptions to this rule are
very few and may, in practice, be disregarded. An
attack of one of them does not, however, protect an
individual from the other members of the group.
On the contrary it seems to render him more sus-
ceptible to the poison of the others.
Two or more infectious diseases may run their
course concurrently in the same individual. The
experience of the fever hospitals shows that this is
far from uncommon. The opinion is generally held
that there are no modifications of the characters of
one disease by the co-existence within the body of
another ; and that there is no interference with the
incubation period of either. The following case is
24 INFECTIOUS DISEASES IN SCHOOLS
evidence to the contrary. A boy returned to school
on May 6th, having been to a place of public enter-
tainment on the previous day. On the gth he was
found to have a copious scarlatinal rash, and was at
once isolated in a room at the sanatorium which had
not, previously, been used for any other disease. The
scarlatina ran an ordinary uncomplicated course,
the fever being rather prolonged ; convalescence
was reached on the twelfth day, the temperature
remaining normal for the next ten days. Then, on
the 22nd day from his isolation, the temperature
again rose rapidly, and an eruption of chicken pox
appeared on his body. The attack was very severe
and the temperature reached 104° on four successive
evenings.
In this case the incubation period of the chicken-
pox was certainly not less than twenty-two days and
was probably twenty-six, as the patient most likely
received the poison of both diseases on the occasion
of his visit to London.
The diseases of this group, which will be considered
here, are Measles, Rubella, Scarlet Fever, and
Chicken Pox.
They present certain features in common. In
each of them, after the reception of the poison, there
is a period of latency while the poison is multiply-
ing— period of incubation, during which there are
no obvious manifestations of disease ; this is fol-
lowed by a period of somewhat indefinite symptoms
-prodromal period ; after which the characteristic
rash appears and runs its comse—exanthemic period ;
to this succeed the periods of defervescence and
convalescence.
Rashes are described, according to their character-
istics, in the following terms
THE ACUTE EXANTHEMATA
25
^ ■ u
N
J
11 1 1
Mil
MM
MM
1 11 1
3
1 1 t 1
1 1 II
11 1 1
MM
U]X
Irs "
«^ J
1
1 1 1 1
iTTr
-4^
II II
MM
MM
1 llT
Tm-
■44-iJ_
1 1 1 1
11 1 1
1 1 1 1
11 1
to
Tttt
MM.
" -
(■ 1 1 w
-4-Ul
^111
MM
— 7-
1 1 1 1
c
1 1 II
t M 1
1 II 1
1 1 II
1 1 1 1
" -
«^ =
J
11 11
1 II 1
1 1 1 1
1 1 1
1 II 1
^ u
J
,1111
1 II 1
1 1 1 1
1 1 11
111 1
MM
r
^ I 1 I
E
1 1 1 1
II 1 1
II II
11 1 1
1 II 1
N
J ^
1 1 II
1 1 1 1
1 1 1 1
1 1 1 1
<
MM
L
3
J
E
II 11
1 1 1 r
II 1 1
1 1 1 1
1 11 1
lr->
b
:
lJ
1 1 1 1
1 1 1 1
MM
1 1 1 1
:
J
E
1 1 1 1
1 1 1 1
1 1 1 1
inM_
, 1 1^
IMP
L
:
J
E
1 1 1 1
Jill
1 11 1
1 11 1
t "
rsl '
J
r
1 1 1 1
1 1 1 1
1 1 11
1 1 iT
H^M
1 1
1 1 1
b
^ ..
Li
F
1 1 1 1
1 1 iT
1' ' ' '
MM
) 1
1 1.1
L
J ^ ^
MM
1 1 1 1
iTTr
1 1 1
a>
J
F
gusb' uc
1 1 1
CO
J
1 1 1 1
E
\ t iT
-XJJI
1 1 II
' 1 1 M
1 1 1
N
J ^ ^
E
1 1 1 1
Mil
1 1 1 1
MM
CO
I UOI
i
MM
1 1 1
1 1 1 1
E
1 1 1 1
MM
II 11'
MM
1 II 1
1 1 1
^
E
1 1 II
iiTr
1 1 1 1
MM
Id
1 1 1 1
INI
11 II
MM
MM
1 1 1
N
II 1 1
MM
MM
MM
1 1 II
1
Ul
Mil
II II
'mm
MM
Mil
MM
DAY OF
DISEASE
— -' 1 1 1 1
u •«■.<"
I
F
- • r-TTT
S
r 1 1 T
to
3
- 1 T-^ r
1 1 1 T 1
2
1
« «
31 -a
35 1
00
0)
26 INFECTIOUS DISEASES IN SCHOOLS
Erythematous, consisting of a superficial inflam-
mation of the skin, with redness, slight swelling, and
often some desquamation. An erythema is said to
be Punctate, when it presents the appearance of
rninute red points, situated on a less brilHantly red
background.
Macular, consisting of spots or blotches of various
tints, circular, oval or irregular in shape, and slightly
raised above the skin.
Papular, consisting of small, soHd, somewhat
pointed sweUings of the skin, varying in size from a
pin's head to a pea.
Vesicular, consisting of small raised bladders,
containing clear fluid derived from the serum of the
blood.
Pustular, consisting of small globular or conical
elevations of the skin, usually surrounded by a red
margin, and containing matter or pus. Vesicles
often become pustular.
Urticarial, consisting of indurated wheals raised
on the surface of the skin, which are white at the
top and red at the edges ; they itch very much, and
come and go, sometimes several times a day.
Though each of the exanthemata has a character-
istic eruption which aids in distinguishing one from
the other, similar rashes may be produced by other
causes, and it is not possible to diagnose an infectious
fever by the appearance of the rash alone.
Certain drugs, e.g.. Belladonna, many of the
Balsams, Morphia and Quinine, occasionally produce
rashes, usually of the urticarial type, but sometimes
having a scarlatinal or measly appearance.
Some articles of food, e.g., mushrooms, eggs, straw-
berries, shell-fish, etc., produce rashes in susceptible
individuals.
THE ACUTE EXANTHEMATA
27
The serum used in antitoxin inoculations frequently
produces rashes of various sorts, some hke scarlatina
and some like measles. They appear from seven to
fourteen days after the injection, and are often
accompanied by some fever and other S3miptoms of
illness. The rash usually makes its first appearance
at the seat of injection.
The use of enemata, especially if hard soap is
used, is not uncommonly followed by the appearance
of a rash. This sometimes takes the form of a
punctate erythema, not unlike the rash of scarlatina ;
usually the backs of the wrists are the first to be
affected.
Boys who handle caterpillars or the cocoons of
certain species of moths, get a rash on their hands,
which can be transferred, by rubbing, to other
parts of the body. The eyes are specially liable
to be affected, becoming swollen, red and watery,
thus simulating rubella or measles in their early
stages.
The most common of the above species are, the
Gold tail* (P. similis), the Vapourer (0. antigua),
the common Tiger or Woolly Bear [A. caia), the
Lackey (M. neustria), the Oak Eggar {B. quercus),
the Fox moth [B. rubi), the Drinker (C. potatoria).
Contact with certain plants, especially those
belonging to the Primula group, e.g., Primula
obconica, is capable of setting up irritant rashes.
The rash of idiopathic rose-rash closely simulates
that of the infectious variety, and a diagnosis between
the two may be impossible. The idiopathic variety,
* The Gold tail is also known as Liparis Auriflua, and
in the North of England as the Palmer worm. Possibly
the moth is irritant also, especially when freshly emerged
from the cocoon.
28 INFECTIOUS DISEASES IN SCHOOLS
however, is frequently patchy, disappearing from one
place and appearing in another.
It is well to remember that a brush, vigorously
applied to the skin of the chest or elsewhere, will
produce a rash not unlike that of rubella. This is
only local, and confined to the parts which have
been treated.
H. G. A.
29
CHAPTER III.
MORBILLI. MEASLES.
French : Rougeole. German : Masern.
MEASLES is an acute infectious disease, of which
the characteristic symptoms are catarrh of the
respiratory passages, a pecuhar rash on the mucous
membrane of the mouth, and a blotchy eruption on
the skin. Its geographical distribution is very wide,
for measles occurs in every portion of the civilized
world, though certain districts have, at times,
remained free from it for a considerable period.
Though we have no certain knowledge of its
antiquity, it was probably known to the early
Arabian writers, but it was not separated from
scarlet fever, and described as an independent
disease, till the middle of the eighteenth century ;
and it was not till towards the end of the last century
that the distinction was estabhshed between true
measles and the disease now known as rubella, and
popularly caUed German measles.
Measles never entirely dies out, but persists as an
endemic disease, which at intervals bursts forth into
epidemic form. The length of the intervals between
epidemics is to a great extent determined by the
number of susceptible individuals — ^i.e., unprotected
by a previous attack — ^who are added to a community.
Experience in large schools of four or five hundred
boys shows that, when the number of those thus
30 INFECTIOUS DISEASES IN SCHOOLS
unprotected reaches one third of the total number, an
outbreak may be looked for.
Susceptibility to the contagion of measles is almost
universal, and owing to this it is almost entirely a
disease of childhood. In England, in the elemen-
tary schools, 84 per cent of the children have been
attacked before reaching the age of ten years; in
the preparatory and public schools, 35 per cent
have been attacked before the age of nine, 68 per
cent before fourteen, and at the termination of the
school period not more than 3 per cent have
escaped. It has been found, however, that when
introduced into districts from which it has been
absent for a considerable period, measles attacks
both old and young indiscriminately, and the older
people suffer most severely. This was the ex-
perience in the Faroe Islands, when the disease
was introduced in 1846, after an absence of sixty-
five years. Panum states that 6000 out of a popula-
tion of 7782 were attacked. Similar observations
have been reported from Mauritius, Iceland and Fiji.
In these outbreaks the mortality was very large,
which gives some reason to suppose that, in districts
where epidemics constantly recur, there is, to some
extent, a transferred immunity from parent to child,
leading to a milder type of the disease. The opposite
to this is also true, for there seems in some families
to be a certain hereditary transmission of a pre-
disposition in their children to a special severity of
type.
The infection of measles is, in almost all cases,
contracted by direct personal intercourse. There is
very little, if any, positive evidence that it can be
conveyed by intermediaries or by fomiies, such as
articles of clothing or utensils ; on the other hand,
MORBILLL MEASLES
31
the evidence to the contrary is very strong. The
poison is given off from the affected person during
the prodromal stage, before the characteristic eruption
has appeared, during the eruptive stage, and possibly
for some days after the rash has disappeared : the
secretions from the eyes, nose, mouth, and respiratory
passages being the principal vehicles. The poison is
air-borne to a limited distance. Observations made
in cases where infection has spread during the time
of attendance in chapel, indicate that the outside
range is twelve feet, but the great majority of those
infected were found to have been within six feet of
the focus.
Though it is practically certain that measles is due
to a specific micro-organism, its nature is as yet
unknown.
Incubation. — From the time of the reception of the
poison till the appearance of the characteristic
eruption on the skin, a fairly definite period of from
thirteen to fifteen days elapses. This period is
divided into two : the incubation stage and the
prodromal stage ; that of incubation usually lasting
ten days, of prodromal three days; but this is
liable to variation.
The stage of incubation presents no easily
recognisable symptoms, though complaint may be
made of lassitude and general indisposition.
Meunier, a French physician, has, however, called
attention to a peculiar alteration of weight which is
known as Meunier' s sign. He says, " There exists
during the stage called incubation of measles a
phenomenon which we have constantly observed,
and which consists in a marked lowering of the body
weight. It begins about the fourth or fifth day
after contagion, that is to say five or six days before
32 INFECTIOUS DISEASES IN SCHOOLS
the appearance of the first catarrhal or febrile
symptoms, eight or ten days before the eruption.
It lasts several days, more often even to the beginning
Day
1
2
3
4
5
6
7
g
g
10
//
ft
to
/■f
SSl: 81
t
7
-s-
\i
- f
o
r
5
u
b-
o-
-03-
V.
4
to
o
tri
C-
Oj
3
8-
•0
.. 2.
—
Rist
Fall
• of
(if
2
3
lbs
Ilia
■s
c
«;
1
0
Fig. 1. — Chart showing rise and fall of weight in incubation of Measles.
of invasion. The loss of weight is about lo oz., or
i| oz. a day in a child of four or five years ; it may
reach 22 oz., and has not been observed less than
3 oz." Observations made on the lines indicated by
Day
1
2
3
4
5
6
7
8
3
10
II
12
13
14
.... .
6St- 61b. f.
-a
*•
Q
q
7
-5
%
6
0
ii
--8-
t
si
>
5
A
:§
■s
4
"1
0
/
-c—
•a
3
g--
A
2
Q
r
1
V
0
■Fig. 3- — Chart showing rise and fall of weight in Measles.
Meunier, show that the weight rises during the
first five or six days, and then gradually falls as
shown in the charts (2 and 3). The fall is greater
MORBILLI. MEASLES
33
than that stated by him, probably accounted for by
the fact that the observations were made on older
and heavier subjects.
About the sixth day the glands, especially those in
the neck and armpits, become enlarged ; not at first
tender, but they usually become so a day or two
later. The swelling and tenderness of the glands
continue till the termination of the fever, but
suppuration rarely takes place.
Prodromal Stage. — On the tenth day from infec-
tion, in a typical case, the period of invasion, or
prodromal stage, is reached. In most cases the
onset is sudden, but in some the symptoms develop
gradually. Of these the earliest are a moderate
degree of fever, the temperature rising to from ioi°
to 103°, running from the eyes and nose, catarrh of
the upper air passages, with a troublesome cough.
The patient presents the ordinary symptoms of a
cold in the head. During the prodromal stage, and
two or three days before the appearance of the rash
on the skin, a peculiar eruption may be seen on the
mucous membrane of the mouth. This was first
described by Flindt in his reports to the Danish
Board of Health, but the credit of drawing attention
to its diagnostic importance belongs to KopHk of
New York.*
The changes in the mouth appear in the following
order : —
On the first day of fever there is a slight diffuse
redness of the tonsils.
On the second day, the redness of the tonsils has
* Koplik's spots are not always found ; their absence does
not negative the diagnosis of measles. In 187 cases, KopUk's
spots were unmistakably present in 169, absent in 8, doubtful
in 10 (Holt).
3
34 INFECTIOUS DISEASES IN SCHOOLS
increased and spread to the pillars of the fauces and
the soft palate; and certain characteristic spots—
KopUk's spots — appear on the mucous membrane
lining the cheeks. These may usually first be seen
opposite the molar teeth. They consist of small
irregular spots of a bright red colour. In the centre
of each spot may be noted, in strong daylight, a
F'ig-. 4. — Temperature Chart in Measles.
tninute bluish-white speck. These specks on a red
background may be regarded as diagnostic of
measles, for they occur in no other disease. The
gums, also, show evidence of congestion, are red,
injected, and slightly swollen, being covered with a
white patchy scum, which may readily be removed.
The tongue is covered by white fur, its edges are
red, and the papillae enlarged.
MORBILLI. MEASLES
35
On the third day, the rash in the mouth has become
more intense. The soft palate is entirely covered
and the hard palate involved. The Kophk's spots
have greatly increased in number and may be
observed on the inner sides of the Hps. The eruption
now begins to appear on the skin.
During the prodromal stage, there is frequently.
Fif. 5.— Temperature Chart in Measles.
on the second or third day, a remission of all the
symptoms; the temperature may fall to normal
or a little above, while the cough and catarrh may
almost entirely disappear. This remission may often
give a false sense of security and the nature of the
illness may be overlooked. (Figs. 4 and 5.)
In the stage of primary fever, evanescent rashes
often appear and disappear on the skin. The most
36 INFECTIOUS DISEASES IN SCHOOLS
common of these is a spotty rash not unlike the
proper one of the disease. In some epidemics a
general erythema on the trunk, similar to the rash
of scarlet fever, has been observed. Attacks of
nettle rash are not uncommon.
Eruptive Stage. — ^The skin eruption of measles
appears, as a rule, first upon the face near the mouth
and nose, or behind the ears, and spreads downwards
over the neck, chest and arms, and lastly over the
abdomen and lower extremities. It is not uncommon,
however, for the first appearance to be on the neck
or the sides of the chest. There is no foundation for
the beHef that the severity of the subsequent attack,
or the liability to comphcations, is influenced by the
situation in which the rash first makes its appearance.
The eruption consists of shghtly elevated, deep rosy
or dark red separate spots, scattered irregularly, and
fading on pressure. The individual spots quickly
increase in size and coalesce with one another to form
crescentic blotches. The rash continues to increase
for from two to three days, the blotches becoming
continuous in many places, more elevated, and of a
darker colour. But even at its maximum develop-
ment, patches of unaffected skin can be seen con-
trasting with the deep colour of the rash. Shortly
after attaining its maximum, the eruption fades
rather quickly in the same order in which it appeared,
leaving behind a yellowish discoloration, which may
persist for some time. In a proportion of cases
minute haemorrhages appear on the skin, especially in
the flexures of the joints ; in a few the entire eruption
becomes haemorrhagic. With the appearance of the
rash and its increasing development, the temperature
continues to rise and may often reach, in a case of
moderate severity, 105°. In most cases, however,
PLATE 1.
Fig. 6. — Mkasles ; second day of rash. The appearance often
r< seinbles chicken-pox or small-pox ; but the features have a
characteristic bloated appearance.
Face page
MORBILLI. MEASLES
37
104° is not exceeded. The eruption on the skin and
the temperature, usually reach their maximum
development on the fifteenth day from infection, or
the sixth from the primary fever. Both then subside,
and a normal temperature is reached in from two to
three days. During the eruptive stage all the
symptoms of the prodromal stage increase in severity.
The eyes become inflamed and there is often great
intolerance of light. The cough is persistent and
troublesome, and there is catarrh of the upper air
passages, due, probably, to the downward spread of
the eruption from the throat. Often there is a
moderate amount of bronchitis, the respirations
being short and frequent, and there is usually some
complaint of soreness of the throat. The pulse is
quickened in proportion to the temperature. The
patient is generally restless, and the sleep much
disturbed by the cough. The tongue usually con-
tinues furred, but occasionally the fur peels off,
giving the red appearance with enlarged papillae,
usually associated with scarlet fever.
The disappearance of the eruption is followed by
some desquamation of the skin, of a branny
description, which may last a week or more.
The above is a picture of an ordinary typical
attack of measles, as seen in a child of school age.
It is hable, however, to some variations. The com-
mencement of the prodromal stage may be delayed
till the twelfth or the thirteenth day, and the appear-
ance of the rash may also be delayed for one or two
days. In every epidemic some cases are seen of
very mild type, the amount of fever being small and
the eruption slight and evanescent. On the other
hand, the effects of the poison may be profound and
the fever more intense and prolonged.
38 INFECTIOUS DISEASES IN SCHOOLS
Compiicaiions.—The most important are those
which affect the larynx, the lungs and the ears.
The extension of the rash from the mouth to the
larynx may cause swelling of the vocal cords, with
symptoms of croup, difficulty of breathing, knd a
short barking cough, occurring in paroxysms.
The bronchial catarrh, which is common to all
cases of measles, may develop into a general bron-
chitis ; or the lung may itself be involved and
pneumonia, in one of its forms, result. This, a grave
complication, may take place at any period of the
attack, even in the prodromal stage, but more
commonly at or about the time of the maximum
intensity of the fever. If the patient appears dull
and apathetic, the fever unusually high and remain-
ing so, and if the ratio between respiration and pulse
is altered,* an oncoming pneumonia may be feared
and its physical signs looked for.
Inflammation may spread up the Eustachian tubes
to the middle ear, giving rise to pain and, possibly,
abscess. Occasionally this spreads through the bone
tissue and affects the brain and its membranes.
Among the rarer complications are various kinds
of paralysis.
Diarrhoea is often present. This varies greatly in
different epidemics. In some it is almost a constant
symptom, in others almost absent. It has been
observed that in those epidemics, in which there is
much diarrhoea, lung complications are less common.
Bleeding from the nose frequently occurs. If this
* The normal being i to 4 (for example, respiration 20 to
pulse 80 with a temperature of 99°), the ratio in oncoming
pneumonia often approximates i to 3 ; for example, with a
temperature of 104° the respirations rise to 40, the pulse to
only 120. — Nothnagel's EncyclopcBdia, Translator's note.
MORBILLI. MEASLES
39
is not severe, it may be regarded as beneficial.
Patients often feel relief of their general symptoms
after a moderate loss of blood, and it seems to
diminish the tendency to ear troubles. The bleeding
may, however, be so severe as to call for special
treatment.
Convulsions not unfrequently occur in the pro-
dromal stage, especially in young children, and are
not, necessarily, of serious import. When they occur
in the later stages their significance is very grave.
Diagnosis. — There is little difficulty in detecting a
well marked case of measles, especially when it
occurs in the course of an epidemic. The non-
specific eruptions, which may be mistaken for
measles are referred to on page 26. They may be dis-
tinguished, partly by the character of the rash, but
more by the absence of the typical symptoms of
the disease. The main features distinguishing
measles, rubella and scarlet fever are set out in
tabular form on page 56.
