THE HERODS OF OUR DAY: SCARLET FEVER, MEASLES, AND WHOOPING-COUGH

Why is a disease a disease of childhood? First and fundamentally, because that is the earliest period at which a human being can have it. But the problem goes deeper than this. There is no more interesting and important group of diseases in the whole realm of pathology than those which we calmly dub “the diseases of childhood,” and thereby dismiss to the limbo of unavoidable accidents and discomforts, like flies, mosquitoes, and stubbed toes, which are best treated with a shrug of the shoulders and such stoic philosophy as we can muster. They are interesting, because the moment we begin to study them intelligently we stumble upon some of the profoundest and most far-reaching problems of resistance to disease; important, because, trifling as we regard them, and indeed largely just because we so regard them, they kill, or handicap for life, more children in civilized communities than the most deadly pestilence. Measles, for instance, according to the last United States census, causes yearly nearly thirteen thousand deaths, while smallpox causes so few that it is not listed among the important causes of death. Scarlet fever causes sixty-three hundred and thirty-three deaths, as compared with barely five thousand from appendicitis and the same number from rheumatism. Whooping-cough causes ninety-nine hundred and fifty-eight deaths, more than double the mortality from diabetes and nearly equal to that of malarial fever.

In medicine, as in war, the gravest and deadliest mistake that you can make is to despise your enemy. These trivial disorders, these trifling ailments, which every one takes as a matter of course, and expects to go through with, like teething, tight shoes, and learning to smoke, sweep away every year in these United States the lives of from forty to fifty thousand children, reaching the bad eminence of fifth upon our mortality lists, only consumption, pneumonia, heart disease, and diarrh[oe]al diseases ranking above them. Of course, it is obvious that these diseases outrank many other more serious ones among the “captains of the men of death,” largely upon the familiar principle of the old riddle, whereby the white sheep eat more grass than the black, “because there are more of them.”

While only a relatively small percentage of us ever have the bad luck to be attacked by typhoid fever, rheumatism, or appendicitis, to say nothing of cholera and smallpox, the vast majority of us have gone through two or more of these diseases of childhood; so that, though the death-rate of each and all of them is low, yet the number of cases is so enormous that the absolute total mounts high. But the pity and, at the same time, the practical importance of this heavy death-roll is that at least two-thirds of it is absolutely preventable, and by the exercise of only a very moderate amount of intelligence and vigilance. It is, of course, obvious that in a group of diseases which numbers its victims literally by the million every year there will inevitably occur a certain minute percentage of fatal results due to what might be termed unavoidable causes, like a badly nourished condition of the child attacked, unusual circumstances preventing proper shelter or nursing, or an exceptional virulence of the disease, such as will occur in two or three cases of every thousand in even the most trifling infectious malady. But even after making liberal allowance for what might be termed the unavoidable fatalities, at least two-thirds, and more probably nine-tenths, of the deaths from children’s diseases might be prevented upon two grounds:-

First, that they are contagious and absolutely dependent upon a living germ, whose spread can be prevented; and secondly, and practically even more important, that more than half the deaths from them are due, not to the disease itself, but to complications occurring during the period of recovery, caused, for the most part, by gross carelessness on the part of the mother or nurse. A large majority, for instance, of the nearly thirteen thousand deaths attributed to measles are due to bronchitis, caught by letting the child go out-of-doors too soon after recovery, which means, of course, either a chill falling upon the irritated and weakened bronchial mucous membrane, or an infection by one of the score of disease-germs, such as those of influenza, pneumonia, bronchitis, and even tuberculosis, which are continually lying in wait for just such an emergency as this-just such a weakening of the vital resistance.

It is a sadly familiar statement in the history of fatal cases of tuberculosis that the trouble “began with an attack of measles,” or whooping-cough, or a bad cold, and was mistaken for a mere “hanging on” of one of these milder maladies until it had gained a foothold that there was no dislodging. As breakers of the wall of the hollow square of the body-cells, drawn up to resist the cavalry charges of tuberculosis, pneumonia, and rheumatism, few can be compared in deadliness with the diseases of childhood and “common colds.”

