CHAPTER I

Contagious Diseases

Scarlet Fever—Symptoms and Treatment—Precautions Necessary—Measles—Communicating the Disease—Smallpox—Vaccination—How to Diagnose Chickenpox.

ERUPTIVE CONTAGIOUS FEVERS (including Scarlet Fever, Measles, German Measles, Smallpox, and Chickenpox).—These, with the exception of smallpox, attack children more commonly than adults. As they all begin with fever, and the characteristic rash does not appear for from one to four days after the beginning of the sickness, the diagnosis of these diseases must always be at the onset a matter of doubt. For this reason it is wise to keep any child with a fever isolated, even if the trouble seems to be due to "a cold" or to digestive disturbance, to avoid possible communication of the disorder to other children. While colds and indigestion are among the most frequent ailments of children, they must not be neglected, for measles begins as a bad cold, smallpox like the grippe, and scarlet fever with a sore throat or tonsilitis, and vomiting.

By isolation is meant that the sick child should stay in a room by himself, and the doors should be kept closed and no children should enter, nor should any objects in the room be removed to other parts of the house after the beginning of its occupation by the patient.

The services of a physician are particularly desirable in all these diseases, in order that an early diagnosis be made and measures be taken to protect the family, neighbors, and community from contagion. The failure of parents or guardians to secure medical aid for children is regarded by the law as criminal neglect, and is subject to punishment. Boards of health require the reporting of all contagious diseases as soon as their presence is known, and failure to comply with their rules also renders the offender liable to fine or imprisonment in most places.

SCARLET FEVER (Scarlatina).—There is no difference between scarlet fever and scarlatina. It is a popular mistake that the latter is a mild type of scarlet fever. Fever, sore throat, and a bright-red rash are the characteristics of this disease. It occurs most frequently in children between the ages of two and six years. It is practically unknown under one year of age. Prof. H. M. Biggs, of the New York Department of Health, has seen but two undoubted cases in infants under twelve months. It is rare in adults, and one attack usually protects the patient from another. Second attacks have occurred, but many such are more apparent than real, since an error in diagnosis is not uncommon. The disease is communicated chiefly by means of the scales of skin which escape during the peeling process, but may also be acquired at any time from the onset of the attack from the breath, urine, and discharges from the body; or from substances which have come in contact with these emanations. Scarlet fever is probably a germ disease, and the germs may live for weeks in toys, books, letters, clothing, wall paper, etc. Close contact with the patient, or with objects which have come in close touch with the patient, is apparently necessary for contagion.

Period of Development.—After exposure to the germs of scarlet fever, usually from two to five days elapse before the disease shows itself. Occasionally the outbreak of the disease occurs within twenty-four hours of exposure, and rarely is delayed for a week or ten days.

Symptoms.—The onset is usually sudden. It begins with vomiting (in very young children sometimes convulsions), sore throat, fever, chilliness, and headache. The tongue is furred. The patient is often stupid; or may be restless and delirious. Within twenty-four hours or so the rash appears—first on the neck, chest, or lower part of back—and rapidly spreads over the trunk, and by the end of forty-eight hours covers the legs and entire body excepting the face, which may be simply flushed. The rash appears as fine, scarlet pin points scattered over a background of flushed skin. At its fullest development, at the end of the second or third day, the whole body may present the color of a boiled lobster. After this time the rash generally fades away and disappears within five to seven days. It is likely to vary much in intensity while it lasts. As the rash fades, scaling of the skin begins in large flakes and continues from ten days to as many weeks, usually terminating by the end of the sixth to eighth week. One of the notable features is the appearance of the tongue, at first showing red points through a white coating, and after this has cleared away, in presenting a raspberry-like aspect. The throat is generally deep red, and the tonsils may be dotted over with white spots (see Tonsilitis) or covered with a whitish or gray membrane suggesting diphtheria, which occasionally complicates scarlet fever. The fever usually is high (103° to 107° F), and the pulse ranges from 120 to 150; both declining after the rash is fully developed, generally by the fourth day. The urine is scanty and dark. There is, however, great variation in the symptoms as to their presence or absence, intensity, and time of occurrence and disappearance.

Complications and Sequels.—These are frequent and make scarlet fever the most dreaded of the eruptive diseases, except smallpox. Enlarged glands under the jaw and at the sides of the neck are common, and appear as lumps in these sites. Usually not serious, they may enlarge and threaten life. Pain and swelling in the joints, especially of the elbows and knees, are not rare, and may be the precursors of serious inflammation of these parts. One of the most frequent and serious complications of scarlet fever is inflammation of the kidneys, occurring more often toward the end of the second week of the disease. Examination of the urine by the attending physician at frequent intervals throughout the course of the disorder is essential, although puffiness of the eyelids and face, and of the feet, ankles, and hands, together with lessened secretion of urine—which often becomes of a dark and smoky hue—may denote the onset of this complication. The disease of the kidneys usually results in recovery, but occasionally in death or in chronic Bright's disease of these organs. Inflammation of the middle ear with abscess, discharge of matter from the ear externally, and—as the final outcome—deafness, is not uncommon. This complication may be prevented to a considerable extent by spraying the nose and throat frequently and by the patient's use of a nightcap with earlaps, if the room is not sufficiently warm. Inflammation of the eyelids is an occasional complication. The heart is sometimes attacked by the toxins of the disease, and permanent damage to the organ, in the form of valvular trouble, may result. Blindness and nervous disorders are among the rarer sequels including paralyses and St. Vitus's dance.

Determination of Scarlet Fever.—When beginning with vomiting, headache, high fever, and sore throat, and followed in twenty-four hours with a general scarlet rash, this is not difficult; but occasionally other diseases present rashes, as indigestion, grippe, and German measles, which puzzle the most acute physicians. Measles may be distinguished from scarlet fever in that measles appears first on the face, the rash is patchy or blotchy, and does not show for three to four days after the beginning of the sickness. The patient seems to have a bad cold, with cough, running at the nose, and sore eyes. German measles is mild, and while the rash may look something like that of scarlet fever, the patient does not seem generally ill, is hardly affected at all, though rarely troubled with slight catarrh of the nose. In no sickness are the services of a physician more necessary than in scarlet fever; first, to determine the existence of the disease, and then to prevent or combat the complications which often approach insidiously.

Outlook.—The average death rate of scarlet fever is about ten per cent. It is very fatal in children about a year old, and most of the deaths occur in those under the age of six. But the mortality varies greatly at different times and in different epidemics. In 1904–5, in many parts of the United States, the disease was very prevalent and correspondingly mild, and deaths were rare.

Duration of Contagion.—The disease is commonly considered contagious only so long as peeling of the skin lasts. But it seems probable that any catarrhal secretion from the nose, throat, or ear is capable of communicating the germs from a patient to another person for many days after other evidences of the disease are past. Scarlet fever patients should always be isolated for as long a period as six weeks—and better eight weeks—without regard to any shorter duration of peeling, and if peeling continues longer, so should the isolation.

Treatment.—In case a physician is unobtainable the patient must be put to bed in the most airy, sunshiny room, which should be heated to 70° F., and from which all the unnecessary movables should be taken out before the entrance of the patient. A flannel nightgown and light bed clothing are desirable. The fever is best overcome by cold sponging, which at the same time diminishes the nervous symptoms, such as restlessness and delirium. The body is sponged—part at a time—with water at the temperature of about 70° F., after placing a single thickness of old cotton or linen wet with ice or cold water (better an ice cap) over the forehead. The part is thoroughly dried as soon as sponged, and the process is repeated whenever the temperature is over 103° F. There need be no fear that the patient may catch cold if only a portion of the body is exposed at any one time. If there is any chilliness following sponging, a bag or bottle containing hot water may be placed at the feet. It is well that a rubber bag containing ice, or failing this a cold cloth, be kept continually on the head while fever lasts. The throat should be sprayed hourly with a solution of hydrogen peroxide (full strength) and the nose with the same, diluted with an equal amount of water, three times a day. The outside of the throat it is wise to surround with an ice bag, or lacking this, a cold cloth frequently wet and covered with a piece of oil silk (or rubber) and flannel.