Prognosis. — When the disease is treated under
favourable hygienic conditions, the mortality is not
great. Fatal cases are almost always due to lung
comphcations or to extensions of inflammation from
the ears to the brain. Epidemics vary much in
their severity, and age has a considerable influence.
Before the age of five and after fifteen the tendency
to severe attacks is increased.
Treatment. — An ordinary case of measles does not
require much treatment ; the anticipation and
prevention of comphcations being the most important.
The patient should be put to bed and kept there for
a fortnight. The room should contain 1500 cubic
feet of air-space ; if other patients are treated in the
same room, the floor area allotted to each bed should
40 INFECTIOUS DISEASES IN SCHOOLS
be sufficient to allow of free ventilation without the
production of draughts. The temperature of the
room should be kept at about 65°. The windows
should be shaded, but complete darkness is undesir-
able. Fresh air and sunshme are very beneficial.
Patients who complain much of intolerance of
light may be supplied with a shade: a suitable
one can be made out of blue sugar paper to
which tapes are attached. Sponging with tepid
water, to which some mild disinfectant, such as
Condy's fluid, has been added, reheves the skin
irritation ; but baths during the febrile stage are
not desirable.
The diet should be hght, consisting of milk, eggs
beaten up with milk, beef tea or chicken broth. To
relieve the thirst, fluids, such as plain water, lemon
or barley water, may be freely supphed. Should
there be much prostration, small doses (two to four
teaspoonfuls) of brandy may be added to the milk
and egg mixture.
For the cough, chlorodyne and Friar's balsam in
suitable doses, often gives rehef . The apphcation to
the neck and chest of a liniment, composed of goose
grease, 2 parts ; soap liniment, 2 parts ; and oil of
amber, i part, gives much relief, induces expectora-
tion, and seems to avert lung complications. The use
of antiseptic applications to the mouth, throat and
and nose is very desirable. A solution of boric acid
(i or 2 per cent) is suitable, and may be applied as
a mouth-wash, a spray, or better with a syringe.
Gargling is inefficient and undesirable. Lozenges
composed of formalin and menthol may be frequently
sucked ; they relieve the throat irritation and the
cough, and diminish the probabihty of ear compHca-
tions. Nose bleeding may, when necessar}-', generally
MORBILLI. MEASLES
41
be stopped by the injection of hot water into the
nostrils. Plugging the back of the nose should be
done only by the doctor, and should be avoided
unless absolutely essential, as the plug quickly
becomes foul, and may set up septic conditions.
For diarrhoea, castor oil in emulsion is useful ;
astringents should not be used while the motions are
unhealthy. If there is much laryngeal trouble with
symptoms of croup, the air should be kept moist by
the use of a steam kettle or spray, to which a
teaspoonful of Friar's balsam, or a few drops of
creasote may be added.
So far as medicine is concerned, a mixture con-
taining acetate or citrate of potash is all that is
required. The more severe complications will require
special treatment adapted to each case. It is, how-
ever, very important to remember that the pneu-
monia of measles is itself an infectious complaint.
Patients with this complication should not be nursed
in the same room as other cases.
During the convalescent stage, the patient should
have nourishing food, tonics and out-door exercise in
suitable weather during the third week. A dis-
infecting bath should be taken each night.
Duration of Infectiveness. — A patient should be
regarded as infectious for three weeks from the
appearance of the rash.
H. G. A.
42
CHAPTER IV.
RUBELLA. ROSE-RASH.
French: Rubeole. German: Rotheln.
7DUBELLA is an acute infectious disease, charac-
terised by a short prodromal period, a rose-
red papular rash upon the skin, slight sore throat,
and marked enlargement of the glands.
About 150 years ago it began to be recognised that
there was an infectious eruptive disease, differing
essentially from scarlet fever and measles, although
somewhat resembHng both in some of its features.
Much doubt existed as to the nature of the affection,
and for a long time it was regarded as a hybrid
between measles and scarlet fever, but this idea has
now been entirely abandoned. In 1875 it was accur-
ately described in German medical literature under
the name of Rotheln, which was, unfortunately,
translated into Enghsh as German Measles.*
This has led to much confusion, and the term
German measles ought to be abandoned, for it cannot
be too strongly insisted upon that rubella, measles,
and scarlet fever are different diseases, each due to
a separate and distinct poison. An attack of one
of them does not render an individual immune from
the other two. The disease is universally distributed.
* In their issue of the Nomenclature of Diseases, 1905,
the Royal College of Physicians adopted the title of Rubella
with the synonyms, German Measles — Epidemic Roseola.
R U BELLA . ROSE-RA SH
43
First accurately described in Germany, it has received
attention from many writers in England, France,
Italy and India, and it is well recognised in both
North and South America.
Most medical writers state that the disease is most
prevalent in young children ; but this appears to be
an error, it being more commonly seen in adolescents
and young adults. From statistics obtained from a
number of Preparatory Schools, it was found that not
more than 5 per cent of their entrants had already
been attacked and, of the entrants at the Pubhc
Schools, only 22 per cent are protected by a previous
attack.
Epidemics of the disease are most liable to prevail
in the late spring and early summer months. The
disease is highly infectious and, in most, if not in all
cases, is communicated by direct personal intercourse.
There is no evidence that the poison is retained in
or conveyed by fomites.
Incubation. — Owing to the insignificance of the
early symptoms it is not easy to determine the
exact duration of the incubation period. In the
great majority of cases it is fourteen days ; in a few,
a day or two more or less.
Eruptive stage. — After a short prodromal period,
not usually more than twenty-four hours, in which
there is some headache and feehng of general ill
health, the rash appears on the face, especially at
the base of the nose and round the mouth. From
the face it quickly spreads to the neck and body, the
whole of which may be covered by the second day
of the disease. The appearance of the eruption
presents three varieties : (i) Papules, varying in
size from a pin's head to a small bean, sHghtly
elevated above the skin, usually round or oval in
44 INFECTIOUS DISEASES IN SCHOOLS
shape, and of a rosy-red colour. This somewhat
resembles the rash of measles, but the colour is
hghter and there is not the same tendency to the
formation of crescentic blotches. (2) Like measles
on the face and body and a diffuse erythema on the
Hmbs, (3) Erythematous throughout and resembling
that of scarlet fever, but without the punctate
appearance. The eyes are frequently suffused and
present a bright red appearance, but, usually, there
is no intolerance of light.
The glandular system is always involved ; the
glands in the sides of the neck, at the back of the ears,
and especially those at the back of the head are en-
larged and tender ; those in the armpits and groins
are usually affected also. It is very uncommon for
the inflammation of the glands to proceed to suppura-
tion and abscess. There is often some complaint of
sore throat, and the tonsils and soft palate are
swollen and red. The respiratory organs are not
affected, and although there is occasionally some
cough, there is no bronchial catarrh.
The amount of fever varies greatly in different
epidemics. In a few cases the temperature may rise
to from 103° to 104°, but a maximum of 101° is more
usual. In a recent epidemic of two hundred cases,
two of them had a temperature of 103°, in 25 per
cent the temperature reached 100°, and in the
remainder, it did not reach that figure.
There is practically no feehng of illness, even in
those cases in which the temperature is raised. On
the third or fourth day the rash has entirely dis-
appeared, some discoloration of the skin may be
left, and there is, generally, some branny desquamation
of the skin, more copious in those cases in which the
eruption has been of the scarlatiniform type.
RUBELLA. ROSE-RASH
45
The swelling of the glands may persist for some
time after the disappearance of the eruption.
Treatment. — Little treatment is required during
the attack. The patient should be kept in bed
during the eruptive period and may then be allowed
out-of-doors. Tonics, such as Easton's syrup, may
be useful during convalescence.
Duration of Infectiveness. — patient may be
regarded as not infectious after eight or ten days
from the appearance of the rash.
Diagnosis. — ^The non-specific eruptions resembling
rubella are referred to on page 26.
The main features distinguishing rubella, measles,
and scarlet fever are set out in tabular form on
page 56.
H. G. A.
46
CHAPTER V.
SCARLATINA. SCARLET FEVER.
French: Scarlatine. German: Scharlach.
OCARLET FEVER is a specific infectious disease,
^ attended by inflammation of the tonsils and
by a punctate scarlet eruption, followed by des-
quamation of the skin.
Although it is probable that scarlet fever must
have existed long before it was described as a
separate disease by medical writers, the first definite
record, according to Hirsch, dates from 1543. Its
original habitat is unknown, but in later times it
has been confined principally to Europe and North
America.
Susceptibility to the contagion of scarlet fever is
not nearly so universal as that to measles. When it
was introduced into Thorshaven in 1873, only 38 per
cent of the inhabitants, who were unprotected by a
previous attack, were affected ; whereas 99 per cent
of the unprotected were attacked by measles two
years later. In England, in the elementary schools,
12 per cent of the children have been attacked before
reaching the age of ten years; in the preparatory
and public schools, 8 per cent have been attacked
before the age of nine, 11 per cent before fourteen,
and about 13 per cent before the termination of their
school career.
Age has a considerable influence. About one-
SCARLATINA. SCARLET FEVER 47
third of the cases occur in children under five years
of age ; another third between five and ten ; and
of the remainder, one-half are under fifteen. No
age is altogether exempt, but cases over twenty-five
are uncommon.
Some individuals seem to have a special immunity
to the disease, and although frequently exposed to
infection, are never attacked. Sometimes this immu-
nity is common to all the members of the same family.
One attack of scarlet fever confers immunity to a
second attack, which usually persists through life ;
but second attacks in the same individual occasion-
ally occur. The infection of scarlet fever is in most
instances due to direct personal intercourse. But
there is no doubt that the poison can be retained in
and conveyed by fomites, such as articles of clothing,
cups, syringes, etc., used by the sick ; books and
letters ; the clothes of doctors and nurses ; and
articles of food. It retains its vitality for a con-
siderable period; and articles of clothing or toys,
which have been put away, unexposed to light and
air, may be sources of danger for a long time. There
is some doubt whether it is ever water-borne, but
many instances have been recorded of the poison
having been conveyed by milk. The poison is
chiefly air-borne, but probably not to a great
distance. Residents in the neighbourhood of fever
hospitals do not appear to be specially Hable to
attack. The secretions of the throat and nose, and
the particles detached from the skin, especially in
the early stages of desquamation, are the principal
vehicles of infection.
It is certain that scarlet fever is due to a specific
micro-organism, and various claims that this has
been isolated and identified, have been put forward.
48 INFECTIOUS DISEASES IN SCHOOLS
These have not yet been substantiated, and the
matter is still sub judice.
Predisposing Causes. — Amongst these are a recent
attack of another infectious disease ; poverty ;
overcrowding ; ill health ; surgical injuries, especially
bums ; and operations, especially those on the
throat and nose, such as the removal of tonsils or
adenoids.
Incubation. — ^The incubation period is, in the
great majority of cases, less than seven days ; most
often three or four days. Where milk has been the
vehicle of infection, the period is somewhat shorter,
averaging two or three days. There seems some
reason to beheve that in scarlet fever as in diphtheria,
the poison may be received into the body and remain
latent, probably in the tonsils, tiU some disturbing
factor, such as ill health, accident or operation,
renders the individual more susceptible to its
development.
Prodromal Stage. — In most cases the attack develops
with rapidity. For one or two days there may be
evidences of ill health, indicated by shivering,
general pains, headache, furred tongue, and loss of
appetite. The most typical symptoms are sore
throat and vomiting, the latter being specially
common in young children. The sore throat is
indicated by difficulty in swallowing, and by pain
and tenderness at the angles of the jaws. The
temperature quickly rises from ioi° to 104°. As a
rule the severity of the initial symptoms, particularly
as regards vomiting, is an indication of that of the
subsequent attack. Adults sometimes complain of
sore throat for some days previous to the other
symptoms of invasion.
Eruptive Stage.— TYit eruption is characteristic.
SCARLATINA. SCARLET FEVER 49
usually appearing within twenty-four hours of the
first symptoms and rarely being delayed beyond the
second day. This consists of two parts ; first there
is a general deep red blush (erythema), and scattered
over it are a number of minute, deeper red, slightly
elevated spots, giving a peculiar punctate appearance.
Usually it is brightest on the chest, loins and inner
sides of the arms and thighs.
In the flexures of the joints, especially in the arm-
pits, elbows and groins, the punctate appearance is
most evident. The rash entirely disappears on
pressure unless, as is often seen on the neck and
flexures of the joints, there are minute haemorrhages
(petechiae) in the skin. The parts over the collar-
bones and breast-bone are first affected, and later the
trunk and hmbs, the legs being reached last. Certain
portions of the skin are, almost invariably, unaffected,
namely the face, scalp, palms of the hands, and soles
of the feet. The freedom of the face from rash is a
valuable distinction between this disease and rubella.
The face is often deeply flushed, especially over the
prominences of the cheeks, and on the second or
third day appears to be dusted over with a fine
white powder, giving the so-called powder-and-rouge
appearance. The region about the mouth is not
flushed, but is bloodless and pale (circum-oral pallor),
contrasting vividly with the surrounding redness.
The skin, where affected by the rash, becomes swollen
with effusion, and difficulty may be experienced in
bending the joints. The eruption fades in the same
order in which it appeared, and with it the sub-
cutaneous effusion. In an ordinary well-developed
case, it is gone by the end of a week, leaving
behind a yellowish parchment-like appearance of the
skin.
4
50 INFECTIOUS DISEASES IN SCHOOLS
The tongue, during the initial stages, is covered
with a thick creamy fur ; the papillae are enlarged
and stand out as red points through the fur. Early
in the eruptive stage this begins to peel off at the
tip and edges of the tongue, which by the fourth
day presents a red moist surface, the condition
being known as " strawberry tongue." This, though
common in, is not peculiar to scarlet fever, as it is
also seen in other diseases, by no means rarely in
measles. The inflammation of the throat bears a
relation to the severity of the general attack. In
the early stages the tonsils and uvula are red, dry,
and shining. Should the disease be intense, these
become swollen and velvety, and covered with a
white secretion which may be seen exuding from the
mouths of the follicles.
The glands in the neck are moderately enlarged
and painful, in sympathy with the inflammation of
the throat. The temperature, which was raised
during the initial period, continues high, ioo° to 104°,
during the eruptive stage. With the fading of the
rash the fever recedes, and the normal is reached in
from five to seven days from the onset (Fig. i,
page 25).
The pulse is always accelerated, much more so
than is accounted for by the amount of fever. The
disproportion between the pulse and temperature
rates is an important point in distinguishing between
scarlet fever and other eruptive diseases. In the
early days of convalescence the pulse and temperature
may be subnormal.
Desquamation. — ^With the subsidence of the febrile
and eruptive symptoms, a characteristic desquama-
tion of the skin commences, appearing first on the
face in a white powder. Peeling may usually be
PLATE II
Face f>ag^e
SCARLATINA. SCARLET FEVER
first observed on the ears and lips, but soon after-
wards extends to the neck, where it often has a pin-
hole appearance. The palms and soles, from which
the skin comes off in flakes or scales, are the last
to become free. The amount of desquamation is
usuahy, but not always, in proportion to the inten-
sity of the eruption and the swelling of the sub-
cutaneous tissues.
Varieties. — Scarlet fever varies more than the
other eruptive diseases. There are three principal
varieties, which have not however any fixed line of
demarcation.
1. Scarlatina Simplex. — ^The fever and throat
affection are so shght that httle discomfort is felt.
The eruption is slight and transient.
2. Scarlatina Latens. — ^This also is very mild and
sometimes overlooked, only being recognised by the
sequelae.
3. Scarlatina Maligna. — All the symptoms are pro-
nounced ; the fever is high and prolonged ; the throat
affection severe, with, possibly, some sloughing of the
tonsils ; a copious discharge from the nose of clear,
■««iscid, irritating fluid, which may appear on the
second day ; the rash is unusually livid, and haemor-
rhages (petechiae) are common ; sleeplessness and
delirium ; a tendency to complications.
Complications. — ^The most common are : —
1. Inflammation of the ears, more especially in
cases where there is much throat trouble, the inflam-
mation spreading up the Eustachian tubes. This also
occurs in mild cases, especially in young children.
2. Inflammation of the kidneys, indicated by the
passage of blood and albumin in the urine, and
dropsy. The appearance of albumin in the urine
during convalescence does not necessarily imply
62 INFECTIOUS DISEASES IN SCHOOLS
that there is inflammation of the kidneys, for adoles-
cents, who are the subjects of functional albuminuria,
very frequently give, under these circumstances, evi-
dences of this condition. This is also the case during
convalescence from other infectious diseases.
3. Severe inflammation of glands, leading to
suppuration and abscesses.
4. Rheumatic affections of the joints, usually
appearing at the end of the first week. These do not
differ from ordinary rheumatism, and may give rise
to heart complications.
5. Secondary rashes, appearing towards the
termination of the second week. These are papular
or erythematous in appearance, and are usually due
to absorption of septic matter from the throat.
Diagnosis. — well marked case of scarlet fever
presenting the features given above can hardly be
mistaken for anything else. In mild and atypical
cases the diagnosis may be difficult or even impossible.
From tonsillitis, especially when it is accompanied,
as is often the case, by some erythema of the neck
and chest, there may be considerable doubt in draw-
ing a distinction. In tonsillitis there is, as a rule, no
vomiting, the rash is not punctate, nor does it spread,
and one tonsil is usually affected before the other ; the
tongue remains furred and does not peel. A very high
initial temperature is rather in favour of tonsillitis.
The non-specific eruptions resembling scarlet fever
are referred to at page 26.
The main features distinguishing scarlet fever,
rubella, and measles are set out in tabular form,
page 56. For those distinguishing it from diph-
theria, see Diphtheria.
Should there be any doubt, it is better to err on
the safe side and isolate the case " on suspicion."
SCARLATINA. SCARLET FEVER 63
Prognosis— This, at the present time, is favourable ;
the case mortality during the last thirty years having
considerably decreased. It must be remembered,
however, that history shows that it is the nature of
the disease to pass through alternate cycles of great
and slight severity. It is by no means improbable
that there will be a recurrence to the severe type of
forty years ago.
Treatment. — ^The patient should be put to bed in a
well ventilated room with a capacity of not less
than 1500 cubic feet. Even a mild case should be
kept in bed for not less than fourteen days, the period
being lengthened according to the severity of the
attack. The temperature of the room should be
from 55° to 60°. The body should be sponged daily
with tepid water containing some mUd disinfectant.
In all cases antiseptic treatment should be given to
the throat and nasal passages. The best antiseptic
for this purpose is chlorine water, made in the
following way. In a closely stoppered bottle put
ten grains of chlorate of potash, and pour on twenty
drops of strong hydrochloric acid, cork tightly and
leave for five minutes ; then add water, two ounces
at a time, to twelve ounces, replacing the stopper
and shaking the bottle on each addition. To this
some syrup may be added before use, but it is not
essential. In mild cases, this may be used as a spray ;
in severe cases the throat and nostrils should be
syringed every two or three hours and the tonsils
swabbed with cotton-wool soaked in the solution.
Garghng is quite ineffective. The insufflation of
flowers of sulphur on to the throat after it has been
thus treated, has a very beneficial effect.
Mild cases need no medicine except an ordinary
febrifuge mixture and purgatives to counteract the
64 INFECTIOUS DISEASES IN SCHOOLS
constipation which is usually present. Salicylate of
soda and salol are valuable drugs for the treatment
of severe cases, and seem to have some influence in
preventing rheumatic complications.
Complicated and severe cases will require special
treatment according to their symptoms.
The diet should be light, consisting for the first
few days of milk, and beaten-up eggs, arrowroot and
cornflour ; later, beef -tea, broth, and meat jellies
may be added. Water or lemon-water to drink, and
fruit, such as oranges or grapes, may be allowed at
any time. At the termination of the febrile stage,
meat, fish, poultry, etc., may be commenced. There
is no reason for withholding nitrogenous food on the
theoretical ground that it may induce kidney trouble.
Specific remedies, for the prevention of, or cutting
short attacks and diminishing the periods of infective-
ness, have from time to time been suggested. None
of them stand the test of time and experience.
Duration of Infectiveness. — ^This is summed up in
the Medical Annual for 1912 thus : " The question
is frequently asked, ' How long does a scarlet-fever
patient remain infectious ? ' It is not so very long
ago that the stereotyped reply was, ' As long as he
continues to peel.' But it is now recognised that
desquamation is not to be taken as a sign of
infectivity. One may say that scarlatina is a
moderately infectious disease for two weeks after
the onset, but that a majority of the cases cease to
be infectious some time during the second fortnight,
so that at the end of the fourth week, only a smaU
percentage remain so. Out of this small percentage
some, including some mild cases, probably remain
infectious for several months, though they are not
so recognisable by any known method ; it is possible
SCARLATINA. SCARLET FEVER 55
a stiU smaller number retain the power of infecting
for a much longer period, perhaps even as long as a
year."
At present the best working rule is to regard every
case as infectious for six weeks, the period bemg
extended if local affections, such as discharges from
the throat, nose, or open sores, make it necessary.
Disinfection should in all cases be thorough. The
patient and nurse must be completely isolated.
Handkerchiefs and rags used for wiping discharges
should be at once burnt ; and at the tennination of
the case, books, toys, games, etc., should be dealt
with in the same way. jj q ^
THE FOURTH DISEASE.