Further, while all of them except scarlet fever have a mortality so low that it might almost be described as what the French delicately term une quantité négligeable, yet a surprisingly large number of the survivors do not escape scot-free, but bear scars which they may carry to their graves, or which may even carry them to that bourne later. Again, the actual percentage of the survivors who are marked in this fashion is small, but such milliards of children are attacked every year that, on the old familiar principle, “if you throw plenty of mud some of it will stick,” quite a serious number are more or less handicapped by these remainders. For instance, quite a noticeable percentage of cases of chronic eye troubles, particularly of the lids and conjunctiva, such as “granulated” lids, styes, ulcers of the cornea, date from an attack of measles or even whooping-cough. Many cases of nasal catarrh or chronic throat trouble or bronchitis in children date from the same source. A large group of chronic discharges from the ear and perforations of the ear-drum are a direct after-result of scarlet fever; and the frequency with which this disease causes serious disturbances of the kidneys is almost a household word. Less definitely traceable, but even more serious in their entirety, are the large group of chronic depression of vigor, loss of appetite, various forms of indigestion and of bowel trouble, which are left behind after the visitation of one of these minor pests, particularly among the children of the poorer classes, who are unable to obtain the highly nutritious, appetizing, and delicately cooked foods which are so essential to the full recovery of the little invalids.

One of the English commissions which was investigating the alleged physical deterioration of city and town populations stumbled upon a singularly interesting and significant fact in this connection, while plotting the curves of the rate of growth of the children in a given district in Scotland during a series of years. They were struck with the fact that children born in certain years in the same families, neighborhoods, and presumably the same circumstances, grew more rapidly and had a lower death-rate than those born in other years; and that, on the other hand, children born in other years fell almost as far below the normal in their rate of growth. The only factor which they found to coincide with these differences was that in the years in which those children who made the slowest growth were born there had been unusually heavy epidemics of children’s diseases and a high mortality; while, on the other hand, those years whose “crop” of children made the best growth had been unusually free from such epidemics and had a correspondingly low mortality, showing clearly that even the survivors of children’s diseases were not only not benefited, but distinctly handicapped and set back in their growth by the energy, so to speak, wasted in resisting the onslaught.

This brings us to an aspect of these diseases which from both a philosophic and a practical point of view is most interesting and profoundly significant; and that is the question with which we opened: Why is a disease a disease of childhood? The old, primitive view was as guileless and as simple as the age in which the diseases occurred. They were regarded not merely by the laity but by grave and reverend physicians of the Dark Ages as a sort of necessary vital crisis peculiar and appropriate to each particular age of life,-a sort of sweating out and erupting of “peccant humors” of the blood, which must be got rid of or else the individual would not thrive. Incredible as it may seem, so far was this idea extended, that the great Arabian physician-philosopher, Rhazes, actually included smallpox in this group, as the last of the “crises of growth” which had to appear and have its way in young manhood or womanhood. Quaint little echoes of this simple faith still ring in the popular mind, as, for instance, in the widespread notion about the dangerousness of doing anything to check the eruption in measles and cause it to “strike in.” Any mother in Israel will tell you, the first time you propose a bath or a wet pack to reduce the temperature in measles, that if you so much as touch water to the skin of that child it will “drive the rash in” and cause it to die in convulsions. And, of course, one of the commonest of a physician’s memories is the expression of relief from the mother or aunt in any of these mild eruptive fevers, where the skin was well reddened and spotted: “Well, anyway, doctor, it is a splendid thing to get the rash so well out!” Until within the last ten or fifteen years it was no uncommon thing to hear the expression: “Well, I suppose we might just as well let Willie and Susie go on to school and get the measles and have done with it. It seems to be a real mild sort this time.” Of course this view was scientifically shattered two or more decades ago by our recognition of the infectious nature of these diseases, but practically its hold on the public mind constitutes one of the most serious and vital obstacles in the way of the health-officer when he endeavors to attack and break up an epidemic of measles, whooping-cough, or chicken-pox.

It cannot be too strongly emphasized that, mild and in their immediate results trifling, as most of these “little diseases” are, they are genuine members of that class of pathologic poison-snakes, the germ-infections; that when they bite, they bite to kill; that two to five times in every hundred they do kill; that, like all other infections, they are capable of inflicting serious and permanent damage upon the great vital organs, the heart, the kidneys, the liver, and the brain; and that they are the very jackals of diseases, tracing down and pointing out the prey to the lions that work in partnership with them. With whatever we may treat measles and whooping-cough, never treat them with contempt!