The diet should consist of milk, broths, or thin gruels, and plenty of water should be allowed. Sweet oil or carbolized vaseline should be rubbed over the whole body night and morning during the entire sickness and convalescence. The bowels must be kept regular by injections or mild cathartics, and, after the fever subsides, vegetables, fruit, cereals, and milk may be permitted, together with meat or eggs once daily. It is imperative for the nurse and also the mother to wear a gown and cap over the outside clothes, to be slipped off in the hall at the door of the sick room when leaving the latter.

MEASLES.—Measles is a contagious disease, characterized by a preliminary stage of fever and catarrh of the eyes, nose, and throat, and followed by a general eruption on the skin. One attack practically protects a person from another, yet, on the other hand, second attacks occur with extreme rarity. It is more contagious than scarlet fever, and isolation of a patient in a house is of less service in preventing communication to other inmates, whereas in scarlet fever half the number of susceptible children may escape the disease through this precaution. The germs which cause measles perish rapidly, so that infected clothes or other objects merely require a thorough airing to be rendered safe, whereas in scarlet fever the danger of transmission of the contagion may lurk in infected clothing and other substances for weeks, unless they are subjected to proper disinfection. A patient with measles is capable of communicating the disorder from its onset, before the appearance of the rash, through the breath, discharges from the nose and eyes, tears and saliva and all the secretions. At the end of the third week of the disease the patient is usually incapable of giving the disease to others. Close contact with a patient is commonly necessary for one to acquire the disease, but it is frequently claimed that it is carried by a third person in the clothes, as by a nurse. It is infrequent in infants under six months, and most frequent between the second and sixth year. Adults are attacked by measles more often than by scarlet fever.

Development.—A period of from seven to sixteen days after exposure to measles elapses before the disease becomes apparent.

Symptoms.—The disease begins like a severe nasal catarrh with fever. The eyes are red and watery, the nose runs, and the throat is irritable, red, and sore, and there is some cough, with chilliness and muscular soreness. The fever, higher at night, varies from 102° to 104° F., and the pulse ranges from 100 to 120. There is often marked drowsiness for a day or two before the rash appears. Coated tongue, loss of appetite, occasional vomiting, and thirst are present during this period. The appearance of minute, whitish spots, surrounded by a red zone, may often be seen in the inside of the mouth opposite the back teeth for some days before the eruption occurs.

The preliminary period, when the patient seems to be suffering with a bad cold, lasts for four days usually, and on the evening of the fourth day the rash breaks out. It first appears on the face and then spreads to the chest, trunk, and limbs. Two days are generally required for the complete development of the rash; it remains thus in full bloom for about two days more, then begins to subside, fading completely in another two days—six days in all.

The rash appears as bright-red, slightly raised blotches on the face, which is generally somewhat swollen. The same rash extends to the abdomen, back, and limbs. Between the mottled, red rash may be seen the natural color of the skin. At this time the cough may be hoarse and incessant, and the eyes extremely sensitive to light. The fever and other symptoms abate when the rash subsides, and well-marked scaling of the skin occurs.

Complications and Sequels.—Severe bronchitis, pneumonia, croup, laryngitis, sore eyes, ear abscess and deafness, violent diarrhea, convulsions, and, as a late result, consumption sometimes accompany or follow measles. For the consideration of these disorders, see special articles in other parts of this work.Outlook.—The vast majority of healthy patients over two years old recover from measles completely. Younger children, or those suffering from other diseases, may die through some of the complications affecting the lungs. The disease is peculiarly fatal in some epidemics occurring among those living in unhygienic surroundings, and in communities unaccustomed to the ravages of measles. Thus, in an epidemic attacking the Fiji Islanders, over one-quarter of the whole population (150,000) died of measles in 1875. Measles is more severe in adults than in children.

Diagnosis.—For one not familiar with the characteristic rash a written description of it will not suffice for the certain recognition of the disease, but if the long preliminary period of catarrh and fever, and the appearance of the eruption on the fourth day, be taken into account—together with the existence of sore eyes and hoarse, hard cough—the determination of the presence of measles will not be difficult in most cases.

Treatment.—The patient should be put to bed in a darkened, well-ventilated room at a temperature of 68° to 70° F. While by isolation of the patient we may often fail to prevent the occurrence of measles in other susceptible persons in the same house, because of the very infectious character of the disease, and because it is probable that they have already been exposed during the early stages when measles was not suspected, yet all possible precautions should be adopted promptly. For this reason other children in the house should be kept from school and away from their companions, and they ought not to be sent away from home to spread the disease elsewhere. The bowels should be kept regular by soapsuds injections or by mild cathartics, as a Seidlitz powder. If the fever is over 103° F. and is accompanied by much distress and restlessness, children may be sponged with tepid water, and adults with water at 80° F., every two hours or so as directed under scarlet fever. When cough is incessant or the rash does not come out well, there is nothing better than the hot pack.

The patient is stripped and wrapped from feet to neck in a blanket wrung out of hot water containing two teaspoonfuls of mustard stirred into a gallon of water. This is then covered with two dry blankets and the patient allowed to remain in the blankets for two or three hours, when the application may be repeated. It is well to keep a cold cloth on the head during the process. Cough is also relieved by a mixture containing syrup of ipecac, twenty drops; paregoric, one teaspoonful, for an adult (or one-third the dose for a child of six), which should be given in one-quarter glass of water and may be repeated every two hours. If there is hoarseness, the neck should be rubbed with a mixture of sweet oil, two parts; and oil of turpentine, one part, and covered with a flannel bandage. The cough mixture will tend to relieve this condition also. A solution of boric acid (ten grains of boric acid to the ounce of water) is to be dropped in both eyes every two hours with a medicine dropper. Although usually mild, the eye symptoms may be very severe and require special treatment, and considerably impaired vision may be the ultimate result. Severe diarrhea is combated with bismuth subnitrate, one-quarter teaspoonful, every three hours. For adults, the diet consists of milk, broths, gruels, and raw eggs. Young children living on milk mixtures should receive the mixture to which they are accustomed, diluted one-half with barley water. Nourishment must be given every two hours except during sleep. The patient should be ten days in bed, and should remain three days in his room after getting up (or three weeks in all, if there are others who may contract measles in the house), and after leaving his room should stay in the house a week longer. The principal danger after an attack of measles is of lung trouble—pneumonia or tuberculosis (consumption)—and the greatest care should be exercised to avoid exposure to the wet or to cold draughts.

GERMAN MEASLES (RÖtheln).—German measles is related neither to measles nor scarlet fever, but resembles them both to a certain extent—more closely the former in most cases. It is a distinct disease, and persons who have had both measles and scarlet fever are still susceptible to German measles. One attack of German measles usually protects the patient from another. Adults, who have not been previously attacked, are almost as liable to German measles as children, but it is rare that infants acquire the disease. It is a very contagious disorder—but not so much so as true measles—and often occurs in widespread epidemics. The breath and emanations from the skin transmit the contagium from the appearance of the first symptom to the disappearance of the eruption.

Development.—The period elapsing after exposure to German measles and before the appearance of the symptoms varies greatly—usually about two weeks; it may vary from five to eighteen days.

Symptoms.—The rash may be the first sign of the disease and more frequently is so in children. In others, for a day or two preceding the eruption, there may be headache, soreness, and redness of the throat, the appearance of red spots on the upper surface of the back of the mouth, chilliness, soreness in the muscles, loss of appetite, watering of the eyes. Catarrhal symptoms are most generally absent, an important point in diagnosis. When present, they are always mild. These preliminary symptoms, if present, are much milder and of shorter duration than in measles, where they last for four days before the rash appears; and the hard, persistent cough of measles is absent in German measles. Also, while there is sore throat in the latter, there is not the severe form with swollen tonsils covered with white spots so often seen in scarlet fever. Fever is sometimes absent in German measles; usually it ranges about 100° F., rarely over 102° F. Thus, German measles differs markedly from both scarlet fever and measles proper. The rash usually appears first on the face, then on the chest, and finally covers the whole body, in the space of a few hours—twenty-four hours at most. The eruption takes the form of rose-red, round or oval, slightly raised spots—from the size of a pin head to that of a pea—sometimes running together into uniform redness, as in scarlet fever. The rash remains fully developed for about two days, and often changes into a coppery hue as it gradually fades away. There are often lumps—enlarged glands—to be felt under the jaw, on the sides and back of the neck, which occur more commonly in German than in true measles. The glands at the back of the neck are the most characteristic. They are enlarged in about two-thirds of the cases.