Clement Dukes [Lancet, July 14th, 1900) has
suggested that there is another infectious disease, in
some respects similar to both rubella and scarlet fever,
but in others differing from either. To this he has
given the provisional title of "The Fourth Disease."
He says that the principal characteristics are : —
An incubation period of nine to twenty-one days ; a
short and ill-defined prodromal stage ; an eruption
somewhat similar to that of scarlet fever, which is
followed by desquamation ; a temperature varying
from normal to 104° ; pulse, if quickened, bearing a
ratio to the amount of fever ; throat red and swollen ;
glands universally enlarged and tender ; tongue
slightly furred, but not peehng and giving the
strawberry appearance ; no sequelae or compHcations ;
the duration of the illness short ; the period of
infectivity not more than twenty-one days.
The suggestion has received the careful attention
of many observers, but has not been confirmed.
H. G. A.
56
INFECTIOUS DISEASES IN SCHOOLS
INFECTIOUS DISEASES IN SCHOOLS 57
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CHAPTER VI.
VARICELLA. CHICKEN POX.
French : La Varicelle. German : Wasserpochen.
/^HICKEN POX is a specific infectious disease,
^ of which the characteristic symptom is an
eruption of vesicles, usually appearing in successive
crops.
For a long time it was confounded with smallpox,
but since the two diseases were differentiated in the
latter part of the eighteenth century, no one of any
authority has affirmed their identity. An attack
of smallpox confers no immunity against a subsequent
attack of chicken pox, and vice versa ; and vaccination
has no influence in protecting from chicken pox.
Moreover smallpox is readily inoculable in unpro-
tected persons, but attempts to do this with the
material from the vesicles of chicken pox have
generally, if not always failed.
The disease occasionally prevails in epidemic
form, the highest seasonal prevalence being in the
winter months. Children are more frequently
attacked, but adults and even old people are not
exempt. Statistics show that of the entrants at the
preparatory schools, 32 per cent have already had
the disease, and 32 per cent get it before leaving ;
at the public schools, 7 per cent are attacked, and
29 per cent leave school unattacked.
The infection of chicken pox is due to direct
personal intercourse ; but it is possible that the
PLATE III.
Fig. 8. — Chicken pox. Often the marks are closer together, as
in smallpox, with which the eruption may be confused, as well as
with measles.
Face pti^c
VARICELLA. CHICKEN POX 69
poison may be retained in and conveyed by fomites.
The specific organism has not yet been isolated.
Incubation.— A wide margin of from twelve to
twenty days is given by most authorities, but in the
great majority of cases fourteen days elapse between
exposure to infection and the first appearance of
the rash.
Prodromal Symptoms. — ^These are not well marked
and may be entirely absent. Usually, in young
children especially, there is some headache, lassitude,
and peevishness ; the temperature is occasionally
raised. A prodromal rash, sometimes morbilliform
and sometimes erythematous, and sometimes one
followed by the other, is occasionally seen upon the
chest and abdomen.
The Eruption makes it appearance, usually, on
the first day and rarely later than the second day ;
and is, often, the first thing to attract attention.
There is no definite rule as to the part of the body
which is first affected ; more generally, perhaps,
the chest and back, but, also, in many cases the face
and scalp, in which case the glands at the back of
the ear are swollen and tender. The eruption, at
first, consists of a number of smaU rose-coloured
spots, which fade on pressure. They are circular
or oblong in shape and slightly raised above the skin.
Very quickly, usually in an hour or two, the spots
are converted into vesicles, containing clear watery
fluid.' In from twelve to twenty-four hours each
vesicle begins to dry up and a scab forms which in
five or six days falls off and leaves a reddened, flat,
or slightly indented surface. Occasionally the
papular stage is wanting, and the vesicles then look
hke small drops of water on the skin. The eruption
comes out in crops, most often on three successive
60 INFECTIOUS DISEASES IN SCHOOLS
days. After the appearance of the successive crops,
the eruption can be seen in its different stages of
papules, vesicles and scabs on the body at the same
time. Some of the papules, especially those of the
last crop, do not become vesicles. It is not uncommon
for some of the vesicles to become purulent. Spots
often appear on the mucous surfaces of the mouth
and inside the eyelids.
The distribution of the rash is characteristic of the
DAYOr
DISEASE
/
2
3
4
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e
7
TIME
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■^'Ir. g.— Temperature Chart in Chicken Pox.
disease ; appearing most abundantly on the trunk
and scalp, less so on the face and limbs, and sparsely
on the hands and feet. The palms and soles generally
escape.
Symptoms.— In most cases chicken pox runs
a mild course, without any marked symptoms.
Sometimes there is considerable skin irritation,
especially if the vesicles are abundant. There may
be only sHght elevation of the temperature, but
VARICELLA. CHICKEN POX 61
frequently there is an evening rise with morning
remission on three or four successive days, coinciding
with each fresh outcrop of spots {Fig. 9),
Convalescence is usually reached in the course of a
fortnight, by which time all the scabs have fallen off.
When the vesicles become pustular, a suppurative
condition of the skin may follow, which will require
special attention (see Impetigo).
Treatment. — Little treatment is required. Cases
should be kept in bed for a week, and a further period
of a week allowed for convalescence. The skin
irritation will be relieved by the application of a
lotion containing calamine and oxide of zinc ; or a
dusting powder, consisting of oxide of zinc and
starch in equal parts, may be used.
Duration of Infectiveness. — Fourteen days from
the appearance of the rash.
H. G. A.
62
CHAPTER VII .
MUMPS.
(Specific or Epidemic Parotitis.)
French: Oreillons. German: Ziegenpeter.
IVTUMPS is an acute infectious disease usually
characterized by swelling and inflammation
of the parotid glands, which are salivary glands
situated in the cheek just in front of the ears. Most
of the cases are mild, but severe symptoms occasion-
ally occur. These, however alarming they may
appear, nearly always end in recovery.
It is a disease of children and young adults, the
majority of cases occurring between 5 and 15 years,
but young men over 20 are not very infrequently
attacked. Some think that epidemics occur more
commonly in cold, wet and windy weather.
Although the disease has been recognized smce
the time of Hippocrates, its cause has not even now
been determined with certainty, though it is most
likely a bacterium.*
Incubation Period. — Very short incubation periods,
such as three, four, or five days and very long ones,
such as thirty-five days or even six weeks, are men-
tioned in the literature on the subject. If these really
occur they must be very exceptional and can be dis-
regarded in practice. Fourteen to twenty-six days
may be taken as the usual limits; in the majority
* The Diplococcus of Laveran.
MUMPS
63
of cases the first symptoms appear between seventeen
and twenty-one days after exposure to infection.
Quarantine. — Usually twenty-four days is con-
sidered sufficient.
Infectivity. — ^The secretions of the mouth are no
doubt infectious, and the disease is usually trans-
mitted directly from patient to patient. Those
sleeping in adjoining beds or sitting next to one
another at work are very likely to transmit and
receive the disease. It is only carried a very short
distance by third persons, and does not readily
spread from one house to another. The patients
are probably infectious for a few days before recogniz-
able symptoms of the disease begin, and remain
infectious for at least a week after all symptoms have
subsided. Cases are recorded in which they have
apparently remained infectious for much longer
(three or four weeks), but this is exceptional, and as
a rule no harm will be done if patients are allowed
to return to ordinary life a clear week after they
have apparently recovered.
Clinical Course. — ^The incubation period may be
free from any symptoms which attract attention,
but in some cases there may be, for a day or two,
ill-defined feelings of indisposition, or even more
definite prodromal or preliminary symptoms, such
as nose-bleeding, earache, sore throat or fever.
An interesting and httle known symptom was
described by Mirchamp in 1903 as occurring in
mumps even before the sweUing and pain in the
parotid. If the patient's tongue is touched with
a drop of vinegar or some similar substance of sharp
flavour, a marked secretion of saliva from the parotid
takes place which is accompanied by a spasm of pain.
The sign might be of value in testing those who had
64 INFECTIOUS DISEASES IN SCHOOLS
been exposed to infection, towards the end of the
probable incubation period.
The onset, in the great majority of cases, however,
is marked by a sweUing behind the jaw, just in front
of the ear, accompanied by a rise of temperature,
and more or less feeling of illness. The swelling
rapidly increases, and in two or three days may
become very considerable, extending down the neck
and forwards on to the cheek. All movement of
the jaws becomes very painful, and it is difficult for
the patient to open his mouth, to swallow, or even
speak. The corresponding gland on the other side
usually begins to sweU a day or two after the first.
Nose-bleeding and earache are not uncommon. In
a few days the swelling begins to subside, and the
whole attack may be over in a week or ten days,
leaving no permanent damage. As a rule, adults
who contract mumps have a more severe attack than
children. Although mumps is nearly always a mild
disease, and it appears to be very doubtful if any one
ever died of it, it should always be carefully nursed
and treated because certain compHcations may
occur which are distressing in themselves and
occasionally leave serious results behind them.
These compHcations are much more frequent in some
epidemics than in others, so that a comparatively
limited experience of mild cases should not put us
off our guard. A simple, uncompHcated attack
may give rise to severe fever, or t*b actual delirium,
and symptoms which closely resemble those of
meningitis. The chief compHcation is pain, inflam-
mation, and swelling of the testicle (known as
orchitis) which occurs more commonly in older boys
and adults. It always subsides, but in some cases
the organ subsequently atrophies. This complication
MUMPS
65
usually begins when the swelling in the cheek is
subsiding, but it may come on quite early or even
occur as a first symptom. Owing to the possibility
of this complication (which cannot be foreseen in
any particular case) older boys with mumps have
to be kept in bed for ten days. Another compli-
cation is inflammation of the pancreas, a gland
concerned in digestion which lies in the upper
part of the abdomen. This gives rise to pain and
often serious symptoms of illness, such as vomiting
of blood, passage of blood with the stools, and con-
siderable collapse. It appears however always to end
in recovery. In girls, inflammation of the breasts is
said to occur occasionally. Symptoms which have
been attributed to inflammation of the ovaries are
also said to have been observed, but this is very rare.
The most serious complication is probably deafness,
which, when it occurs, is sometimes permanent.
All these occasional complications point to the
fact that mumps is a general, not a local disease, and
is due to some germ which circulates in the body
and though usually making its effects seen in the
parotid gland, at times lodges in other organs also.
In fact cases have been described in which the
parotid gland escaped while one of the other struc-
tures mentioned became inflamed.
The submaxillary gland (another salivary gland
lying under the side of the jaw) is also sometimes
involved, either alone or with the parotid. When
an epidemic of mumps is in progress these cases give
rise to no especial difficulty, but when, as sometimes
happens, a single case of inflammation of the
submaxillary gland occurs, its true nature may not
be recognized, until, perhaps, the infection has been
transmitted to another person who develops the
disease in its usual situation. J. M. F.-B.
66
CHAPTER VIII.
WHOOPING COUGH. PERTUSSIS.
French : Coqueluche. German : Keuchhusten.
"V^HOOPING cough is a specific infectious disease,
' ' characterized by catarrh of the respiratory-
passages, and by a pecuHar spasmodic cough. It is
specially common in children under five, but may
occur at any age, cases having been recorded at
eighty years. Although no case of whooping cough
is to be treated lightly, it is hardly ever fatal in
children over ten ; 997 per cent of the deaths in
England and Wales from this disease in 1908
occurred in children below this age. It is said to
occur more frequently in the wet, cold weather ; and
though cases are always present in large towns,
epidemics usually take place only every three or four
years.
Whooping cough is generally believed to be due
to a germ which, hke that of diphtheria, is lodged in
the respiratory passages, and thence diffuses its
poisons or toxins into the blood.*
Incubation. — ^The period is not easy to determine,
but seems to he between four and fourteen days or
longer.
Quarantine is fixed at twenty-one days to allow
* A germ described by Bordet and Gengou in 1906 is the
best accredited among several which have been described
as the causal agents.
WHOOPING COUGH. PERTUSSIS 67
for cases in which slight catarrhal symptoms may
be overlooked owing to the whoop not appearing
for a week or so.
InfecUvUy. — ^There appears to be no doubt that
the most infectious stage of whooping cough is that
before the whoop develops, and that from the
appearance of this symptom the infectiousness of
the patient begins to dechne. After six weeks, in
most cases at any rate, the patient has ceased to be
infectious ; certainly he is so if the whoop has been
absent a fortnight. In very brief, slight cases the
infectivity is no doubt still shorter, and in severe
cases it may be longer, but the occurrence of an
occasional whoop, or even of several such, months
after the disease has apparently ceased cannot be
held to denote that the patient is necessarily still
infectious. As the infection is in the catarrhal
secretions of the throat, and is spread by coughing,
fairly close contact is necessary for its transference
to other persons. It is not very easily carried by
third persons, as the germ soon dies on exposure to
light and air, but at least one well authenticated
case is on record in which it was conveyed by clothes
which had been weU sprinkled with germs by an
infected child, and retained their infectivity for
some hours. Thorough washing and cleaning is
probably all that is necessary for the disinfection
of rooms in which whooping cough patients have
been isolated.
Clinical Course. — ^The period of invasion, after the
usual incubation, is characterized by what appears
to be a feverish cold and cough, and for a week
there may be nothing absolutely typical.
In suspected cases, however, or where the patient
is known to have been exposed to infection, an
68 INFECTIOUS DISEASES IN SCHOOLS
examination of the blood may help to clear up the
diagnosis before the typical symptoms have developed.
The total number of white blood cells is normally
greater in young children than in adults, but it is
still further increased in whooping cough, and the
proportion of the various kinds of cells is also altered.
The test, however, can only be made by one accus-
tomed to this form of blood examination, and the
transmission of specimens for examination at a distant
laboratory, though methods have been devised for its
accomplishment, is not a satisfactory proceeding.*
The cough usually becomes less frequent and more
" paroxysmal " in character towards the end of this
period, and then the second stage is ushered in by
an attack of vomiting or a definite whoop. This
second stage is the one in which the disease is most
frequently first recognized : though, as the patient
often begins to whoop at night, it is the nurse and
not the doctor who is usually able to make the
diagnosis. A typical attack of coughing consists
of a number of rapid expiratory efforts, such as are
made by any unfortunate person who has swallowed
a dry breadcrumb " the wrong way." The face in
a severe paroxysm becomes swollen, puffy and
congested, and especially in younger children, the
choking nature of the seizure is very painful to
witness. Then suddenly the cough comes to an end
and the patient succeeds in drawing air into his
lungs again with a loud, crowing noise ; this is the
* Bordet and Gengou have also described a method of
diagnosis which is dependent on finding the bacillus in the
expectoration. This may be done early in the disease, when
it is most abundant. The method is somewhat costly and
elaborate, and is therefore quite unsuited for routine practice.
In special cases it might be advisable to adopt it
WHOOPING COUGH. PERTUSSIS 69
"whoop." Sometimes several of these paroxysms
follow one another immediately; often the attack
ends in vomiting. Sometimes a little blood-stained
mucus is ejected at the end of the cough, and at
times there may be considerable haemorrhage from
the nose or elsewhere. These bleedings however
are not as a rule at all dangerous. In some cases
the attacks may occur as often as once an hour, and
the child if young may become seriously exhausted.
Usually, however, they are not nearly so frequent
even at the height of the attack, and older children
are generally fairly well between the fits. The stage
of defervescence is marked by a diminution in
number and violence of the fits, until they gradually
cease altogether.
During the first or catarrhal stage, patients are
best in bed, during the second or " whooping " stage
they are usually best up and about, and in good
weather can go out-of-doors. The danger of whoop-
ing cough is that it is liable, like measles, to be
followed by broncho-pneumonia. Among young
children and among those who are badly fed and
nursed, this is a very fatal complication. It usually
appears in the third or fourth week after the onset
of the symptoms. In infants, convulsions may
complicate an attack and may prove fatal. In
patients of any age the violence of the cough may
more or less strain the heart. The protection against
a second attack afforded by whooping cough is very
complete. The majority of cases in which a second
attack appears to occur are no doubt instances of
mistaken diagnosis. This is rendered probable by
the difficulty of making a positive diagnosis which
even experienced doctors may feel in some cases.
J. M. F.-B.
CHAPTER IX.
GLANDULAR FEVER.
(Febrile Polyadenitis).
French : Fievre Ganglionare.
German : Drusenfieber.
HIS condition was first described as an acute
specific disease in 1889 by Pfeiffer, the
discoverer of the influenza bacillus. It usually
occurs in children between four and twelve years of
age, and is not common in younger or older persons.
It is almost certainly due to a germ, which probably
enters through the mucous membrane of the throat
or nose ; it does not, however, appear certain
that the same germ is responsible for all epidemics.
The patient is presumably infectious during the
continuance of the symptoms.
Incubation Period. — ^This appears to vary. In one
case it was as short as twenty-four hours. In other
epidemics the limits have been seven to nine days,
and four to seven days.
Clinical Course. — The onset is fairly sudden, with
fever and pain in the neck ; sometimes there is sore
throat, swallowing may be difficult, and vomiting
or shivering sometimes marks the beginning of the
disease. In twenty-four to forty-eight hours the
glands in the neck become swollen, painful, hard,
and tender to touch. They may continue in this con-
dition for some days. Sometimes there is pain and
GLANDULAR FEVER
71
tenderness in the abdomen, and glands in other
parts of the body may be affected. They never
form abscesses. When the glands subside (which
is usually in two or three weeks) the fever abates,
and recovery is usually absolute, though convales-
cence may be prolonged. There is often constipation
during the attack, less frequently diarrhoea occurs.
Complications are rarely observed, and usually
also end in recovery. The most serious is inflam-
mation of the kidney. Bleeding from the nose and
from the bladder may occur.
Mortality. — In 96 cases i died.
J. M. F.-B.
72
CHAPTER X.
DIPHTHERIA.
French : Diphterie. German : Diphtherie.
^ characterized by the formation of a mem-
branous exudation in the throat, nose, and upper
air passages, and later by the occurrence of paralysis
in various parts of the body, in a certain proportion
of cases.
History. — ^The disease appears to have been
recognized in very early times. It was probably
known to Hippocrates and Galen and is described
by Aretasus (iii a.d.). It was not, however, till
the eighteenth century that its clinical features were
accurately distinguished, and the name is compara-
tively recent, having been coined by Bretonneau in
1821.
Considerable difficulty was experienced, however,
in separating cases of diphtheria from other severe
kinds of sore throat, until in 1883 Klebs demon-
strated the causal organism, which was first success-
fully cultivated on an artificial medium by Loeffier
in the following year.*
The bacillus can easily be cultivated on special
media in from eighteen to twenty-four hours and
then presents, when stained by appropriate methods,
specific infectious disease
* This organism is now known as the Diphtheria or Klebs^
Loeffler bacillus.
DIPHTHERIA
73
a characteristic appearance under the microscope.
At present, therefore, there are two methods by
which diphtheria can be recognized, and in all cases
it is important that both should be employed, for
reasons which will appear shortly. The first is
the " cHnical " method, and until the bacillus had
been discovered, this was the only one available.
Physicians by observing the symptoms can, with
considerable accuracy, determine whether a given
case is one of diphtheria or not. The second method
is the " bacteriological." A small cotton - wool
swab is rubbed over the throat of the suspected
person, and sent in a closed tube to a bacteriologist.
The latter, by transferring the material absorbed
by the cotton-wool swab on to a suitable culture
medium, obtains in some twenty hours, a "culture"
or " growth " of the organisms from the throat,
which he examines. In a large percentage of cases
he is able to report definitely the presence or absence
of the characteristic bacillus.
These two methods of diagnosis should always
be employed together, for the following reasons.
In typical cases an experienced physician can gener-
ally diagnose diphtheria with certainty, but in a
certain number, the signs he expects to observe are
misleading or absent, and here the bacteriologist is of
great assistance. It is now known that other bacteria
can produce a condition in the throat closely resem-
bling diphtheria. On the other hand, it is not safe
to rely solely on the bacteriological examination,
for several fallacies may occur. In the first place
the swab may fail to " catch " any of the bacilli,
especially if only a few are present or if there is any
difficulty in applying it to the part of the throat
affected. In the second place, even though the
74 INFECTIOUS DISEASES IN SCHOOLS
baciUi are taken up on the swab they may not grow
properly when cultivated. This, in many cases,
is due to some antiseptic having been applied to the
throat a short time before the swab was taken. In
other cases the reason may be obscure. In the third
place, cases of undoubted diphtheria have been
known to occur in which the bacilli have not been
found until quite late in the case, while in what is
known as " laryngeal " diphtheria they may be
situated only in the larynx too far down for any
ordinary swab to reach them.
At present it may therefore be definitely laid down,
that though swabs should be taken in all suspected
cases, the appropriate treatment should always be
adopted where the cHnical evidence points to diph-
theria, even though the results of the bacteriological
examination are negative. On the other hand, if
the baciUi are shown to be present, the treatment
should be adopted, even if the case is not typical
from the clinical point of view. The treatment of
" carriers " will be discussed later on.
As regards the life of the diphtheria bacillus
outside the body, comparatively little is known.
It is thought by some to have its habitat in the soil,
and importance has been attached in this connection
to the opening up of old drains or foundations as
setting free the bacilli and starting epidemics.
