Part 27

Sanitary Care of the Household Articles.--Dishes must be isolated, washed, dried separately and boiled daily. Thermometers must be isolated, kept in a corrosive sublimate solution one to one thousand, which must be removed daily. Linen when soiled must be soaked in carbolic acid, one cup of carbolic acid to twenty of water, for two hours before being sent to the laundry. Stools must be thoroughly mixed with an equal amount of milk of lime and allowed to stand for one hour. Urine must be mixed with an equal amount of carbolic acid, one to twenty, and allowed to stand one hour. Bed pans, urinals, must be isolated and scalded after each time of using. Syringes and rectal tubes must be isolated, and the latter boiled after using. (See Nursing Department). Tubs should be scrubbed daily, canvasses changed daily and soaked in carbolic acid as the linen is. Hands must be scrubbed and disinfected after giving tubs or rubbing over typhoid fever patients. Blankets, mattresses, and pillows must be sterilized after use in steam sterilizer. I know some people have not all the necessary conveniences, especially in the country, but the greatest care must be taken. A professional nurse was once taking care of a very severe case of typhoid for me. I was continually cautioning her to be more careful of herself. She did not heed it, and finally took the disease and battled eight long weeks with it, before there was much improvement. Careful nursing and a well regulated diet are the essentials in a majority of cases. Put the patient in a well ventilated room, and confine him to the bed from the beginning, and have him remain there until well. The woven wire bed with soft hair mattress, upon which there are two folds of blanket, combines the two great qualities of a sick bed, smoothness and elasticity. A rubber cloth should be placed under the sheet. An intelligent nurse should be in charge; when this is impossible, the attending physician should write out special instructions, regarding diet, treatment of the discharges and of the bed linen.

Much of the above on typhoid is from the world-wide authority, Dr. Osler, and should be-followed in all cases if possible.

Diet and Nursing in Typhoid Fever.--Milk is the most suitable food. Three pints every twenty-four hours may be given when used alone, diluted with water or lime-water.

The stools will show if the milk is digested. Peptonized milk, if not distasteful, may be used. Curds are seen in the stools if too much milk is given and is undigested. Mutton or chicken broth or beef juice can be used; fresh vegetable juices can be added to these, instead of milk. The animal broths are not so good when diarrhea is present. Some patients will take whey, buttermilk, kumiss, when ordinary milk is distasteful. Thin barley gruel well strained is an excellent food for this disease. Eggs may be given, either beaten up in milk or better still, in the form of albumin water, This is prepared by straining the whites of eggs through a cloth and mixing them with an equal quantity of water, which may be flavored with lemon. Water can be given freely; iced tea, barley water, or lemonade may be used, and there is no objection to weak coffee or cocoa in moderate quantities. Feed the patient at stated intervals. In mild cases it is well not to arouse the patient at night. When there is stupor, the patient should be aroused for food at the regular intervals night and day. Do not give too much food. I once had a case in which I did not give more than one quart of liquid food in four weeks, as it distressed her. She made a good recovery on plenty of water.

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Cold Sponging.--The water may be warm, cool, or ice cold, according to the height of the fever. A thorough sponge bath should take from fifteen to twenty minutes. The ice cold sponging is quite as formidable as the full cold bath, for which there is an unsuperable objection in private practice.

The Bath.--This should be given under the doctor's directions, and I will not describe it.

Medical Treatment.--Little medicine is used in hospital practice. Nursing is the important essential in typhoid fever.

Management of the Convalescent.--An authority writes, My custom has been not to allow solid food until the temperature has been normal for ten days. This is, I think, a safe rule, leaning perhaps to the side of extreme caution; but after all with eggs, milk toast, milk puddings, and jellies, the patient can take a fairly varied diet. You cannot wait too long before you give solid foods, particularly meats, They are especially dangerous. The patient may be allowed to sit up for a short time about the end of the first week of convalescence, and the period may be prolonged with a gradual return of strength. He should move about slowly, and when the weather is favorable should be in the open air as much as possible. Keep from all excitement. Constipation now should be treated with an enema. A noticeable diarrhea should restrict the diet to milk and the patient be confined to the bed. There are many who cannot have a professional nurse. Good nursing is necessary in typhoid fever. Any sensible person who is willing to follow directions can do well. But she must do as the doctor directs.

