Chapter 13

INFECTIOUS OR CONTAGIOUS DISEASES

Rules to be Observed in the Treatment of Contagious Diseases--What Isolation Means--The Contagious Sick Room--Conduct and Dress of the Nurse--Feeding the Patient and Nurse--How to Disinfect the Clothing and Linen--How to Disinfect the Urine and Feces--How to Disinfect the Hands--Disinfection of the Room Necessary--How to Disinfect the Mouth and Nose--How to Disinfect the Throat--Receptacle for the Sputum--Care of the Skin in Contagious Diseases--Convalescence After a Contagious Disease--Disinfecting the Sick Chamber--The After Treatment of a Disinfected Room--How to Disinfect the Bed Clothing and Clothes--Mumps--Epidemic Parotitis--Chicken Pox--Varicella--La Grippe--Influenza--Diphtheria--Whooping Cough--Pertussis--Measles--Koplik's Spots--Department of Health Rules in Measles--Scarlet Fever--Scarlatina--Typhoid Fever--Various Solutions--Boracic Acid Solution--Normal Salt Solution--Carron Oil--Thiersch's Solution--Solution of Bichloride of Mercury--How to Make Various Solutions.

RULES TO BE OBSERVED IN THE TREATMENT OF CONTAGIOUS DISEASES

Every mother should know the elementary principles involved in the treatment of contagious diseases. They are contagious because they may be conveyed from one individual to another or because a person nursing a victim of a contagious disease may carry that disease to another person without having the disease herself. For this reason, certain rules have been established by the medical profession, which experience has taught are necessary in order to preserve the health of the community when such diseases are prevalent.

The very first rule to which the physician will direct the mother's attention, when there is a contagious disease, will be that the child must be "isolated."

What Isolation Means.--Isolation means the complete seclusion of the patient in a room by himself, so that no one will see him or come in contact with him except the physician and the nurse or mother who will tend him during the entire course of the disease. Isolation implies more than it would seem to mean. It implies that every article used during the sickness will be thoroughly disinfected before it leaves the room in which the patient himself is isolated. Mothers must always remember that every article used by the patient may carry the germs of the disease to some other member of the family or to some other individual. These articles are the clothing of the child, the bedclothes, napkins, handkerchiefs, towels, dishes, knives and spoons, rags, the various discharges--sputum, urine, and bowel passages--and, we may add to this list, flies, insects, and domestic animals. Every precaution must, therefore, be taken to safeguard any dissemination of the disease by means of these articles.

Thorough isolation also implies that the nurse shall frequently bathe and disinfect her person and her clothing, and that the sick-room itself shall be carefully dusted with a moist cloth and disinfected from time to time.

The Contagious Sick-Room.--The contagious sick-room will be prepared in exactly the same way as the ordinary sick-room which has been previously described. In addition, however, it will be safeguarded in the following manner. A wet sheet will be hung up outside the door. This sheet will be kept constantly moistened with a solution of chloride of lime. One-half pound to an ordinary house-pail of water is the strength of the solution to use. Every window must be effectively screened to prevent the ingress and egress of flies and other insects.

Conduct and Dress of the Nurse.--She will remain in the sick-room all the time unless when she takes outdoor exercise. Her dress will consist of a long gown which will entirely cover her person from the neck to the shoes and will be of plain, white, easily washed material, without tucks or ruffles or adornment of any kind. She should wear an ordinary pair of house slippers made of light leather. Her cap will be large enough to cover and include her hair and head. When she leaves the room, she will remove her cap, gown, and slippers, disinfect her hands in a disinfecting solution and wash her face, neck, and hands in soap and water. She should go directly out and in, without coming in contact with any occupant of the home.

Feeding the Patient and Nurse.--The meals for the patient and nurse should be left on a table outside the door of the sick-room, from which place the nurse will then take them into the room. The utensils used for these meals should not be used by other members of the family during the entire sickness. After the patient and nurse have eaten, the utensils should be placed in a chloride of lime solution for disinfection. If any of the food is left over it should be put into a jar in which it may be disinfected and rendered harmless before being disposed of.

How to Disinfect the Clothing and Linen.--All bed and body linen, towels, handkerchiefs, napkins, etc., should be immediately put into a large receptacle--a wash boiler, or tub, will answer the purpose admirably--containing a five per cent. solution of carbolic acid in which an adequate quantity of soft soap has been dissolved. They should remain in this mixture for two hours, after which they may be wrung out and taken to the laundry.