Determination.—The diagnosis or determination of the existence of measles must be made, in the absence of a physician, on the general symptoms rather than on the rash, which requires experience for its recognition and is subject to great variations in appearance, at one time simulating measles, at another scarlet fever.

German measles differs from true measles in the following points: the preliminary period—before the rash—is mild, short, or absent; fever is mild or absent; the cold in the nose and eyes and cough are slight or may be absent, as contrasted with these symptoms in measles, while the enlarged glands in the neck are more pronounced than in measles. The onset of German measles is not so sudden as in scarlet fever and not accompanied with vomiting as in the latter, while the sore throat and fever are much milder in German measles. The peeling, which is so prominent in scarlet fever with the disappearance of the rash, is not infrequently present. It may be absent. Its presence or absence seems to depend upon the severity of the eruption. The desquamation when present is finer than in either measles or scarlet fever.

Outlook.—Recovery from German measles is the invariable rule, and without complications or delay.

Treatment.—Little or no treatment is required. The patient should remain in bed in a darkened room on a liquid diet while fever lasts, and be isolated from others indoors until all signs of the eruption are passed. The eyes should be treated with boric acid as in measles; the diet, during the fever, consisting of milk, broths, thin cereals, beef juice, raw eggs or eggnog, for adults and older children; while infants should have their milk mixture diluted one-half with barley water. A bath and fresh clothing for the patient, and thorough cleansing and airing of the sick room and clothing are usually sufficient after the passing of the disease without chemical disinfection.

SMALLPOX.—Smallpox is one of the most contagious diseases known. It is extremely rare for anyone exposed to the disease to escape its onslaught unless previously protected by vaccination or by a former attack of the disease. One is absolutely safe from acquiring smallpox if recently and successfully vaccinated, and thus has one of the most frightful and fatal scourges to which mankind has ever been subject been robbed of its dangers. The contagium is probably derived entirely from the scales and particles of skin escaping from smallpox patients, and in the year 1905–6 the true germ of the disease was discovered by Councilman, of Boston. It is not necessary to come in direct contact with a patient to contract the disease, as the contagium may be transmitted some little distance through the air, possibly even outside of the sick room. One attack almost invariably protects against another. All ages are liable to smallpox; it is particularly fatal in young children, and during certain epidemics has proved more so in colored than in white people.

Development.—A period of ten or twelve days usually elapses after exposure to smallpox before the appearance of the first symptoms of the disease. This period may vary, however, from nine to fifteen days.

Symptoms.—There is a preliminary period of from twenty-four to forty-eight hours after the beginning of the disease before an eruption occurs. The onset is ushered in by a set of symptoms simulating those seen in severe grippe, for which smallpox is often mistaken at this time. The patient is suddenly seized with a chill, severe pains in the head, back, and limbs, loss of appetite and vomiting, dizziness on sitting up, and fever—103° to 105° F. In young children convulsions often take the place of the chill seen in adults. On the second day a rash often appears on the lower part of the belly, thighs, and armpits, which may resemble that characteristic of measles or scarlet fever, but does not last for over a day or two. It is very evanescent and, consequently, rarely seen. Diarrhea often occurs, as well as vomiting, particularly in children. On the evening of the fourth day the true eruption usually appears; first on the forehead or face, and then on the arms, hands, and legs, palms, and soles. The eruption takes successively four forms: first, red, feeling like hard pimples or like shot; then, on the second or third day of the eruption, these pimples become tipped with little blisters with depressed centers, and surrounded by a red blush. Two or three days later the blisters are filled with "matter" or pus and present a yellowish appearance and are rounded on top. Finally, on about the tenth day of the eruption, the pustules dry up and the matter exudes, forming large, yellowish or brownish crusts, which, after a while, drop off and leave red marks and, in severe cases, pitting. The fever preceding the eruption often disappears upon the appearance of the latter and in mild cases does not reappear, but in severe forms the temperature remains about 100° F., and when the eruption is at its height again mounts to 103° to 105° F., and gradually falls with convalescence. The eruption is most marked on the face, hands, and forearms, and occurs less thickly on the body. It appears also in the mouth and throat and when fully developed on the face gives rise to pain and considerable swelling and distortion of the features, so that the eyes are closed and the patient becomes frightfully disfigured and well-nigh unrecognizable. Delirium is common at this time, and patients need constant watching to prevent their escape from bed. In the severe forms the separate eruptive points run together so that the face and hands present one distorted mass of soreness, swelling, and crusting. In these, pitting invariably follows, while in those cases where the eruption remains distinct, pitting is not certain to occur. A still worse form is that styled "black smallpox," in which the skin becomes of a dark-purplish hue, from the fact that each pustule is a small blood blister, and bleeding occurs from the nose, mouth, etc. These cases are almost, without exception, fatal in five to six days.

The patient may say that the eruption was the first symptom he observed. This was particularly noticed in negroes, many of whom had never been vaccinated. The eruption may exhibit but a dozen or so points, especially about the forehead, wrists, palms, and soles. After the first four days the fever and all the disagreeable symptoms may subside, and the patient may feel absolutely well. The eruption, however, passes through the stages mentioned, although but half the time may be occupied by the changes; five or six days instead of ten to twelve for crusts to form. In such cases the death rate has been exceedingly low, although it is perfectly possible for a person to contract the most severe smallpox from one of these mild (and often unrecognized) cases, as has unfortunately happened. Smallpox occurring after successful vaccination resembles, in its characteristics, the cases just described, and unless vaccination had been done many years previously, the results are almost always favorable as regards life and absence of pitting.

Detection.—Smallpox is often mistaken for chickenpox, or some of the skin diseases, in its mild forms. The reader is referred to the article on chickenpox for a consideration of this matter. The mild type should be treated just as rigidly as severe cases with regard to isolation and quarantine, being more dangerous to the community because lightly judged and not stimulating to the adoption of necessary precautions. The preliminary fever and other symptoms peculiar to smallpox will generally serve to determine the true nature of the disease, since these do not occur in simple eruptions on the skin. The general symptoms and course of smallpox must guide the layman rather than the appearance of the eruption, which requires educated skill and experience to recognize. Chickenpox in an adult is less common than in children. Smallpox is very rare in one who has suffered from a previous attack of the disease or in one who has been successfully vaccinated within a few years.

Outlook.—The death rate of smallpox in those who have been previously vaccinated at a comparatively recent date, or in varioloid, as it is called when thus modified by vaccination, is only 1.2 per cent. There are, however, severe cases following vaccinations done many years previous to the attack of smallpox. While these cannot be called varioloid, yet the death rate is much lower than in smallpox occurring in the unvaccinated. Thus, before the mild epidemic of 1894 the death rate in the vaccinated was sixteen per cent; since 1894 it has been only seven per cent; while in the unvaccinated before 1894 it was fifty-eight per cent; and since that date it has been but seventeen per cent, as reported by Welch from the statistics of 5,000 cases in the Philadelphia Municipal Hospital.

Complications.—While a variety of disorders may follow in the course of smallpox, complications are not very frequent in even severe cases. Inflammation of the eyelids is very common, however, and also boils in the later stages. Delirium and convulsions in children are also frequent, as well as diarrhea; but these may almost be regarded as natural accompaniments of the disease. Among the less common complications are: laryngitis, pneumonia, diseases of the heart, insanity, paralysis, various skin eruptions, inflammation of the joints and of the eyes and ears, and baldness.

Treatment.—Prevention is of greatest importance. Vaccination stands alone as the most effective preventive measure in smallpox, and as such has no rival in the whole domain of medicine. The modern method includes the inoculation of a human being with matter taken from one of the eruptive points on the body of a calf suffering with cowpox. Whether cowpox is a modified form of smallpox or a distinct disease is unknown.