The next conception of the “whyness” of children’s diseases was that as one star differs from another in glory, so does one germ differ from another in virulence; that the germs of these particular diseases just happened to be from the beginning unusually mild and at the same time highly contagious, so that they remained permanently scattered about throughout the community, and attacked each successive brood of newborn children as quickly as they could conveniently get at them. Being so mild and so comparatively seldom fatal, little or no alarm was excited by them and few efforts made to check their spread, so that they continued to flourish, generation after generation. Upon this theory the germs of measles, chicken-pox, whooping-cough, mumps, would be in something like the same class as the numerous species of bacteria and other germs that normally inhabit the human mouth, stomach, and intestines; for the most part, comparatively harmless parasites, or what are technically now known as “symbiotes” (from two Greek words, bios, “life,” and syn, “with"), a sort of little partners or non-paying boarders, for the most part harmless, but occasionally capable of making trouble. There are scores of species of such germs in our food-canals, some of which may be even slightly helpful in the process of digestion. Only a very small per cent of the bacilli of any sort in the world are harmful; the vast majority are exceedingly helpful.

There is evidently some truth in this view of children’s diseases, especially so far as the reason for their steady persistence and undiminished spread is concerned, namely, the comparative carelessness and indifference with which they are regarded and treated. But some rather striking developments of recent years have raised grave doubts in our minds as to whether they were always the mild and inoffensive “house cats” that they pass for at present. These are the astonishing and almost incredible developments that occur when for the first time these mild and harmless “diseaselets” are introduced to a savage or half-civilized tribe. Like an Arabian Nights’ transformation, our sleepy, purring, but still able to scratch, “pussy cat” flashes out as a ravenous man-eating tiger, killing and maiming right and left. Measles-harmless, tickly, snuffly, “measly” little measles-kills from thirty to sixty per cent of whole villages and tribes of Indians and cripples half the remainder!

My first direct experience with this feature of our “household pets” was on the Pacific Coast. All the old settlers told me of a dread pestilence which had preceded the coming of the main wave of invading civilization, sweeping down the Columbia River. Not merely were whole clans and villages swept out of existence, but the valley was practically depopulated; so that, as one of the old patriarchs grimly remarked, “It made it a heap easier to settle it up quietly.” So swift and so fatal had been its onslaught that villages would be found deserted. The canoes were rotting on the river bank above high-water mark. The curtains of the lodges were flapped and blown into shreds. The weapons and garments of the dead lay about them, rusting and rotting. The salmon-nets were still standing in the river, worn to tatters and fringes by the current. Yet, from the best light that I was able to secure upon it, it appeared to have been nothing more than an epidemic of the measles, caught from the child of some pioneer or trapper and spreading like wildfire in the prairie grass. A little later I had an opportunity to see personally an epidemic of mumps in a group of Indians, and I have seldom seen fever patients, ill of any disease, who were more violently attacked and apparently more desperately ill than were sturdy young Indian boys attacked by this trifling malady. Their temperatures rose to one hundred and five or one hundred and six degrees, they became delirious, their faces were red and swollen, they ached in every limb, and the complications that occasionally follow mumps even in civilized patients were frequent and exceedingly severe. In like manner, influenza will slay its hundreds in a tribe of less than a thousand members. Chicken-pox will become so virulent as to be mistaken for smallpox. Several of the epidemics of alleged smallpox that have occurred among Indians and other savage tribes are now known to have been only measles. At first, pathologists were inclined to receive these reports with some degree of skepticism, and to regard them either as travelers’ tales, or as instances of exceptional and accidental virulence in that particular tribe, the high death-rate due to bad nursing or horrible methods of voodoo treatment.

