Chapter 27

CARE OF PATIENTS WITH COMMUNICABLE DISEASES

The first chapter of this book described the ways in which communicable diseases are carried from person to person, and also some principles underlying methods of prevention. This chapter aims to show how these principles apply in the actual care of patients whose diseases are transmissible. In order to apply them intelligently, it is necessary to keep in mind certain facts in regard to the transmission of infections. A brief summary of these facts follows.

Disease germs are present in the bodies of persons suffering from communicable disease, but they may also exist in the bodies of persons in good health; if present in the body, they may leave it in any bodily discharge. While every kind of germ does not leave the body by all the different routes, it is nevertheless true that most germs expelled from the body are carried in discharges from the nose, throat, bladder or bowels. Germ-laden discharges of an infected person may be distributed to other persons by water, milk and other foods, by certain insects, by unclean hands, by common drinking cups, towels, handkerchiefs, and similar articles, and directly by nose and throat spray. After they have been thus conveyed to other persons, the germs make their entrance into the body of their new victims through the digestive tract, through the nose, throat, and other mucous membranes, or through breaks in the skin. Prevention of communicable diseases, therefore, depends upon the measure of success attained in blocking the transit of germs from person to person; but methods of prevention, though easy to understand, are unfortunately sometimes difficult to carry out. In order to carry them out effectively one must devote to the problem great accuracy, unremitting care, considerable intelligence, and a highly developed conscience.

Care of a patient suffering from transmissible disease is adequate only when it accomplishes two definite results. One result, which concerns the patient primarily, is to bring about his recovery as rapidly and as surely as possible; the other result, which concerns the community rather than the individual, is to make it impossible for the patient to infect others with his disease. In every case of communicable disease, from a slight cold in the head up to serious cases of pneumonia or typhoid fever, both the patient and the community must be constantly safe-guarded.

INCUBATION PERIOD.--The interval between the moment when pathogenic germs enter the body, and the time when symptoms first appear and the patient begins to feel ill, is called the incubation period. Incubation periods vary according to the disease from a few hours to two or three weeks. The length of the period also varies somewhat in different cases of the same disease.

CARE OF PATIENTS WITH COLDS OR OTHER SLIGHT INFECTIONS.--The usual symptoms of infectious diseases include fever, chill, sore throat, nasal discharge, cough, headache, vomiting and other digestive disturbances, and a general feeling of being sick all over. When one or more of these symptoms appear, unless they are very slight, a doctor should be sent for. The patient, whether child or grown person, should go to bed in a room alone and should stay in bed at least as long as the fever and symptoms of cold in the head continue, in order to protect others as well as himself. Persons in active life, it is true, are not always able to go to bed during colds; but there is no doubt that ultimately they would save time by doing so. It is especially necessary for children to remain in bed when suffering from colds, not only to insure their own well-being but also to protect others, since children are notably careless in regard to coughing, sneezing, and borrowing handkerchiefs. The patient needs mental rest as well as physical, and should not be allowed to work in bed.

The patient's nose and throat discharges should be received only in material that can be burned, like old linen or muslin, gauze, or paper napkins. As soon as they are soiled these handkerchief substitutes should be placed in strong paper bags and afterward burned. Soiled handkerchiefs lurking under pillows or in other parts of the bed may infect other people or re-infect the patient. Handkerchiefs that may not be burned should be placed as soon as soiled in a covered receptacle filled with cold water containing a little washing soda; when several have been collected they should be boiled in the same covered receptacle for 20 minutes. After boiling they may go to the regular laundry.

The patient's diet at first should be liquid or semi-solid. Large amounts of nourishment are not necessary during the first day or two, especially if the illness is likely to be short, but water should be taken as freely as possible. Cold drinks are generally acceptable during the feverish stage, but lemonade and other acids should be used with caution, since they sometimes irritate a sore throat. When the active symptoms have subsided the patient will need more food than usual, and a liberal, nourishing diet for a few days will do much to prevent the weakness and depressed vitality that often follow colds, tonsilitis, and other comparatively slight infections.

The bowels should be carefully regulated, and a mild cathartic is often beneficial at the outset.

Even during slight illness a patient should receive the daily care already described, and should be made as comfortable as possible. As in any illness, sponging and alcohol rubs are refreshing. An ice bag or cold compress may relieve headache, and hot applications or a cold compress on the throat are often soothing. The throat may be gargled with a solution of one teaspoonful of common salt dissolved in a pint of boiled water. If the patient perspires profusely he should be rubbed with a towel until dry, and provided with fresh warm, night clothes. An alcohol rub may well follow. It is most unwise for a patient who is perspiring freely to get up in a cold room and attend to himself.