These are some things you need to do: Look out for bad symptoms; twitching of the tendons, grasping at imaginary things are bad symptoms. Inform the doctor and soon. Never allow the patient to sit up in bed. The stool must be passed lying flat and you must place the bed pan without the patient's aid. Bleeding may be started by the least exertion. I knew of one woman who lost her life through necessity of getting up and passing the stool sitting on a chamber. Bleeding came on suddenly, and before the doctor could get there she was nearly gone. Cough and sudden pain in the lungs need prompt attention. I dismissed a boy on one Wednesday as convalescent. That night it became suddenly cold and he became chilled. The mother sent for me the next day, and we pulled him through pneumonia. Suppose she had waited another day? She was not that kind of a mother. Your greatest trial will come in convalescence, when the patient is so hungry. Be careful or you will kill the patient by kindness. A minister I knew killed himself by going against the doctor's orders and eating a hearty dinner. The doctor was rather profane, and when he went to see the preacher, after the relapse caused by the dinner, he relieved his mind in no gentle manner. Again allow no visitors in the sick room or one adjacent. They are an abomination. Many people are killed by well-intentioned ignoramuses. Do not whisper; the Lord save the patient who has a whisperer for a nurse. I cannot urge too strongly proper nursing in this disease. It is an absolute necessity. A nurse to be successful must have good sense and also must obey all directions. A diet is a necessity in this disease. The patient must not move any more than is absolutely necessary for his comfort. He must never try to help move himself. The muscles of the abdomen must remain lax and quiet. The danger, I think, is in the bowels. The mucous covering in the interior is inflamed and ulcerated, and there is always some danger of the ulceration eating through the coating into the blood vessels, causing more or less bleeding and even eating the bowel enough to cause an opening (perforation) and the escape of the bowel contents into the abdominal cavity causing inflammation of the peritoneum (peritonitis) and almost certain death. Walking typhoid is dangerous for that reason. The food must be of such nature that it is all digested. It must not leave lumps to press upon the sore places in the bowels causing more trouble there and more diarrhea.

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TYPHUS FEVER, (Filth Disease).--Typhus fever is an acute, infectious disease, characterized by a sudden onset, marked nervous symptoms, and spotted rash and fever ending quickly after two weeks. Also called jail, camp, hospital, or ship fever. Filth has a great deal to do with its production. There is no real characteristic symptom except the eruption.

Symptoms.--It generally lasts two weeks. Incubation period of twelve days or less, marked at times by slight weary feeling. The onset is usually sudden, by one chill or several, with high fever, headache, pain in back and legs, prostration, vomiting, and mild and active delirium. Pulse does not have the double beat, often there is bronchitis.

Eruption.--"This appears on the third to fifth day; the fever remaining high. During the second week all the symptoms increase and are weakening with marked delirium and coma vigil" (unconscious, delirious, but with the eyes open). When death occurs it usually comes at the end of the second week from exhaustion. Favorable cases terminate at this time by crisis; the prostration is extreme; but convalescence is rapid.

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Fever.--Sudden onset to even 104 to 105 degrees; steady rise for four or five days with slight morning remissions; terminating by crisis on the twelfth to fourteenth day, falling in some cases below normal; in fatal cases there is a rapid rise to 108 or 109 degrees. The eruption appears on the abdomen on the third to fifth day.

Treatment like Typhoid.--Mortality, twelve to twenty per cent.

SMALLPOX or Variola.--Smallpox is an acute infectious disease. It has a sudden onset with a severe period of invasion which is followed by a falling of the fever, and then the eruption comes out. This eruption begins as a pimple, then a watery pimple (vesicle) which runs into the pus pimple (pustule) and then the crust or scab forms. The mucous membrane in contact with the air may also be affected. Almost all persons exposed, if not vaccinated, are almost invariably attacked. It is very contagious. It attacks all ages, but it is particularly fatal to young children.

Cause.--An unknown poison in the contents of the pustules or crusts in secretion and excretion, apparently, and in the exhalations of the lungs and skin; one attack does not always confer immunity for life. It is contagious from an early period. Direct contact does not seem to be necessary, for it can be carried by one who does not have it.

Symptoms.--Incubation lasts from ten to fourteen days, and is usually without symptoms. Invasion comes suddenly with one or more chills in adults, or convulsions in children, with terrible headache, very severe pain in the back and extremities, vomiting, the temperature rising rapidly to 103 or 104 degrees.

Eruptions.--This usually appears on the fourth day as small red papules on the forehead, along the line of the hair and on the wrists, spreading within twenty-four hours over the face, extremities, trunk and mucous membrane.

Symptoms of fever diminish with the appearance of the rash, which is most marked on the face and ripens first there. The papules become hollowed vesicles and a clear fluid fills them on the fifth or sixth day. They fill with pus about the eighth day, and their summits become globular, while the surrounding skin is red, swollen and painful. The general bodily symptoms again return and the temperature rises for about twenty-four hours. Drying of the eruption begins the tenth or eleventh day. The pustules dry, forming crusts, while the swelling of the skin disappears and the temperature gradually falls. The crusts fall off, leaving scars only where the true skin has been destroyed.