How to Disinfect the Urine and Feces.--The urine and the stools should be passed into vessels containing a solution of four ounces of carbolic acid to the gallon of water. This vessel should be covered and the mixture allowed to stand for one hour, after which time it may be thrown out.

How to Disinfect the Hands.--Any of the following solutions may be used for disinfection of the nurse's hands: Creolin, one teaspoonful to the quart of water; chloride of lime, one-half pound to a pail of water; formalin, thirty-two drops to a quart of water. A basin containing one of the above solutions should be constantly kept standing for the frequent disinfection of the nurse's hands. After disinfection, the hands should be washed in plain water and soap.

Disinfection of Room Necessary.--The room in which a contagious patient is confined requires systematic attention on the part of the nurse. Every other day all flat or projecting surfaces should be disinfected. Mantels, window-sills, door knobs, picture moldings, furniture, chairs, and bed-railings, should be wiped with cloths moistened in a disinfecting solution. A suitable solution for this purpose is one containing one ounce of carbolic acid to the quart of water.

How to Disinfect the Mouth and Nose.--In the course of all contagious diseases the mouth and throat of the patient and nurse should be thoroughly disinfected as a matter of routine. It should be done at least twice daily unless more frequent disinfection is called for because of the nature of the disease. In measles and diphtheria, for example, the nasal and throat conditions will undoubtedly call for more frequent and more thorough disinfection than twice daily. This may also apply to scarlet fever if the throat is involved as is often the case.

Pocket handkerchiefs should never be used by a patient suffering from a contagious disease. The nose and mouth should be wiped with pieces of gauze or cheesecloth, cut into small squares for this purpose. These should be immediately burned after being used.

To disinfect the throat, a solution of formalin, six drops to six ounces of water, is effective. To disinfect the nose, a solution of Glyco-Thymoline is suitable. These applications should be made by means of an atomizer, a different atomizer being used for the patient and nurse.

Receptacle for the Sputum.--A cuspidor, or basin, should be constantly kept at the side of the bed in which the patient may conveniently expectorate. This utensil should contain the chloride of lime solution previously mentioned.

Care of the Skin in Contagious Diseases.--As in all other sick conditions, the skin of the patient should be bathed frequently with an alcoholic solution. In the later stages of measles and scarlet fever it is essential to anoint the skin while the patient is scaling. This may be done with carbolated vaseline. Mothers should understand why this is necessary. These diseases have a distinct rash or eruption. This eruption practically kills the skin cells and at a certain period these cells are cast off by the new growth of skin underneath. This process is called scaling. In measles the scales are small, and are cast off in the form of bran like dust. In scarlet fever, the cells adhere together and are cast off in large scales. These scales are contagious. They are very light and will float in the air if dry. The movement of the patient, changing the bed clothing, etc., will waft a multitude of these contagious scales into the air of the room and infect every article they may land on. This would make the disinfection of the room difficult and tedious. In order to obviate this tendency experience has taught us that much of the difficulty and nearly all of the risk of contagion may be overcome by rubbing some oily or sticky substance on the skin. By this method the dust and scales are rendered heavier than the air, stick together and will not float. During the scaling period there is a constant itch present which irritates the little patient. By using carbolated vaseline to anoint the skin we accomplish two purposes. The carbolic acid in the vaseline relieves the itch, and the vaseline itself greases the skin so that the scales remain in the bed. Each day the nurse changes the bed-sheet, gathers the scales in the sheet and puts all in the disinfecting solution.

Convalescence After a Contagious Disease.--Complete isolation must be kept up until all danger from contagion is passed. In diphtheria this period is not reached until the examination of the throat contents under the microscope is returned negative. In diseases Which have a rash this period is not reached until all scaling is completed. Even then, and for a number of days or weeks, the patient may be taken out for exercise daily, but must not be allowed to play with other children until his strength justifies active exercise. It takes a much longer period to rid the system of the poison of a contagious disease than most mothers appreciate. Many children have died from heart failure after they were considered well simply because the active exercise overtaxed the heart before the system was wholly free from the poison of the disease.

Before the child is removed from the sick-room for the first time he should have a disinfecting bath. This bath should be in a solution of bichloride of mercury, the strength of which should be one part to five thousand parts of water. The towels used to dry the patient after the bath should be fresh and should not have been in the sick-room. He should then be dressed in clothing which has never been in the sick-room.