The period of protection afforded by a successful vaccination is uncertain, because it varies with different individuals. In a general way immunity for about four or five years is thus secured; ten or twelve years after vaccination the protection is certainly lost and smallpox may be then acquired. Every individual should be vaccinated between the second and third month after birth, and between the ages of ten and twelve, and at other times whenever an epidemic threatens. An unvaccinated person should be vaccinated and revaccinated, until the result is successful, as immunity to vaccination in an unvaccinated person is practically unknown. When unsuccessful, the vaccine matter or the technique is faulty. A person continuously exposed to smallpox should be vaccinated every few weeks—if unsuccessful, no harm or suffering follow; if successful, it proves liability to smallpox. A person previously vaccinated successfully may "take" again at any time after four or five years, and, in event of possible exposure to smallpox, should be revaccinated several times within a few weeks—if the vaccination does not "take"—before the attempt is given up. An unvaccinated person, who has been exposed to smallpox, can often escape the disease if successfully vaccinated within three days from the date of the exposure, but is not sure to do so.

Diseases are not introduced with vaccination now that the vaccine matter is taken from calves and not from the human being, as formerly. Most of the trouble and inflammation of the vaccinated part following vaccination may be avoided by cleanliness and proper care in vaccinating.

In the absence of a physician, vaccination may be properly done by any intelligent person when the circumstances demand it. Vaccination is usually performed upon the outside of the arm, a few inches below the shoulder, in the depression situated in that region. If done on the leg, the vaccination is apt to be much more troublesome and may confine the patient to bed. The arm should be thoroughly washed in soap and warm water, from shoulder to elbow, and then in alcohol diluted one-third with water. When this has evaporated (without rubbing), the dry arm is scratched lightly with a cold needle which has previously been held in a flame and its point heated red hot. The point must thereafter not be touched with anything until the skin is scratched with it. The object is not to draw blood, but to remove the outer layer of skin, over an area about one-fourth of an inch square, so that it appears red and moist but not bleeding. This is accomplished by very light scratching in various directions. Another spot, about an inch or two below, may be similarly treated. Then vaccine matter, if liquid, is squirted on the raw spots, or, if dried on points, the ivory point is dipped in water which has been boiled and cooled, and rubbed thoroughly over the raw places. The arm must remain bare and the vaccination mark untouched until the surface of the raw spot is perfectly dry, which may take half an hour. A piece of sterilized surgical gauze, reaching halfway about the arm and kept in place with strips of adhesive plaster (or an absolutely clean handkerchief bound about the arm, and held by sewing or safety pins), ought to cover the vaccination for three days. After this time the sore must only come in contact with soft and clean old cotton or linen, which may be daily pinned in the sleeve of the under garment. If the scab is knocked off and an open sore results it should be treated like any wound.

If the vaccination "takes," it passes through several stages. On the third day following vaccination a red pimple forms at the point of introduction of the matter, which is surrounded by a circle of redness. Some little fever may occur. On the fifth day a blister or pimple containing clear fluid with a depressed center is seen, and a certain amount of hard swelling, itchiness, and pain is present about the vaccination. A sore lump (gland) is often felt under the arm. The full development is reached by the eighth day, when the pimple is full and rounded and contains "matter," and is surrounded by a large area of redness. From the eleventh day the vaccination sore dries, and a brown scab forms over it about the end of the fourteenth day, and the redness and swelling gradually depart. At the end of about three weeks the scab drops off, leaving a pitted scar or mark. Not infrequently the vaccination results in a very slight pimple and redness, which passes through the various stages described, in a week or ten days, in which case the vaccination should be repeated. Unless the vaccination follows very closely the course described, it cannot be regarded as successful, although after the first one or two vaccinations the result is often not so severe, and the time of completion of the various stages somewhat shortened.

Rarely an eruption, resembling that at the vaccination site, appears on the vaccinated limb and even becomes general upon the body, due to urticaria or to inoculation, through scratching.

The special treatment of an attack of smallpox is largely a matter of careful nursing. A physician or nurse can scarcely lay claim to any great degree of heroism in caring for smallpox patients, as there is no danger of contracting the disease providing a successful vaccination has been recently performed upon them. The patient should be quarantined in an isolated building, and all unnecessary articles should be removed from the sick room, in the way of carpets and other furnishings. It is well that the room be darkened to save irritation of the eyes. The diet should be liquid: milk, broths, and gruels. Laudanum, fifteen drops, or paregoric, one tablespoonful in water, may be given to adults, once in three hours, to relieve pain during the first few days. Sponging throughout the course of the disease is essential; first, with cool water, as directed for scarlet fever, with the use of cold on the head to relieve the itching, fever, and delirium. The cold pack is still more efficient. To give this, the patient is wrapped in a sheet wrung out in water at a temperature between 68° and 75° F. The sheet surrounds the naked body from feet to neck, and is tucked between the legs and between the body and arms; the whole is then covered with a dry blanket, and a cold, wet cloth or ice cap is placed upon the head. The patient may be permitted to remain in the pack for an hour, when it may be renewed, if necessary, to allay fever and restlessness; otherwise it may be discontinued. The cold sponging or cold pack are indicated when the temperature is over 102.5° F., and when with fever there are restlessness and delirium. Great cleanliness is important throughout the disease; the bedclothes should be changed daily and the patient sponged two or three times daily with warm water, unless fever is high. Cloths wet with cold carbolic-acid solution (one-half teaspoonful to the pint of hot water) should be kept continuously on the face and hands. Holes are cut in the face mask for the eyes, nose, and mouth, and the whole covered with a similar piece of oil silk to keep in the moisture. Such applications give much relief, and to some extent prevent pitting. The hair must be cut short, and crusts on the scalp treated with frequent sponging and applications of carbolized vaseline, to soften them and hasten their falling. The boric-acid solution should be dropped into the eyes as recommended for measles, and the throat sprayed every few hours with Dobell's solution. Diarrhea in adults may be checked with teaspoonful doses of paregoric given hourly in water. Vaseline and cloths used on a patient must not be employed on another, as boils are thus readily propagated. All clothing, dishes, etc., coming in contact with a patient must be boiled, or soaked in a two-per cent carbolic-acid solution for twenty-four hours, or burned. When the patient is entirely free from scabs, after bathing and putting on disinfected or new clothes outside of the sick room, he is fit to reËnter the world.

CHICKENPOX.—Chickenpox is a contagious disease, chiefly attacking children. While it resembles smallpox in some respects, at times simulating the latter so closely as to puzzle physicians, it is a distinct disease and is in no way related to smallpox. This is shown by the fact that chickenpox sometimes attacks a patient suffering with, or recovering from, smallpox. Neither do vaccination nor a previous attack of smallpox protect an individual from chickenpox. Chickenpox is not common in adults, and its apparent presence in a grown person should awaken the liveliest suspicion lest the case be one of smallpox, since this mistake has been frequently made, and with disastrous results, during an epidemic of mild smallpox. One attack of chickenpox usually protects against another, but two or three attacks in the same individual are not unknown. The disease may be transmitted from the patient to another person from the time of the first symptom until the disappearance of the eruption. The disease ordinarily occurs in epidemics, but occasionally in isolated cases.

Development.—A period of two weeks commonly elapses after exposure to the disease before the appearance of the first symptom of chickenpox, but this period may vary from thirteen to twenty-one days.

Symptoms.—The characteristic eruption is often the first warning of chickenpox, but in some cases there may be a preliminary period of discomfort, lasting for a few hours, before the appearance of the rash; particularly in adults, in whom the premonitory symptoms may be quite severe. Thus, there may be chilliness, nausea, and even vomiting, rarely convulsions in infants, pain in the head and limbs, and slight fever (99° to 102° F.) at this time. The eruption shows first on the body, in most cases, especially the back. It consists of small red pimples, which rapidly develop into pearly looking blisters about as large as a pea to that of the finger nail, and are sometimes surrounded by a red blush on the skin. These blisters vary in number, from a dozen or so to two hundred. They do not run together, and in three to four days dry up, become shriveled and puckered, and covered with a dark-brown or blackish crust, and drop off, leaving only temporary red spots in most cases. The fever usually continues during the eruption. During the first few days successive fresh crops of fresh pimples and blisters appear, so that while the first crop is drying the next may be in full development. This forms one of its distinguishing features when chickenpox is compared with smallpox. In chickenpox the eruption is seen on the unexposed skin chiefly, but may occur on the scalp and forehead, and even on the palms, soles, forearms, and face. In many cases the eruption is found in the mouth, on its roof, and the inside of the cheeks. The blisters rarely contain "matter" or pus, as in smallpox, unless they are scratched. Scratching may lead to the formation of ugly scars and should be prevented, especially when the eruption is on the face. Pitting rarely occurs.