However this may be, it appears certain that the
spread of the disease is almost entirely a matter of
personal contact, and that the segregation and treat-
ment of persons harbouring the bacillus is at present
the most successful method of arresting the course
of an epidemic.
Mode of Infection. — ^The diphtheria bacillus lodges
on the mucous membrane (usually on some part of
DIPHTHERIA
75
the upper respiratory passages) and there proceeds
to grow. A slight abrasion, microscopic possibly
in size, which may easily be produced by accidental
causes, allows of the poison produced by the organism
becoming absorbed into the body, while the local
damage to the mucous membrane favours the growth
of the bacillus and leads to the formation of the
so-caUed membrane. The bacillus itself does not pass
into the body fluids, at any rate not to an appreciable
extent, but remains growing on the mucous membrane
and manufacturing the toxins or poisons which give
rise to most of the symptoms of the disease.*
Incidence. — Diphtheria is for the most part a
disease of childhood, though adults are not exempt.
It is not very frequently seen in infants, but between
the second and twelfth years the large majority of
the cases occur. An attack confers only a very
short period of immunity.
Clinical Course. — ^The incubation period is short,
and may be only twenty -four hours. Usually it is
two or three days, but may be a week. The
* The foregoing account is necessarily much simplified,
as the bacteriology of diphtheria is in reaUty a very large
subject in itself, and many of the problems connected with
it have not yet been satisfactorily solved in spite of the
enormous amount of work which has been lavished upon them.
It may be as well, however, to mention that, besides the
diphtheria bacillus proper, organisms closely resembling it
are known and found in healthy and diseased throats. Of
these one, called Hofmann's bacillus, occupies a peculiar
and very dubious position, and its presence in the respiratory
passages has been variously interpreted. At least this can
be said concerning it, that during an epidemic its presence
should be regarded as a suspicious circumstance, sufficient
to justify further investigation and a certain amount of local
treatment ; isolation of the persons harbouring it need not
however be insisted upon at the present stage of our know-
ledge.
76 INFECTIOUS DISEASES IN SCHOOLS
quarantine period of ten days is certainly a full
allowance. The infectiviiy of the patient is now
determined by the presence or absence of the
diphtheria bacillus and by this alone. When
three negative results have been obtained at a few
days' interval, the patient being otherwise free from
all symptoms and apparently well, he may be re-
garded as non-infectious.
The first symptom of an attack of diphtheria is
usually fever, that is a rise of temperature which is
moderate in most cases, accompanied by headache,
vague pains, malaise and sometimes vomiting.
The subsequent symptoms will depend upon the
situation of the lesion, which may be in the tonsils
and palate (faucial), in the larynx (laryngeal), or
in the nose (nasal). Other parts of the body are
occasionally affected, but these are the usual
situations. In the faucial cases, which comprise
the majority, the symptoms are those of a sore
throat, together with enlargement of the glands in
the vicinity of the throat and, what is very important,
a much greater depression of the general health
than either the temperature or the amount of soreness
experienced in the throat would seem to warrant.
The patient is languid, sometimes drowsy,
apathetic, and ill ; although there may not be much
difficulty in swallowing, and the temperature, never
very high, may fall in a few days. Meanwhile the
throat, if examined, shows a more or less charac-
teristic condition, being covered by large or small
patches of greyish white ghstening " membrane "
or exudation which varies in amount, consistency,
and distribution, but is often distinguished by the
facts that it is not limited to the tonsils and that if
removed it leaves a raw inflamed surface beneath.
DIPHTHERIA
77
In the laryngeal cases, the earhest characteristic
symptom is the hard brassy cough which denotes the
presence of some obstructing substance in the larynx,
and which is commonly described as Croup. This
croupy cough may doubtless occur in many other
conditions besides laryngeal diphtheria, but it is
also certain that, before the advent of modem
methods of diagnosis, many cases diagnosed as croup
were in reality due to the diphtheria bacillus. Then,
sooner or later, symptoms of serious obstruction to
respiration arise due to the presence of membrane
in the larynx. Attacks of dyspnoea or difficulty in
breathing occur, and the patient becomes blue in the
face, gasps for breath, and — in young children especi-
ally— the spaces between the lower ribs become
sucked in with each attempt at inspiration. These
attacks become more frequent until the child is in
a condition of permanent suffocation which, unless
prompt measures are taken, is almost certain to
prove fatal.
The nasal type of diphtheria is characterized in
most cases by a persistent nasal discharge, and
sometimes by the presence of actual membrane in
the nasal passages. Constitutional symptoms are
often but sHght, although the patient is extremely
infectious, and is very difficult to cure even under
careful treatment.
It must be understood that any one of these types
may pass into any other type by extension and
growth of the membrane, especially in untreated cases.
The subsequent course of the case wiU depend on
the severity of the attack, the situation of the
membrane, and the period at which the patient
first receives treatment by antitoxin. A consider-
able degree of general weakness is usually seen both
78 INFECTIOUS DISEASES IN SCHOOLS
during and after an attack, and besides this, the
toxins or poisons are specially prone to attack the
heart and certain parts of the nervous system,
causing cardiac failure and diverse forms of paralysis.
Heart failure may occur early in a case of
diphtheria, that is within the first week or fortnight,
and is a most serious complication, frequently ending
fatally. Sometimes death occurs quite suddenly
and almost unexpectedly. But the possibility of
heart failure does not cease after the acute stage of
the disease has passed off, and convalescents may
suddenly coUapse, especially if due care has not been
taken to save them from exertion or physical strain
of all kinds. A child apparently nearly weU may
sit up in bed and fall back dead, or, in less severe
instances, faint away owing to some shght extra
exertion.
The various forms of paralysis usually appear after
the second week, but may occur earlier. They are
mostly seen in the more severe cases. The common-
est form of paralysis is that affecting the soft palate
which leads to the regurgitation of fluids through
the nose when an attempt is made to swallow them,
and imparts a peculiar twang to the voice. The
muscles moving the eyes may be affected, causing
squint, or loss of power to accommodate the sight
for near objects, so that the patient becomes unable
to read. Paralysis of the limbs is fairly common,
so that the patient cannot stand or move his arms
and legs. The muscles of respiration are also affected
in some cases, as well as those in other parts of the
body.
Unless the heart is affected, the outlook in these
various forms of paralysis is usually hopeful, and
complete recovery ultimately occurs, but their
DIPHTHERIA
79
significance is really important as indicating a
tendency to heart failure and necessitating the most
careful treatment and watching.
Treatment— It is practically of Httle use to try
and destroy the baciUi in the throat by means of
antiseptics, though mild antiseptics are of use in
most cases. In view of the fact that the patient is
suffering from a severe form of poisoning and is
hable to heart failure, rest in the recumbent position,
a nourishing and easily digested diet, and very care-
ful nursing by experienced persons, are absolutely
essential in all cases.
The main point in the treatment of diphtheria
is, however, the early administration of antitoxin
(see page 7). The details of this process must be
left to the judgment of the medical adviser, but it
wiJl not be out of place here to mention some of the
reasons which have convinced the vast majority of
medical men of the value of this method.
I. The mortality from diphtheria has fallen, since
the use of antitoxin became general, in all parts of
the world from which statistics are available.
Considering the large number of figures whch have
been collected this evidence in itself is of considerable
value ; but it must be allowed that it is not absolutely
conclusive, because there is reason to believe that
the type of the disease is somewhat milder than
formerly, and because many very mild cases can
now be correctly diagnosed by bacteriological methods,
which in earher times would not have been classed
as diphtheria at all. As an example, however, the
figures of the MetropoHtan Asylums Board may be
quoted. The average mortahty in the hospitals of
the board during the five years before the introduction
of antitoxin was about 33 per cent, whereas in the
80 INFECTIOUS DISEASES IN SCHOOLS
seven years following its introduction it fell to about
i6 per cent, and in the subsequent years to 9-5 per
cent.
2. Better evidence can be obtained from the
mortality returns of the laryngeal diphtheria, which
is always a severe and dangerous form, owing to the
extreme likelihood of asphyxia. Before antitoxin
the mortahty in these cases was quoted as about
66 per cent, and after antitoxin the mortahty fell to
about 27 per cent.
3. Probably the strongest point in favour of the
value of antitoxin in diphtheria is that the mortahty
can be shewn to decrease progressively the earlier
the remedy is administered. Thus at the Brook
Hospital (Metropolitan Asylums Board) during
eleven years, cases treated on the first day had
a mortahty of zero ; those on the second day a
mortahty of over 4 per cent ; those on the third
day of over 11 per cent ; those on the fourth diy of
over 16 per cent ; those on the fifth and later days
of over 18 per cent.*
There are two points with regard to the adminis-
tration of antitoxin which may be mentioned, as they
are sometimes urged as reasons against its use. In
the first place it has been said that since antitoxin
has been generally employed more cases of diphtheritic
paralysis have been observed, and that consequently
the antitoxin must predispose persons to this. There
is, however, no positive evidence as to this being a
direct instance of cause and effect. Diphtheritic
paralysis is more likely to occur in cases of virulent
infection, and as, before antitoxin was introduced,
* For these points the writer is indebted to Bosanquet
and Eyre's Serums, Vaccines, and Toxines, 2nd edition, 1909.
DIPHTHERIA
81
a much larger proportion of such cases died early in
the course of the disease, it manifestly follows that
fewer survived to manifest the compUcation.
In the second place, in a small proportion of cases,
unpleasant symptoms such as fever, pains over the
body, and peculiar irritable rashes, have been
observed. These symptoms are not due to the
antidiphtheritic principles in the injection, but to
the serum, or vehicle in which they exist, and may
occur if the blood serum of any animal is injected
into one of another species. The condition is seldom
more than annoying to the patient, and soon passes
off. It should not be allowed to weigh against the
now well estabHshed advantages of antitoxin in so
serious a condition as diphtheria.
In cases where the membrane is situated in the
larynx, the obstruction to respiration may necessitate
the operation of tracheotomy, in which an opening
is made in the wind-pipe or trachea, below the point
of obstruction, and a tube is inserted through which
the patient breathes. Great relief is often afforded
and many lives have been saved by this proceeding,
but sometimes the patients succumb to the poisoning
of the system which, of course, is not directly
influenced. The early use of antitoxin has certainly
rendered this operation less frequently necessary.
In place of tracheotomy, the procedure known
as " intubation " may be adopted. By means of
special instruments a small tube is inserted through
the mouth and lodged in the larynx ; through this
the patient is enabled to get sufficient air, in spite of
the presence of the membrane. The choice between
these two methods must be left to the practitioner
in charge of the case, and will reasonably depend
partly upon the experience he has had ; every^man
6
82 INFECTIOUS DISEASES IN SCHOOLS
will be more likely to get a good result from a method
with which he is familiar than from one of which he
has little practical experience. In general, however,
it may be said that intubation, although it avoids
a cutting operation, and is less likely to be followed
by bronchopneumonia, requires the more constant
and immediate presence of the doctor, and is thus
hardly suitable for cases where it may be some time
before he can be brought in case of emergency. In
hospitals where there is always a medical officer at
hand, intubation is undoubtedly a very valuable
proceeding, and presents many advantages and but
few disadvantages ; in the country, on the other
hand, tracheotomy is perhaps, on the whole, a safer
method, as a trained nurse can deal with any emer-
gency until the arrival of the doctor.
Prophylaxis. — ^As has been said, the spread of
diphtheria is nearly always a matter of personal
contact, so that whenever a case occurs in a school
the throats of all those in contact with the patient
should be submitted to a bacteriological examination.
In private schools the boys and all members of the
household should be thus examined ; in pubhc schools
it is generally enough if the boys and others hving in
the same house are so tested. When this is done, it
may often be found that several persons not show-
ing any sign of illness, are carrying the diphtheria
bacillus in their throats or noses. These persons
are called " carriers " and are a source of possible
infection in others. They should therefore be
isolated, but not placed with actual sufferers from
the disease, as the bacilli they carry may not be
virulent, and they are hable therefore to acquire a
fresh and virulent strain of bacillus from the patients.
Antitoxin is not of much value in the treatment
DIPHTHERIA
83
of "carriers," as it mainly acts by neutralizing the
poisons formed by the bacillus. In " carriers " there
is little or no poisoning going on, as is evidenced by
the absence of the symptoms of illness. Antiseptics
of various kinds may be tried ; probably the most
ef&cacious is some preparation of peroxide of hydro-
gen. But in spite of the most active treatment, the
bacilli still remain present in the throat for long
periods in some cases. Three to six weeks is by no
means an unusual time, and in exceptional cases
the bacilli have been present for a year. When a
case of this sort occurs, it is possible to test the
virulence of the bacilli by means of an animal
experiment ; and this should always be done when
the bacilli are found for more than a month in an
apparently healthy throat.
Animals may be a source of infection ; it is not
certain that pigeons or fowls can convey diphtheria
to human beings, but the case against cats is fairly
well proved.
Diphtheria may in certain cases be traced to an
infected milk supply, so that not only should full
enquiries be made as to the source of the milk and
the possibility of its contamination, but a sample
should be sent for bacteriological examination. The
detection of the diphtheria bacillus in milk is, how-
ever, a somewhat complicated process and is beset
with certain sources of error. Great care must
therefore be taken in selecting a thoroughly com-
petent and well known bacteriologist to perform
the test. It is also advisable to have the drainage
system overhauled. In the opinion of the writer
defective drains are far more often a predisposing
than an immediate cause of an outbreak of diphtheria,
and in a great number of cases no sanitary defect
84 INFECTIOUS DISEASES IN SCHOOLS
exists in houses where the disease occurs. Still, it is
never advisable to omit any reasonable precaution
in a serious condition such as diphtheria, and an
assurance that all is well with the drainage is decidedly
advantageous from the pubhc point of view. Strict
isolation of the patient and of all "carriers" is
essential in diphtheria, and all articles used by them
must be carefully disinfected after use (see page 15).
The Klebs-Loeffler bacillus is destroyed by
exposure to a temperature of 54° C. (130° F.) for ten
minutes, if not in a dry state. Thorough room
disinfection is also necessary after the patient has
recovered (see page 16), as the baciUi may be found
on walls and furniture, and can probably live on
under these conditions for a fortnight (see page 18).
Finally, by way of prophylaxis it is often advisable
to give a small dose of anti-diphtheritic serum to all
those who have been in immediate contact with the
patient. The necessity for this somewhat elaborate
precaution must be decided in each instance by the
medical man in charge. In the opinion of some
recent authorities prophylactic injections of antitoxin
should only be given to weakly children who have
been exposed to a particularly virulent type of
infection, and to those who are suffering from some
other disease, such as scarlet fever or measles.
J. M. F.-B.
85
CHAPTER XL
TYPHOID FEVER.
(Enterica, Enteric Fever.)
French: Fievre Typhoide.
German: Abdominal-Typhus.
TYPHOID fever is an acute specific disease with a
somewhat prolonged course, characterized by
the formation of ulcers in certain parts of the small
intestine, a distinctive rash, and more or less severe
general depression of the system.
History. — ^The medical writers in classical times,
although conversant with typhoid fever, did not
differentiate it from other superficially similar con-
ditions. It was not, indeed, until the beginning of
the nineteenth century that the distinction between
typhoid and typhus or jail fever was made ; the
latter disease, now very uncommon in England,
suggested the name by which the fever now under
consideration is generally known, because it was
thought so similar in many of its features. The
final differentiation of typhoid from typhus was made
by Sir William Jenner in the middle of the last
century. Various theories were held as to the
causation of typhoid, mainly based on the view that
it was connected with defective drainage. The great
sanitary advance made in the mid- Victorian period
decreased the incidence of the disease considerably,
but it was not until 1880, when Eberth discovered
86 INFECTIOUS DISEASES IN SCHOOLS
the bacillus of typhoid, that the way in which
epidemics arose was understood.
Bacteriology. — very large amount of important
work has been devoted to this subject since 1880.
The bacillus* is closely related to one of the normal
denizens of the intestinal canal of man and many
other terrestrial animals, called the Colon bacillus.
It is present in the intestines of infected persons, but
its presence, in the early stages of the disease, is not
easily demonstrated, so that (unlike diphtheria) no
ready means of diagnosis can be obtained by an
examination of the stools. It is also present in the
blood, but here, too, technical difficulties deprive
this fact of practical apphcation. A patient suffering
from typhoid fever, however, in a very large propor-
tion of cases, develops certain substances in his
blood about the end of the first week of the disease
which produce a typical reaction when added to a
pure culture of the bacillus of Eberth.
The careful study of this reaction by Durham and
Bordet in 1895 was followed in 1896 by its apphcation
to practical medicine almost simultaneously by
Widal and Griinbaum ; it is now usually known as
Widal's test. In practice, a few drops of the patient's
blood are drawn into a small glass bulb and sent to
a bacteriologist, who reports on the dilution of this
blood which gives the characteristic reaction with
the bacillus, known as " agglutination " or " clump-
ing." If the blood in high dilution gives the reaction,
the diagnosis is practically certain ; lower dilutions
are not so conclusive, and a negative reaction does
not absolutely prove that the case is not one of
* Now generally known as the Typhoid Bacillus, Bacillus
typhosus, or Eberth's Bacillus.
TYPHOID FEVER
87
typhoid. Patients who have previously suffered
from typhoid fever, may sometimes show the char-
acteristic reaction in their blood for a long time
after recovery, in a few cases even for years. In
some, the reaction is only developed late in the
course of the disease, and in one remarkable instance
it was absent during the primary attack and also
during several relapses, being at last present in what
proved to be the final relapse. In a suspected case,
therefore, the test if at first negative should be
periodically repeated. The limit of error from all
sources is probably about 5 per cent.
Mode of Infection. — ^The bacillus of typhoid is prob-
ably always swallowed, and thus reaches the small
intestine, where it lodges, grows and multiphes.*
The principal ways in which the bacillus may
reach the mouth and thus get taken into the body
are as follows : —
I. Directly from another patient. A person suffer-
ing from typhoid is continuously giving off the
bacilli both in the stools and urine. Under these
circumstances his skin, clothes, and surroundings
generally are practically certain to become con-
taminated, and contact with him or his belongings
leads to the transference of the bacilli on to the
hands and persons of others, who then ingest these
bacilli and acquire the disease. Dirt and overcrowd-
ing obviously facilitate the direct transference of the
disease and, in fact, the ordinary cleanliness of the
well-to-do educated classes in this country would not
be sufficient to prevent its spread from the sick to
the healthy, in the absence of special precautions.
* Recently, however, the view has been put forward that
the bacillus enters the body by the tonsils, and is excreted
into the intestine.
88 INFECTIOUS DISEASES IN SCHOOLS
2. Articles of food, especially milk, butter and
cream, handled by infected persons, or those in
contact with infected persons, may easily transfer
the bacillus to others. " Ice creams " sold in the
streets have many times been a source of infection.
3. The stools of a typhoid patient may be thrown
into a faultily constructed drain, through which
sewage percolates into the sources of a water supply.
Thus the bacillus, which lives quite comfortably in
water, may be spread broadcast, either when the
water is used for drinking or when it is employed
for washing articles in which food is placed, such as
milk cans, dishes, cups and the Hke. Water-borne
epidemics are well-known.
4. Contaminated material may be left exposed to
the air, and flies settling upon it may carry the
bacillus on to articles of food to be consumed by
others.
5. In dusty regions, the dust may similarly act as
a carrier.
. 6. Sewage, when contaminated by typhoid bacilli,
may carry them to oyster and mussel beds, and so
infect those who consume these shell fish in the raw
condition.
7. It has recently been shown both in this country
and Germany, that a certain number of persons who
have had typhoid fever continue to carry the bacilli
in their intestines and elsewhere for long and in-
definite periods. These are the " typhoid carriers,"
and their treatment from a pubHc health point of
view is still an anxious and much-debated question.
A certain intermittence has been noted in their power
of infecting others, which does not tend to simphfy
the problem.
Incidence— Typhoid fever is widely distributed
TYPHOID FEVER
89
over the globe. It is essentially a disease of young
adults, but children over five are not infrequently
affected. It is rare in the aged.
Clinical Course— Th.& incubation period in typhoid
is apparently usually about a fortnight, but many
cases are recorded in which it has been much shorter,
and some in which it has been extended to three
weeks.
Quarantine is not as a rule an effective agent in
arresting the spread of an epidemic, because with
the discovery of the cause the occurrence of fresh
cases should immediately cease. When under special
circumstances it is applicable it should last for three
weeks.
The period of invasion in typhoid is some-
what indefinite in the early stages. The disease
begins to show itself very gradually, little being
noticed at first but slight feelings of indisposition.
Gradually these increase ; there is slight shivering,
headache, and perhaps abdominal pain. The bowels
are usually confined ; but there may be, on the other
hand, diarrhoea. Often there is a slight cough,
sometimes vomiting, and sometimes nose-bleeding.
With these symptoms fever gradually sets in, and the
temperature usually rises a little higher every evening,
and fails to fall quite so low every morning as on the
previous one, till at the end of a week or so it reaches
101° or 102° or more in the evening, only dropping a
degree or two lower in the morning.