Common colds are far more serious than they are usually supposed to be.

"More people suffer from common colds than from any other single ailment.... Could the sum total of suffering, inconvenience, sequelæ, and economic loss resulting from common colds be obtained, it would at once promote these infections from the trivial into the rank of the serious diseases.... Colds are contracted from other persons having colds, just as diphtheria is contracted from diphtheria. Arctic explorers exposed to all the conditions ordinarily supposed to produce colds do not suffer from these ailments until they return to civilization and become infected by contact with their fellowmen.... While common colds are never fatal, the complications and sequelæ are serious. These are rheumatic fever, pneumonia, sinusitis, nephritis, and a depressed vitality which favors other infections and hastens the progress of organic diseases.

"Common colds are perhaps most contagious during the early stages. If persons isolate themselves by remaining in bed during the first three days of a cold, they would not only benefit themselves, but would largely prevent the spread of the infection. The contagiousness and severity of colds differ in different epidemics and in different seasons of the year, depending upon the particular micro-organism involved and other factors not well understood.

"PREVENTION.--The prevention of colds consists, first in avoiding the infection, and, secondly, in guarding against the predisposing causes. Contact should be avoided with persons who have colds, especially in street cars, offices, and other poorly ventilated spaces where the risk of persons coughing or sneezing directly in one's face is imminent. Contact with the infection may further be guarded against by a careful self-education in sanitary habits and cleanliness, based upon the modern conception of contact infection.

"Colds, like other diseases conveyed in the secretions from the nose and mouth, are often conveyed by direct and indirect contact through lack of hygienic cleanliness and a disregard of sanitary habits. Kissing, the common drinking cup, the roller towel, pipes, toys, pencils, fingers, food, and other objects contaminated with the fresh secretions will transmit the disease."--("Preventive Medicine and Hygiene," Rosenau.)

CARE DURING MORE SERIOUS INFECTIONS.--When a patient is suffering from serious transmissible disease, he needs the most skillful care available, and for the sake of others he must be strictly isolated or quarantined. By isolating or quarantining a patient is meant making such arrangements that germs expelled by the patient are necessarily destroyed before they can enter the body of another person. Isolation, therefore, includes disinfection, and while methods vary according to the nature of the particular disease, yet the principles given below are applicable in most cases.

The first essential is that the patient should have a room to himself. No one except those caring for him should enter the sick-room for any purpose whatever; visitors should be rigidly excluded. At the outset all unnecessary articles should be removed from the sick-room, and it should be possible to boil, burn, scrub, or otherwise thoroughly clean everything allowed to remain. The windows should be screened in summer, and flies must be excluded. Fresh air is especially needed by patients with communicable diseases, and ventilation of the room must be adequate both day and night. Foul odors plainly indicate that the patient or something in the room is not clean. The remedy is obvious and deodorants are quite unnecessary if the patient and the room are properly cared for. It is highly desirable to reserve a bath room for the exclusive use of the patient and his attendant and also to reserve a room adjoining the patient's room for the exclusive use of the attendant. When it is impossible, as it often is, to give up so much space, each family must make the best arrangement it can to separate the patient and his attendant from the rest of the family.

The attendant must remember that her ten fingers are the ten most active agents in distributing the communicable diseases. After handling the patient or anything that the patient has touched, and whenever she leaves the patient's room, she must scrub her hands thoroughly with warm water, soap, and a nail brush. She should not soil her hands unnecessarily, even though she intends to scrub them later. She must remember for her own protection to keep her hands away from her mouth and face, and to cleanse them with special care just before eating. If disinfection is needed in addition to the scrubbing, she must use conscientiously whatever solution the doctor orders.

At the same time that she is caring for a patient with a communicable disease, the attendant ought not to care for children or other members of the family, she ought not to prepare food, and she ought not to handle dishes or utensils used by other persons. Every day, however, many women are doing just these things, and it is true that in many instances no bad results are observed. Yet if any arrangement to insure safety can possibly be made, it is inexcusable to run the risk of spreading diseases which kill thousands of persons every year and injure many more for life.