Determination.—The discrimination between chickenpox and smallpox is sometimes extremely puzzling and demands the skill of an experienced physician. When one is unavailable, the following points may serve to distinguish the two disorders: smallpox usually begins like a severe attack of grippe, with pain in the back and head, general pains and nausea or vomiting, with high fever (103° to 104° F.) These last two or three days, and may completely subside when the rash appears. In chickenpox preliminary discomfort is absent, or lasts but a few hours before the eruption. The eruption of smallpox usually occurs first on the forehead, near the hair, or on the palms of the hands, soles of the feet, the arms and legs, but is usually sparse on the body. The eruption appears about the same time in smallpox and not in successive crops, as in chickenpox. Chickenpox is more commonly a disease of childhood; smallpox attacks all ages. The crusts in chickenpox are thin, and appear in four or five days, while those of smallpox are large and yellow, and occur after ten or twelve days.

Outlook.—Chickenpox almost invariably results in a rapid and speedy recovery without complications or sequels. The young patients often feel well throughout the attack, which lasts from eight to twelve days.

Treatment.—Children should be kept in bed during the eruptive stage until the blisters have dried. To prevent scratching, the calamine lotion may be used (Vol. II, p. 145), or carbolized vaseline, or bathing with a solution of baking soda, one teaspoonful to the pint of tepid water. The diet should be that recommended for German measles. Patients should be kept in the house and isolated until all signs of the eruption are passed, and then receive a good bath and fresh clothing before mingling with others. The sick room should be thoroughly cleaned and aired; thorough chemical disinfection is not essential.

The services of a physician are always desirable in order that it may be positively determined that the disease is not a mild form of smallpox.

CHAPTER II

Infectious Diseases

Typhoid Fever—How it is Contracted—Complications and Sequels—Rest, Diet, and Bathing the Requisites—Mumps—Whooping Cough—Erysipelas.

TYPHOID FEVER (ENTERIC FEVER).—Through ignorance which prevailed before the discovery of the germ of typhoid fever and exact methods for determining the presence of the same, the term was loosely applied and is to this day. Thus mild forms of typhoid are called gastric fever, slow fever, malarial fever, nervous fever, etc., all true typhoid in most cases; while typhoid fever, common to certain localities and differing in some respects from the typical form, is often named after the locality in which it occurs, as the "mountain fever" common to the elevated regions of the western United States. This want of information is apt to prevail in regions remote from medical centers, and leads to neglect of the necessary strict measures for the protection of neighboring communities, for the excretion of one typhoid patient has led to thousands of cases and hundreds of deaths.

Typhoid fever is a communicable disease caused by a germ which attacks the intestines chiefly, but also invades the blood, and at times all the other parts of the body, and is characterized by continued fever, an eruption, tenderness and distention of the bowels, and generally diarrhea. It is common to all parts of the earth in the temperate zones, and occurs more frequently from July to December in the north temperate zone, from February to July in the south temperate zone. It is most prevalent in the late summer and autumn months and after a hot, dry summer. Individuals between the ages of fifteen and thirty are more prone to typhoid fever, but no age is exempt. The sexes are almost equally liable to the disease, although it is said that for every four female cases there are five male cases. The robust succumb as readily as the weak.

Cause and Modes of Communication.—While the typhoid germ is always the immediate cause, yet it is brought in contact with the body in various ways. Contamination of water supply through bad drainage is the principal source of epidemics of typhoid. Before carefully protected public water supplies were in vogue in Massachusetts, there were ninety-two deaths from typhoid fever in 100,000 inhabitants, while thirty-five years after town water supplies became the rule, there were only nineteen deaths for the same population. Whenever typhoid is prevalent, the water used for drinking and all other household purposes should be boiled, and uncooked food should be avoided. Flies are carriers of typhoid germs by lighting on the nose, the mouth, and the discharges of typhoid patients, and then conveying the germs to food, green vegetables, and milk. Cooking the food, preventing contact of flies with the patients, and keeping flies out of human habitations becomes imperative. Milk is a source of contagion through contaminated water used to wash cans, or to adulterate it, or through handling of it by patients or those who have come in contact with patients. Oysters growing in the mouths of rivers and near the outlets of drains and sewers are carriers of typhoid germs, and, if eaten raw, sometimes communicate typhoid fever. Dust is an occasional medium of communication of the germ. It is probable, however, that the germ always enters the body by being swallowed with food or drink, and does not enter through the lungs. There is little doubt on this point. Ice may harbor the germ for many months, for freezing does not kill it, and epidemics have been traced to this source. Clothing, wood, utensils, door handles, etc., which have been contaminated by contact with discharges from patients, may also prove mediums of communication of the typhoid germ to healthy individuals. Typhoid germs escape from patients sick with the disease chiefly in the bowel discharges and urine, sometimes in the sweat, saliva, and vomited matter.

Sewer gas and emanations from sewage and filth will not communicate typhoid fever directly, but the latter afford nutriment for the growth of the germ, and after becoming infected, may eventually come in contact with drinking water or food, and so prove dangerous. Improper care of discharges of excrement and urine—with the assistance of flies—are responsible for the enormous typhoid epidemics in military camps, so that in the late Spanish-American War one-fifth of all our soldiers in camp contracted the disease. In the upper layers of the soil typhoid germs may live for six months through frosts and thaws. The disease is preventable, and will probably be stamped out in time. In some of the most thickly populated cities in the world, as in Vienna, its occurrence is most infrequent, owing to intelligent sanitary control and pure water supply, while in the most salubrious country districts its inroads are the most serious and fatal through ignorance and carelessness.

Development.—From eight to twenty-three days elapse from the time of entrance of typhoid germs into the body before the patient is taken sick. One attack usually protects one against another, but two or three attacks are not unheard of in the same person.

Symptoms.—Typhoid fever is subject to infinite variations, and it will here be possible only to outline what may be called a typical case. In a work of this kind the preliminary symptoms are of most importance in warning one of the probability of an attack, so that the prospective patient can govern himself accordingly, as in no other disease is rest in bed of more value. Patients who persist in walking about with typhoid fever for the first week or so are most likely to die of the disease.The average duration of the disease is about one month. During the first week the onset is gradual, the temperature mounting a little higher each day—as 99.5° F. the first evening, 101° the second, 102° the fourth, 104° the fifth, 105° the sixth, and 105.5° the seventh. In the morning of each day the temperature is usually about a degree or more lower than that of the previous night. From the end of the first week to the beginning of the third the temperature remains at its highest point, being about the same each evening and falling one or two degrees in the morning. During the third week the temperature gradually falls, the highest point each evening being a degree or so lower than the previous day, while in the fourth week the temperature may be below normal in the morning and a degree or so above normal at night. So much for this symptom. After the entrance of typhoid germs into the bowels and before the recognized onset of the disease, there may be lassitude and disinclination for exertion. The disease begins with headache, backache, loss of appetite, sometimes a chill in adults or a convulsion in children, soreness in the muscles, pains in the belly, nosebleed, occasional vomiting, diarrhea, coated tongue, often some cough, flushed face, pulse 100, gradually increasing as described.

These symptoms are, to a considerable extent, characteristic of the beginning of many acute diseases, but the gradual onset with constant fever, nosebleed, and looseness of the bowels are the most suggestive features. Then, if at the end of the first week or ten days pink-red spots, about as large as a pin head, appear on the chest and belly to the number of two or three to a dozen, of very numerously, and disappear on pressure (only to return immediately), the existence of typhoid fever is pretty certain. Headache is now intense. These rose spots—as they are called—often appear in crops during the second and third weeks, lasting for a few days, then departing.