Confluent form.--All the symptoms are more severe. The eruption runs together and all the skin is covered.

Varioloid.--This is smallpox modified by vaccination. The invasion may be sudden and severe. It is usually mild and gradual, but with severe pain in the back and head. A scanty eruption of papules, often only on the face and hands, appears on the third or fourth day, with disappearance of constitutional symptoms.

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Treatment.--Vaccinate the children the second or third month, and all persons about every six years, and always after exposure to the disease or during epidemics. Put the patient in a room cleared of all furniture, carpets, curtains, rugs, etc.; keep the patient thoroughly clean, and the linen should be frequently changed. The bed clothing should be light. Disinfect and sterilize everything thoroughly that has been in contact with the patient. Get a good experienced nurse, and one who has been around the disease.

Diet.--Give the supporting diet early. During the first stage give milk, broths of different kinds, albumin water. Relieve the intense thirst by water and lemonade. When the first (initial) fever subsides and the patient feels improved, give milk, eggs, chops, steak, or rare roast meat, bread or toast; vegetables, such as potato, spinach, celery, asparagus tips, cauliflower tops. When the second fever returns go back to the liquid diet again, and give regularly and as much as possible every two or three hours during the day, and every three or four hours during the night. Milk, plain or peptonized; milk punch, raw eggs, broths, beef juice. If swallowing is difficult, give food cold and oftener, and in less quantity. Increase the diet rapidly during convalescence.

Cold drinks should be freely given. Barley water and oatmeal water are nutritious and palatable. Milk broths, and articles that give no trouble to digest.

Nursing.--Nursing is the main thing. The bowels should be kept open with salts. There is no special medicine we can claim will do good. Aconite may be used for the fever at first, in drop doses every hour for twenty-four hours. But the least medicine that is given the better it will generally be.

There is, I believe, something in protecting the ripening papules from the light. The constant application on the face and hands of lint soaked in cold water, to which antiseptics such as carbolic acid or bichloride may be added, is perhaps the most suitable treatment. It is very pleasant for the patient at least, and for the face it is well to make a mask of lint which can be covered with oiled silk. When the crusts begin to form, the chief point is to keep them thoroughly moist, which may be done with oil or glycerin; vaselin is particularly useful, and at this stage can be freely used upon the face. It frequently relieves the itching also. For the odor, which is sometimes so characteristic and disagreeable, the diluted carbolic acid solutions are probably the best. If the eruption is abundant on the scalp the hair should be cut short. During, convalescence frequent bathing is advisable. It should be done daily, using carbolic soap freely in order to get rid of the crusts and scabs. There is danger to others as long as the skin is not smooth and clean, and not free from any trace of scabs. As you must have a physician, I give but little medical treatment. Nursing is the main thing in this disease.

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General Rules for Disinfection.--The walls, woodwork, and ceiling may be cleaned by washing with one to one thousand solution of corrosive sublimate solution, or a five per cent carbolic acid solution, Or by rubbing with bread if solutions would injure. All dust must be removed. Plastered walls and ceilings may be white-washed. Woodwork must then be scrubbed with soap and thoroughly wiped. Then fumigate, at least three pounds of sulphur should be burned in the room for each 1,000 cubic feet of space. Placing it in a pan supported in another containing water to guard against fire. After scrubbing or fumigating, the room and its contents should be freely aired for several days, admitting sunlight if possible. All useless articles and badly soiled bedding should be burned. Such pieces of clothing as will not be injured may be boiled or soaked in a one to one thousand formaldehyde solution (one ounce of twelve per cent solution in one gallon of water), or two per cent carbolic acid solution. Clothing, bedding, etc., may be disinfected in the steam sterilizer.

Hands, Body, etc.--Special outer garments may be worn while in the sick room and removed, and clothing aired before leaving. Hands of the attendant should be washed in one to one thousand corrosive sublimate solution.

Vaccination and Re-vaccination and its Prevention of Smallpox. We quote in part from an article prepared by the State of Michigan. It is well known that smallpox can be prevented or modified by vaccination; and a widespread epidemic of the disease can be attributed only to an equally widespread ignorance or willfulness concerning smallpox and its prevention by vaccination and re-vaccination.

A Good Time to be Vaccinated.--Smallpox is usually most prevalent in the winter and spring months, reaching the highest point in May. The rarity of smallpox in Michigan for several years led to a feeling of security and to neglect vaccination, resulting in an increased proportion of inhabitants not protected by recent vaccination. This made possible a widespread epidemic. The proper preventive of such an epidemic is general vaccination and re-vaccination of all persons not recently thus protected. There is no better settled fact than that vaccination does protect against smallpox. But after a time the protection is weakened, therefore after a lapse of five years there should be re-vaccination.