When home conditions render adequate care and strict isolation of the patient impossible, hospital care should be seriously considered. No personal or sentimental objections should be allowed to influence the decision, if removing the patient to a hospital is necessary to safeguard his welfare or the welfare of the family. Hospital care should be considered especially for patients with typhoid fever, because untrained persons cannot safely care for patients so seriously ill. Since a patient with typhoid needs skilled care, and since he greatly endangers other persons, most authorities consider hospital care essential unless the patient can have the continuous services of a trained nurse and almost ideal home conditions. Many cases of typhoid, it is true, are successfully nursed at home in extremely adverse conditions by visiting nurses; yet in few kinds of sickness is continuous care by a graduate nurse more necessary to protect the community as well as to safeguard the patient himself.

Members of a family in which there is typhoid should be immunized if the doctor advises it. This process, which is performed by the doctor, in the majority of cases renders a person immune to typhoid fever for three or four years.

The question of home or institutional care for persons with tuberculosis must also be carefully considered. In some cases tuberculosis may be cared for at home with comparative safety, and in some other cases the risk is not very great if the patient is intelligent, careful, and well supervised. But everyone should face the fact that all cases of tuberculosis of the lungs involve some risk to others in the family, and most cases involve great risk. The danger to children is greater than to adults. Most tuberculosis infections, it is now believed, are acquired in childhood. The bad results of an infection acquired in childhood may not show themselves for years, since the germs may remain inactive until the person's resistance is lowered by some unfavorable condition.

THE CHILDREN'S DISEASES.--The so-called children's diseases are probably the most familiar and the least regarded of all those belonging to the communicable group. Most persons, it is true, realize that scarlet fever is serious; everyone should also realize that measles and whooping-cough are serious. For example, in the State of New York during the year 1916, more children died from each of these diseases than from scarlet fever: in that year 745, or four times the number that died of scarlet fever, lost their lives from whooping-cough, while 913 died of measles. If diseases that kill hundreds of children every year are not serious, one is at a loss to know what a serious disease is.

Some parents even expose children unnecessarily to these infections on the fatalistic theory that they must have the diseases sometime, and therefore the sooner the better. Nothing could be more mistaken; the diseases are not inevitable, and there is no advantage whatever in having them if escape is possible. Moreover, serious as the children's diseases are in themselves, their after-effects may be even more serious. At this very moment hundreds of people are going through life handicapped by weakened hearts or kidneys, by defective sight or hearing, merely because their parents considered the children's diseases necessary. The common belief that children should have these diseases as early as possible is also erroneous, since statistics show that the younger the child the more likely is the disease to prove fatal.

Every mother should realize that the children's diseases are most infectious in the early stages. Early symptoms include fever, sore throat, and nasal discharge, and the trouble at first often resembles a severe cold. During this stage the diseases are most easily communicated. Measles in particular is generally not recognized until its most infectious stage has passed. The moral to be drawn is that sore throats, coughs, and colds should never be regarded lightly, and that their spread should be prevented by all possible means.

The accompanying table taken from the regulations of the New York State Department of Health, gives symptoms of communicable diseases among children, and rules for isolation and exclusion from school.