When this stage has been reached the period of
invasion may be considered ended, and the patient
enters into a condition of high fever, usually with
much prostration, which may last one or two weeks
or, in severe cases, much longer. In a typical case of
average severity the patient during this period is in a
90 INFECTIOUS DISEASES IN SCHOOLS
peculiarly apathetic, dull, and prostrate condition.
He exhibits little interest in his surroundings, is
extremely stupid mentaUy, often more or less deaf,
and at night may be slightly dehrious. There is often
some loose cough, the headache continues, the mouth
becomes dry and parched, and the tongue coated
with whitish or brown fur, especially in the middle,
while the tip and sides are left red. The abdomen
is distended, and if there is diarrhoea the stools are
of a characteristic yellow, fluid nature, and have
been compared to pea-soup. They are usually very
offensive.
On or about the sixth day a number of small
raised pink spots appear on the abdomen and
sometimes elsewhere, which bear a strong likeness to
flea bites. There is, however, no small dark central
point which marks the spot where the proboscis of
the insect enters the skin. When lightly pressed the
pink colour of the spots completely disappears. They
are called the " rose spots," and are usually described
as lenticular or lentil shaped. They come out in
crops during this and the following stages of the
disease, each crop lasting two or three days, and vary
very much both in number and distribution. They
are present in at least half the cases, or perhaps
more. The spleen is always enlarged, and this
enlargement can be demonstrated by examination
in the majority of cases. Towards the close of this
period the patient has often become extremely thin ;
there is also marked pallor of the skin, though the
cheeks may show small flushed areas. The ej^es are -
bright and clear, and the pulse." soft," that is, easily
compressed by the finger.
During the third week, or perhaps later, the
temperature should in favourable cases begin to fall
TYPHOID FEVER
91
in a gradual, step-like manner, corresponding to its
rise during the period of invasion. This is the period
of defervescence, and after this a gradual return to
health occurs, the symptoms clearing up and the
patient usually becoming extremely hungry. Re-
lapses, which usually resemble mild and shortened
primary attacks, occur in some cases after the tem-
perature has become normal. Their frequency
varies very much in different epidemics, and they
may occur in as much as i8 per cent of the cases.
Two or more relapses may follow at intervals.
After an attack of typhoid the general physical
and mental powers of the patient are often markedly
depressed for some months.
Varieties of Typhoid. — In young children typhoid
is often a mild disease, which is fortunate, as the
restraints as to movement which are imposed on
older patients are almost impossible to enforce.
Besides this, mild cases occur in adults in which,
though feehng ill, the patients are able to get about
and thus expose both themselves and others to serious
risks. A fatal and sudden complication may be the
first symptom for which the medical man is consulted.
Severe cases are those in which the temperature
remains high and the period of defervescence does
not set in during the third or fourth week. Marked
delirium, absolute prostration, rapidity and weak-
ness of the pulse, and sometimes severe diarrhoea
characterize these cases. The later in the disease
that the patient comes under proper treatment, the
more Ukely is it that the attack will be severe.
Generally speaking, children over ten present the
same course and symptoms as adults. In those
under that age the onset is apt to be less gradual,
nervous symptoms are more marked in the severe
92 INFECTIOUS DISEASES IN SCHOOLS
cases, and complications are less frequent. The rash
is also seen in a smaller percentage of cases.
Dangers of Typhoid. — Severe cases are always the
cause of considerable anxiety, as the patient may
die from the general poisoning produced by the
bacillus of typhoid. In addition there are two very
serious comphcations or accidents which depend on
the presence of the ulcers in the intestine, (i) The
ulcer may become so deep that only a very thin layer
of the outer wall of the bowel remains intact. Some
slight cause, often not apparent, but which may be
some sudden movement of the patient, the passage
of hard material over the ulcer, or a little distension
of the bowel by gas, may tear a hole in this thin
layer. This is called " perforation." It usually
occurs during the third week, when the ulcerative
process is at its height. It is fortunately not a
common event, most statistics show that it occurs in
between 2 and 3 per cent of the cases, though others
give a higher figure. This nearly always proves
fatal, as severe peritonitis is set up by the escape of
the contents of the bowel into the abdominal cavity.
Sometimes immediate surgical operation may save
the patient's Hfe. The earhest symptoms are pain in
the abdomen, which may be sudden and violent, a
faU in the temperature, and collapse. In addition
there is sometimes a shght shivering fit and vomiting.
In other cases, especially when the patient is already
very ill and almost comatose, the symptoms may be
very slight and ill defined. Perforation is however
not hmited in its occurrence to the severe types of
the disease, and may arise in cases which are regarded
as mild. (2) The ulcers may bleed severely. Slight
haemorrhages are not very uncommon ; those suffi-
ciently serious to be classed as a comphcation occur
TYPHOID FEVER
93
in a varying proportion of cases, usually not earlier
than the third week. It is a more frequent compHca-
tion than perforation. Severe haemorrhage probably
does not occur in much more than 3 per cent of the
cases, but if the sHghter instances are counted in,
the percentage may be reckoned as at least double
that figure. The symptoms vary with the amount of
blood lost. Sometimes the only indication is the
appearance of blood in the stools ; in more copious
haemorrhages the patient becomes pale and collapsed
and his temperature falls. Recovery may occur,
even when very large amounts of blood are lost.
SequelcB and Complications. — ^These are not very
common, and need not be described in detail.
Pneumonia is perhaps the most frequent ; then come
neuritis, periostitis and bone disease, inflammation
of the joints (arthritis) and of the middle ear (otitis
media). The gall bladder also becomes inflamed in
some cases.
General outline of Treatment. — ^The treatment of
typhoid is so much a matter of special knowledge and
experience, that the details from first to last must be
left entirely to the medical man in charge of the
case, and to the nurses who, under him, are responsible
for carrying them out successfully. It may not be
improper here, however, to mention the main objects
which all treatment is designed to secure. In the
first place rest, as absolute as possible, must be
secured for the patient, not only because the prolonged
course of the fever puts a great strain on his powers,
but in order to avoid the risks of perforation and
haemorrhage. In the second place, the diet is so
regulated and restricted that while the maximum
possible of nourishment is allowed, no hard or
indigestible matter can enter the intestine and damage
94 INFECTIOUS DISEASES IN SCHOOLS
Still further its ulcerated walls. In the third place,
to combat the damaging effects of the prolonged
fever, cold sponging or sometimes cold baths are
employed. This tends to lower the temperature and
diminish the severity of the nervous symptoms. Drugs
are employed to a certain extent, some with a view
to disinfecting the contents of the bowels and others
to reduce the temperature. The latter class are not
often employed in this country, though in Germany
they seem to be more extensively used. Finally, it
may be laid down that no amateur should ever
attempt to nurse a case of typhoid, however mild
may be its symptoms. A httle want of experience
and training may have the most serious results for
the patient, and also expose the nurse to the risk of
contracting the disease herself. Well-trained and
careful nurses occasionally take typhoid from their
patients, and the chances of an untrained person
doing so are immensely greater. So far no anti-
typhoid serum has been found of any great practical
value in treatment.
Prophylaxis. — Patients with typhoid fever are
usually nursed in the wards of general hospitals,
along with persons suffering from other diseases.
Special precautions, however, are adopted, and as
these are somewhat elaborate, in most hospitals there
is a rule which Umits the number of typhoid cases
which may be nursed at one time in a ward. In
private, however, typhoid patients should be isolated
as are other infectious cases, though where the
nurses are quite trustworthy and the general arrange-
ments adequate, there could be no objection to
responsible persons occasionally visiting the patient,
at the discretion of the doctor.
The infection of typhoid being spread by the stools
TYPHOID FEVER
95
and urine of the patient, these must always be
disinfected before being thrown into the drains, and
hnen and washable articles must be soaked in disin-
fectant before being washed (see page 21). All
utensils used in feeding and otherwise ministering to
the patient should be kept for his use alone and
specially washed, and a special lavatory and sink
should be reserved for deaUng with such articles.
They are also to be disinfected after use. The room
in which a typhoid patient has been nursed may be
disinfected after his recovery, and the bedding and
blankets sterihzed by steam. Careful investigation
as to the origin of the infection will have to be made
in conjunction with the local sanitary authority.
This will include an examination of the milk supply,
the water supply, and the drainage system, together
with any other possible source of food infection, such
as may occur in the case of oysters, ice-creams, or
uncooked vegetables. As patients who have appar-
ently recovered may still continue to discharge
typhoid bacilU in their stools and urine, specimens
of these should always be sent to a bacteriologist
for examination before these persons are again
allowed to mix with others, and they should not be
regarded as free from infection until the bacilli are
no longer found to be present.
Recently considerable success has attended the
preventive inoculation of a typhoid vaccine in those
who are Hkely to be exposed to infection. Although
it does not in all cases confer absolute immunity,
it considerably diminishes the risk of a severe attack.
The usefulness of the method is, however, somewhat
impaired by the fact that for a short time after the
inoculation has been made the individual is rendered
more Uable to contract the disease, so that it is unwise
96 INFECTIOUS DISEASES IN SCHOOLS
to inoculate those who are aheady in the danger zone.
Three inoculations are made during successive weeks,
and the last should be some weeks before any special
risk of infection is hkely to occur. The inoculations
are entirely without serious risk, though for a few
days there may be temporary symptoms of an
unpleasant character, such as pains, fever, and the
like.
PARATYPHOID FEVER.
There are several strains of bacilli which are
closely related to the typhoid bacillus and are also
capable of setting up disease in human beings.
They are collectively known as the paratyphoid
group. The infection they set up resembles typhoid
clinically, but ulcers are not usually present in the
intestines. The blood of these patients fails to give
the " Widal reaction " with the bacillus of Eberth,
but gives a similar reaction with one or other of the
members of its own group.
J. M. F.-B.
97
CHAPTER XIL
CEREBRO-SPINAL MENINGITIS.
(Spotted Fever).
French: Meningite Cerebro-spinal epidemique.
German : Epidemische Genickstarre.
CEREBRO-SPINAL meningitis is a specific in-
fectious disease, due to an inflammation of the
membranes covering the brain and spinal cord,
characterized by fever, a peculiar rigidity in certain
muscles, and in some cases by a rash, and Hable to
cause permanent damage to the brain and special
senses in those cases which recover.
History. — It is probable that this form of meningitis
was not in former times properly distinguished from
others, the causal organism and the methods for
detecting it having only been described in recent
years. A resemblance in the rash to that of typhus
fever has also led to confusion in the reports of
earlier epidemics. Four great epidemics have been
described between 1805 and 1885, and four others
since then in New York (1894-5), Glasgow (1906-7),
Germany (1905-6), and Belfast (1907-8). Besides
this form of meningitis, " sporadic " cases, that is
single instances which have not spread, are recognized
as not infrequently occurring, and are often known
as " posterior basic meningitis."*
* These may however be due to a slightly different
organism.
7
98 INFECTIOUS DISEASES IN SCHOOLS
Bacteriology.— The causal organism was discovered
by Weichselbaum in 1885 * It is thought to gain
access to the system through the nose and throat,
whence it makes its way into the spaces surrounding
the brain and spinal cord ; it may also be found in
the blood. It is capable of existing in the nose and
throat (of adults especially) without producing
symptoms, and these " carriers " are thought to be
an important factor in setting up an epidemic. The
organism can be fairly easily recognized in the fluid
which surrounds the spinal cord, and this fact has
been utilized in the diagnosis of the disease. In a
suspected case, a hollow needle is thrust into the
spinal cavity between the vertebrae of the loin, and
some of the spinal fluid is withdrawn by means of
a syringe and examined by a bacteriologist.
This procedure is found to be perfectly safe provided
certain precautions as to asepsis are taken, and has
now become a routine method.
Mode of Infection. — ^This has already been indicated,
but the subject is not yet quite completely understood.
The disease does not appear to be highly infectious
from one person to another ; " carriers " are probably
an important Hnk in tracing the spread of an epidemic.
Overcrowding no doubt increases the chances of an
epidemic occurring, and the outbreaks are often
" institutional " in character, affecting a limited
number of persons in a school, a barrack, or an
asylum.
Incidence. — Cerebro-spinal meningitis is mainly
seen in children, but adults are also attacked.^ It
* It is known by the somewhat cumbrous name of the
Micrococcus intracellularis meningitidis. Frequently " for
short " it is called Weichselbaum's meningo-coccus.
CEREBROSPINAL MENINGITIS 99
has been observed in many parts of the world, and
epidemics are most frequent in the winter and spring.
Clinical Course. — The incubation period has not
been determined with any certainty ; probably it is
only a few days.
The quarantine period cannot therefore be laid
down, but it would be reasonable to isolate " carriers "
until a bacteriological examination showed they were
free from the organism. Secondary cases have been
observed to occur a month after the primary batch,
but the bearing of this on a possible quarantine is
not at present clear.
The onset of the disease is in most cases remarkably
sudden and is marked by two main features, severe
headache and vomiting. Sometimes for a few days
or hours before the definite onset there are vague
feelings of illness, sometimes these are entirely
absent, and the patient may fall down suddenly in
the street or elsewhere with intense giddiness and
headache. The temperature rises abruptly to 102°
or 104°, and for the first few days the patient may
have all the appearances of one suffering from acute
pneumonia. The breathing is disproportionately
rapid, the face flushed, the eyes bright and perhaps
bloodshot, and there is abundant herpes (small crops
of vesicles) round the corners of the mouth and nose.
Usually, however, quite early there is some stiffness
and rigidity in the muscles of the neck and perhaps
the back, and the signs of pneumonia cannot be heard
in the lungs. The rash, which consists of small
haemorrhages under the skin of a purplish colour
and not fading when pressed, appears usually on the
fourth or fifth day, and may continue to come out
in crops throughout the illness. It is by no means
always present, however, and varies very much in
100 INFECTIOUS DISEASES IN SCHOOLS
extent and distribution. During the height of the
fever the mental condition varies with the severity
of the illness. In bad cases the patient may be com-
pletely unconscious or actively delirious. In mild
PLATE IV.
Juice pas'c loi
CEREBROSPINAL MENINGITIS 101
cases there is only drowsiness or hardly any inter-
ference with the mental functions. The worst cases
may die in thirty-six hours — ^usually too early for a
diagnosis to be made — others may live a few days.
In less severe attacks after a day or two the vomiting
ceases, but the comatose condition deepens gradually ;
the stiffness of the back increases, so that it becomes
arched backwards, the patient resting on his heels
and the back of his head (opisthotonos) ; or the head
becomes excessively drawn back and rigidly fixed in
that position. Sometimes there is tenderness of
the skin; groups of muscles become weakened or
paralysed ; squint and irregular movements of the
eyes develop ; and the breathing becomes very
irregular in rhythm and perhaps slow and sighing at
intervals. The fever continues high, the coma
deepens, restlessness is succeeded by ominous quiet,
and the patient dies within the first fourteen days
from the onset of the symptoms.
No disease, however, shows more variation in type
and symptoms than cerebro-spinal meningitis. The
temperature is occasionally quite low, even in fatal
cases ; the rash is more often absent than present ;
the patient though in extremis may retain his full
consciousness; or after more than three weeks of
severe illness may recover completely.
The longer the acute symptoms last the more
likely is the patient to pass into the chronic stage,
provided he survives. This is characterized by the
same variations which mark the acute stage. Some-
times periods of acute illness resembling that just
described alternate with others in which the tempera-
ture faUs to normal and aU the symptoms subside.
In others the temperature is quite irregular, in
others again it may be normal or subnormal.' A
102 INFECTIOUS DISEASES IN SCHOOLS
marked feature in the chronic stage is the persistent
and extreme emaciation, which occurs in spite of the
fact that the patient usually takes his food well.
A patient may die at any period of the chronic stage,
either suddenly from collapse, or with an access of
fever and delirium ; or gradually, in a semi-comatose
condition, may sink to his end. Varied forms of
paralysis, usually temporary, are seen during this
period, and not infrequently the patient becomes
both deaf and bhnd. In cases which ultimately
recover, the paralysis and sometimes the bUndness
pass away, but the deafness is usually permanent and
complete. The duration of the chronic stage may
be for several months.
The mortality from cerebro-spinal fever is very
high ; in many epidemics more than three-quarters
of the cases have died, but possibly the employment
of the serum treatment may considerably reduce this
terrible percentage in the future.
The Serum Treatment. — large number of sera
have been prepared, mostly with a view to injection
under the skin, but the results obtained have, on
the whole, been disappointing. A more promising
preparation is the serum of Flexner, which is injected
directly into the spinal canal. This serum should
always be used when it can be obtained, but failing
this, one of the others may be tried, as they cannot
make the outlook worse, and may perhaps improve it.
Prophylaxis. — ^The patients should, in cases occur-
ring in schools and private houses, be isolated, just as
typhoid patients are isolated, though in general
hospitals they can be safely nursed in the wards under
suitable precautions. Where possible, a bacterio-
logical examination should be made of the nose and
throat organisms of all who have been in contact
CEREBROSPINAL MENINGITIS 103
with the cases, and if any are found to harbour the
micrococcus they should be isolated and treated with
antiseptic mouth- and nose- washes. All the secretions
from the mouth and nose of patients should be disin-
fected, and all feeding and drinking vessels treated
as are those used in typhoid cases. A thorough
cleaning and disinfection of houses where patients
have Hved, or in which they have been nursed, should
be carried out, as the organism sometimes appears to
cHng to rooms and buildings.
J. M. F.-B.
104
CHAPTER XIII.
EPIDEMIC POLIOMYELITIS.
BRIEF note on this disease, which has recently
^ attracted considerable attention, may not be
without interest in a work such as the present, al-
though a detailed consideration of the many points
still under discussion is not possible. For the last
twenty-five years it has been recognized that a
form of paralysis, so usually limited to children as to
be commonly known as " Infantile Paralysis," occa-
sionally occurred in groups, and its infective nature
has been suggested in most medical text-books.
During the last six years definite epidemics have been
observed in many countries, such as Norway (1903-6)
New England (1907), New York (1907), Australia,
The Rhine Provinces (1909), Lower Austria (1909),
France (1910), while less extensive ones occurred in
Essex (1908), New York (1909), and North Devon
{191 1). In 1910, indeed, the disease appeared in a
large number of countries at once. The epidemics
have in some instances followed those of cerebro-
spinal meningitis, and in others they have coincided
with them. The diseases are, however, quite distinct,
epidemic pohomyelitis being due to an extremely
minute organism which has not yet been isolated ; it
passes through a bacterial filter, and is probably too
small to be visible by means of the microscope. It
EPIDEMIC POLIOMYELITIS 105
may belong to the same class as the unseen virus
which is responsible for rabies or hydrophobia.
Epidemic poliomyelitis is only feebly infective, and
the mode of infection is not clearly understood. The
incubation period seems usually to be about a week,
but varies very much in experimental cases (four to
forty-six days in monkeys). The onset is usually
with fever, vomiting, and convulsions, followed by
pains which may easily be mistaken for those of acute
rheumatism. In some epidemics catarrh and inflam-
mation of the nose and throat are constant]y observed.
In others these symptoms are absent. In many cases
again, there are intestinal disturbances such as
diarrhoea. Paralysis of groups of muscles or entire
limbs generally occurs within a week, and is followed
by wasting of the affected parts. In most instances,
however, only a portion of the parts originally
involved become permanently affected. A few cases
occur without paralysis or pain. Complete recovery
is uncommon (5 per cent), but recovery with only
shght paralysis is not infrequent. A fatal issue during
the acute stage is not frequently seen, but in some
epidemics has reached 15 per cent. There is no
specific treatment.
Prophylaxis. — So little is known of the methods by
which the disease is spread that it is dif&cult to lay
down definite rules. Isolation for three weeks and
the usual methods of disinfection are probably advis-
able. In some cases dirty swimming baths have been
thought to spread the disease ; so that for this, if for
no other reason, all swimming baths should be kept
as bacteriologically clean as possible.
Dust has been held responsible for the spread of the
disease, and in one epidemic (Stowmarket, 191 1) the
cases ceased when thorough watering of the streets
106 INFECTIOUS DISEASES IN SCHOOLS
with antiseptic solutions was adopted. Flies have
also been accused of carrying the disease ; but
epidemics do not always coincide with the times in
which flies are most prevalent. The worst months
are June, July, and August. Many slight and abor-
tive attacks arise which may transmit the disease,
as may also human " carriers." Domestic animals,
such as hens and rabbits, have sometimes been
thought to be connected with the outbreaks.
J. M. F.-B.
107
CHAPTER XIV.
INFECTIOUS DISEASES OF THE EYE.