During the second week there is often delirium and wandering at night; the headache goes, but the patient is stupid and has a dusky, flushed face. The tongue becomes brownish in color, and its coat is cracked, and the teeth are covered with a brownish matter. The skin is generally red and the belly distended and tender. Diarrhea is often present with three to ten discharges daily of a light-yellow, pea-soup nature, with a very offensive odor. Constipation throughout the disease is, however, not uncommon in the more serious cases. The pulse ranges from 80 to 120 a minute.

During the third week, in cases of moderate severity, the general condition begins to improve with lowering of the temperature, clearing of the tongue, and less frequent bowel movements. But in severe cases the patient becomes weaker, with rapid, feeble pulse, ranging from 120 to 140; stupor and muttering delirium; twitching of the wrists and picking at the bedclothes, with general trembling of the muscles in moving; slow, hesitating speech, and emaciation; while the urine and fÆces may be passed unconsciously in bed. Occasionally the patient with delirium may require watching to prevent him from getting out of bed and injuring himself. He may appear insane.

During the fourth week, in favorable cases, the temperature falls to normal in the morning, the pulse is reduced to 80 or 100, the diarrhea ceases, and natural sleep returns.

Among the many and frequent variations from the type described, there may be a fever prolonged for five or six weeks, with a good recovery. Chills are not uncommon during the disease, sometimes owing to complications. Relapse, or a return of the fever and other symptoms all over again, occurs in about ten per cent of the cases. This may happen more than once, and as many as five relapses have been recorded in one patient. A slight return of the fever for a day or two is often seen, owing to error in diet, excitement, or other imprudence after apparent recovery. Death may occur at any time from the first week, owing to complications or the action of the poison of the disease. Pneumonia, perforation of and bleeding from the bowels are the most frequent dangerous complications. Unfavorable symptoms are continued high fever (105° to 106° F.), marked delirium, and trembling of the muscles in early stages, and bleeding from the bowels; also intense and sudden pain with vomiting, indicating perforation of the intestines. The result is more apt to prove unfavorable in very fat patients, and especially so in persons who have walked about until the fever has become pronounced. Bleeding from the bowels occurs in four to six per cent of all cases and is responsible for fifteen per cent of the deaths; perforation of the bowels happens in one to two per cent of all cases and occasions ten per cent of the deaths.

Detection.—It is impossible for the layman to determine the existence of typhoid fever in any given patient absolutely, but when the symptoms follow the general course indicated above, a probability becomes established. Unusual types are among the most difficult and puzzling cases which a physician has to diagnose, and he can rarely be absolutely sure of the nature of any case before the end of the first week or ten days, when examination of the blood offers an exact method of determining the presence of typhoid fever. Typhoid fever—especially where there are chills—is often thought to be malaria, when occurring in malarial regions, and may be improperly called "typhoid malaria." There is no such disease. Rarely typhoid fever and malaria coexist in the same person, and while this was not uncommon in the soldiers returning from Cuba and Porto Rico, it is an extremely unusual occurrence in the United States. Examination of the blood will determine the presence or absence of both of these diseases.

Complications and Sequels.—These are very numerous. Among the former are diarrhea, delirium, mental and nervous diseases, bronchitis, pleurisy, pneumonia, ear abscess, perforation of and hemorrhage from the bowels, inflammation of the gall bladder, disease of heart, kidney, and bladder, and many rarer conditions, depending upon the organ which the germ invades. Among sequels are boils, baldness, bone disease, painful spine, and, less commonly, insanity and consumption. While convalescence requires weeks and months, the patient often gains greatly in flesh and feels made over anew, as in fact he has been to a great extent, through the destruction and repair of his organs.

Outlook.—The death rate varies greatly in different epidemics and under different conditions. During the Spanish-American War in the enormous number of cases—over 20,000—the death rate was only about seven per cent, which represents that in the best hospitals of this country and in private practice. Osler states that the mortality ranges from five to twelve per cent in private practice, and from seven to twenty per cent in hospital practice, because hospital cases are usually advanced before admission. The chances of recovery are much greater in patients under fifteen years, and are also more favorable between the twenty-second and fortieth years.

Treatment.—There is perhaps no disease in which the services of a physician are more desirable or useful than in typhoid fever, on account of its prolonged course and the number of complications and incidents which may occur during its existence. It is the duty of the physician to report cases of typhoid to the health authorities, and thus act as a guardian of the public health. If, however, in any circumstances one should have the misfortune to have the care of a typhoid patient remote from medical aid, it is a consolation to know that the outlook is not greatly altered by medicine or special treatment of any sort. There have been epidemics in remote parts of this country where numbers of persons have suffered with typhoid without any professional care, and yet with surprisingly good results. Thus, in an epidemic occurring in a small community in Canada, twenty-four persons sickened with typhoid and received no medical care or treatment whatever, and yet there was but one death. The essentials of treatment are comprised in Rest, Diet, and Bathing. Rest to the extent of absolute quiet in the horizontal position, at the first suspicion of typhoid, is requisite in order to avoid the dangers of bleeding and perforation of the bowels resulting from ulceration of structures weakened by the disease. The patient should be assisted to turn in bed, must make no effort to rise during the sickness, and should pass urine and bowel discharges into a bedpan or urinal under cover. In case of bleeding from the bowels, the bedpan should not be used, but the discharges may be received for a time in cloths, without stirring the patient.

Diet.—This should consist chiefly of liquids until a week after the fever's complete disappearance. A cup of liquid should be given every two hours except during a portion of the sleeping hours. Milk, diluted with an equal amount of water, forms the chief food in most cases unless it disagrees, is refused, or is unobtainable.

In addition to milk, albumen water—white of raw egg, strained and diluted with an equal amount of water, and flavored with a few drops of lemon juice or with brandy—is valuable; also juice squeezed from raw beef—in doses of four tablespoonfuls—coffee, cocoa, and strained barley, rice, or oatmeal gruel, broths, unless diarrhea is marked and increased by the same. Soft custard, jellies, ice cream, milk-and-flour porridge, and eggnog may be used to increase the variety. Finely scraped raw or rare beef, very soft toast, and soft-boiled or poached eggs are allowable after the first week of normal temperature, at the end of the third or fourth week of the disease, and during the course of the disease under circumstances where the fluids are not obtainable or not well borne. An abundance of water should be supplied to the patient throughout the disease.

Bathing.—The importance of cold, through the medium of water, in typhoid fever accomplishes much, both in reducing the temperature and in stimulating the nervous system and relieving restlessness and delirium. Bathing is usually applied when the temperature rises above 102.5° F., and may be repeated every two or three hours if restlessness, delirium, and high temperature require it.

The immersion of patients in tubs of cold water, as practiced with benefit in hospitals, is out of the question for use by inexperienced laymen. The patient should have a woven-wire spring bed and soft hair mattress, over which is laid a folded blanket covered by a rubber sheet. Sponging the naked body with ice water will suffice in some cases; in others, when the temperature is over 1021/2° F., enveloping the whole body in a sheet wet in water at 65°, and either rubbing the surface with ice or cloths wet in ice-cold water, for ten or fifteen minutes, is advisable. Rubbing of the skin of the chest and sides is necessary during the application of cold to prevent shock. The use of a cold cloth on the head and hot-water bottle at the feet, during the sponging, will also prove beneficial. In children and others objecting to these cold applications, the vapor bath is effective. For this a piece of cheese cloth (single thickness) is wet with warm water—100° to 105°—and is wrapped about the naked body from shoulders to feet, and is continually wet by sprinkling with water at the temperature of 98°. The evaporation of the water will usually, in fifteen to twenty minutes, cool the body sufficiently if the patient is fanned continuously by two attendants. In warm weather the patient should only be covered with a sheet for a while after the bath, which should reduce the temperature to 3°. Hot water at the feet, and a little brandy or whisky given before the sponging if the pulse be feeble, will generally prevent a chill. Patients should be gently dried after the bath and covered with dry bedclothing. The utmost care should be taken not to agitate a feeble patient during sponging.