NEW YORK STATE DEPARTMENT OF HEALTH COMMUNICABLE DISEASES AMONG CHILDREN RULES FOR ISOLATION AND EXCLUSION FROM SCHOOL

HERMAN M. BIGGS, M.D. Commissioner

Issued by the Division of Public Health Education

======================================================================= DISEASE | PRINCIPAL SIGNS | METHOD OF | | AND SYMPTOMS | INFECTION | -------------+------------------------------+-------------------------+ CHICKENPOX | Rarely begins with fever. | Contact with discharges | | Rash appears on second day | from nose and throat of | | as small pimples, which in | a patient. | | about a day become filled | | | with clear fluid. This fluid | | | becomes yellow colored, a | | | crust forms and the scab | | | falls off in about 14 days. | | | Successive crops of papules | | | appear until tenth day. | | -------------+------------------------------+-------------------------+ DIPHTHERIA | Onset may be rapid or | Contact with discharges | | gradual. The back of the | from nose and throat, | | throat, tonsils, or palate | occasionally by | | may show patches. The most | drinking infected milk. | | pronounced symptom is sore | | | throat. There may be hardly | | | any symptoms at all. | | -------------+------------------------------+-------------------------+ MEASLES | Begins like cold in the | Contact with discharges | | head, with running nose, | from nose and throat | | sneezing, inflamed and | of a patient. | | watery eyes and fever. | | | Mulberry-tinted spots appear | | | about the third day; rash | | | first seen behind the ears, | | | on forehead and face. The | | | rash varies with heat; may | | | almost disappear if the air | | | is cold, and come out again, | | | with warmth. | | -------------+------------------------------+-------------------------+ MEASLES | Illness usually slight. | Same as above. | (LIBERTY) | Onset sudden. Lymph nodes in | | | back of neck enlarged. Rash | | | often first thing noticed; | | | no cold in head. Usually | | | have fever, sore throat, and | | | the eyes may be inflamed. | | | Rash sometimes resembles | | | measles and scarlet fever, | | | variable. | | -------------+------------------------------+-------------------------+ MUMPS | Onset may be sudden, | Same as above. | | beginning with sickness and | | | fever, and pain about the | | | angle of the jaw. The | | | parotid glands become | | | swollen and tender. Opening | | | the mouth is accompanied by | | | pain. | | -------------+------------------------------+-------------------------+ POLIOMYELITIS| Onset sudden, fever, | Contact with discharge | | excitable, pain on bending | from nose, throat or | | neck forward, pain on being | bowels of a patient | | handled, headache, vomiting. | or carrier. | | Sometimes sudden development | | | of weakness of one or more | | | muscle groups. | | -------------+------------------------------+-------------------------+ SCARLET | The onset is usually sudden, | Discharges from nose | FEVER | with headache, fever, sore | and mouth, suppurating | | throat, and often vomiting. | glands or ears of a | | Usually within twenty-four | patient. | | hours the rash appears as | Milk may convey | | fine, evenly diffused, and | infection. | | bright red dots under skin. | | | The rash is seen first on | | | the neck and upper part of | | | chest, and lasts three to | | | ten days, when it fades and | | | the skin peels in scales, | | | flakes, or even large | | | pieces. | | -------------+------------------------------+-------------------------+ SMALLPOX | Onset sudden usually with | All discharges of a | | fever and severe backache. | patient and particles | | About third day upon | of skin or scabs. | | subsidence of constitutional | | | symptoms red shot-like | | | pimples, felt below the | | | skin, and seen first about | | | the face and wrists most on | | | exposed surfaces, develop. | | | They form little blisters | | | and after two days more | | | become filled with yellowish | | | matter. Scabs form which | | | begin to fall off about the | | | fourteenth day. | | -------------+------------------------------+-------------------------+ SORE THROAT, | Begins with sore throat and | Discharges from nose | ACUTE, | weakness. Throat diffusely | and mouth of a | SEPTIC | reddened and may show | patient. | | patches like diphtheria. | | -------------+------------------------------+-------------------------+ WHOOPING | Begins with cough which is | Discharges from nose | COUGH | worse at night. Symptoms may | and mouth of a | | at first be very mild. | patient. | | Characteristic "whooping" | | | cough develops in about 2 | | | weeks, and the spasm of | | | coughing sometimes ends with | | | vomiting. | | ======================================================================= =============================================================== | EXCLUSION FROM SCHOOL | |-------+-------------------+--------------------+ | | OTHER CHILDREN | OTHER SCHOOL | | | OF SAME | CHILDREN | DISEASE | | HOUSEHOLD | ESPECIALLY EXPOSED | | +--------+----------+--------+-----------+ |Patient| | | | | | | Non- | | Non- | | | | immunes|Immunes[3]| immunes| Immunes[3]| | | | | | | -------------+-------+--------+----------+--------+-----------+ CHICKENPOX | Yes | Yes | No | Yes | No | -------------+-------+--------+----------+--------+-----------+ DIPHTHERIA | Yes | Yes | Yes | Yes | Yes | -------------+-------+--------+----------+--------+-----------+ MEASLES | Yes | Yes | No | Yes | No | -------------+-------+--------+----------+--------+-----------+ MEASLES | Yes | Yes | No | Yes | No | (LIBERTY) | | | | | | -------------+-------+--------+----------+--------+-----------+ MUMPS | Yes | Yes | No | Yes | No | -------------+-------+--------+----------+--------+-----------+ POLIOMYELITIS| Yes | Yes | Yes | Yes | Yes | -------------+-------+--------+----------+--------+-----------+ SCARLET | Yes | Yes | Yes | Yes | Yes | FEVER | | | | | | -------------+-------+--------+----------+--------+-----------+ SMALLPOX | Yes | Yes | Yes | Yes | No | -------------+-------+--------+----------+--------+-----------+ SORE THROAT, | Yes | No | No | No | No | ACUTE, | | | | | | SEPTIC | | | | | | -------------+-------+--------+----------+--------+-----------+ WHOOPING | Yes | Yes | No | Yes | No | COUGH | | | | | | =============================================================== ================================================================================ | DURATION OF EXCLUSION FROM DATE OF ONSET | +--------------+------------+-------------------------+------------+ | | PATIENT | PATIENT REMAINS | | | | GOES TO | ISOLATED AT | | | | HOSPITAL | HOME | | DISEASE | +------------+------------+------------+ | | PATIENT | Other | Other | Children | Children | | | children | children | who leave | exposed | | | of | who | household | at | | | the same | remain at | as soon as | school | | | household | home | disease is | | | | | | discovered | | ------------+--------------+------------+------------+------------+------------+ CHICKENPOX | Until all | Exclude if non-immune until |Exclude | | scabs are | 21st day after child last |from | | shed and | saw patient. |school if | | disinfection | |non-immune | | of person; | |during | | at least | |11th to 22d | | 12 days. | |days after | | | |child last | | | |saw patient.