DISINFECTING THE SICK-CHAMBER

How to Disinfect a Room.--The most efficient way to disinfect a room is by means of formaldehyde gas. This, however, requires a special apparatus which can only be used by one familiar with the process. In all large cities the Department of Health usually undertakes the disinfection of rooms after any contagious disease. The next best method is by sulphur.

When sulphur is employed it should be used in the form of powder or in small pieces. This is placed in a shallow iron pan set on a couple of boards in a tub partly filled with water. The sulphur is moistened with alcohol before it is set on fire.

It is always necessary, of course, before disinfecting by any process to make the room as nearly air tight as is possible. To accomplish this the windows must be tightly closed, the doors locked, and the cracks and keyhole sealed with pieces of paper or adhesive paper. The room should remain closed for six or eight hours, after which it should be thoroughly aired for several days.

The After Treatment of a Disinfected Room.--The walls, ceiling, and all flat surfaces, such as mantels, window-sills, etc., should be washed with a fresh chloride of lime solution. The floor should be scrubbed with a four per cent. soda solution. All carpets and curtains, if any, should be removed, taken to a vacant lot and thoroughly beaten and then exposed to direct sunlight for a number of hours. The room should then be well aired again for a couple of days before it is again occupied.

How to Disinfect the Bed Clothing and Clothes.--The surest way is to boil them for half an hour; otherwise they may be left in the room while it is being disinfected. Spraying the clothes with a spray of formaldehyde is an effective way of disinfecting them.

MUMPS: EPIDEMIC PAROTITIS

Mumps is a contagious disease. It is most common between the fourth and sixth years. Infants are rarely affected. The disease is not very contagious, direct contact being necessary to communicate it. Every case should be isolated for a period of three weeks from the beginning of the disease.

The seat of the affection is the parotid gland which is located in front of and on a level with the ear. One or both glands may be affected at the same time or one may follow the other in succumbing. The duration of the disease from the time the swelling becomes noticeable is about ten days. It is contagious for a week after the swelling subsides. The period of incubation is from one to three weeks.

Symptoms.--In the majority of cases the first symptom is the swelling and the discomfort which it causes. In more severe cases the child feels sick and is listless for from twenty-four to forty-eight hours. There may be a headache, vomiting, pains in the back and limbs, and fever. There is pain in the swelling which is increased by movement of the jaws and by pressure. The degree of the swelling varies with the severity of the attack. It may be very little or it may be so great as to completely distort, and render unrecognizable, the face. It must be remembered that, though mumps is not regarded as an important or dangerous disease, it may assume dangerous characteristics.

We sometimes see distressing complications with mumps. In boys, orchitis, or inflammation of the testicles, occasionally occur. In girls, ovaritis, or inflammation of the ovaries may be present. These complications may be avoided by keeping the patients in bed.

Treatment.--Keep the child in bed until the fever is gone. Keep him in the house for one week after the swelling has entirely subsided. He should be put on a liquid diet while the fever lasts. The bowels should move each day.

The mouth should be kept clean by an antiseptic mouth wash. If there is much pain in the swollen gland, warm, wet dressings give the best results. Sometimes it is advisable to paint the gland with belladonna ointment. If it is not very painful, the most comfortable way to dress the gland is simply to place over it a large pad of absorbent cotton held in place by a broad strip of flannel cloth.

CHICKEN POX. VARICELLA

Chicken pox is an affection almost entirely special to children, in whom it may be observed from their first year, although it is especially frequent from the ages of two to six. It appears often in the epidemical form and spreads by contagion.

Some doctors are inclined to regard varicella as a very attenuated form of smallpox, hence the name "chicken pox," by which it is popularly known. This opinion is based merely on the analogy between the two types of skin eruptions and the coincidence sometimes observed between two epidemics of smallpox and chicken pox. But the theory falls on considering that, on the one hand, chicken pox offers no safeguard against infection by smallpox and does not prevent the effects of vaccination, and, on the other hand the disease may occur in children who have been vaccinated or who have had smallpox. Chicken pox, too, differs essentially from smallpox in the course of its development.

After a period of incubation, extending over a fortnight, chicken pox becomes apparent by such symptoms as slight shivering, extreme fatigue and a general but not very intense condition of fever. In less than twenty-four hours small pink spots will appear on the skin, and these after a few hours are topped by a vesicle, and the next day the whole rash shows a vesiculous appearance.

