That protection, indeed, is not absolute, nor was the protection afforded by inoculation absolute; but small-pox after vaccination, even when it does occur, is very rarely severe, and still more seldom fatal.
There seems good reason for believing that the protecting power of vaccination tends to diminish with the lapse of time; though apparently this is not always the case, nor can any direct statement be made as to the conditions which favour this in one case, or prevent it in another. As a matter of fact, however, we do know that such a tendency does exist, and that this tendency calls for the repetition of vaccination from time to time; such re-vaccination carefully performed being as nearly as possible an absolute guarantee against small-pox. All persons engaged as nurses or attendants at the Small-Pox Hospital during the past thirty-two years, have been vaccinated or re-vaccinated before entering on their duties, and during this period not a single case of the disease has occurred among the whole staff. The experience of other small-pox hospitals for a shorter period is identical. As far as we know, every seventh year is a reasonable interval at which re-vaccination should be performed.
One great cause of the failure of the protective power of vaccination is the unintelligent and careless manner in which it is too often performed, especially among the poor. To this same cause it is also due that in some cases of almost infinite rarity one special constitutional disease has been known to be communicated. I have never seen such a case, but I know there are such. They are, however, no more a reason against vaccination than the occasional death from an overdose of opium is a reason against the use of that drug.
To avoid any risk of this kind, and also with the idea that the power of the vaccine matter may have become weakened by transmission through many thousands of persons, vaccination direct from the calf has been introduced of late years, especially in America and on the Continent. The time, however, that has as yet elapsed is scarcely sufficient to test the comparative preservative power of this as compared with vaccination from the human subject. Its immediate local effects are somewhat more severe; I do not know any reason why its influence should not be equally abiding.
There is absolutely no foundation for the idea that scrofula, consumption, or any similar disease can be transmitted by vaccination. In some infants, whose skin is very delicate, and especially in those, some members of whose family have been liable to eruptions on the skin, vaccination has seemed to act as an irritant, and to give occasion to an eruption, or aggravate an eruption already existing. Such cases, however, are not frequent, and the eruption is not more troublesome than those which often appear in teething children. The occurrence of actual erysipelas around the puncture, while very dangerous, is, as I have already stated, of excessive rarity.
A thoroughly dispassionate review of the whole subject appears to me to warrant the following conclusions:—
1st. That vaccination, though not a perfect guarantee against small-pox, diminishes immensely the risk of its occurrence; and that by periodical revaccination, this guarantee is rendered all but absolute.
2nd. That a very large proportion of the failures of vaccination are due to its careless and imperfect performance.
3rd. That to such careless performance and to the introduction of the blood and not of the vaccine matter alone, from one child to another are due the extremely rare instances in which one special disease has been transmitted by vaccination.
4th. That there is absolutely no evidence of the transmission of scrofula, consumption, or any similar disease by vaccination.
5th. That vaccination direct from the calf appears to present some decided advantages; but it has not yet been practised for a sufficient time to admit of a comparison between its preservative power and that of vaccination from one child to another.
6th. That in either case it is expedient that vaccination be performed within the first three months after birth, so as to avoid the irritation of teething which is unfavourable to successful vaccination, and also because the disposition to those skin diseases which vaccination tends to aggravate is never so considerable before the age of three months as it becomes subsequently.
Even when vaccination fails to protect against small-pox it tends to produce a modified and so much milder form of the disease, that while one patient died out of every two in the Homerton Small Pox Hospital who had the disease naturally, the deaths were only one in four of those who had been imperfectly vaccinated, and one in forty-three of those whose arms bore evidence of perfectly good and successful vaccination.
The influence of previous vaccination often scarcely shows itself in the stage which precedes the appearance of the eruption of small-pox, the fever being often just as intense, and the general symptoms just as severe as in the unmodified disease. The difference, however, becomes at once obvious with the appearance of the rash. The pocks are always much fewer than even in mild small-pox, sometimes even not more than twenty. They never attain above half the size of the ordinary small-pox pustules; they run their course and dry off in half the time, and consequently the dangerous fever which accompanies their development in the natural disease is almost or altogether absent in the vast majority of instances.