The long period of lying in bed favors the occurrence of bedsores. These are apt to appear about the lower part of the spine, and begin with redness of the skin, underneath which a lump may be felt. Constant cleanliness and bathing with alcohol, diluted with an equal amount of water, will tend to prevent this trouble, while moving the patient so as to take the pressure off this region and avoiding any rumpling of the bedding under his body are also serviceable, as well as the ring air cushion. Medicine is not required, except for special symptoms, and has no influence either in lessening the severity of or in shortening the disease. Brandy or whisky diluted with water are valuable in severe cases, with muttering delirium, dry tongue, and feeble pulse; it is not usually called for before the end of the second week, and not in mild cases at any time. A tablespoonful of either, once in two to four hours, is commonly sufficient. Pain and distention of the belly are relieved by applying a pad over the whole front of the belly—consisting of two layers of flannel wrung out of a little very hot water containing a teaspoonful of turpentine—and covered by a dry flannel bandage wrapped about the body. Also the use of white of egg and water, and beef juice, instead of milk, will benefit this condition.

Diarrhea—if there are more than four discharges daily—may be checked by one-quarter level teaspoonful doses of bismuth subnitrate, or teaspoonful doses of paregoric, once in three hours. Constipation is relieved by injections of warm soapsuds, once in two days. Bleeding from the bowels must be treated by securing perfect quiet on the patient's part, and by giving lumps of ice by the mouth, and cutting down the nourishment for six hours. Fifteen drops of laudanum should be given to adults, if there is restlessness, and some whisky, if the pulse becomes feeble, but it is better to reserve this until the bleeding has stopped. Patients may be permitted to sit up after a week of normal temperature, but solid food must not be resumed until two or three weeks after departure of fever, and then very gradually, avoiding all coarse and uncooked vegetables and fruit.

The greatest care must be exercised by attendants to escape contracting the disease and to prevent its communication to others. The bowel discharges must be submerged in milk of lime (one part of slaked lime to four parts of water), and remain in it one hour before being emptied. The urine should be mixed with an equal amount of the same, or solution of carbolic acid (one part in twenty parts of hot water), and the mixture should stand an hour before being thrown into privy or sewer. Clothing and linen in contact with the patient must be soaked in the carbolic solution for two hours. The patient's expectoration is to be received on old muslin pieces, which must be burned. The bedpan and eating utensils must be frequently scalded in boiling water. The attendant should wash his hands always after touching the patient, or objects which have come in contact with patient or his discharges, and thus will avoid contagion. If farm or dairy workers come in contact with the patient, the latter precaution is especially important. If there is no water-closet in the house, the disinfected discharges may be buried at least 100 feet from any well or stream. Typhoid fever is only derived from the germs escaping in the urine, and in the bowel, nose, or mouth discharges of typhoid patients.

MUMPS.—Mumps is a contagious disease characterized by inflammation of the parotid glands, situated below and in front of the ears, and sometimes of the other salivary glands below the jaw, and rarely of the testicles in males and the breasts in females.

Swelling and inflammation of the parotid gland also occur from injury; and as a complication of other diseases, as scarlet fever, typhoid fever, etc.; but such conditions are wholly distinct from the disease under discussion. Mumps is more or less constantly prevalent in most large cities, more often in the spring and fall, and is often epidemic, attacking ninety per cent of young persons who have not previously had the disease. It is more common in males, affecting children and youths, but rarely infants or those past middle age. One attack usually protects against another.

Development.—A period of from one to three weeks elapses, after exposure to the disease, before the first signs develop. The germ has not yet been discovered, and the means of communication are unknown. The breath has been thought to spread the germs of the disease, and mumps can be conveyed from the sick to the well, by nurses and others who themselves escape.

Symptoms.—Sometimes there is some preliminary discomfort before the apparent onset. Thus, in children, restlessness, peevishness, languor, nausea, loss of appetite, chilliness, fever, and convulsions may usher in an attack. Mumps begins with pain and swelling below the ear on one side. Within forty-eight hours a large, firm, sensitive lump forms under the ear and extends forward on the face, and downward and backward in the neck. The swelling is not generally very painful, but gives a feeling of tightness and disfigures the patient. It makes speaking and swallowing difficult; the patient refuses food, and talks in a husky voice; chewing causes severe pain. After a period of two to four days the other gland usually becomes similarly inflamed, but occasionally only one gland is attacked. There is always fever from the beginning. At first the temperature is about 101° F., rarely much higher than 103° or 104°. The fever continues four or five days and then gradually declines. The swelling reaches its height in from two to five days, and then after forty-eight hours slowly subsides, and disappears entirely within ten to fourteen days. The patient may communicate the disease for ten days after the fever is past, and needs to be isolated for that period. Earache and noises in the ear frequently accompany mumps, and rarely abscess of the ear and deafness result. The most common complication occurs in males past puberty, when, during recovery or a week or ten days later, one or both testicles become painful and swollen, and this continues for as long a time as the original mumps. Less often the breasts and sexual organs of females are similarly affected.

Complications and Sequels.—Recovery without mishap is the usual result in mumps, with the exception of involvement of the testicles. Rarely there are high fever, delirium, and great prostration. Sometimes after inflammation of both testicles in the young the organs cease to develop, and remain so, but sexual vigor is usually retained. Sometimes abscess and gangrene of the inflamed parotid gland occur. Recurring swelling and inflammation of the gland may occur, and permanent swelling and hardness remain. Meningitis, nervous and joint complications are among the rarer sequels.

Treatment.—The patient should remain in bed while the fever lasts. A liquid diet is advisable during this time. Fever may be allayed by frequent sponging of the naked body with tepid water. High fever and delirium demand the constant use, on the head, of the ice cap (a rubber bag, made to fit the head, containing ice). The relief of pain in the swollen gland is secured by the frequent application of a thick layer of sheet cotton, large enough to cover the whole side of the neck, wrung out of hot water and covered with oil-silk or rubber sheeting, with a bandage to retain it in place.

Paregoric may be given for the same purpose—a tablespoonful for adults; a teaspoonful for a child of eight to ten, well diluted with water, and not repeated inside of two hours, and not then unless the pain continues unabated. Inflammation of the testicles demands rest in bed, elevation of the testicle on a pillow after wrapping it in a thick layer of absorbent cotton, or applying hot compresses, as recommended for the neck. After the first few days of this treatment, adjust a suspensory bandage, which can be procured at any apothecary shop, and apply daily the following ointment: guiacol, sixty grains; lard, one-half ounce, over the swollen testicle.

WHOOPING COUGH.—A contagious disease characterized by fits of coughing, during which a whooping or crowing sound is made following a long-drawn breath. Whooping cough is generally taken through direct contact with the sick, rarely through exposure to the sick room, or to persons or clothing used by the sick. The germ which causes the disease is probably in the mucus of the nose and throat. Whooping cough is usually more or less prevalent in all thickly settled civilized communities, at times is epidemic, and often follows epidemics of measles. It occurs chiefly in children from six months to six years of age. Girls and all weak and delicate subjects are slightly more susceptible to the disease. Some children are naturally immune to whooping cough. One attack usually protects against another.

Development.—A variable period elapses between the time of exposure to whooping cough and the appearance of the first symptoms. This may be from two days to two weeks; usually seven to ten days.