| ------------+--------------+--------------------------------------+------------+ DIPHTHERIA |Until | Until two cultures at least 24 | | |patient is | hours apart are reported | | |recovered | negative. Those showing | | |and has two | diphtheria bacilli should not | | |cultures | necessarily be immunized | | |from throat | unless symptoms appear. | | |and nose which| | | |contain no | | | |diphtheria | | | |bacilli; | | | |cultures not | | | |to be taken | | | |until 9 days | | | |from date of | | | |onset. | | | |Disinfection | | | |of person. | | | ------------+--------------+--------------------------------------+------------+ MEASLES | Until | Exclude non-immunes until |If | | recovery and | 15th day after child last |non-immune | | disinfection | saw patient. |exclude | | of person; | |from school | | at least 7 | |during 8th | | days from | |to 15th | | onset. | |day after | | | |child last | | | |saw patient.| ------------+--------------+--------------------------------------+------------+ MEASLES | Until | Exclude if non-immune until |Exclude from| (LIBERTY) | recovery and | 22d day after child last |school if | | disinfection | saw patient. |non-immune | | of person; | |during 11th | | at least 8 | |to 22d days | | days. | |after | | | |child last | | | |saw patient.| ------------+--------------+--------------------------------------+------------+ MUMPS |Two weeks | Exclude 15th to 22d day after |Exclude | |after onset | child last saw patient. |from 15th | |and one week | |to 22d day | |after | |after child | |disappearance | |last saw | |of swelling | |patient. | |and after | | | |disinfection | | | |of person. | | | ------------+--------------+------------+------------+------------+------------+ POLIO- | Until | 14 days | Until 14 | 14 days | | MYELITIS | patient is | from time | days | from time | | | recovered. | child | after | child | | | Disinfection | last saw | quarantine | last | | | of person at | patient. | raised. | saw | | | least 21 | | | patient. | | | days. | | | | | ------------+--------------+------------+------------+------------+------------+ SCARLET |At least 30 | Seven days | Until | Seven | | FEVER |days and until| from time | seven days | days from | | |discharges | child | after | time | | |have ceased | last saw | quarantine | child | | |and | patient. | raised. | last saw | | |disinfection | | | patient. | | |of person. | | | | | ------------+--------------+------------+------------+------------+------------+ SMALLPOX |Recovery and |Exclude if |Exclude if |Exclude if |Exclude 20 | |disinfection |non-immune |non-immune |non-immune |days unless | |of person |until 21st |until 20 |until 21st |they have | |at least 14 |day after |days after |day after |been | |days. |child last |quarantine |child last |successfully| | |saw patient,|has been |saw patient,|vaccinated | | |or 7 days |raised or |or 7 days |within 1 | | |after |7 days after|after |year in | | |successful |successful |successful |which | | |vaccination |vaccination |vaccination |case they | | |and |and |and |may return | | |disinfection|disinfection|disinfection|at once. | | |of person. |of person. |of person. | | ------------+--------------+------------+------------+------------+------------+ SORE THROAT,|Until | | | ACUTE, |recovery. | | | SEPTIC | | | | ------------+--------------+--------------------------------------+------------+ WHOOPING |Eight weeks | Fourteen days provided no cough | | COUGH |or until 1 | develops. | | |week after | | | |last | | | |characteristic| | | |cough and | | | |disinfection | | | |of person. | | | ================================================================================ ================================================================= DISEASE | Remarks | | | -------------+--------------------------------------------------+ CHICKENPOX | A mild disease and seldom any after effects. | -------------+--------------------------------------------------+ DIPHTHERIA | Very dangerous, both during attack and from | | after effects. When diphtheria occurs in a | | school all children suffering from sore throat | | should be excluded and the health officer | | notified. The medical school inspector or | | health officer should take cultures from all | | inflamed throats and noses. There is great | | variation of type, and mild cases are often | | not recognized, but are as infectious as | | severe cases. There is frequently no immunity | | from further attacks. | -------------+--------------------------------------------------+ MEASLES | After effects often severe. Period of greatest | | risk of infection three days, before and after | | the rash appears. Great variation in type | | of disease. Dangerous in children under 2 | | years of age. During an outbreak all children | | having a temperature over 99°F. should | | be sent home and the health officer notified. | -------------+--------------------------------------------------+ MEASLES | After effects slight. Regulations strict, | (LIBERTY) | because frequently confused with scarlet fever. | -------------+--------------------------------------------------+ MUMPS | Seldom leaves after effects. Very infectious. | | Inflammation of genital organs of male or | | female may occur. | -------------+--------------------------------------------------+ POLIOMYELITIS| Disease is most communicable in the early | | stages. After effect is paralysis of certain | | muscle groups, transitory or permanent. | | Death is due usually to paralysis of | | respiratory muscles. | -------------+--------------------------------------------------+ SCARLET | Dangerous both during attack and from after | FEVER | effects. Great variation in type of disease. | | Slight attacks are as infectious as severe | | ones. Many mild cases not diagnosed and | | many concealed. A second attack is rare. | | When scarlet fever occurs in a school, all | | cases of sore throat should be sent home and | | health officer notified. Most fatal in | | children under ten years. | -------------+--------------------------------------------------+ SMALLPOX | Peculiarly infectious. When smallpox occurs | | in connection with a school or with any of | | the children's homes all persons exposed | | must be vaccinated or quarantined for a | | period of 20 days. Cases of modified smallpox | | in vaccinated persons, may be, and often | | are, so slight as to escape detection. Fact | | of existence of disease may be concealed. | | Mild or modified smallpox is as infectious as | | severe type. | -------------+--------------------------------------------------+ SORE THROAT, | Often leads to serious results, affections of | ACUTE, | heart, kidneys, etc. Very apt to occur in | SEPTIC | epidemics due to milk contaminated by a | | patient suffering from the disease. | -------------+--------------------------------------------------+ WHOOPING | After effects often very severe and disease | COUGH | causes great debility. Relapses are apt to | | occur. Second attack rare. Specially | | infectious for first week or two. If a child | | vomits after a paroxysm of coughing, it is | | probably suffering from whooping cough. | | Great variation in type of disease. Often | | fatal in young children. | =================================================================