If vaccination did no more than this it would be hard to overestimate its value, or to praise as it deserves the merit of its discoverer.
Chicken-Pox is an ailment of such slight importance that it would scarcely call for notice if it were not that the resemblance of the eruption to that of small-pox sometimes leads to its being mistaken for that disease.
It is highly contagious, and for this reason perhaps it is usually met with in infancy and early childhood. Sometimes, though by no means constantly, the eruption is preceded for twenty-four or thirty-six hours by slight feverishness; but oftener the appearance of the rash is the first indication of anything being the matter. It shows itself in the form of small pimples, which in a few hours change into small circular pocks containing a little slightly turbid fluid. They appear on the forehead, face, and body, but very rarely on the limbs; they enlarge for some two or at most three days, then shrivel and dry up; and at the end of a week the crusts or scabs fall off, scarcely ever causing any permanent pitting of the skin. They are usually not above twenty or thirty in number, though every now and then they are much more numerous without any obvious reason. Their distinction from the small-pox eruption consists not only in the smaller size of the pocks, and in the entirely different course which they run, but also in the fact that two or three successive crops of the eruption appear in the course of five or six days, so that new ones, those at maturity, and those on which the crusts have already formed, or from which they have already fallen, may be seen on the child at the same time. This is sufficient of itself to establish the difference between the two diseases, and also to distinguish between chicken-pox and the milder variety of small-pox which is sometimes observed in children who have been already vaccinated.
Measles is a disease with which almost everyone is familiar, and one which with proper care is not generally attended with danger. Its great risks are twofold; first, that of its being complicated with bronchitis, or inflammation of the lungs during its progress, and next of its being followed by an imperfect recovery, and by the awakening into activity any tendency to scrofulous or consumptive disease. On these two accounts the disease is not to be made light of, and special watchfulness is to be exercised during the whole time of convalescence. It is also unwise when one child in a family is attacked by measles to expose the others, as is often done, to its contagion, in order, as people say, 'to get it over;' for its mildness in one case furnishes no guarantee of its mildness in another, and the danger of the disease is almost in exact proportion to the tender age of those who are attacked by it.
The early symptoms of measles are those of a bad feverish cold; the eyes grow red, weak, and watery, and are unable to bear the light, the child sneezes very frequently, sometimes almost every five minutes, and is troubled by a constant short dry cough. About the fourth day, a rash makes its appearance on the face, forehead, and behind the ears, and in the course of the next forty-eight hours travels downwards over the body and limbs, and then in another forty-eight hours it fades in the same way, being at its height on the body when it has already begun to disappear from the face. It first shows itself in the form of small red circular spots, not unlike fleabites, but very slightly raised above the somewhat reddened skin, and looking for a few hours not unlike the very early stages of small-pox, before the eruption has lost the character of minute pimples. On the face the spots sometimes run together, and then form irregular blotches about a third of an inch long by half that breadth; while elsewhere they present an irregular crescentic arrangement. As the rash fades it puts on a dirty yellowish red appearance; the surface of the skin often becomes slightly scurfy, and it continues somewhat stained of a reddish hue for some days after the eruption has disappeared.
The only other point on which it is necessary to dwell is this, that the symptoms do not, as in small-pox, become less severe immediately on the appearance of the eruption, but continue just as troublesome as before for twenty-four hours or more, the voice being hoarse, the cough even more incessant, and the throat often slightly sore and red. Soon, however, improvement becomes apparent, the fever lessens, the cough grows looser; and in less than a fortnight the patient is usually convalescent.
The above is pretty nearly the ordinary course of measles, for we do not meet with that extreme variation in its severity which is observed in scarlatina, where one child will seem scarcely to ail at all, while its brother or sister may be in a state of extreme peril. It is not wise, however, to trust a case even of apparently mild measles to domestic management, for while the cough is troublesome in almost every case, the ear of the experienced doctor is needed to ascertain whether it is merely the cough of irritation which attends the measles, or the graver cough due to bronchitis.