The vesicles are sometimes small and pointed, sometimes more voluminous and globular in form. They are filled with a limpid or a slightly yellowish liquid. Their base is sometimes surrounded by an inflammatory ring. By the third day the contents of the vesicle has become thicker and tends to become purulent. On the fourth day desiccation commences, and the vesicles shrivel and shrink in and form small brownish scabs, which fall about the eighth day. Frequently the child will scratch them off with the finger nails before they are entirely desiccated. The vesicles leave small reddish spots, which generally disappear gradually, almost always without a scar.

An eruption of chicken pox does not burst out all over the body at once, but appears in successive rashes. It is not confined to any special parts of the body. It may begin and spread at the same time from the face, the trunk of the body or the limbs. A dozen pimples may be seen the first day, while three or even ten times as many may be visible the next day, and so on for several days in succession.

Sometimes the vesicles appear on mucous membrane at different parts--the mouth, tongue, soft palate and tonsils--and may also invade the conjunctiva and cornea, or the larynx, where they will set up laryngitis.

Owing to the very contagious nature of chicken pox, the first thing to be done is to provide for the complete isolation during a period of twelve to fifteen days of all patients attacked by the disease.

The treatment of the disease is solely a matter of hygiene. The more severe the fever the stricter the diet should be, and in the case of great fever, the diet should be restricted to broth and milk. If there is no fever the child need not be placed on any special diet.

If the intestines are sluggish, they may be stimulated by administering a dose of castor oil. It is advisable to make the patient rinse his mouth two or three times a day with a mouth wash. It is also well to apply a lotion around the eyes and face, consisting of two per cent. boracic acid solution with the chill taken off. Finally, in order to prevent the child scratching the sores and the consequent danger of inoculation by the finger nails, it is a good practice to rub a small amount of carbolated vaseline over the itching parts. It is frequently found necessary to have the little patient wear white woolen gloves to prevent scratching and infecting the sores. If a child scratches the sores on the face it will leave an unsightly mark which will stay for the rest of its life.

The child, of course, should not be allowed to rejoin his playmates without having had a good bath, and having had his clothes completely disinfected.

INFLUENZA: LA GRIPPE

The most important feature with reference to influenza in children is its very active tendency to develop complications. These complications generally affect the respiratory tract. So we find in children suffering from grippe an easy disposition to get bronchitis or broncho-pneumonia. The younger the child the greater the danger.

The disease itself, so long as it remains an uncomplicated influenza, is not of much importance or severity. The lesson to be learned, therefore, is to treat the disease with respect and take every precaution to avoid the possibility of developing a complication.

La Grippe is a highly contagious disease. It prevails epidemically, and after an active epidemic it may remain in the vicinity for a number of years. It is more frequently seen in the late winter months and early spring. The poison of the disease clings to clothing and apartments as well as to railroad and street cars. The germ is found in the sputum and in the nasal secretions.

Sneezing is one of its symptoms and it is one of the ways by which the disease is spread around. Children should never be brought near an adult suffering from influenza. One attack does not render the patient immune to a subsequent attack as is the case with most of the contagious diseases. The reverse is the rule with La Grippe because one attack favors the development of another attack. It is a common experience for many people to have influenza every winter or spring.

Symptoms.--If a child "catches" grippe, it becomes quite sick abruptly. There is usually chilliness, pains in the muscles all over the body, more or less fever, sometimes nausea and vomiting. If the attack is a more severe one, the prostration is more marked, the temperature higher and the signs of shock and poisoning of the system are more in evidence. A child a few months old can get influenza so severely as to cause collapse and death in thirty-six hours. As a rule the type of grippe most common in infancy is of a very mild character. It lasts about a week. Children may be a little slow in convalescing and it may be three or four weeks before they regain their health.

Complications.--As has been intimated, the most frequent complication is bronchitis and the most fatal one is broncho-pneumonia.

A congestion of the entire mucous membrane of the respiratory tract, producing a nasal discharge, a sore and inflamed throat, pains and a feeling of compression, with a cough in the chest, may accompany the disease.

Gastric symptoms, with vomiting, intestinal disturbance, diarrhea, with or without mucus and blood, are quite common in some epidemics.

Not infrequently we have numerous cases in which the ear seems to be the vulnerable part. As a consequence running ears have to receive most of our attention. When the ears are affected, the glands of the neck become inflamed. They swell up and add considerable to the discomfort of the little patient.