[3] Immunes are those who have had the diseases or in smallpox, who have been successfully vaccinated within a year.

DISINFECTION: The cleansing and disinfection of the person includes washing the entire body and the hair with soap and water; thorough brushing of the teeth; rinsing the mouth; gargling the throat, and douching and spraying the nose with an antiseptic solution; and finally, a complete change of clothing (or a change of underwear and a thorough shaking and brushing of the outer garments out of doors before these are put on again). (_Facing p. 247_)

It may be added that the ways by which poliomyelitis, or infantile paralysis, is spread are not definitely known at the time of writing. We are justified, however, in believing that investigation now in progress will make exact information available in the near future.

"The weight of present opinion inclines to the view that poliomyelitis is exclusively a human disease, and is spread by personal contact, whatever other causes may be found to contribute to its spread. In personal contact we mean to include all the usual opportunities, direct or indirect, immediate or intermediate, for the transference of body discharges from person to person, having in mind as a possibility that the infection may occur through contaminated food.

"The incubation period has not been definitely established in human beings. The information at hand indicates that it is less than two weeks, and probably in the great majority of cases between 3 and 8 days."--(Report of Special Committee on Infantile Paralysis, American Journal of Public Health, November 1916.)

DISINFECTION

Specific directions for disinfecting in every kind of communicable disease would be too extended to be given here. In each case the attendant should learn from the doctor just how that particular disease is communicated, just what discharges, utensils, linen, etc., need to be disinfected, and just what disinfectants he prefers to have used. The following general methods are now in use, but it must be remembered that from time to time new methods are devised and new disinfectants are discovered.