One other caution will not be out of place. The danger of exposure to cold is very real, but that does not necessitate the loading the child with excessive covering, or the abstaining from washing its hands and face. The child should be kept moderately cool; and sponging its hands and face frequently with tepid water soothes it and relieves the painful irritation and itching.
German Measles.—There is a disorder which seems to hold a middle place between measles and scarlatina, akin to both, identical with neither, and furnishing no sort of protection from their occurrence.
It is known in this country by the name of German measles, or sometimes by its German name of Rötheln; the first clear description of its character having been given by German writers.
It is unfortunate that a very slight resemblance of some of its symptoms to those of scarlet fever has led to its being sometimes mistaken for it, and as the ailment is almost always very trivial, doctors anxious to avoid alarming their patients' friends, too often allow the error to go unrectified, and the disease to pass as one of mild scarlet fever.
The resemblance of German measles to scarlet fever is, however, extremely slight, and is almost entirely limited to the existence of a slight sore-throat, unaccompanied with glandular swelling. The rash in no respect resembles the uniform redness of the scarlatinal eruption, and there is no peeling of the skin, nor even any roughness of the surface left behind.
Slight feverishness sometimes precedes the appearance of the rash for twenty-four hours; but the cough, and sneezing, and running at the eyes and nose, which usher in measles are entirely absent. The rash usually appears in the course of twenty-four hours, is never postponed beyond the second day; it begins, like that of measles, on the face, and, like it, travels downwards, but always disappears on the third day, while that of measles is not entirely gone before the eighth or ninth. The rash itself also has a different character. It consists of small, slightly elevated, round red spots which now and then coalesce into small patches, but never have the somewhat crescentic arrangement observed in the rash of measles. The colour of the spots is somewhat darker than that of the eruption of measles, while the skin between them remains pale, and does not assume the flush of measles. As it disappears it simply fades, and does not at all change its tint as that of measles does, and it leaves the skin unroughened.
Now and then German measles are severe, and are attended with a good deal of fever for a day or two, and even with symptoms of bronchitis. These cases are, however, very unusual, are seen only at times when the disease prevails epidemically; and even then the symptoms of the affection are sufficiently marked to preserve from error all but those who wish to be deceived, and to flatter themselves that their child is henceforth protected from scarlatina.
Scarlatina, or Scarlet Fever, for the two names mean the same thing, the former being only the Latin term, and not implying any greater mildness of the disease, is one of the most formidable ailments of childhood, and especially of early childhood, since the highest mortality from it takes place during the third year of life.
It is more dreaded in a household, and justly so, than any other disease of childhood, though, indeed, it is not limited in its occurrence to early life, and instances are familiar to us all in which the mother, devoting herself to the care of her little ones, has herself fallen a victim to the poison.
I do not think it so directly contagious, from person to person, as small-pox, chicken-pox, or measles, but its infection appears to be specially abiding in its character, and to cling longer to the clothes, the bedding, and even the room of a scarlet fever patient, than that of the other eruptive fevers, except perhaps small-pox.
It is an object of special dread also for two other reasons. One of these reasons is the extreme and causeless variations in its severity; so that I have known more than one or two children in the same family to have it so slightly as scarcely to be ill, two to have their lives placed in jeopardy, and two to die. The other reason for special dread is that the mildness of the disease at its outset affords but a slight guarantee against the occurrence of serious complications in its course, and still slighter against secondary diseases which may follow in its train, and either destroy life directly, or leave behind some irremediable mischief.
Scarlatina has been divided by medical men into three classes, according to its different degrees of severity; the mild—that accompanied with bad sore-throat—and the malignant variety.
We have specially to do with the first of the three; for it is in it only that there is danger of the disease being overlooked, or mistaken.