Treatment.--Cases of influenza should be isolated. Children should be put in a room by themselves and the other children of the family should not be permitted to see them. The rooms should be disinfected after the case is over. As complications are the dangerous element in grippe, we should try to prevent them. This can be best done by promptly putting the child in bed, making him comfortable, opening his bowels by castor oil or calomel. He should be made to drink hot lemonade. He should be kept on a light diet from which meat and vegetables are excluded.

The above treatment will usually suffice in the ordinary uncomplicated grippe. If complications arise they must be treated according to the conditions.

It is well to remember that the degree of prostration following a rather severe attack of grippe is out of all proportion to the extent of the disease. These little patients sometimes suffer considerably and do not regain their strength promptly. Experience has taught us that the best thing to do is to send them away. A change of climate will do wonders for them, more quickly and more thoroughly than all the medicine we can give them at home. The seashore is particularly good for them.

DIPHTHERIA

Diphtheria is an acute, specific, infectious, communicable disease. It affects the tonsils, throat, nose, or larynx. It is most frequently seen in children between the ages of two and five years, though it may appear at any time during life. The two sexes are equally liable to it. The same person may have the disease twice or more times at different ages. Children suffering from disease of the nose or throat are more likely to get it than are others. Such diseases are cold in the head with running nose, catarrh of the nose and throat, inflammation of the mucous membranes of the nose or throat.

Diphtheria may occur at any time of the year, though it is more frequent during the cold months. The incubation, or the length of time between exposure to the disease and the development of the symptoms, is between two and five days. In its mild form the disease may be present without giving any constitutional symptoms. In its severe form, however, it is one of the most dangerous diseases of childhood. In large cities it is present all the year round with more or less frequent outbreaks in the form of local epidemics. In the country it is only seen in its epidemic form. It does not arise without a cause, that is, there is always a preceding case from which an epidemic springs, though it is not always easy to trace the connection. The child inhales the bacilli which cause the disease with the air it breathes. The bacilli may lodge on toys or other articles from which the child gets them. Direct infection is usually the mode of communication through which a child obtains the disease. The saliva and mucus from the nose contain the bacilli in large quantities and if a patient coughs or sneezes they are expelled in this way and infect others. Frequently a child suffering from a mild form of diphtheria may attend school and infect others without it being known that the child has the disease.

Symptoms.--The symptoms vary with the severity of the attack. There are mild cases, as has been stated, that give no constitutional symptoms. There may be a small amount of local disturbance in the throat or nose and there may be some membrane present, but, for some reason, there does not seem to be any absorption of the poison into the system and the child escapes the systemic disturbance. Even as a local condition these cases vary. There is always a fever at the beginning, but the child never seems sick enough to go to bed. If the throat is examined it will be found to be red and slightly inflamed, there may be spots on the tonsils, or there may be a gray film over them. There is no discharge from the nose and the child does not complain of an excess of mucus from the throat. The spots may last for a week and then disappear. These cases are difficult to diagnose without making a culture, and if the physician insists upon keeping the child confined to bed while apparently well the family as a rule object, though it is absolutely necessary. These are the cases that do great harm in school, and no mother should object if the physician insists in taking preventative measures to stop an epidemic if the bacilli have been found in the child's throat. She should rather feel thankful that the child escaped so easily.

Since the introduction of antitoxin we do not see the severe cases now, so that a description of them would not be of any use in a book of this character. Mothers should, however, know that it is absolutely criminal to take any chances with a "sore throat." Antitoxin is a prompt and an absolute remedy if used soon after the onset of the disease. It is more sure if used the first or second day, still reliable the third day, but its efficacy diminishes the longer we postpone its use from the date of the onset of the disease. When, therefore, a child complains of being sick and states that its throat hurts, medical aid should be at once sought.

The disease may develop in one of two ways. It may begin as a slight indisposition for a day or two, and perhaps some soreness of the throat. The fever may be slight. The child will continue to be sick despite any treatment given and will get slowly worse until the fourth or fifth day, when it will be impossible to mistake the condition.