But from all over the world came ringing in the same story, not merely from scores of travelers, but also from army surgeons, medical missionaries, and medical explorers, until it has now become a definitely established fact that the mild, trifling diseases of infancy, “colds” and influenzas of civilized races, leap to the proportions of a deadly pestilence when communicated to a savage tribe. Whether that tribe be the Eskimo of the Northern ice-sheet or the Terra del Fuegian of the Southern, the Hawaiian of the islands of the Pacific or the Aymaras of the Amazon, all fall like grain before the scythe under the attack of a malady which is little more than the proverbial “little ’oliday” of three days in bed to civilized man. Evidently civilized man has acquired a degree and kind of immunity that uncivilized man has not. Either the disease has grown milder or civilized man tougher with the ages.

The probability is that both of these explanations are true. These diseases may originally have been comparatively severe and serious; but as generation after generation has been submitted to their attack, those who were most susceptible died or were so crippled as to be seriously handicapped in the race of life and have left fewer and less vigorous offspring. So that, by a gradual process of weeding out the more susceptible, the more resisting survived and became the resistant civilized races of to-day.

On the other hand, any disease which kills its victim so quickly that it has not time to make sure of its transmission to another one before his death, will not have so many chances of survival as will a milder and more chronic disorder. Hence, the milder and less fatal strains of germs would stand the better chance of survival. This, of course, is a very crude outline, but it probably represents something of the process by which almost all known diseases, except a few untamable hyenas, like the Black Death, the cholera, and smallpox, have gradually grown milder with civilization. If we escape the attack of these attenuated diseases of infancy until fifteen or sixteen years of age, we can usually defy them afterward; though occasionally an unusually virulent strain will attack an adult, with troublesome consequences.

At all events, whatever explanation we may give, the consoling fact stands out clearly that civilized man is decidedly more resistant to these pests of civilization than is any half-civilized race, and there is good reason to believe that this is a typical instance of his comparative vigor and endurance all along the line.

If this view of the original character and taming of these diseases be correct, it also accounts for the extraordinary and otherwise inexplicable cases where they suddenly assume the virulence of cholera, or yellow fever, and kill within forty-eight or ninety-six hours, not merely in children but also in adults.

To group these three diseases together simply because they all happen to occur in children would appear scarcely a rational principle of classification. Yet, practically, widely different as they are in their ultimate results and, probably, in their origin, they have so many points in common as to their method of spread, prevention, and general treatment, that what is said of one will with certain modifications apply to all.

I said “probably” of widely different origin, because, by one of those strange paradoxes which so often confront us in real life, though the infectiousness and the method of spread of all these diseases is as familiar as the alphabet and as firmly settled, the most careful study and innumerable researches have failed to identify positively the germ in any one of them. There are a number of “suspects” against which a great deal of circumstantial evidence exists: a streptococcus in scarlet fever, a bacillus in whooping-cough, and a protozoan in measles; but none of these have been definitely convicted. The principal reason for our failure is a very common one in bacteriological research, whose importance is not generally known, and that is, that there is not a single species of the lower animals that is subject to the diseases or can be inoculated with them. This unfortunate condition is the greatest barrier which can now exist to our discovery of the causation of any disease. We were absolutely blocked, for instance, by it in smallpox and syphilis until we discovered that our nearest blood relatives, the ape and the monkey, are susceptible to them; and then the Cytoryctes Variolae and the Treponema pallida were discovered within comparatively a few months. Some lucky day, perhaps, we may stumble on the animal or bird which will take measles, scarlet fever, or whooping-cough, and then we will soon find out all about them.

But, fortunately, our knowledge of these little diseases, like Mercutio’s wound, is “not so deep as a well, nor so wide as a church door; but ’t is enough” for all practical purposes. The general plan of treatment in all of them might be roughly summed up as, rest in bed in a well-ventilated room; sponge-baths and packs for the fever; milk, eggs, bread, and fruit diet, with plenty of cool water to drink, either plain, or disguised as lemonade or “fizzy” mixtures; mild local antiseptic washes for nose and throat, and mild internal antiseptics, with laxatives, for the bowels and kidneys. There is no known drug which is specific in any one of them, though their course may be made milder and the patient more comfortable by the intelligent use of a variety of remedies, which assist nature in her fight against the toxin. Not knowing the precise cause, we have as yet no reliable antitoxin for any.