CARE OF NOSE AND THROAT DISCHARGES.--The care of handkerchiefs has already been described on page 239. Cloths or cotton used to wipe the eyes or to receive any other bodily discharge including vomitus, should be collected in the same way and burned. Everyone should be taught in early childhood to cover the nose and mouth with a handkerchief during coughing and sneezing; if the patient has not already learned to do so he must be taught now. If the amount of expectoration is great, waterproof receptacles should be provided, which should be burned with their contents.

CARE OF DISCHARGES FROM THE BOWELS AND BLADDER.--At the present time the following preparations are commonly used to disinfect stools and urine: 5% solution of carbolic acid; chloride of lime solution, made freshly whenever needed by mixing thoroughly ½ pound of chloride of lime with one gallon of water; and unslaked lime to which is added _hot_ water. The amount of carbolic solution used should be about equal in bulk to the amount of material to be disinfected; the chloride of lime solution should be at least twice, and the unslaked lime at least one-eighth the bulk. Fecal masses should be broken up so that the disinfectant may reach every part; they may be stirred with tightly twisted toilet paper, which should be left in the bedpan and disinfected with the stools. If these substances are used, disinfection is considered complete at the end of an hour, and the contents of the bedpan may then be emptied into the toilet with safety. It may be necessary to provide two bedpans so that one may be available for use while the contents of the other is being disinfected. Bedpans and urinals should be boiled daily and kept thoroughly clean at all times.

In places having no sewerage system, disinfected discharges may be emptied into a trench situated at a distance from the well, and then covered with earth. As an extra precaution, the disinfected discharges may be mixed with sawdust or kerosene and burned in the trench. Directions for installing a sanitary privy may be found in Bulletin 68 of the United States Public Health Service.

BATH WATER and water that has been used for cleansing the teeth and mouth may be disinfected in the same way as urine, or it may be emptied into a suitable receptacle and boiled ten minutes.

CARE OF THE HANDS.--Disinfectants for the hands should be used in addition to scrubbing with soap and water, not as a substitute. The hands may be disinfected after scrubbing by soaking them for three minutes in one of the following solutions: alcohol 70%, carbolic acid solution 2½%, or a solution made by adding one teaspoonful of lysol or of creolin to a pint of water. These disinfectants are poisons if taken internally; the bottles must be carefully labeled and kept in a safe place. It is a good plan to wear rubber gloves when handling infective material; the gloves should afterward be boiled for ten minutes.

CARE OF UTENSILS.--A sufficient number of dishes, spoons, tumblers, basins, etc. must be reserved for the patient's exclusive use; these utensils must be washed separately and dried with towels not used for other dishes. Mistakes frequently occur by which other persons use the patient's dishes, and in consequence his dishes should not be kept in the cupboard with other dishes; if no other safe place can be found, they had better stay in the patient's room covered with a clean cloth or napkin. The dishes should be scalded daily and at the termination of the illness they must be boiled briskly for ten minutes before they are returned to general use. Food left on the patient's tray should be burned; it should not be eaten by any one else, nor placed in the pantry or refrigerator with other food.

CARE OF LINEN.--A satisfactory way to disinfect towels, night gowns, bed linen, etc. is to place the articles immediately in a wash boiler filled with cold water to which a little washing soda has been added, and then to boil them in the same water for twenty minutes; they can afterward go safely into the regular laundry. The boiling may be done once a day; articles soiled in the meantime may be left to soak in the cold water and soda.

DISINFECTION OF THE PERSON.--"The cleansing and disinfection of the person includes washing the entire body and the hair with soap and water; thorough brushing of the teeth; rinsing the mouth; gargling the throat, and douching and spraying the nose with an antiseptic solution; and finally, a complete change of clothing (or a change of underwear) and a thorough shaking and brushing of the outer garments out-of-doors before these are put on again."--(New York State Department of Health.)

TERMINATION OF QUARANTINE.--After the patient has recovered, he and the attendant should, if the doctor thinks it necessary, disinfect themselves as directed above before they mingle again with other people. The exact time when it is safe for a person to come out of quarantine and resume ordinary life varies in different diseases. Moreover, opinion differs in regard to quarantine periods for the same diseases, so that the regulations of Boards of Health in different cities show wide variations. It is of course impossible to say at just what moment every patient, or even the majority of patients, will stop expelling germs. Quarantine periods are intended to protect the community as completely as possible without causing unnecessary hardship to individuals. In any given case, the local regulations should be strictly observed but release from quarantine is not a guarantee that the patient is not still discharging germs, and extreme care should still be taken to prevent the spread of saliva and other discharges.