The symptoms of scarlatina usually appear within three days after exposure to its contagion, and there is very good authority for believing that the interval never exceeds six days. I should not, however, feel quite secure until after the lapse of ten days, and during this time the child ought to be isolated from his brothers and sisters. In the mildest form of the disease the appearance of the rash upon the surface, usually with, but sometimes even without slight sore-throat and feverishness, may be the first indication of an affection which is sometimes so deadly. In the majority of cases, however, it is ushered in by vomiting once or oftener, accompanied by headache, heaviness, of head, great heat of skin, and some measure of sore-throat. The brain is easily disturbed in children, as has already been said, and delirium at night during the first twenty-four hours of an attack of scarlet fever need not excite anxiety, for it then often passes away, and the disease runs a perfectly favourable course. The continuance of delirium later is an attendant only on the graver forms of scarlet fever.
The rash often makes its appearance within twenty-four hours after the commencement of the illness, at latest in the course of the second day. It usually shows itself first on the neck, breast, and face, whence it extends in twenty-four hours to the body and limbs, and is then not seldom specially vivid on the inside of the thighs. Its colour is a very bright red, due in part to a general flush of the skin, in part to the presence of innumerable red dots or spots, which do not communicate any sense of roughness to the hand, though now and then extremely minute red pimples are interspersed. For three days the rash usually continues to become of a deeper colour, and more generally diffused over the whole surface; it then slowly declines, but does not wholly disappear until the seventh or eighth day of the disease. As the rash subsides the skin is left rough, and by degrees scales off, often in large flakes from the hands and feet, but elsewhere in a sort of branny scales. Sometimes this process is over in five or six days, while in other cases the skin peels and is reproduced several times in succession, so that it is protracted for three or four weeks or even longer. The degree of this peeling also varies as well as its duration. It is usually most considerable where the rash has been most abundant, while where the rash has been scanty, it is sometimes scarcely apparent except at the tips of the fingers and toes and just around the insertion of the nails.
Besides the rash there are commonly other symptoms not less characteristic of scarlatina, and among them the sore-throat is one of the most invariable. Even in mild cases, it is very rarely absent, and if not present at the beginning, it comes on on the second or third day. The palate and tonsils, in these circumstances are red, and the latter are usually more or less swollen, while swallowing is attended with pain, or at any rate with discomfort. The redness of the palate, which extends also to the back of the throat, is a finely spotted redness closely resembling the rash on the surface. The tongue is coated with a thick white or yellowish coating, through which project numerous bright red points, papillæ as they are called, and this appearance of the tongue is as distinctive of scarlatina as the rash itself. Later, as the rash begins to fade, the coating separates from the tongue, which is left of a bright red colour, looking raw and shining, with the little raised red points projecting beyond its surface, and constituting what has been called in medical language, the strawberry tongue.
When all these symptoms are present, no one can doubt but that the case is one of scarlatina. But the decision is far less easy in mild cases, for in them the rash is sometimes extremely evanescent, the general disturbance of health very slight, and the fever and accompanying rise of temperature small. The risk in such circumstances of the disease being altogether overlooked is even greater than that of its being confounded with some other eruptive fever. The rash of measles cannot be confounded with that of scarlatina, and the distinctly spotty character of the rash of German measles ought, apart even from other differences, to render mistake impossible.
Perhaps the best rule that can be laid down is that every diffused red rash, not obviously formed by distinct spots, even though it be not uniform but appears in patches on the neck, breast, back, or inside of the thighs, and persists for more than twelve hours, is scarlatinal. Further, that in any instance in which even very slight feverishness, or very slight sore-throat, have preceded or accompanied the rash, the nature of the ailment is stamped beyond the possibility of doubt. Mistakes are made from want of careful observation, much more than from any insuperable difficulty in distinguishing one disease from the other. When the least hesitation is felt as to the nature of any rash which may appear on a child, with, or without previous illness, the question should be at once referred to a medical man. People are too apt in these circumstances to wait for a few days, and then to appeal to the doctor when all traces of rash have disappeared, and when the grounds no longer exist on which he could base a positive opinion.