EPIDEMICS of acute inflammation of the eyes
have long been recognized as one of the
pathological troubles incidental to school life, and
are spoken of vaguely as " Ophthalmia," or by the
descriptive term of " Pink Eye." The epidemics
usually occur in the spring and early summer, but
are by no means limited to such times. They come
on suddenly, and usually cannot be attributed to a
definite source, and involve a very large proportion
of those exposed to the morbid influence. The
trouble very often produces a much greater degree of
anxiety than the severity of the symptoms demands,
among parents and guardians, and consequently
among the school authorities. As a matter of fact,
however, the symptoms and incidental disabiUties,
as well as their possible gravity, are not so marked as
those of a " cold " that is recognized as " catching "
and generally " runs through " a household. The
symptoms are readily recognized by those who have
been in contact with an epidemic ; a sense of sandi-
ness in one or other eye, sometimes both, accompanied
by, it may be, some watering, followed the next morn-
ing or the morning after by some yellowish discharge
sticking the eyehds together, and in an increasing
degree for two or three days ; in those who had one
eye affected first, the other will take on the same
108 INFECTIOUS DISEASES IN SCHOOLS
trouble Within a couple of days. The eyes become
very red and bloodshot, and in the more severe cases
spots of haemorrhage appear on the " white " of the
eye. There is generaUy a good deal of dazzling and
irntabiUty. After the attack has reached its height,
It begins to ameliorate, and practicaUy passes off in
from ten to fourteen days, though a slightly blood-
shot appearance, especially of the inner surface of the
lids, may persist for some days longer. Occasionally
exacerbations or recurrences occur, and the attacks
may last for four or five weeks ; but ultimately com-
plete recovery may be looked for. Such is the usual
order of events, though variations occur ; for instance
sometimes only a few may be affected ; at other
times the attacks may not be so short and sharp.
The means by which the infection is spread are not
clear. It is popularly supposed to be due to using
the same water and towels ; but boys, at any rate
those in the better-class schools, where the trouble is
as rife as elsewhere, do not use the same water for
washing, though they may be careless about their
towels. Probably the only measures, that are really
of any avail, are prophylactic ones, such as bathing
the eyes of those who have not been attacked, with
some antiseptic lotion, as saturated solution of boracic
acid. Each person in the infected area should swab
his eyes three or four times a day with this lotion, and
smear the eyelids and lashes with boracic ointment
before going to bed. The lotion is easily made by
placing some boracic acid in a bottle, and adding
water as it is used, so long as some of the boracic acid
remains undissolved at the bottom. This bathing,
however, is not an easy matter to carry out with boys,
and a more effectual expedient is to remove them out-
side the infected area, if such a thing is possible.
INFECTIOUS DISEASES OF THE EYE 109
After the symptoms have set in, probably no treat-
ment whatever is of any avail, so far as the actual
attack is concerned, for cure is brought about by a
process of self-immunization arising from the disease ;
but to prevent the spread of the infection and subse-
quent comphcations the utmost cleanliness of the
part must be observed.
This account of the usual form of the epidemic
must not conceal the fact that more serious trouble
may arise in much the same way, and thus no epidemic
should be hghtly viewed until medical sanction has
authorized it, for, as will presently be pointed out,
the infection in these epidemics is not always, though
such is usually the case, of the same kind, some being
more serious than others.
Besides these attacks of acute ophthalmia, there
are other chronic forms, which, though they do not
occur in epidemics, are not the less contagious —
I allude particularly to the form that presents
redness and scurfiness at the outer corners of the
eyes, where the skin may be sore and excoriated.
There is no discharge of matter, but some mucus,
and, when the condition is severe, the affected part
is wet and soppy. The condition is undoubtedly
contagious, is very chronic, and, when estabhshed,
shows httle tendency to get better, or, in cleanly
surroundings, worse. It is one of the most satisfac-
tory troubles to treat, for however long it has lasted,
it is easily cured by sulphate of zinc lotion.
Not in the least resembling this, though the descrip-
tion may sound much the same, are the red, scurfy
edges of the Hds that are so commonly seen, and
which are too often taken as a matter of course and
neglected, the consequence being that they become
a hfelong disfiguring trouble ; and, in some cases.
110 INFECTIOUS DISEASES IN SCHOOLS
from destruction of the hair bulbs, loss of the eye-
lashes occurs. Such a condition is not infectious in
the ordinary sense of the word, but in its estabhshed
form is always associated with infection of the hair
bulbs and the glands arranged along the edge of the
lid. The cause of the infection is present with every
individual, and consequently the only precaution
that can be taken against infection is to prevent an
unhealthy condition of the parts.
Such occurs frequently from congestion due to eye
strain in those who need spectacles, or who have a
natural intolerance of the parts to wind or glare. In
those who show this tendency to redness of the lids,
errors of refraction should be corrected and, when a
natural intolerance exists, the parts should be stimu-
lated to a healthier and more robust condition by the
inunction of yellow mercurial ointment, which has at
the same time the advantage of being an antiseptic
and, therefore, destroys or prevents infection.
Before proceeding to the more technical description
of these infectious ailments, their complications, and
treatment, it may be well to draw attention to an
epidemic of ophthalmia of a certain trivial kind, which
arises from more or less mechanical causes, such, for
instance, as exposure to a very keen, cold wind, or
non-infective dust, in which may be included the
pollen of fir or other trees ; this especially has been
confounded with the acute contagious ophthalmia,
and may certainly render the eyes more susceptible
to contagious infection of any kind. For the above
condition bathing with boracic acid lotion may well
be adopted.
In quite another category is the irritation called
hay-fever, extreme in some cases, that arises from the
pollen of flowers in those who are susceptible thereto,
INFECTIOUS DISEASES OF THE EYE 111
and the implication of the skin as well as the surface
of the eyes excited by the primula group, and, more
rarely, by certain other flowers. In these cases there
appears to be an influence of a certain chemical poison.
The question, however, has not been satisfactorily
cleared up.
It is necessary also to mention that form of oph-
thalmia that used to be, and still is to a less extent,
the curse of the Poor-law schools of large cities. It
is this condition which tends to raise the scare which
surrounds the term " ophthalmia " when it occurs in
better-class schools. It has been known by various
names, such as Egyptian ophthalmia, workhouse
ophthalmia, granular ophthalmia, but it is techni-
cally known as trachomatous ophthalmia. It is not
ordinarily met with in better-class schools, nor is
there any danger that it may become epidemic in
them, but individual cases now and then occur, which
would be a source of danger if the patient were
allowed to remain with the others. It would not be
wise, therefore, under any conditions, to allow such
a one to remain at school, even with the most elabor-
ate precautions. Scares of outbreaks of this trouble
have every now and then occurred, but they have not
been substantiated, nor is there any real danger for
somethmg more than infection is required to give
rise to an epidemic.
The real difficulty in deaUng with these cases is
the recogmtion of the disease, for so-called granula-
tions occur quite commonly in the Hds of the young
which have nothing in common with trachoma granu-
lations, but with which they are often confused. The
innocent granulations are commonly described as
foUicles. They consist of lymphoid tissue, like " ade-
noids, and are usually to be observed on the inside of
112 INFECTIOUS DISEASES IN SCHOOLS
the lower lids near the eyeball. They are translucent,
and when present in sufficiently large numbers are
situated in rows. They do not occur to any extent
in the upper lids, but may be seen sometimes creep-
ing round from the lower hd at the inner and outer
corner.
Other than this, granulations of any kind on the
upper Ud should give rise to the gravest suspicion.
The granulations due to trachoma resemble a very
small boiled sago grain. When inflamed, as they
frequently may be, they give rise to a condition of
follicular ophthalmia which can further be classified
under the cause which has given rise to the inflamma-
tion. They arise in eyes that have been subject to
irritation or eye-strain, or excessive use of drops, such
as atropine or cocaine. They have been recently
described as the result of an attack of epidemic
ophthalmia, though in the writer's experience, while
they may arise from any chronic irritation, an acute
inflammatory attack will bring about their disap-
pearance, had they been present. Such eyes, too,
show themselves as particularly liable to become
attacked, when the patients are present in the infec-
tive zone of an epidemic. It is always advisable to
get rid of these foUicles by active treatment with
astringents, and especially by removing the cause, if
it can be ascertained. It is well, therefore, to add
that eye-strain from the need of spectacles is a very
frequent cause. From the school point of view, the
only treatment that need here be mentioned as
regards trachoma is as above stated, that the boy
must be removed from the school at once. _
Of late years scientific enquiry into the causes of
conjunctivitis has led to considerable alteration of the
nomenclature of this form of disease, and, although
INFECTIOUS DISEASES OF THE EYE 113
there is still a good deal of uncertainty in the share
that the several micro-organisms, which have been
discovered, take in the production of the inflammation,
yet they form a good general basis for the classifica-
tion, scientific study, and treatment of the inflam-
matory conditions of the conjunctiva. While laying
special stress on the epidemic produced by infection
with the Koch-Weeks bacillus, and the infectious
character of the Morax-Axenfeld diplococcus, the
writer will do Httle more than mention the other
forms of ophthalmia due to infection, for the study
of which the reader is referred to a more complete
treatise.
Acute Contagious Conjunctivitis (" Pink-eye,"
Acute Muco-purulent Ophthalmia, etc.).
Symptoms. — Irritability and a feeling as of sand in
the eye mark the early stage after infection. Usually
on the second morning, the eyes are stuck together by
muco-purulent discharge, the conjunctiva is congested,
the lids puffy, and free lacrymation occurs. These
symptoms increase in severity for about two days,
and in severe cases small conjunctival haemorrhages
take place. This stage lasts for three or four days,
when the acute symptoms begin to subside, and after
ten days from the outset little trace of the attack is
left, except, may be, some redness of the lids, and in
a fortnight most patients are practically well. Occa-
sionally exacerbations or relapses take place, and the
attack may be prolonged for' another two or three
weeks. Sometimes phlyctenules and corneal ulcers
supervene.
Cause. — The inflammation is due to infection by
micro-organisms, and that which is present in a very
large majority of cases is the Koch-Weeks bacillus ;
but the pneumococcus or influenza bacillus may be
8
114 INFECTIOUS DISEASES IN SCHOOLS
found, in which cases the attacks are usually milder,
but the microscope is needed for differentiation.
Treatment. — Cleanliness is all important, and it is
very doubtful if anything more is needed, for re-
covery is due to self-immunization, although the
immunity does not necessarily last for long. When
relapses and exacerbations occur, astringents are
recommended ; but for the usual cases some anti-
septic wash, as a saturated solution of boracic acid,
perchloride of mercury lotion i in 9000, or diluted
glycothymoline is sufficient. Some authorities re-
commend more strenuous treatment, such as nitrate
of silver or argyrol. Where complications arise,
such as ulcers of the cornea, atropine or other
treatment apphcable to the compUcation must be
used.
Prophylaxis. — ^This is an important question, for
an epidemic of this sort upsets school routine so much.
At the same time precautions, unless they are very
thorough, will avail Httle. The exact means by
which the infection is conveyed is not yet determined.
The vitahty of the Koch- Weeks bacillus very readily
perishes, and is easily destroyed, and the fact that
drying destroys it would seem to indicate that it is
not conveyed by air as one might otherwise suppose.
Bathing the eyes of those who are uninfected two
or three times a day with some antiseptic lotion
would certainly be valuable, but this must be done
consistently. Complete isolation of those infected
would also tend to prevent the spread of the trouble.
This is, however, seldom possible, and in cases
where it would be, the question arises whether such
a step is required for so comparatively trivial a
disease, especially as no guarantee can be given
that the trouble will not continue to spread.
INFECTIOUS DISEASES OF THE EYE 115
Subacute Contagious Conjunctivitis. (Angu-
lar Conjunctivitis).
Symptoms. — Irritability, with excoriation and a
soppy condition, of the skin at the corners of the eyes,
especially the outer, accompanied by redness of the
margins of the Hds. In long-continued cases, the
condition of the corners of the eye may spread all
round the Kd margins. There is no secretion of
matter, and the hds do not tend to stick together.
There is, however, some mucous discharge. The
condition is especially chronic, and occasionally small
ulcers form on the margin of the cornea.
Cause. — Infection by the Morax-Axenfeld diplo-
baciUus.
Treatment. — ^The condition is readily cured by
sulphate of zinc drops, two grains to the ounce. If
ulcers of the cornea occur, the same drops, but half
the strength, combined with atropine, half a grain to
the ounce, should be used.
Trachomatous Conjunctivitis need only be
mentioned, as such cases should not be treated in
schools. A specific micro-organism probably exists,
but has not been definitely isolated. Other condi-
tions, however, which are not present in high-class
schools, are required, in addition to the infective
virus, to bring about an epidemic.
Membranous Conjunctivitis is a comparatively
rare disease, usually due to the presence of the
bacillus of diphtheria or a streptococcus, and some-
times to other micro-organisms. The diphtheria
bacillus should always be suspected and the patient
treated accordingly. Besides the membranous form,
a mild attack of acute conjunctivitis may be due to
the streptococcus occurring in cases of impetigo.
Acute Purulent Ophthalmia.— This is hardly
116 INFECTIOUS DISEASES IN SCHOOLS
likely to occur in schools. The infection is due to the
gonococcus, and in milder cases to the diplococcus
catarrhalis and meningococcus.
There are other micro-organisms which affect the
conjunctiva, but which need not be enumerated
here ; it may, however, be weU to mention that under
unfavourable conditions of the part, when its vitahty
is lowered, the staphylococcus aureus will excite
acute conjunctivitis.
R. W. D.
117
CHAPTER XV.
RINGWORM. TINEA.
RINGWORM is a well-defined and distinct
affection of the skin, caused by different
varieties of a microscopic parasite, and due to a
minute fungus invading the outer layer of the skin,
the hair-follicles, and the hairs. It is highly con-
tagious; and when occurring on the head, if not
properly treated in the early stages, may rapidly
spread and become rebellious to ordinary treatment,
and seriously interfere with a child's education.
It is a mistake to think ringworm is due to dirt
or want of personal cleanliness. Dirt affords no
pabulum for the fungus to grow in ; and the disease
is not found in a greater percentage in dirty and
neglected children than in those who are clean.
Washing the head does not prevent the fungus from
developing if it has effected a lodgement on the
skin.
The most common age for ringworm of the head
is from five to eleven years, and about three out of
four cases commence between those ages. From the
examination of boys (coming from all classes) for
admission into Christ's Hospital during the last
forty years, I have come to the conclusion that
ringworm of the head is rapidly declining. From
1875 to 1885 I rejected (on account of ringworm)
118 INFECTIOUS DISEASES IN SCHOOLS
about 8 per cent of the candidates for admission ;
from 1887 to 1897 this was reduced to per cent ;
and during the last ten years the number rejected
has been only about 3 to 2 per cent. This proves
that ringworm is now diagnosed and treated more
efficiently than formerly, and that by care it ought
to become a rare disease.
Incubation Period. — ^This is uncertain, but a small
spot may form in a few days from the implanta-
tion of the fungus. If the disease is contracted it
can usually be detected by an expert within a fort-
night, but sometimes the fungus may remain latent
for a time.
It is very difficult to say how long any place must
have existed before being seen, as the rate of growth
varies. Thus it is unwise to give a decided opinion,
though an experienced observer can give a fair
guess. A small place may develop in twenty-four
hours, and a moderate sized one in a few days ; but
on the other hand, a small place may have existed
for some time.
It is impossible to say how long it wiU take to cure
any case of ringworm of the head. It may remain
uncured, especially if treated by the old methods
with ointments or lotions, for months or even years.
In some children the fungus takes but slight hold,
and is easily destroyed, while others are very sus-
ceptible and the disease quickly spreads.
The Fungus* consists of branching hollow tubes
called mycelia, and of conidia or spores ; and when it
* The Different Forms : —
Tinea Tonsurans — ringworm of the head ; and Tinea
Circinata — ringworm of the body. . .
Tinea Tonsurans is divided into: Microsporon Audouim
—tinea with small spores, and Tricophyton megalosporon—
PLATE V.
Fig. 12. — Ringworm of i he Head. Tinea Tonsurans : ihe
small spore variety, or Microspcron And(ni>ni. X 300 diani.
Plates V, VI, VII, reproduced by kind permission- from
"Ringworm and Alopecia Areata."
Face I>age
PDA TE VI.
Fig. 13- — Ringworm of the Head. Tinea Tonswans: the
large spore variety, or Tricophytoii Megalosporon^ {cndothrix
resistant). X 300 cliam.
RINGWORM
119
invades the skin it develops into mycelium tubes
which pass between the cells of the outer skin (epi-
dermis or cuticle), and cause irritation and inflam-
mation, and often a ring of minute papules and
vesicles. If the head be involved, the hairs get
diseased, and the case is infinitely more difficult to
cure than if the body be the seat of the disease.
Diagnosis. — Patches on the body are fairly easy
to detect, but there is no disease of the skin in which
so many mistakes are made in diagnosis as in ring-
worm of the head ; and when the results of such
errors are considered, it is surprising that those who
may have to discover this trouble, or to give certifi-
cates, do not more thoroughly acquaint themselves
with the simple facts concerning its diagnosis, and
what constitutes a " cure." Errors are often made,
and children with well-marked ringworm are even
certified to be cured and sent back to school; and
yet there are definite signs by which anyone can tell
whether a child has or has not ringworm, and mis-
takes ought not to be made.
In examining a head it is essential to have a good
lens and a bright fight (daylight best), and the light
should be on the right side of the examiner.
The hairs should be turned up by a pair of forceps
in the reverse way to the growth, so as to expose the
whole scalp httle by little. Any scurfy spot should
be examined with a lens, when any uneven or broken-
off hairs wiU stand out and be observed, even with the
naked eye.
tinea with large spores. The latter is also divided into
M. endothnx, the commoner variety, and M. ectothrix the
rarer. Then there are two varieties of M. endothrix— resistant
(much the commoner), tnd /ragile mycelium. The latter is
rarely seen m so-called black-dot and disseminated ringworm
RINGWORM
121
with those who are free ; but, as ringworm is con-
tagious and not infectious, there is very Jittle risk of
children taking the disease from simply being in the
same room for lessons or meals with a case of ring-
worm, provided it is under efficient treatment.
One of the commonest causes of the spread of this
trouble is the contact of healthy children with the
head of, or with infected articles belonging to, a
child with chronic, unknown, and therefore untreated
ringworm, which is so often thought to be scurf or
eczema.
Recent Ringworm. — At the earliest stage there
is only a small scaly circular spot containing, perhaps,
hairs more brittle than usual, but it is rare for a case
to be discovered before a few hairs are involved and
broken off. The usual position is the dome of the
head, and attention may first be drawn to the case
by the child scratching his head, or by the nurse or
hair-dresser observing a partly bare place.
The patches vary in number from one to many,
are more or less circular, non-symmetrical, and
extend from the circumference. A typical patch
of small-spore is usually a marginated one, where
most of the hairs lie in one direction, and easily
break off, " stumps " being left ; but it is a great
mistake to imagine that ringworm on the head
usually presents the appearance of a red scaly spot,
almost destitute of hair, with a raised edge and
decided ring-hke form. This appearance of ring-
Worm of the body is rarely seen on the head.
The part looks as if nibbled, and this appearance
is very distinctive and should never be mistaken for
scurf or eczema. In the very early stage before the
hairs break, the only way to diagnose the case is to
examme the scales under the microscope for mycelium.
122 INFECTIOUS DISEASES IN SCHOOLS
Stumps.— The diagnostic "stumps" are short
broken-off diseased hairs, and care must be taken not
to confound them with short cut-off healthy hairs.
It is absolutely useless to examine (or to send up for
examination) healthy short cut-off hairs for the
fungus.
The stumps are usually thickened, lustreless, and
easily broken off on attempted extraction with
forceps; whereas healthy hairs, or the stumps in
alopecia* {Fig. 15) will come out entire with the root.
In cases of chronic ringworm, especially after long
treatment, the stumps are often difficult to find, as
they may be hidden amongst the long hairs, or
fastened down under scales, and only appear when
the scales are carefully removed. They may even
be found on the under-surface of the removed scales,
sometimes twisted hke a corkscrew.
A stump may sometimes be removed entire by
using very gentle traction with the forceps, but more
usually it breaks off a Httle way down the hair-
follicle, leaving the bulb and some of the shaft
behind. It is this little bit of hair (if a whole stump
cannot be extracted) which should be examined
under the microscope.
Sometimes the stumps, instead of sticking up, may
be found lying close to the surface of the skin, looking
dull and thickened, and often of a hghter or yellow
colour, and possibly glued to the scalp by sebaceoum
matter.
Microscopical Examination. — ^The stumps should
be placed on a glass sHde with a drop of Liq. potassas,
and a thin cover-glass applied. It is best to let the
specimen soak for an hour or two to make it trans-
* Alopecia areata — bare smooth patches. (See page 125.)
RINGWORM
123
parent ; but if it must be examined at once, the under-
surface of the glass sUde should be sUghtly warmed.
Prolonged soaking brings the fungus, especially the
mycelium, into view; and it is better to soak the
specimen some hours than to use heat, which may
destroy the mycehum. Before examining, the cover-
glass should be gently pressed down, and any excess
of potash removed by blotting paper. It is also
essential to have a good microscope with ith object
glass, so as to magnify about 600 diameters. Stumps
appear opaque if examined too soon, or if heated too
much.
Often the form of fungus can be diagnosed at once
as the sheath in the small-spore gets pressed out
on either side of the stump, and looks whitish to the
naked eye.
Small-spore Diagnosis.— The patches are usually
round and distinctly circumscribed, more or less bare,
and sometimes of a greyish or slatey colour. The
skin is often raised above the surrounding level and
the follicles appear prominent, having the appearance
of " goose skin." The surface is covered with dry
lamellated scales, giving the place a dirty scaly
appearance, and at times slight crusts form. Small
lustreless, sheath-like coverings* of a dull white or
grey colour, and composed of innumerable spores,
more or less surround the bases of the stumps.