Now very briefly as to the earmarks of each particular member of this children’s group. It may be said in advance that the “openings” of all of them (as chess-players call the first moves) are very much alike. All of them are apt to begin with a little redness and itching of the mucous membranes of the nose, the throat, and the eyes, with consequent snuffling and blinking and complaints of sore throat. These are followed, or in severe, swift cases may be preceded, by flushed cheeks, complaints of headache or heaviness in the head, fever, sometimes rising very quickly to from one hundred and four to one hundred and five degrees, backache, pains in the limbs, and, in very severe cases, vomiting. In fact, the symptoms are almost identical with those of an attack of that commonest of all acute infections, a bad cold, and probably for the same reason, namely, that the germs, whatever they may be, attack and enter the system by way of the nose and throat.

One of the most difficult practical points about the beginning of this group of diseases is to distinguish them from one another, or from a common cold. The important thing to remember is that, theoretically important as it may be to make this distinction, practically it isn’t necessary at all, as they should all be treated exactly alike in the beginning. The only vital thing is to recognize that you are dealing with an infection of some sort, isolate promptly the little patient, put him to bed, and make your diagnosis later as the disease develops. Fortunately neither scarlet fever nor measles usually becomes acutely infectious until the rash appears, and as neither is particularly dangerous to adults, especially to such as have had them already, a one-room quarantine is sufficient for the first few days of any of these diseases. We will lose nothing and gain enormously by adopting this routine plan in all cases of snuffling noses, sore throats, headache, and fever in children, for these are the early symptoms of all their febrile diseases, from colds to diphtheria; all alike are infectious and all, even to the mildest, benefited by a few days of rest and seclusion.

After this first general blare of defiance on the part of the system to the enemy, whoever he may be, the battle begins to take on its characteristic form according to the nature of the invader. We will take first the campaign of scarlet fever, since this is the swiftest and first to disclose itself. After the preliminary snuffles and headache have lasted for a few hours, the temperature usually begins to rise; and when it does, by leaps and bounds often reaching one hundred and four or one hundred and five degrees within twelve hours, the skin becomes dry and hot, the throat sore, the tongue parched, and the little patient drowsy and heavy-eyed. Within from twenty-four to forty-eight hours a bright red or pinkish rash appears, first on the neck and chest, and then rapidly spreading all over the surface of the body within another twenty-four hours.

Meanwhile the throat becomes sore and swollen, ranging, according to the severity of the case, from a slight reddening and swelling to a furious ulcerative inflammation, with the formation of a thick membrane-like exudate, which sometimes is so severe as to raise a suspicion of possible diphtheria. The tongue becomes red and naked, with the papillae showing light against a red ground, so as to give rise to what has been known as “the strawberry tongue.” The temperature is usually high, and the little patient when he drowses off to sleep is quite apt to become more or less delirious. In the vast majority of cases, after two to four days of this, the temperature goes down almost as swiftly as it came up, the rash begins to fade, the throat gets less sore, and the rebound toward recovery sets in. About this time the daily examination of the urine will begin to show traces of albumin, but this, under strict rest in bed and careful diet, will usually diminish and ultimately disappear. In the event of a relapse, however, or setback from any cause, the kidneys may become violently attacked, and a considerable per cent of the fatal cases die from suppression of the urine. After this crisis has occurred, however, in ninety-nine per cent of all cases it is comparatively plain sailing; the throat is still sore and troublesome, the skin itches and tickles, and the eyes smart, but the little patient steadily improves day by day. Anywhere from three to five days after the break in the fever the skin begins to get rough and scaly, and gradually peels off, until in some cases the entire coating of the body is shed, having been killed, as it were, by the violence of the eruption. These flakes and scales of the skin are exceedingly contagious, and no case should be regarded as fit to be released from isolation until every particle has been shed and got rid of. This constitutes one of the most tiresome and annoying periods of the disease, as complete shedding is seldom finished before two weeks, and sometimes may last from three to five.

However, this long period of contagiousness has been found to be really a blessing in disguise, inasmuch as we now know that even more strikingly than in the other children’s diseases it is the period of recovery that is the period of greatest danger in scarlet fever. Like the Parthians of Greek history it is most dangerous when in retreat. Keeping the child at rest for the greater part of the time, in bed or on a lounge, in a well-ventilated room, or later on a porch or terrace, for five weeks from the beginning of the disease, is well worth all the trouble and inconvenience that it causes, for the sake of the almost absolute protection it gives against dangerous and even fatal complications, particularly of the kidneys, heart, or lungs.