At other times the disease begins abruptly. The child complains of being sick. It may vomit, or suffer from headache, chilly feelings, and a fever. The glands in the neck may swell and cause considerable disturbance. There is, as a rule, an abundant discharge from the nose and there is an excess of mucus in the throat. Membrane is seen in the throat. It may cover the tonsils and spread over the entire throat cavity, or it may extend up into the nose and over the roof of the mouth. All the parts are much swollen and breathing is interfered with, sometimes seriously. If the attack is very severe there is an active absorption of poison going on from the throat which soon renders the little patient intensely sick. There is marked weakness and prostration, the circulation becomes poor, the pulse rapid and the child falls into a stupor.

The physician will, of course, have taken complete charge of the case before the patient has gone thus far. The nursing of the case, which may fall to the mother if no trained nurse is present, is most important. She should preserve absolute cleanliness of herself and of the sick room. She should never eat or sleep in the same room with the patient, and should use a gargle, which the physician should prescribe, frequently during the day. She should dress simply, so that whatever is worn can be changed often and washed easily. Every article of furniture must be taken out of the sick room that is not absolutely essential in the care of the case. If toys are allowed they should be burned as soon as the child is tired of them, never left around the house after the case is over. The room should be a large one and it should be thoroughly aired each day. The floor should be washed each day with a solution of bichloride of mercury, and all dusting should be done with a wet cloth. The bed linen and any rags or handkerchiefs used should be treated as in scarlet fever. All vessels in which the patient expectorates should have an antiseptic in them. The room must be disinfected after the case is over.

The patient must be kept in bed during the entire attack. He must not be allowed to even sit up in bed until the physician gives him permission. This is a very important essential in the treatment of this disease, and the nurse must be held responsible for the conduct of the patient in this respect. Because of the character of the poison, there is a tendency to paralysis of the heart, and frequently children have been allowed to sit up too soon only to fall back dead in bed. The same thing has occurred later in the disease when children have been allowed to play too heartily before the poison had an opportunity to completely eliminate itself. Nursing children should be fed on breast milk pumped from the mother, but they must not nurse it themselves. Older children can take milk and should depend upon it mostly. The physician will give any other special directions that he may think necessary, the duty of the mother being to see that they are faithfully carried out.

WHOOPING-COUGH

Whooping-cough is usually seen in young children. It may, however, affect a person at any age. It is contagious. During infancy it is one of the most fatal diseases. During adult life it is a dangerous condition, while in childhood it is simply regarded as a mildly contagious disease.

It is most contagious during the catarrhal stage,--the first ten days. Children suffering from whooping-cough should not be allowed to mix or play with other children for two months. After an exposure to the disease it takes about fourteen days for a case to develop. The danger of whooping-cough is the tendency to develop pneumonia or bronchitis.

Symptoms.--During the first ten days the child acts as if suffering from an ordinary catarrhal cold with cough. This is called the catarrhal stage. There is no way of telling that whooping-cough is present until the child whoops. Most children do not whoop until the expiration of the catarrhal stage, though a very few do from the beginning of the disease. If a child is treated for an ordinary cold with cough and does not respond to treatment, and whooping-cough is epidemic, it is fair to assume that whooping-cough has been contracted. When the cough shows a distinct tendency to be worse at night it is further proof of this assumption.

When they begin to cough in paroxysms, and whoop, the second, or spasmodic stage begins. These fits of paroxysmal coughing are much more severe than spells of ordinary coughing. These may only be three or four attacks daily, or the child may have from forty to fifty such attacks. When children feel these attacks coming on they seek support, holding on to chairs or they stand by the mother's knee. The coughing is explosive, rapid, and forceful, the child fails to catch its breath and is compelled to take a deep inspiration, which is the whoop; it then goes on coughing more. The face may become purple, the eyes protrude, and the veins of the face swell up. Near the end of the attack the child raises, or vomits a mass of stringy, glutinous mucus. After it is over the child is exhausted, there is a more or less profuse perspiration, and he may be quite dazed. These attacks are, as a rule, more frequent and more severe during the night. This stage lasts about one month and is then followed by the stage of decline, during which the disease subsides into what appears as an ordinary bronchial cold.

It is quite common for these children to get relapses, especially during inclement winter weather, and go on whooping for two or three months longer. Their vitality suffers because their sleep and nourishment is interfered with, and they become nervous and difficult to manage.

Treatment.--Inasmuch as there is no remedy known that will cure whooping-cough, the best we can do is to render the patient physically efficient to stand the severe strain of coughing, which is the worst feature of the disease. Experience has taught us that those children do best who spend their entire time out of doors. We, therefore, advise parents to encourage their children to play in the open air. There is no exception to this rule, even in winter weather, unless it is particularly inclement. If the weather is wet or raw, or if the child has bronchitis, or is running a fever, it would be more safe to keep the child indoors, in a well-aired room, until the temporary conditions pass over, when they could again resume the open-air treatment.