I need not describe the symptoms of severe and dangerous scarlatina, for long before symptoms become really formidable, the patients will have been placed under medical care. It may suffice to say that the danger is almost always in proportion to the severity of the throat-affection and swelling of the glands, and not at all in proportion to the abundance of the rash. Though severe cases usually set in with severe symptoms, yet this is not invariably the case, and medical watching is all the more necessary from the very commencement, since until the end of the first week it is impossible to calculate on the subsequent course of the disease. In malignant scarlatina happily of infrequent occurrence, the child is struck down, as though its blood were poisoned, from the very first; and death takes place often within forty-eight hours, the rash appearing just sufficiently to stamp the nature of the pestilence which has proved so deadly.
It may form a useful conclusion to all that has been said in this little book about the diseases of children, if I endeavour to point out in what consist the duties of parents in cases of scarlatina, or of any disease which resembles it.
1. To watch carefully the commencement of every slight feverish attack in which a diffused red rash appears, even though this should be only in patches, and to bear in mind the possibility of its being due to scarlatina.
2. To remove the child immediately from the others, so long as there is any doubt concerning the nature of the case, and to remove with him his bed, bedding, and all clothes worn by him at the time when the illness began, or the rash appeared.
3. To place the child if possible in a room at the top of the house, so that the other children may not pass by his door.
4. Inasmuch as scarlatina often proves fatal to grown persons who have not already had the disease, to obtain at once the attendance of a skilled nurse, in order to avoid the risk of the disease spreading through the household.
The wife belongs to her husband, the husband to his wife; their mutual duties are paramount over even those of the parent; and neither has the right to jeopardise that life which belongs to the other. To say, 'I shall not catch the disease, because I have no fear,' is as idle as it would be for the soldier to say, 'Because I am brave, therefore I am invulnerable.'
I have been accustomed to insist on the absence from the room of father or mother, supposing either of them not to have had scarlatina, so long as I could give the assurance that every thing was going on well; but on the slightest anxiety I have referred to both parents for their mutual decision as to the course which they would choose to adopt.
From a refusal to be guided by this counsel, it has more than once happened to me, to see the child recover from mild scarlatina without a bad symptom, and the mother who had insisted on nursing the little one die of the disease to which she had needlessly exposed herself.
5. So soon as the disease has declared itself as scarlatina, to take up the carpets and remove the curtains from the sick child's room, to empty the drawers of any clothes which may be in them, and to hang up outside the door a sheet moistened with a solution of carbolic acid.
6. To arrange for all food and necessaries to be placed in an adjoining room, or at the head of the stairs, so that there may be no direct communication between the attendants on the sick and the other inmates of the house.
7. To insist on the attendants not wearing either silk or stuff dresses, but dresses of some washable material; and on their changing their garments as well as scrupulously washing themselves before mixing with other inmates of the house, and especially with the children.
8. While in all respects obeying the directions of the doctor, to grease the child all over twice in twenty-four hours with suet or lard, to which a small quantity of carbolic acid has been added. This proceeding both lessens the amount of peeling of the skin in a later stage of the disease; lessens the contagiousness of the scales which are detached; and, by promoting the healthy action of the skin, diminishes the risk of subsequent disorder of the kidneys and consequent dropsy.
9. Even when the case has been of the slightest possible kind, to keep the child always in bed for one-and-twenty days. This was a standing rule at the Children's Hospital, and I am certain that its non-observance will be followed three times out of four by dropsy and kidney-disease.
10. When the disease is over, to destroy, if the parents' means at all permit it, the clothes and bedding of the child. When this is not practicable, to have everything exposed to the heat of superheated steam in a Washington Lyons or other similar disinfector, and to have all linen boiled as well as washed. Lastly, to have the ceiling whitewashed, the paint cleaned, the paper stripped, and the room repapered, as well as the floor washed and rewashed with strong carbolic soap.
These precautions are troublesome and costly, but disease is costlier still; and who shall estimate the cost of death!
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