This is a fair description of what might be termed an average case of the disease. We also have the sadly familiar type described as the fulminant or, literally, “lightning-stroke” variety. The child goes down as if struck by an invisible hand; vomiting is one of the first symptoms; delirium follows within ten or twelve hours; the eruption becomes not merely scarlet but purplish from hemorrhage under the skin, giving the name of “black” scarlet fever to this type. The throat becomes furiously swollen, the urine is absolutely suppressed, the child goes into convulsions, and dies within forty-eight hours from the beginning of the attack. Fortunately, this type is rare, but the important thing to remember is that it may develop in a child who caught the disease from one of the mildest of all possible cases! Hence every case should be treated with the strictest isolation, as if it were itself of the most malignant type.

Naturally, the mortality of scarlet fever varies according to the type. Not only may it assume a malignant form in individual cases, but whole epidemics may be of this character, with a mortality of from twenty to thirty per cent. Generally speaking, however, the death-rate is about one in twelve, ranging from as low as one in twenty-five to as high as one in five.

As in the case of diphtheria, the greatest danger and most powerful means of spread of the disease is through the mild, unrecognized cases, which are supposed to have nothing but a cold and are allowed to continue in school or play with other children. We have no antitoxin and no bacteriologic means of positive diagnosis. But one method will stop the spread and within ten or fifteen years exterminate every one of these infections-isolate at once every child that shows symptoms of a cold, sore throat, or feverishness, both for its own sake and for that of the community!

In measles we have to deal with a much more harmless and more nearly domesticated “beast of prey,” but one of a prevalence to correspond. Though probably (exact data being as yet lacking) not more than one-third of all individuals are attacked by scarlet fever, it would be safe to say that not more than one-third, and possibly not more than one-fifth, of us escape measles. Hence, though its mortality is scarcely one-fourth that of scarlet fever, it more than holds its own in the Herod class, as grimly shown by its total death-roll of over twelve thousand, compared with only a little over six thousand to the credit of scarlet fever.

After the preliminary disturbances of snuffles, hot throat, headache, and feverishness, which it shares with all the other “little fevers,” the first thing to mark off measles is usually that the itching and running at the nose and eyes become more prominent, the child begins to turn its face away from the light because it makes its eyes smart, and complains not so much of soreness as of a peppery, burning, itching sensation in its nose and throat. The tongue is coated, the stomach mildly upset; the little patient is more uncomfortable and fretful than seriously ill. This condition drags on, without apparently getting anywhere, for from two to four days, during which time it is often very difficult even for the most experienced physician to say positively what the sufferer has. But about the fourth day a rash begins to appear, typically first upon the cheeks or forehead in the shape of little widely separated dull-red blotches. These grow larger and deeper in color, rising in the middle and spreading at their edges, so that shortly the whole skin becomes puffed and swollen and of a mottled, pinkish-purple color. If the child’s lower lip be pulled down, little red spots will be seen scattered over the lining membrane of the mouth, showing that the eruption is not confined to the skin. Indeed, these Koplik’s spots (as they are called, after their discoverer) in the mouth will often appear a day or more before the eruption upon the skin and give the first clew to the nature of the disease. These are significant, because they probably illustrate the process of eruption, or, at least, irritation, which is taking place, not merely upon the skin, but also upon the mucous membranes of the eyes, nose, and throat, the windpipe and the bronchial tubes, and which is the cause of the burning, running, and, later, occasional serious inflammatory symptoms in all these regions.

When you look at the hot, angry-looking, swollen skin of the little victim of measles, the weeping eyes and running nose, and remember that this same sort of process is either going on or is likely to occur all over his entire lining, so to speak, from lungs to bowels, you can easily grasp how important it is to keep him absolutely at rest and protected from every possible risk in the way of chill, over-exertion, or injudicious feeding, until the whole process has completely subsided and been forgotten. Neglect of these precautions is the reason why so many cases of measles, on the least and most trifling exposure and overstrain during the two or three weeks following the disease, will blaze up into a fatal bronchitis or pneumonia.