Naturally delicate children if under two years of age should not risk staying out of doors too much in very cold or raw weather, even if not suffering from any of the above complications.

The bedrooms of children suffering from whooping-cough should be large and thoroughly aired day and night.

The nourishment in these cases is of great importance. They should be carefully fed, and if they vomit with the paroxysms of coughing, they should be fed small quantities frequently. Any form of digestive disturbance is very apt to accentuate the frequency of coughing. A fluid diet of milk is the best. Milk punches aid in keeping up the strength; malted milk and eggs beaten in milk are nutritious and easily digested.

So far as internal medication is concerned, I have found pertussin to be the most efficacious remedy. If it is begun early and in sufficient dosage, it not only favors an early termination of the disease, but it lessens the frequency and the severity of the paroxysms. If it is suspected that the child has been exposed to whooping-cough, pertussin may be given during the catarrhal stage with the advantage that it will render the whole course of the disease milder. If it is given during the course of an ordinary catarrhal cold, it will in most cases be as effectual as any ordinary cough remedy. The dosage should be large enough to produce results. I have found a teaspoonful every two hours to a child of three years to be the average dose. In older children I give two teaspoonfuls every three hours. It is necessary to continue its use throughout the disease. The taste of pertussin is pleasant and young children take it willingly.

When the disease is inclined to a protracted course, or when the cough does not subside, especially during unfavorable weather, it is of great importance to send the child away. A change of climate, preferably to the seashore, even for a short time, will act like a charm, and will cure the cough of whooping-cough quicker than any other possible measure.

MEASLES

Measles is the most widely prevalent, eruptive, contagious disease. With few exceptions, every human being "gets" measles. As an uncomplicated disease it is never fatal, and is not even regarded as dangerous. Because of this characteristic, however, parents are neglectful and complications occur, and these frequently prove fatal. One attack renders the patient immune. It is very highly contagious and spreads with great rapidity among those who have never had it. It is not possible to carry the disease any great distance by a third person or by means of living objects. It does not, however, cling to clothing or other objects as long as scarlet fever. Its period of incubation is from eleven to fourteen days.

Symptoms.--The symptoms develop gradually. A severe cold in the head is the first and most characteristic symptom of the disease. There is a discharge from the nose, swollen and watery eyes, sneezing and a hoarse, harsh cough. The patient may complain of the throat being painful and examination will reveal a general congestion of the parts. There are also headache, lassitude, pains in the back, and there may be vomiting and diarrhea. Children in the early stages of measles are tired and sleepy.

Koplik's Spots.--Three or four days, in rare cases somewhat longer, before the appearance of the rash there appears on the mucous membrane of the cheeks small, bluish white, or yellowish white points, the size of a small pin head. These points are surrounded with reddened areas which give the appearance of a general rash with fine white points upon it. These points resemble milk particles. They adhere firmly to the mucous membrane and when an effort is made to remove them it is found that the underlying surface is ulcerated and excoriated.

The Koplik spots are not of much value to the mother other than that they may be relied upon to indicate the coming disease with which they child is affected. Physicians look for them as an aid in diagnosis before the rash would of itself indicate the disease.

The rash appears on the third, fourth, or fifth day of the disease. From the day of the infection to the outbreak of the rash about thirteen days intervene. It is seen first at the roots of the hair on the forehead, behind the ears or on the neck. It may be seen first on the cheeks. The beginning rash appears as small, dark red, dull spots. At first there are only a few, but they soon become more numerous, they join together, and soon the surface looks inflamed as if entirely covered with the rash. The rash covers the entire body, including the soles and palms. In twenty-four hours it is at its height on the face. It spreads downward like a wave, first the face, then the neck and chest, then the abdomen and later the legs. By the time it invades the legs it has begun to fade on the face. It fades slowly in the order of its appearance. Its duration is about four days.

The skin is swollen; it burns and itches. The eyes are swollen and red and intensely sensitive to light. There is usually a muco-pus discharge from them. The cough is invariably an annoying feature. The fever is high and reaches its highest point when the rash is at its height. As the rash fades the fever subsides.