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Why Vaccinate.--Because vaccination is a preventive of all forms of smallpox, and because by traveling, or by travelers, by articles received in the mail or from the stores or shops, or other various ways anyone at any time, may, without knowing it, be exposed to smallpox, it becomes important so far as possible without injury to health to render every person incapable of taking the disease. This may be done so perfectly by vaccination and re-vaccination with genuine bovine vaccine virus that no question of ordinary expense or trouble should be allowed for a day to prevent the careful vaccination of every man, woman and child in Michigan, and the re-vaccination of every one who has not been vaccinated within five years. It is well established that those who have been properly vaccinated are far less likely to take smallpox if exposed to it, and that the very few who have been properly vaccinated and have smallpox have it in a much milder form and are much less disfigured by it than those who have not been thus vaccinated. The value of vaccination is illustrated by the following facts: On March the 13th, 1859, Dr. E. M. Snow, of Providence, R. 1., found in a cluster of seven houses twenty-five families, and in these families ten cases of smallpox, all apparently at about the same stage of the disease. In the same families there were twenty-one children, who had never been vaccinated. The ten cases and the remaining members of the families, including the twenty-one children, were quarantined at home, and the children were all vaccinated and compelled to remain with the sick. Several other cases of smallpox occurred in the persons previously exposed, but not one of the twenty-one children referred to had the slightest touch of the disease.

In Sweden, the average number of deaths in each year from smallpox per million inhabitants was:

Before the introduction of vaccination (1774-1801), 1,973; During the period of optional vaccination (1802-1816), 479; And during the period of obligatory vaccination (1817-1877), 189.

Vaccination was introduced in England near the beginning of the nineteenth century, and since 1853 compulsory vaccination has been attempted. In England the number of deaths in each year from smallpox per one million inhabitants was:

At the close of the eighteenth century, 3,000. From 1841 to 1853 (average), 304. From 1854 to 1863 (average), 171.

Smallpox entirely prevented by re-vaccination.--In the Bavarian army re- vaccination has been compulsory since 1843. From that date till 1857, not even a single case of unmodified smallpox occurred, nor a single death from smallpox. During the year of duty, Dr. Marson, physician of the London Smallpox Hospital, has never observed a single case of smallpox in the officers and employees of the hospital, who are re-vaccinated when they enter the service, and who are constantly exposed to the infection.

"Out of more than 10,000 children vaccinated at Brussels with animal lymph, from 1865 to 1870, and who went through the terrible epidemic of smallpox, which in 1870 and 1871 frightened the world, not a single one was to my knowledge reported as being attacked by the disease. The same immunity was shared by those, a much larger number, whom I had re-vaccinated and who at the same time were living in epidemic centers."--Dr. Warlemont, of Brussels.

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Who should be Vaccinated.--Everybody, old and young, for his own interest, and that he may not become a breeding place for the distribution of smallpox to others, should seek that protection from smallpox which is afforded by vaccination alone. It is believed that all persons except those mentioned in the following paragraph may, if the operation is properly performed, at the proper time, and with pure bovine virus, be vaccinated with perfect safety to themselves. Even those who have had smallpox should be vaccinated, for otherwise they may take the disease; and it seems to be proved that a larger proportion, of those who have smallpox a second time, die than of those who have the disease after vaccination.

Who should not be Vaccinated.--Unless exposure to smallpox is believed to have taken place or likely to take place, teething children, pregnant women, persons suffering from measles, scarlet fever, erysipelas, or susceptible to and recently exposed to one of these diseases, persons suffering with skin diseases or eruption, and in general feeble persons not in good health, should not be vaccinated. In all cases in which there is any doubt as to the propriety of vaccinating or postponing vaccination the judgment of a good physician should be taken. The restriction, as to vaccinating teething children makes it important that children should be vaccinated before the teething process has begun, because smallpox is very much more dangerous than vaccination. Smallpox is exceedingly dangerous to pregnant women.

When should a person be Vaccinated.--The sooner the better as a rule, and especially whenever there is much liability of exposure to smallpox. Children should be vaccinated before they are four months old; those who have never been vaccinated, should, except teething children, be vaccinated at once. Because the vaccination often loses its protective power after a time, those who have been vaccinated but once or twice should, in order to test and to increase the protective power of the former vaccination, be vaccinated again, and as often as the vaccination can be made to work. In general, to insure full protection from smallpox, one should be vaccinated as often as every five years. It has been found that of those who have smallpox the proportion of deaths is very much less among those who have three or four good vaccination scars than among those who have but one scar.