The rash takes about two or three days to get out, then it begins to fade and the skin to peel off in tiny, branny scales, so small and thin as to be almost invisible-unlike the huge flakes of scarlet fever. At the same time all the other symptoms recede.

But, as in scarlet fever, all cases should be treated alike, by rest, sponging and packing for the fever, light diet with plenty of milk and fruit, and confinement to the room for at least ten days after the disappearance of the fever. The very mildest and most insignificant of attacks may be followed, through carelessness or exposure, by a fatal bronchitis. Indeed, in view of the distressing frequency with which our histories of tuberculosis in children contain the words, “Came on after measles,” it is highly advisable to watch carefully every child as regards abundant feeding, avoidance of overwork or overstrain, and of all unnecessary exposure to infection, wind, or wet, for two months after an attack of measles instead of the customary two weeks. As the disease is acutely infectious, the little victim should be isolated for at least three weeks after the disappearance of the fever; but this again, as in the case of scarlet fever, is emphatically a blessing in disguise from his point of view, as well as a protection to the rest of the community.

Should the “little fever” prove to be whooping-cough, it will be later still in positively declaring its definite intentions. The cold or catarrhal stage will be much milder, the fever lower, the cough a trifle more marked, but will drag on for from a week to ten days before anything definite happens. Usually the child is supposed to be suffering with a slight cold, hence the prevailing impression that colds run into whooping-cough, if neglected. Then one day the child is suddenly seized with a coughing fit, consisting of from ten to fifteen short coughs in rapid succession of increasing intensity, until all the air seems literally pumped out of the lungs of the poor little patient; then, with a tremendous whoop, the youngster gets his breath again and the diagnosis is made. This distressing performance may occur only four or five times a day, or it may be repeated every half-hour or so. So violent is the paroxysm that the eyes of the child protrude, it becomes literally black in the face, and runs to its mother or nurse, or clutches a chair, to keep from falling.

As the same great nerves which supply the lungs supply the stomach, the irritation frequently “radiates,” or spills over, from one division of it to the other, and the coughing fit is frequently followed by vomiting. Unexpectedly enough this may often become the most serious practical symptom of the disease, inasmuch as the stomach is emptied so frequently that the poor little victim is unable to retain any nourishment long enough to absorb it, and may waste away frightfully, and even literally starve to death, or have its resisting power so greatly lowered that an attack of bronchial trouble or bowel disturbance will prove rapidly fatal.

So serious are the disturbances of the circulation all over the body by these spasmodic suffocation-fits, that rupture of small blood-vessels may occur in the eyes, the brain, in the lungs, and on the surface of the skin. The heart becomes distended, and if originally weakened may be seriously dilated or overstrained; the lungs become congested and inflamed, and any of the numerous accidental germs which may be present will set up a broncho-pneumonia, which is the commonest cause of death in this disease, as in measles.

Strangely enough, while, as we do not positively know the germ, and hence cannot state definitely either the cause or the principal seat of the trouble, it is not generally believed that the condition of the lungs or the throat has much to do with the cough.

At all events, it is perfectly idle to treat the disease with cough mixtures or expectorants. The view toward which the majority of intelligent observers are inclined is that whooping-cough is an infection, the germ or toxin of which attacks the nervous system, and particularly the great “lung-stomach” (pneumo-gastric) nerve. At all events, the only remedies which appear to have any effect upon the disease are, in the early stages, mild local antiseptics in the nose and throat, and later those which diminish the irritability of the nerves without upsetting the appetite or depressing the general vigor. The disease is, for all its mildness, one of the most obstinate known.

A small percentage of cases run a violent course, in spite of the most intelligent and anxious care, both medical and household; but the vast majority of such complications as occur are either caused by carelessness or become serious only if neglected. Treating all children with whooping-cough as emphatically sick children, entitled to every care and excuse from exertion, every exemption and privilege that can be given them until the last whoop has been whooped, would prevent at least two-thirds of the almost ten thousand deaths from whooping-cough that yearly disgrace the United States.

To sum up in fine: intelligent, effective isolation of all cases, the mild no less than the severe, would stamp out these Herods of the twentieth century within ten years. In the meantime, six weeks’ sick-leave, with all the privileges and care appertaining thereto, will rob them of two-thirds of their terrors.