TERMINAL DISINFECTION.--A room that has been occupied by a patient with a communicable disease should be thoroughly cleaned at the termination of the illness. Dishes, utensils, bed linen, etc. should be cared for in the ways already described. The floor, bedstead, and other furniture should be washed with hot water, soap, and washing soda. The walls, windows, etc., should be wiped with a cloth wrung out of hot water, soap suds, and soda. The mattress, unless badly soiled with discharges, should be scrubbed with the same solution and a stiff brush, and left out-of-doors in the sunshine for a day or two, or until dry. If badly soiled, it is best to destroy the mattress unless the Board of Health has facilities for steam sterilization. Ordinary washing is all that is generally required for blankets, but if badly soiled they should be sterilized by steam or burned. The room should then be thoroughly sunned and aired for a day or two, with the windows wide open both day and night. Sunning and airing are among the most important measures in disinfecting a room, and should not be slighted. If there has been gross pollution, as when a careless consumptive persists in spitting on the floor and walls, it may be necessary to remove the old paint and paper and have the room done over. The room may safely be occupied after all these measures have been taken.

FUMIGATION.--Many Boards of Health have abandoned fumigation after communicable diseases, except after those which like typhus and yellow fever, are carried by vermin or insects. Dry formaldehyde gas, which was formerly used for fumigation, has a violent effect on mucous membranes, but its power to kill bacteria, even on surfaces, appears to be weak, while its penetrating power is not sufficient to disinfect bedding, carpets, upholstered furniture, and other fabrics. Since fumigation is costly, troublesome, and ineffectual there seems to be no good reason for using it. Moreover, its use gives a false sense of security, so that really effective measures like sunning, airing, and scrubbing are likely to be neglected.

Theory and practice of disinfection, it is clear, have radically changed in recent years. Modern knowledge requires concurrent disinfection, or the destruction of germs from the moment when symptoms are first noticed; all the time, day and night, this disinfection must go on with unremitting care. Today wet sheets are not hung in doorways nor are chemicals left about in open dishes to disinfect quite harmless air, but scrupulous cleanliness at all stages of disease is recognized as one of the most important measures, if not the most important measure, in disinfection.

EXERCISES

1. Summarize the ways in which infectious diseases are spread.

2. What is meant by the incubation period? State the length of the incubation period in measles; Liberty measles; whooping-cough; scarlet fever; chicken-pox; diphtheria; mumps; typhoid fever.

3. Name some of the early symptoms common to most infectious diseases. If such symptoms appear, what should be done while waiting for the doctor to come?

4. Discuss the importance, prevention, and treatment of common colds.

5. What measures should be taken to isolate a patient who is suffering from a communicable disease?

6. What special care should the attendant of a patient with a communicable disease give to her own clothing and person?

7. Why are the children's diseases more serious in reality than they are commonly supposed to be?

8. Describe the symptoms of each of the following: Measles, scarlet fever, chicken-pox, mumps, whooping-cough, and diphtheria.

9. How should bowel and bladder discharges be disinfected?

10. How should dishes and other utensils be disinfected?

11. How should linen be disinfected?

12. Describe measures necessary for concurrent disinfection.

13. Describe measures necessary for terminal disinfection.

FOR FURTHER READING

Preventive Medicine and Hygiene--Rosenau.

The New Public Health--Hill, Chapters VII-XVII.

Essentials of Medicine--Emerson, Chapters XII-XV.

Health and Disease--Roger I. Lee, Chapter X-XIV.

Disease and Its Causes--Councilman, Chapters V-IX.

Publications of the New York State Department of Health, Albany, entitled: The Teacher and Communicable Disease; A Method for the Control of Communicable Diseases in Schools; Regulations and Instructions for Cleansing and Disinfection; The Conduct of an Isolation Period for Communicable Disease in a Home; Tuberculosis; Typhoid Fever; Scarlet Fever; Measles; Whooping-cough; Diphtheria; Poliomyelitis, Acute Anterior (Infantile Paralysis); Smallpox; Septic Sore Throat; Venereal Diseases. (Any of the above pamphlets will be sent upon receipt of a three cent stamp.)