Hundreds of these lying close together give a
white frost-hke look to the skin. Almost all the
hairs are diseased on the places, lie in one direction
without any elasticity, and if pulled generally break.
The diseased hairs are white and lustreless, look
as if covered with fine dust, and when broken off
have a nibbled appearance.
* Called the " circumpilar collarette."
124 INFECTIOUS DISEASES IN SCHOOLS
Under the microscope the most conspicuous
object is the spread-out mass of spores heaped
together on each side of the compressed stump. The
chief characteristic is this mass of innumerable
round spores, which are not arranged in filaments or
linear series, or in the distinct bands and strings of
beads found in the large-spore. They He one against
the other without any definite arrangement, forming
a mosaic by mutual pressure outside the hair.
The surface of the hair is eroded, and mycelial
threads can be seen on the hair and in its substance,
and end at the neck of the bulb in a long terminal
fringe of delicate threads characteristic of the small-
spore.
Large-spore Diagnosis. — In both varieties the
skin is much smoother than in the small-spore, and
at times only broken-off stumps are to be found.
There are no sheaths, and no frost-hke look of the
skin. The places are generally smaller, but large
patches may exist with the hah growing freely, except
that numerous stumps are to be found scattered
amongst the healthy hairs. If the stumps are
scattered about it is called "disseminated ring-
worm ; " and " black dots " may be present, due
to rubbing down of the stumps level with the skin.
Though the places may be smooth and healthy
looking, at times— especially after treatment— the
scalp is very scurfy. This is the form so often over-
looked, and thought to be only scurf. The " stumps "
are generally seen mingled with the long hairs,
erect, swollen, dark, and broken off very short ; and
may only be found under the scales. On attempted
extraction they usually break off very short.
Microscopically, there is no heaped-up mass of
spores round the shaft, and no opaque mass spread
RINGWORM
125
out. Long chains of mycelium, which branch at
times, are found transversely divided at intervals,
and a fringe of mycelium near the bulb, but not
having such long threads as the small-spore. The
mycelium can be seen in the substance of the
hair forming bands of mycelial spores. The divisions
are doubly contoured, almost square, forming bands
like the staves in a ladder, or in the fragile form like a
string of beads. As a rule no mycelium is seen on
the shaft outside the hair follicle, except from burst-
ing of the hair. The shaft is not eroded like the small-
spore, and the epithelium can be seen like so many
minute tiles overlapping. Sometimes there is a
" fish-roe " look of the masses of spores found packing
the hair, resembling a bag of nuts.
Bald Ringworm. — ^The skin may be more or less
smooth and clean, but the diagnostic sign is the
presence of some diseased stumps, at times broken
off and only looking like " black dots." This is a
rare and chronic form, and has been confused with
true Alopecia areata. It is very difficult to get away
any portion of the diseased stumps, but if examined
it will be found to be one mass of fish-roe fungus.
Diagnosis from Alopecia Areata. — Bald places
due to true Alopecia areata may be thought to be
ringworm, and often have " stumps " on them, and
even black dots. The diagnosis is easy, as patches
of alopecia are smooth, white, with absence of scales
and diseased stumps. Generally there are some
typical club-shaped stumps, especially where the
patch is enlarging. The long hairs near the place
may be very loose and come out easily when pulled,
but the skin is not raised, and after a time gets
thinner and depressed. The stumps are typical,
with the ends larger than the root-part— Hke a note
126 INFECTIOUS DISEASES IN SCHOOLS
of exclamation (!) without the dot. These stumps
are easily extracted entire instead of breaking off, *
as usual with the stumps from ringworm. The
roots are small and shrivelled, and under the micro-
scope the bulb is observed to be atrophied, sometimes
swollen at the upper portion and then tapering and
much reduced in size. The shaft is found to be
dilated and darkened in places, forming enlargements
which are deeply pigmented in the centre, with a
large amount of dark granular matter like pith.
The free end is somewhat club-shaped, pigmented,
and often exhibits a cluster of fibres radiating out-
wards in a brush-like form. No mycelium or spores
are to be detected, and if found the case is not true
alopecia, but bald ringworm.
Bald Spots, from cuts or injuries, can easily be
diagnosed by their shape, the depression of the skin,
its white appearance, and the absence of stumps.
Diagnosis of Chronic forms of Ringworm. —
It is a great mistake to think ringworm is cured
because the hair is growing again on the affected
areas. Some of the most chronic cases are those in
which the long hair is growing freely again, but on
close examination " stumps " can be found. It is
impossible to write too strongly on this point, as an
outbreak in a school is generally due to the admission
into it of an over-looked chronic case. Such are sent
back, even with medical certificates, as " cured "
and 'fit for school, and certificates may be given
without a thorough examination of the head. Even
after children have been said to be cured by the
A;-ray treatment I have often found many diseased
stumps left. But apart from difficult cases to
diagnose, I have had children sent to me cerhfied as
" cured "' with typical patches of ordinary ringworm.
RINGWORM
127
covered with scales and scurf, and broken and
twisted short hairs. On pointing this out I have
been gravely informed that the disease was " dried
up and cured, and the stumps of no consequence."
It is often difficult to detect the short diseased
stumps, which only protrude an eighth of an inch
or less; and no patch should be considered " cured "
until the new downy hair commences to grow, and
the case has been carefully watched for a time after
aU treatment has been discontinued. Stumps often
re-appear, so the head should be watched and exam-
ined for weeks after it seems to be free.
The fungus cannot be destroyed by parasiticides
contained in ointments and lotions, so that the
diseased hairs grow healthy again, but all the diseased
hairs must be got out of the hair follicles, and new
downy hair should grow.
Atrophied Stumps. — Sometimes, after shaving
or close cutting, some atrophied stumps will be
found though the case is cured. The diagnosis of
these is easy, for they are bright and fine, and
look like healthy hairs. They come out easily with
atrophied roots, and of course no fungus can be
detected.
Certificates. — It is a wise precaution for school-
masters to insist on a certificate being obtained from
some well-known speciahst when a boy or girl returns
to school after ringworm of the head ; and in all cases
the medical officer of the school should reject the
child if any diseased hairs are present.
Ringworm of the Body is also caused by a
pluraHty of fungi, and is often contracted from
animals, but may be associated with ringworm of
the head. It should be a golden rule always to
examine carefully the head of a child who has a
128 INFECTIOUS DISEASES IN SCHOOLS
patch of ringworm on the body. If the scalp is free
it IS easy to cure the trouble on the body.
The place or places are usually the size of a split-
pea to half a crown, or larger, with circular and well-
defined edges. They are slightly raised, covered
with fine scales, and enlarge by growth at the circum-
ference, while the skin may become more or less
normal again in the centre. They are often distinctly
red, with minute papules and vesicles at the edge,
forming a distinct ring. The affection shows no
disposition to symmetry, and there is usually some
itching of the skin. Patches may be seen on the
back of the wrist having more the appearance of
eczema, but have a well-defined edge and vesicles.
Eczema Marginatum. — Under the combined ac-
tion of heat and moisture, ringworm on the body may
become severe and extensive. It may spread and
be very chronic, especially on the inner and upper
parts of the thighs. This form is called Eczema
marginatum, but it is true ringworm, and often most
difficult to cure.
There have been many cases lately in some schools,
but it is more often seen in young men and adults,
especially in those who ride much.
It commences with a raised red patch with papules
and vesicles and much irritation, causing the patient
to scratch the parts. The circumference has a weU-
marked defined border often thickened and raised,
and it spreads rapidly, with a tendency to heal in
the centre, leaving a dark-red scaly condition of the
skin and, in time, marked pigmentation.
It differs from ordinary ring\\'orm in the
eczematous character of the lesions, and the con-
gestion and pigmentation of the skin. At first there
is a luxuriant growth of large mycelium, and the
RINGWORM
129
fungus can easily be detected if the scales on the
outer edge be examined, but when the disease has
passed into the chronic form, the fungus may be
difficult to find.
In all forms of body ringworm the diagnostic point
is the presence of well-marked mycelium ramifying
amongst the epidermic cells.
Microscopical Examination. — ^To obtain a specimen
for examination, the inner part of the outer ring
should be scraped, and the scales placed in liquid
potash. The glass sHde must be allowed to stand for
some hours, or be gently warmed. The mycelium
is seen as long, slender, sharply-contoured threads
like ribbons, jointed at irregular intervals, and
branching in all directions. Care must be taken not
to mistake shreds of wool or cotton for mycelium,
and not to confound the margins of the epidermic
scales, where they overlap one another, with threads
of mycelium. The diagnosis is easy if the fine
adjustment be used, which will exhibit the outline of
the scales.
Diagnosis. — Eczema, scurfy places, seborrhoea,
and pityriasis may be mistaken for ringworm.
The patches may be circular, raised, sharply
circumscribed with a ring-like border, and scaly. In
Pityriasis rosea, especially, they may even become
more normal in the centre whilst spreading at the
edges, and thus look very like ringworm, and are
often mistaken for it ; but as a rule there are many
small red places not at all hke this disease. If in
doubt, the scales must be examined, and no mycelium
will be detected. Seborrhoea may also simulate ring-
worm, but the patches are generally irregular, and
have the same appearance all over. Even an ex-
perienced observer may be mistaken, and it is
9
130 INFECTIOUS DISEASES IN SCHOOLS
advisable to examine microscopically the scales from
any doubtful spot.
Ringworm of the body should not be considered to
be cured until the place is almost normal again at its
circumference. The place may still be shghtly red
and stained, but the margin should be quite free from
all papules and scurfiness, and should not be raised
above the level of the surrounding skin.
Treatment of Ringworm of the Head. — It is
impossible to say much about the treatment of this
trouble in a small space, and elsewhere* I have fully
described the different ways adopted in the past ;
but since the x-iay treatment has come in, most that
has been written is worthless.
The first thing to do is at once to isolate the patient
and prevent the disease from spreading. This is
often neglected, and some parasiticide is simply
appUed to the place. It is essential that the whole
scalp be treated.
A good plan to adopt (at first) is to cut the hair off
the place or places, and to thoroughly wash the head
with carbohc soap, and carefully dry it. Then at
once to rub in an ointment containing a mild
parasiticide. I prefer sulphur, and use a drachm
and a half of precipitated sulphur to the ounce of
benzoated lard. This should be well rubbed into
the entire head, at first avoiding diseased patches,
and finally rubbing it also into them. A httle
carbolic-glycerine (one part of carboUc acid to seven
parts of glycerine) may also be dabbed on to the
affected parts ; but it is not advisable to use any
strong parasiticide at first, as x-ray treatment may
be adopted later on. The great thing to do, at first,
* "Ringworm and Alopecia Areata."
RINGWORM
131
is to make the whole surface of the skin of the head
(the cuticle) in such a condition that the fungus
cannot grow amongst the epidermic cells, and this
is usually accomplished by using sulphur every day.
Of course, it is well to cut the hair off the patch, but
I never advise shaving the head, as then it is difficult
to find the places. If sulphur be thoroughly rubbed
in, ringworm rarely spreads, though small places
which were not noticed at the first examination may
subsequently be discovered. It is also advisable
to disinfect with formalin any articles that may
convey infection, as clothes, towels, brushes, combs,
etc.
The next question, especially for the schoolmaster,
is what course of treatment is to be adopted, as it
may take many months. My opinion is that cases of
ringworm of the head ought to be sent home, and
not kept at school ; and thus the selection of the
treatment would be left to the medical man attending
to the case.
Parasiticides are essential to stop the spread, but
they rarely cure by killing all the fungus. The
diseased hairs have to be got out of the folHcles,^
and it is by causing inflammation, etc., that most^
of the parasiticides effect a cure. I have utterly
discarded all the old treatments by ointments and
lotions containing parasiticides (their number is
legion). In nine cases out of ten it is simply a
waste of valuable time, and the disease, especially
if parasiticides are not constantly used all over the
head, often spreads. Simple remedies will easily
cure ringworm on the body, as it is easy to get the
parasiticide into contact with the fungus; but in
ringworm of the head we cannot by any amount of
rubbing get parasiticides deeply enough into the
132 INFECTIOUS DISEASES IN SCHOOLS
closed hair-follicles to get into contact with and
destroy the fungus about the roots, and diseased
hairs may continue to grow up for months or even
years.
Before the %-ray treatment was discovered I cured
the cases under my care by the so-called " croton-oil
treatment." That is, by using a small quantity of
croton oil with great care, and constantly bathing
and poulticing the place, I produced sufficient
inflammation of the skin to cause the diseased hairs
to be thrown off, and new downy hair would grow
again. Unfortunately, this treatment requires very
special knowledge and experience, and few adopt it
now that the %-ray treatment has almost entirely
taken its place. Personally I still employ croton oil
for small places of scalp ringworm, as I can get the
places well more quickly than by ;%;-rays. X-ray
treatment also leaves a larger bare place for a time,
and the new hairs do not grow again as quickly as
when the stumps are removed by croton oil. Croton
oil properly apphed only removes the diseased hairs,
while A;-rays cause all the hairs on the part exposed
to them to fall out. Therefore the bare place is
generally much larger than the original spot. Again,
;c-rays only cause the hairs to fall out and do not kill
the fungus, and unless great care is taken the disease
may easily spread while the ;i;7ray treatment is
adopted.
At the present time most experts advise the :*;-ray
treatment for ringworm of the head, even if only one
or a few places. Great care is also exercised con-
cerning the time the part is exposed, and mild
parasiticides are kept over the head to prevent any
spread of the disease. If x-rays be used they ought
to be appHed by some one thoroughly acquainted
RINGWORM
133
with the method and the precautions to be adopted,
as unfortunately if great care be not taken permanent
bare places may be produced, and I have seen several
during the last few years.
If the x-id-Y treatment is to be used, strong
parasiticides should never be applied at first, as no
careful operator will use A;-rays to a patch of ring-
worm that is inflamed by parasiticides.
Then there is the treatment for disseminated
ringworm, and the removal of scattered stumps left
even after x-rd-y treatment has cured the patches.
These can best be removed by what I have elsewhere
described as " croton oil needling." A number of
isolated stumps can be quickly caused to come out
by running a fine special needle, coated with car-
bolised-croton oil, into the hair follicles ; but this
Httle operation requires the hand of an expert, and
also much of his time.
The great point I wish to emphasize is that time
ought not to be wasted in trying first one ointment
and then another, but any spread of the disease
should be stopped by using a parasiticide all over
the head, and the individual places cured by the
%-ray treatment, or by croton oil ; but only by some-
one fully acquainted with its use and dangers.
Disinfection. — Clothing is best disinfected by
formalin, and may be placed in a large closed
receptacle, and formalin (one part of strong formahn
(40 per cent) in ten of water) well sprinkled all over
the clothes (brushes, etc., may be soaked in i in 20
formalin solution), and kept in for twelve hours.
Ringworm of the Body— Treaiment— This is
quite a different matter, and there is no need to send
a boy home ; isolation, and disinfection of the clothes
are advisable, and the head should be examined to see
that it is free.
134 INFECTIOUS DISEASES IN SCHOOLS
Any simple parasiticide will cure body-ringworm,
as the fungus is easily got at. I usually employ
Coster's paste (consisting of iodine and oil of tar).
It can be gently rubbed into the place, and for a
quarter of an inch outside it, and a piece of lint
fastened over it by strips of plaster. The Coster's
paste may usually be applied every day for three to
five days, and then the place will probably be cured ;
but I always keep a sulphur ointment on for a time,
and watch it. If any fresh papules appear at the
edge, more Coster paste should be used. Many other
apphcations may be just as good, as liquor iodi, or
iodine and acetic acid.
Eczema marginatum about the upper part of the
thighs. It is advisable to treat this affection
thoroughly, and with the patient in bed a few days.
Good results are obtained from using Coster's paste,
or the parts may be painted with a strong solution of
iodine and iodide of potassium. Of course this will
cause some pain, but it is an efficient treatment.
SulphuroMS acid may also be used, but should be
freshly made, as the acid gets weaker by keeping,
and may get partly oxidized into sulphuric acid.
Sulphurous (not sulphuric) acid may be sponged on
the parts many times a day. After using strong
applications it is well to apply a sulphur ointment
for a time, and most carefully to watch the edges to
see if any fresh papules or extension of the disease
appear. Thorough disinfection of any clothes worn
next the skin is essential.
H. A.
135
CHAPTER XVI.
IMPETIGO.
French: Impetigo. German: Krustenflechte.
IMPETIGO is a contagious affection of the skin,
which is specially hable to affect football players,
more particularly those taking part in the Rugby
game, — ^FootbaU Impetigo or Scrum Pox.
The disease appears as a slightly-raised erythema-
tous patch on the skin, which quickly becomes a
vesicle. This, at first, contains clear fluid, but rapidly
becomes purulent, and ruptures. The discharged
contents form a crust, which usually is surrounded
by an erythematous margin. The discharge from
the scabs is contagious, and there is a great tendency
for the disease to spread, and for other portions of
healthy skin to be infected by auto-inoculation by
scratching with the nails, towels, etc. The glands in
the neighbourhood of the patches enlarge and are
liable to suppurate and become abscesses.
The disease is due to one or more micro-organisms,
especially to the germs of suppuration.*
In football players the disease appears chiefly on
the face, scalp, and behind the ears. It is produced
by the excoriations received on those parts from
contact with the jerseys, possibly infected, of other
players. Players outside the scrum may become
infected in other accidental ways.
* Staphylococcus pyogenes aureus and albus.
136 INFECTIOUS DISEASES IN SCHOOLS
The poison retains its vitality for a considerable
period. It has been proved that jerseys may retain
their infection for five or six weeks after they have
been worn. Other articles of clothing or toilet, such
as caps, towels, shaving brushes, may similarly be
ihe agents of contagion. The attendant on a patient
may be inoculated while carrying out the treatment.
Treatment. — No boy who has any appearance of
the disorder should be allowed to play till he is
completely cured. The jerseys should be made of
some soft material, as merino ; a linen collar is
desirable. The coarse woollen garment, often used,
causes, by its roughness, the abrasions through which
the poison enters. Jerseys should frequently be
washed, and, on the appearance of the disorder in
a school, they should be disinfected by steam or,
if that be impossible, boiled.
The crusts should be carefully removed by soaking
with boracic lotion, and an antiseptic ointment
applied, such as sulphur and mercury, or dilute
nitrate of mercury. The apphcation of peroxide of
hydrogen (20- volume solution) daily, gives very
satisfactory results.
H. G. A.
137
CHAPTER XVII,
SCHOOL EPIDEMIOLOGY.
EVERY schoolmaster and school doctor will, both
for their own sakes and for that of their school,
naturally be anxious to prevent the introduction of
the infectious diseases to which all associations of
young people, such as schools and institutions, are
specially hable. It is somewhat unfortunate that
the greater care exercised in this direction during
recent years has appeared to operate rather in the
opposite direction, and that the incidence of infec-
tious diseases in schools has increased rather than
diminished.
As an illustration of this the following figures are
given, compiled from statistics, for the last twenty-
eight years, of a large public school. During that
period, the numbers have varied from 400 to 500, and
3843 boys have been admitted at the average age of
thirteen and a half years. Infectious diseases, of one
kind and another, were introduced on ninety-eight
occasions, of which fifty-two were at the beginning
of terms, and forty-six in mid-terms. The total
number of cases was 1850. The yearly average of
these during the first half of the period was forty-two,
that for the second half ninety, more than twice as
many. The reason for this, doubtless, is that the
stringency of the quarantine regulations now im-
posed, makes the parents more anxious to avoid
138 INFECTIOUS DISEASES IN SCHOOLS
the occurrence of any infectious disease in the home ;
and, as a result of this, many more young people
enter school unprotected by previous attacks of the
several diseases.
It is desirable for the purpose of taking precautions
that :—
1. An accurate knowledge shall be obtained of
the diseases with which each pupil has already been
attacked.
2. That information should be obtained of any
pupil having been exposed during the hoUdays to
infectious disease, so that
3. The necessary quarantine should be imposed,
the period of this being determined by the circum-
stances of each case and the incubation period of
each disease.
I. For the purpose of knowing by which diseases
each pupil has been attacked, in addition to state-
ments as to his general health, a record should be
obtained on a form similar to this : —
This paper must be filled up and sent to the Head Master
before the boy joins the School.
1. Name at full length
2. Date and place of birth
3. Has he had Diphtheria, and when ?
4. Has he had Whooping Cough, and when ?
5. Has he had Mumps, and when ?
6. Has he had Measles, and when ?
7. Has he had Rubella (German Measles), and when ?
8. Has he had Scarlet Fever (Scarlatina), and when ?
9. Has he had Chicken Fox, and when ?
10. Has he been vaccinated, and when ?
SCHOOL EPIDEMIOLOGY
139
11. Is his general health good ?
12. Is there any peculiarity of his constitution necessary
to be considered ?
Signed
Address
Date
The information thus received can be kept in a
convenient way on a register similar to this which
shows at a glance the number of individuals un-
protected from each of the diseases : —
Alphabetical List.
From first term, 191 2, to
Names
OF
Scholars
scarlet
FEVER
MEASLES
RUBELLA
CHICKEN POX
MUMPS
WHOOPING
COUGH
Notes
+ Attacked
before entry
— Attacked
after entry
Addison, J .