Symptoms.—Whooping cough begins like an ordinary cold in the head, with cough, worse at night, which persists. The coughing fits increase and the child gets red in the face, has difficulty in getting its breath during them, and sometimes vomits when the attack is over. After a variable period, from a few days to two weeks from the beginning of the cough, the peculiar feature of the disease appears. The child gives fifteen or twenty short coughs without drawing breath, the face swells and grows blue, the eyeballs protrude, the veins stand out, and the patient appears to be suffocating, when at last he draws in a long breath with a crowing or whooping sound, which gives rise to the name of the disease. Several such fits of coughing may follow one another and are often succeeded by vomiting and the expulsion of a large amount of phlegm or mucus, which is sometimes streaked with blood. In mild cases there may be six to twelve attacks in twenty-four hours; in severe cases from forty to eighty. The attacks last from a few seconds to one or two minutes. Occasionally the whoop comes before the coughing fit, and sometimes there may be no whooping at all, only fits of coughing with vomiting. Between the attacks, puffiness of the face and eyes and blueness of the tongue persist. The coughing fits and whooping last usually from three to six weeks, but the duration of the disease is very variable. Occasionally it lasts many months, especially when it occurs in winter. The contagiousness of whooping cough continues about two months, or ceases before that time with the cessation of the cough. Oftentimes there may be occasional whooping for months; or, after ceasing altogether for some days, it may begin again. In neither of these conditions is the disease considered still contagious after two months. When an attack of whooping is coming on, the child often seems to have some warning, as he seems terrified and suddenly sits up in bed, or, if playing, grasps hold of something, or runs to his mother or nurse. Coughing fits are favored by emotion or excitement, by crying, singing, eating, drinking, sudden change of temperature, and by bad air.

Complications and Sequels.—These are many and make whooping cough a critical disease for very young children. Bronchitis and pneumonia often complicate whooping cough in winter, and diarrhea frequently occurs with it in summer. Convulsions not infrequently follow the coughing fits in infants, and, owing to the amount of blood forced to the head during the attacks, nosebleed and dark spots on the forehead and surface of the eyes appear from breaking of small blood vessels in these places. Severe vomiting and diarrhea occasionally aggravate the case, and pleurisy and consumption may occur. The violent coughing may permanently damage the heart. Rupture of the lung tissue happens from the same cause, and paralysis sometimes follows breaking of a blood vessel in the brain. But in the vast majority of cases in children over two years old no dangerous sequel need be feared.

Outlook.—Owing to the numerous complications, whooping cough must be looked upon as a very serious disease, especially in infants under two years, and in weak, delicate children. It causes one-fourth of all deaths among children, the death rate varying from three to fifteen per cent in different times and under different circumstances. For this reason a physician's services should always be secured when possible.

Treatment.—A host of remedies is used for whooping cough, but no single one is always the best. It is often necessary to try different medicines till we find one which excels. Fresh air is of greatest importance. Patients should be strictly isolated in rooms by themselves, and it is wise to send away children who have not been exposed. Morally, parents are criminally negligent who allow their children with whooping cough to associate with healthy children. If the coughing fits are severe or there is fever, children should be kept in bed. Usually there is not much fever; perhaps an elevation of a degree or two at first, and at times during the disease. Otherwise, children may be outdoors in warm weather, and in winter on warm, quiet days. Sea air is especially good for them. It is best that the sick should have two rooms, going from one to the other, so that the windows in the room last occupied may be opened and well ventilated. Fresh air at night is especially needful, and the patient should sleep in a room which has been freshly aired. The temperature should be kept at an even 70° F., and the child should not be exposed to draughts. Vaporizing antiseptics in the sick room has proved beneficial. A two per cent solution of carbolic acid in water is useful for this purpose, or a substance called vapo-cresoline, with which is sold a vaporizing lamp and directions for use. A one per cent solution of resorcin, or of hydrogen dioxide, diluted with four parts of water, used in an atomizer for spraying the throat, every two hours, has given good results. In the beginning of the disease, before the whooping has begun, a mixture of paregoric and syrup of ipecac will relieve the cough, ten drops of the former with five of the latter, for a child of two years, given together in water every three hours. The bromide of sodium, five grains in water, every three hours during the day, for a child of two, is serviceable in relieving the fits of coughing in the day; while at night, two grains of chloral, not repeated, may be given in water at bedtime to secure sleep, in a child of two. The tincture of belladonna, in doses of two drops in water, three times daily, for a child of two, is also often efficacious. Quinine, given in the dose of one-sixth grain for each month of the child's age under a year; or in one and one-half grain doses for each year of age under five, is one of the older and more valuable remedies. It should be given three times daily in pill with jelly, or solution in water. Bromoform in doses of two drops for a child of two, and increasing to five drops for a child of six, may be given in syrup three times daily with benefit. Most of these drugs should be employed only with a doctor's advice, when this is possible. To sum up, use the vapo-cresoline every day. When no physician is available, begin with belladonna during the day, using bromide of sodium at night. If this fails to modify the whooping after five days' trial, use bromide and chloral. In severe cases use bromoform. During a fit of coughing and whooping, it is well to support the child's head, and if he ceases to breathe, he should be slapped over the face and chest with a towel wet with cold water. Interference with sleep caused by coughing, and loss of proper nourishment through vomiting, lead to wasting and debility. Teaspoonful doses of emulsion of cod-liver oil three times daily, after eating, are often useful in convalescence, and great care must be taken at this time to prevent exposure and pneumonia. Change of air and place will frequently hasten recovery remarkably in the later stages of the disease.

ERYSIPELAS.—Erysipelas is a disease caused by germs which gain entrance through some wound or abrasion in the skin or mucous membranes. Even where no wound is evident it may be taken for granted that there has been some slight abrasion of the surface, although invisible. Erysipelas cannot be communicated any distance through the air, but it is contagious in that the germs which cause it may be carried from the sick to the well by nurses, furniture, bedding, dressings, clothing, and other objects. Thus, patients with wounds, women in childbirth, and the newborn may become affected, but modern methods of surgical cleanliness have largely eliminated these forms of erysipelas, especially in hospitals, where it used to be common. Erysipelas attacks people of all ages, some persons being very susceptible and suffering frequent recurrences. The form which arises without any visible wound is seen usually on the face, and occurs most frequently in the spring. The period of development, from the time the germs enter the body until the appearance of the disease, lasts from three to seven days.

Erysipelas begins with usually a severe chill (or convulsion in a baby) and fever. Vomiting, headache, and general lassitude are often present. A patch of red appears on the cheeks, bridge of nose, or about the eye or nostril, and spreads over the face. The margins of the eruption are sharply defined. Within twenty-four hours the disease is fully developed; the skin is tense, smooth, and shiny, scarlet and swollen, and feels hot, and is often covered with small blisters. The pain is more or less intense, burning or itching occurs, and there is a sensation of great tightness or tension. On the face the swelling closes the eye and may interfere with breathing through the nose. The lips, ears, and scalp are swollen, and the person may become unrecognizable in a couple of days. Erysipelas tends to spread like a drop of oil, and the borders of the inflammatory patch are well marked. It rarely spreads from the face to the chest and body, and but occasionally attacks the throat. During the height of the inflammation the temperature reaches 104° F, or over. After four or five days, in most cases, erysipelas begins to subside, together with the pain and temperature, and recovery occurs with some scaling of the skin. The death rate is said to average about ten per cent in hospitals, four per cent in private practice. Headache, delirium, and stupor are common when erysipelas attacks the scalp. The appearance of the disease in other locations is similar to that described. Relapses are not uncommon, but are not so severe as the original attack. Spreading may extend over a large area, and the deeper parts may become affected, with the formation of deep abscesses and great destruction of tissue. Certain internal organs, heart, lungs, spleen, and kidneys, are occasionally involved with serious consequences. The old, the diseased, and the alcoholic are more apt to succumb, also the newborn. It is a curious fact that cure of malignant growths (sarcoma), chronic skin diseases, and old ulcers sometimes follows attacks of erysipelas.

Treatment.—The duration of erysipelas is usually from a few days to about two weeks, according to its extent. It tends to run a definite course and to recovery in most cases without treatment. The patient must be isolated in a room with good ventilation and sunlight. Dressings and objects coming in contact with him must be burned or boiled. The diet should be liquid, such as milk, beef tea, soups, and gruels. The use of cloths wet constantly with cold water, or with a cold solution of one-half teaspoonful of pure carbolic acid to the pint of hot water, or with a poisonous solution of sugar of lead, four grains to the pint, should be kept over small inflamed areas. Fever is reduced by sponging the whole naked body with cold water at frequent intervals. A tablespoonful of whisky or brandy in water may be given every two hours to adults if the pulse is weak. Painting the borders of the inflamed patch with contractile collodion may prevent its spreading. The patient must be quarantined until all scaling ceases, usually for two weeks.