When the rash fades, the patient begins to "scale." The scales of measles are fine, like bran, never in large patches like the scales of scarlet fever. The amount of the scaling varies. It may be quite considerable or it may be so small as to be overlooked.

Complications.--The most important and by far the most frequent complication of measles is broncho-pneumonia. There may be various conditions affecting the stomach, bowels, throat, ears, bronchi, and the nervous system, which may accompany the disease but are seldom of a serious or important character.

Treatment.--Measles runs a certain course and will run that course, no matter what we may or may not do. We cannot stop it, or shorten it, or lessen its severity. We can only hope to make the patient comfortable and to prevent the development of complications.

The child should be put in bed and kept comfortably warm but not too warm. The room should be kept at the ordinary temperature of the sick room, 68° to 70° F. It should be darkened but not dark. The food should be fluid and given regularly. The child may be given all the cool,--not cold,--water it wants to drink. The bowels should be kept open daily. If constipation occurs an enema may be given. The eyes must be carefully watched and washed every hour or two during the day with a boracic acid solution. If the cough is distressing, it may be rendered less distressing, though we cannot hope to stop it until the disease has run its course. The restlessness, headache and general discomfort can be much modified by suitable remedies. If the itching is acute, the body can be rubbed with carbolated vaseline. When the rash subsides and the patient is free from fever a daily warm bath should be given in order to facilitate scaling.

Should complications arise they should be promptly cared for by the attending physician.

SUMMARY:--

1. Measles is the most prevalent infectious disease of childhood.

2. The danger of measles has been and is underestimated. Because of its prevalency many mothers treat it with less respect than they should, with the result that fatal complications occur, or the future health of the child is permanently injured.

3. Children with measles should be put in bed and kept in bed and treated as directed above.

The following rules have been formulated by the Department of Health of New York City, with reference to measles, and embody precautions that should find general observance:

1. All children in the family must be promptly excluded from school attendance.

2. Careful and continued isolation of the patient must be enforced until the case is terminated and fumigation has been ordered by the medical inspector of the Department.

3. All secondary cases must be reported even if the first case is still under surveillance of the Department of Health.

4. Suspected cases must be treated as contagious cases until a sufficiently long observation has shown that the patient has a non-contagious disease. All cases will be considered as measles, if so reported. Any change in the original diagnosis must be made in writing to the Department of Health and must be confirmed by a diagnostician.

5. Physicians must not order the removal of patients to the contagious disease hospital, or elsewhere, in cabs or other vehicles, but must notify the Department of Health and the removal will be effected by a coupé or ambulance of the Department.

6. Whenever there is a case of measles in rooms in the rear of, or communicating with, a store, the inspector is required to have the store closed at once, or to report the case for immediate removal to the hospital.

7. A case of measles must not be removed from one house to another, or even to a different apartment in the same house, without the permission of the Department. Such removal is in direct violation of the provisions of the Sanitary Code.

8. No case of measles shall be discharged from observation until the Department has been notified, the case examined by an inspector to see if desquamation is entirely completed, and the premises ordered fumigated. This examination by the inspector is necessary because the Department of Health must have official information as to the completion of desquamation before a child is dismissed from observation. Other people with children demand this protection. At no other time is the inspector allowed to examine the patient. In any case, however, where isolation has not been maintained and it becomes necessary to remove the patient to the hospital, a diagnostician will make an examination.

It is recommended that physicians provide a special washable gown for each case of measles. This gown should be put on before entering the sick-room and taken off outside the sick-room as soon as the visit is completed. The gown should be kept in a closet or suitable place, separate from all other clothing, and the gown, and the closet should be fumigated after the termination of the case.

10. In private houses only fumigation may be performed under the supervision of the attending physician; provided he follow accurately the directions given in the following rules and regulations. Upon request a blank will be provided upon which he must state the manner and extent of the work performed under his orders and supervision. If satisfactory to the Department, this will be accepted in place of fumigation by the Department. It is essential, however, that he should know that the disinfection has been efficiently carried out.

In every case of fumigation the following regulations must be complied with:

All cracks or crevices in rooms to be fumigated must be sealed or calked, to prevent the escape of the disinfectant, and one of the following disinfectants used in the quantities named:

a. Sulphur, 4 lbs., for every 1,000 cubic feet of air space, 8 hours' exposure.

b. Formaline, 6 oz. for every 1,000 cubic feet of air space, 4 hours' exposure.