+
+
Akenside, M. . .
+
+
Arnold, M. . .
+
+
_
Beaumont, F. . .
+
Blair, R.
+
Blake, W.
+
+
Blunt, G.
+
Browne, T.
+
Cowley, A.
+
Cowper, W.
2. Certificates. — ^The information as to exposure to
infection during the hohdays may be obtained in
two methods {a) The Negative ; (6) The Positive.
140 INFECTIOUS DISEASES IN SCHOOLS
{a) The Negative Method.— Ed.ch. parent or guardian
of a pupil IS supplied with a certificate which he must
fiU up and sign at the termination of each hoHdays
to the following effect : —
Name of School,
Health Certificate.
th^J^h^ H^^'h^f •f.^"^'^ P^''^'^' °^ Guardian, n<,i earlUr
tK^r, ^° ^ '° It '""St be presented by
Head mLIS""^ °" ^""^"^^^^^^ day before to the
I hereby certify that, to the best of my knowledge
and belief
has not, for at least three weeks, been suffering from any-
infectious ailment, or been exposed to infection.
Date
Signed
(Parent or Guardian).
N.B. — If the pupil be exposed to anv infection during the
holidays, immediate notice is to be sent to the Head Master.
{h) The Positive Method. — On each notice, bills, etc.,
sent to Parents or Guardians, the following is inserted :
• No pupil shall enter or return to the School
^ from a house in which there has been any
^ infectious disease, during the holidays, without
giving previous notice to the Head Master and
obtaining his permission. Notice should also
O be given, and permission to return obtained,
in cases where there is the slightest suspicion
^ that a pupil has been in contact with any
*^ infectious disease.
Both methods have their advantages ; but in the
experience of the writer, the second method gives the
same results as the first with much less trouble to all
concerned.
SCHOOL EPIDEMIOLOGY
141
There should be a similar obligation on the part
of the School authorities to give information to the
home, of any infectious disease occurring in the
school, before the boys return for the holidays.
The period of quarantine to be imposed in each
case will be determined by the incubation period of
each disease, a margin of a few days being allowed
for safety. These have been considered in the
previous pages, and are arranged here in tabular
form for convenience of reference.
Table of Incubation, Quarantine, and
Duration of Infectivity
Incuba-
Aver-
(Quaran-
tion
age
tine)
Infectivity
DAYS
DAYS
DAYS
Measles . .
lO-
-13
12
16
21 days.
Rubella (German
Measles)
9-
-1 8
14
20
8 to 10 days.
Scarlet Fever . .
2-
- 8
4
14 «
6 weeks.
Chicken Pox
12-
-20
14
20
14 days.
Mumps . .
17-
-21
19
24
14 days.
Whooping Cough
4-
-14
14
21
5 weeks.
H. G. A.
142
Antiseptic
Antitoxins
Asepsis
Bacillus
Bacteria
Catarrh
Coccus
Coma
Comatose
Conjunctiva
Cornea
Defervescence
Desquamation
Diagnosis
Endemic
Epidemic
GLOSSARY.
Having power to prevent putrefac-
tion. Now technically applied to
those chemical substances which
can check the growth of bacteria.
Antidotes to poisons.
Freedom from germs.
A rod-shaped bacterium.
(Little sticks.) Minute vegetable
organisms, germs.
An increased secretion of mucus.
A cell or capsule, now applied to
germs having a circular shape.
A state of deep sleep.
Lethargic. Affected with coma.
The membrane which lines the inner
surface of the lids and is reflected
forwards on the globe of the eye,
the front part of which it covers.
The strong horny transparent mem-
brane in the fore part of the eye
through which light passes.
The period of a febrile attack in
which the temperature falls.
The separation of the skin in scales.
The discrimination of disease by its
distinctive marks.
Pecuhar to a people, country, or
neighbourhood ; applied to those
infections which are constantly
present in a given locality.
Prevalent among a community ;
applied to infections only occa-
sionally present.
GLOSSARY
143
Erythema
Erythematous
FOMITES
Hair Follicle
" Itis "
Lamellated
Lesion
Malaise
Meningitis
Micro-organism
Mycelium
Papillae
Parasitic
Pathogenic
Prodromal
Prognosis
Prophylaxis
Protozoa
Pus
Pustule
Rigor
Sebaceous
Sequels
Serum
A diifuse red rash on the skin, which
disappears momentarily on pres-
sure.
(Adjective.) Like an erythema.
(Chips of wood.) AppHed to any
substance capable of retaining
particles of contagium.
A depression for the reception of the
root of a hair.
A suffix used to denote inflammation.
Composed of thin plates or scales.
An injury, hurt, or wound.
Undefined uneasiness of the body
not amounting to illness.
Inflammation of the membranes
covering the brain and spinal cord.
A minute organism, visible only
under the higher powers of the
microscope.
The part which ministers to the sup-
port of a plant in opposition to the
structures devoted to reproduction.
Conical projections, especially those
at the root of the tongue.
Growing or living on some other
body.
Disease producing.
Premonitory.
Forecasting the probable course of
a disease.
Preventive treatment.
The lowest class of the animal king-
dom.
Matter from a wound or sore.
A little pimple containing pus.
A strongly marked shivering fit.
Composed of sebum, the secretion of
certain glands in the skin.
Symptoms occurring as a direct
result of disease.
The yellowish transparent fluid of
the blood.
144 INFECTIOUS DISEASES IN SCHOOLS
Spores
Streptococci
Toxin
Ulcer
Vaccine
Vesicle
Virus
Minute bodies capable of reproducing
the parent organism, but less
easily destroyed. Also often ap-
plied to the reproductive organs
of moulds, e.g. tinea.
A chain of cocci linked together.
A poison (originally arrow poison).
Now usually appHed to the pro-
ducts of living organisms.
An open sore.
The killed virus of any specific
disease introduced into the body
by inoculation — originally the
virus of cowpox.
A small bladder.
A poison ; usually, at present, applied
to living organisms which can
produce disease.
PAGE
ACTIVE immunity . . 7
Acquired immunity. . 8
Age incidence of cerebro-
spinal meningitis . . 98
chicken pox . . 58
diphtheria . . . . 75
measles . . . . 30
ringworm .. ..117
rubella . . . . 43
scarlet fever . . 46
whooping cough . . 66
Alformant lamp . . . . 20
Alopecia areata, diagnosis
of, from ringworm 125
Animals and acute polio-
myelitis . . . . 106
Antibodies . . . . . . 7
Antitoxin, diphtheria . . 7
prophylactic use of 14
Antitoxins . . . . . . 7
Bacilli . . . . . . 3
Bacillus of typhoid . . 86
Bacteria, diseases due to . . 4
— forms of . . . . 2
Bedding, disinfection of . . 21
Bordet and Genjou : dia-
gnosis of whooping
cough . . . . 68
germ of whooping
cough . . . . 66
Breasts, inflammation of, in
mumps . . , . 65
Bronchitis in measles . . 38
Broncho-pneumonia in
measles . . . . 38
— after whooping cough . . 69
Brush rashes . . . , 28
" Carriers "
— in cerebro-spinal menin
gitis . .
— diphtheria
— epidemic poliomyelitis
— scarlet fever
— typhoid fever . .
Cerebro-spinal meningitis
bacteriology of
" carriers " in
clinical course of .
definition of
— — history of . .
incidence of
infection of, mode of
mortality of
prophylaxis in
quarantine in
serum treatment of
Certificates . .
— for ringworm . .
Chicken-pox
— age incidence of
— confounded with small
Catarrh in measles
Caterpillar rashes . .
33
27
pox . .
— diagnosis of
— incubation period of
— infection of, mode of
— infectiveness of, dura
tion of
— prodromal stage in .
— rash of . .
— seasonal prevalence of
— treatment of . .
Clothes, disinfection of .
Cocci
Communicable diseases . .
Contagious and infectious
diseases
Convulsions in measles
Croup in measles . .
Convalescence
10
PAGE
9
98
82
106
48
88
97
98
98
99
97
97
98
98
102
102
99
, 102
139
127
58
58
58
58
61
58
58
61
58
58
58
61
21
2
2
9
33
33
24
146
INDEX
PAGE
Deafness in mumps . . 65
Defervescence . . 12, 24
Desquamation in measles 37
— in rubella . . . . 44
— scarlet fever . . . . 50
Diagnosis, differential, of
measles, rubella, and
scarlet fever 56, 57
Diphtheria . . . . . . 72
— animals and . . . . 83
— antitoxin in prophy-
laxis of . . . . 84
paralysis after . . 80
unpleasant effect of 81
— bacillus of . . . . 72
— " carriers " in . . . . 82
— clinical course of . . 78
— definition of . . . . 72
— diagnosis of . . • • 73
— faucial . . . . . . 76
— heart failure in . . 78
— Hofmann's bacillus in 75
— incidence of . . • • 75
— infection of, mode of . . 74
— infectivity of . . . . 76
— laryngeal . . . . 78
— milk and . • . . 83
— nasal . . . . . . 76
— paralysis in . . . . 78
— quarantine in . . . . 76
— treatment of . . • • 79
Diseases : communicable 2
— infectious and contagious 9
— zymotic . . • • 2
Disinfection . . • • 16
— of bedding and clothes 21
— of patient . . . • 19
— in ringworm . . • • i33
— of rooms . . 18, 84
— in scarlet fever . . 55
— of stools and urine . . 21
— by sulphur and formalin 20
Drug rashes • • • • 26
Dust and epidemic polio-
myelitis . . • • 105
— and infection . . . . 10
— and ophthalmia . . no
— and typhoid fever . . 88
Ears, the, in measles . . 38
— scarlet fever . . • • 5 1
Eczema marginatum . . 128
diagnosis of •• 129
treatment of •• I34
PAGE
Enema rash . . . . 27
Epidemic poliomyelitis . . 105
clinical course of . . 105
infectivity of . . 105
mortality in . . 105
prophylaxis of . . 105
Epidemics of measles, time
elapsing between . . 29
Epidemiology, school . . 137
Erysipelas, streptococcus of 4
Erythema . . . . . . 26
Exanthemata, the acute . . 23
concurrence of two
or more . . . . 23
definition of . . 23
immunity to . . 23
susceptibility to . . 23
transmission of . . 23
varieties of.. .. 24
Exanthemic period . . 24
Eye, infectious diseases of
the 107
infection in, mode
of . . . . io8
prophylaxis in
108, 114
recurrence in . . 108
seasonal preva-
lence of . . 107
symptoms of . . 107
treatment of 108, 114
varieties of . . 109
water and towels
as infecting
agents in . . 108
■ varieties of . . 109
Eyes, the, in measles 33, 37
Ferments, living . . . • 2
Fever, management of .. 13
— in measles • . 33i 36
— in rubella . . . • 44
— • in scarlet fever . • 50
— symptoms of . . • • i3
Fevers, eruptive . . • • 2
— infectious . . • • 2
Fomites 1°
Food rashes . • . . 20
Formalin in disinfection . . 20
Fourth disease, the • • 55
German Measles, (see
Rubella) .. .-42
INDEX
147
PAGE
Germs, behaviour of, in
animal bodies . . 5
— diseases due to . . 2
— mode of entry into body 4
Glands, the, in measles . . 33
— in rucella . . • • 44
— in scarlet fever . . 50
Glandular fever . . . . 70
clinical course of . . 70
— — complications of . . 71
incubation period of 70
mortality in • • 7^
Health record . . . . 138
Hofmann's bacilltis in diph-
theria . . . • 75
Immunity, active . . . . 7
— natural and acquired.. 6
— passive . . . . . . 8
— from scarlet fever . . 47
Impetigo . . . . . . 135
— treatment of .. ..136
Incubation periods 12, 24
of chicken pox . . 58
— — glandular fever . . 7°
measles . . . . 31
— — mumps . . . . 62
— — ringworm .. .. 118
rubella . . . . 43
table of . . . . 141
Infantile paralysis (see Epi-
demic poliomyelitis) 105
Infection, direct . . . . g
— indirect . . . . 10
— in chicken pox . . 58
— measles . . . . 30
— rubella . . . . . . 48
— scarlet fever . . . . 47
Infections, specific . . i
Infectious and contagious
diseases . . . . 9
— diseases, causal agents
known . . . . 17
■- probably known 17
unknown . . 17
and drainage .. 11
precautions for pre-
venting introduction
of 138
prophylaxis in . . 14
Infectious fevers, course of 12
Infectiveness, duration of,
in chicken pox . . 61
PAGE
Infectiveness, duration of,
in diphtheria . . 76
— — in measles . . • • 41
mumps . . . . 63
rubella . . • • 45
whooping cough . . 67
table of . . . . 141
Inoculation, preventive . . 14
Intubation.. .. .. 81
Invasion . . . . . . 15
Isolation . . . . • • i5
Kidneys, the, in scarlet
fever . . • . 51
Klebs-Loeffler bacillus . . 72
life of, outside body 74
Koch-Weeks bacillus 113, 114
Koplik's spots in measles. . 33
Lamp, alformant . . . . 20
Leather, disinfection of . . 21
Lingner's apparatus . . ' 20
Macular rash . . . . 26
Malaise .. .. • • 13
Measles . . . . . . 29
— age incidence in . . 30
— antiquity of . . . . 29
— bronchitis in . . . . 38
— broncho-pneumonia in 38
— catarrh in . . • • 33
— complications of . . 38
— croup in . . . . 38
— diagnosis of . . 39, 56
— diarrhoea in . . . . 38
— epidemics of, length of
time between . . 29
— eyes, the, in . . 33, 37
— fever in . . 33, 36
— glands in
33
— incubation period of . . 31
— infection of, mode of . . 30
— infectiveness of, dura-
tion of . . . . 41
— initial rashes in • • 35
— Koplik's spots in • • 33
— Meunier's sign in . . 31
— mouth rash in.. .. 33
— nose bleeding in . . 38
— prodromal period in . . 33
— progiiosis in . . . . 39
— rash in . . . . • • 36
— remission of symptoms 33
— striking range in • • 31
148
INDEX
nr ^ PAGE
Measles, susceptibility to . . 30
— treatment of . . . . 41
— tongue, the, in.. .. 37
Meningitis, cerebro-spinal,
serum for . . . . 7
Meunier's weight sign in
measles . . • • 3X
Mirchamp's symptom in
mumps . . . . 63
Morbilli {see Measles) . . 29
Mouth, the, in measles . . 33
Mumps . . . . . . 62
— ca.usal organism of . . 62
— clinical course of • . 63
— breasts and ovaries,
inflammation of, in 65
— deafness in . . . . 65
— definition of . . . . 62
history of . . . . 62
— incubation period of . . 62
— infectivity of . . . . 63
— orchitis in . . . . 64
— pancreas, inflammation
of, in . . . . 65
= — quarantine in . . . . 63
— submaxillary gland in 65
Natural immunity . . 6
Nose bleeding in measles. . 38
Opisthotonos in cerebro-
spinal meningitis . . 104
Orchitis in mumps . . 64
Organisms, saprophytic and
parasitic . . . . 3
Ovaries, inflammation of,
in mumps . . . . 64
Pancreas, inflammation of,
in mumps . . . . 65
Papular rash . . . . 26
Parasitic organisms . . 3
Paratyphoid fever . . .. 96
Passive immunity . . . . 8
Patient, disinfection of . . 19
Pneumonia in measles . . 38
Posterior basic meningitis 97
Precautions for preventing
introduction of in-
fectious diseases . . 138
Predisposing causes to
scarlet fever . . 48
Preventive inoculation . . 14
Prodromal periods . . 24
Prodromal periods in chic
ken pox
measles
— — rubella
scarlet fever
Prophylaxis of infectious
diseases
of the eye 108,
Pulse, the, in scarlet fever
Punctate rash
Pustular rash . . . '.
Quarantine
— table of, periods
page
59
33
43
48
14
114
50
26
26
21
141
Range, strildng, in measles 31
Rash, the, in chicken pox 58
— measles . . . . 36
— rubella . . . . • • 43
— scarlet fever . . • • 49
— typhoid fever . . . . 90
Rashes, brush . . . . 28
— caterpillar . . . . 27
— drug 26
— enemata . . . . 27
— erythematous . . . . 26
— food . . . . . . 26
— initial, in measles . . 35
— macular . . . . 26
— papular . . . . 26
— punctate . . . . 26
— pustular . . . . 26
— serum . . . . . . 27
— vesicular . . . . 26
Register, method of keeping 139
Remission of symptoms in
measles . . . . 35
Rheumatism in scarlet fever 52
Ringworm .. .. ..117
— age incidence of 1x7
— bald . . . . . . 125
— body . . . . 126, 127
— causation of . . . . 120
— certificates in . . . . 127
— chronic . . . . . . 126
— contagiousness of ..117
— definition of .. ..117
— diagnosis of .. ..119
— disinfection in . . . • 133
— fungus of . . . . X18
— incubation period of .. xi8
— large spore . . 120, 124
— microscopical examma-
tion in . . . . 122
INDEX
149
PAGE PAGE
Ringworm, recent ., 121 Scarlet fever, varieties of . . 51
— small spore . . 120, 123 Scrum pox {see Impetigo) 135
— stumps in . . 122, 127 Seasonal prevalence of-
— treatment of . . • . 130 cerebro-spinal menin-
— ;i;-ray treatment of ..132 gitis .. .. 99
Rooms, disinfection of . . 19 chicken pox . . 58
• in diphtheria . . 84 rubella . . . . 43
Rose rash {see Rubella) . . 42 mumps . . . . 62
idiopathic . . • • 27 whooping cough . . 66
^ spots in typhoid fever. . 90 Septic poisoning in scarlet
Rubella . . . . . . 42 fever . . . . 52
— age incidence of . . 42 Seed and soil . . . . 6
— definition of . . . . 42 Serum in cerebro-spinal
— desquamation in . . 44 meningitis . . . . 7
— diagnosis of . . . . 45 — diphtheria . . . . 79
— distribution of . . 42 — Flexner's, in cerebro-
— fever in.. .. .. 44 spinal meningitis .. 102
— glands in . . • • 44 — in typhoid fever . . 8
— incubation period of . . 43 — rashes . . . . . . 27
— infectiveness, duration of 45 Spirilla . . . . . . 3
— rash in . . . . . . 43 Spores . . . . . . 4
— seasonal prevalence of 43 Stools, disinfection of . . 21
— treatment of . . . . 45 Sub-maxillary gland in
mumps . . . . 65
Saprophytic organisms .. 3 Susceptibility to measles.. 30
Scarlatina {see Scarlet fever) 46 — scarlet fever . . . . 46
Scarlet fever . . . . 46 Sulphur, disinfection by . . 20
age incidence of . . 46 Swimming baths, and epi-
complications of . . 51 demic poliomyelitis 105
desquamation in . . 50
diagnosis of 52, 56 Temperature {see Fever) 13
disinfection in .. 55 Throat, the, in scarlet fever 48, 50
ears, the, in .. 51 Tinea (see Ringworm) .. 117
fever in .. ..50 — different forms of ..118
geographical distri- Tongue, the, in measles . . 37
bution of . . 46 — scarlet fever . . . . 50
glands in . . . . 50 Toxins 5
infection of, mode of 47 Tracheotomy . . . . 81
infectiveness of, dura- Trillet's apparatus . . 20
tion of . . • • 54 Typhoid fever . . . . 85
immunity to • • 47 bacillus of . . . . 86
kidneys, the, in . . 47 "carriers" in ..88
poison of, nature of 47 in children . . . . 91
predisposing causes 48 clmical course of . . 89
prodromal stage of 48 complications of . . 93
prognosis in .. 53 direct infection in . . 87
pulse, the, in . . 50 disinfection of . . 85
r^sh in . . • • 49 drainage and . . 88
rheumatism in . . 52 dust and . . . . 88
septic poisoning in 52 flies and . . . . 88
susceptibility to . . 46 food infection in . . 88
throat the, in 48, 50 haemorrhage in . . 62
tongue, the, in . . 50 history of . . . . 85
treatment of • . 53 infection in.modes of 87
150
INDEX
PAGE
Typhoid fever, incidence
of.. .. .. 88
perforation in . . 92
prophylaxis of . . 94
quarantine in . . 89
relapses in . . . . 91
rose spots in . . 90
serum for . . . . 8
sequelae of . . . . 93
— — treatment of ■ • 93
— vaccine . . • • 95
Urine, disinfection of . . 26
Urticarial rash . . . . 26
Vaccination for small-pox 8
Vaccine ia typhoid fever . . 95
Vaccines . . . . . . 8
Varicella (see Chicken pox) 58
Vesicular rash . . . . 26
Vibriones . . • . . . 3
PAGE
Water and towels as infect-
ing agents in diseases
of the eye . . . . 108
Weight, alteration of, in
measles . . . . 31
Whooping cough . . . . 60
blood examination in 68
broncho-pneumonia
after . . . . 69
clinical course of . . 67
definition of . . 60
germ of . . . . 66
incubation period of 66
infectivity of . . 67
mortality in . . 66
quarantine for . . 66
X-RAYS, treatment of ring-
worm by . . . . 132
Zymse . . . . . . 2
Zymotic diseases . . . . 2
JOHN WRIGHT AND SONS LTDl, PRINTERS, BRISTOL.
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