The Home Medical Library Volume I Part 16

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

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

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

There is, however, great variation in the symptoms as to their presence or absence, intensity, and time of occurrence and disappearance.

=Complications and Sequels.=--These are frequent and make scarlet fever the most dreaded of the eruptive diseases, except smallpox.

Enlarged glands under the jaw and at the sides of the neck are common, and appear as lumps in these sites. Usually not serious, they may enlarge and threaten life. Pain and swelling in the joints, especially of the elbows and knees, are not rare, and may be the precursors of serious inflammation of these parts. One of the most frequent and serious complications of scarlet fever is inflammation of the kidneys, occurring more often toward the end of the second week of the disease.

Examination of the urine by the attending physician at frequent intervals throughout the course of the disorder is essential, although puffiness of the eyelids and face, and of the feet, ankles, and hands, together with lessened secretion of urine--which often becomes of a dark and smoky hue--may denote the onset of this complication. The disease of the kidneys usually results in recovery, but occasionally in death or in chronic Bright's disease of these organs. Inflammation of the middle ear with abscess, discharge of matter from the ear externally, and--as the final outcome--deafness, is not uncommon. This complication may be prevented to a considerable extent by spraying the nose and throat frequently and by the patient's use of a nightcap with earlaps, if the room is not sufficiently warm. Inflammation of the eyelids is an occasional complication. The heart is sometimes attacked by the toxins of the disease, and permanent damage to the organ, in the form of valvular trouble, may result. Blindness and nervous disorders are among the rarer sequels including paralyses and St.

Vitus's dance.

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

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

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

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

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

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

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

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

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

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

=Complications and Sequels.=--Severe bronchitis, pneumonia, croup, laryngitis, sore eyes, ear abscess and deafness, violent diarrhea, convulsions, and, as a late result, consumption sometimes accompany or follow measles. For the consideration of these disorders, see special articles in other parts of this work.

=Outlook.=--The vast majority of healthy patients over two years old recover from measles completely. Younger children, or those suffering from other diseases, may die through some of the complications affecting the lungs. The disease is peculiarly fatal in some epidemics occurring among those living in unhygienic surroundings, and in communities unaccustomed to the ravages of measles. Thus, in an epidemic attacking the Fiji Islanders, over one-quarter of the whole population (150,000) died of measles in 1875. Measles is more severe in adults than in children.

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

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

The patient is stripped and wrapped from feet to neck in a blanket wrung out of hot water containing two teaspoonfuls of mustard stirred into a gallon of water. This is then covered with two dry blankets and the patient allowed to remain in the blankets for two or three hours, when the application may be repeated. It is well to keep a cold cloth on the head during the process. Cough is also relieved by a mixture containing syrup of ipecac, twenty drops; paregoric, one teaspoonful, for an adult (or one-third the dose for a child of six), which should be given in one-quarter gla.s.s of water and may be repeated every two hours. If there is hoa.r.s.eness, the neck should be rubbed with a mixture of sweet oil, two parts; and oil of turpentine, one part, and covered with a flannel bandage. The cough mixture will tend to relieve this condition also. A solution of boric acid (ten grains of boric acid to the ounce of water) is to be dropped in both eyes every two hours with a medicine dropper. Although usually mild, the eye symptoms may be very severe and require special treatment, and considerably impaired vision may be the ultimate result. Severe diarrhea is combated with bis.m.u.th subnitrate, one-quarter teaspoonful, every three hours. For adults, the diet consists of milk, broths, gruels, and raw eggs. Young children living on milk mixtures should receive the mixture to which they are accustomed, diluted one-half with barley water. Nourishment must be given every two hours except during sleep.

The patient should be ten days in bed, and should remain three days in his room after getting up (or three weeks in all, if there are others who may contract measles in the house), and after leaving his room should stay in the house a week longer. The princ.i.p.al danger after an attack of measles is of lung trouble--pneumonia or tuberculosis (consumption)--and the greatest care should be exercised to avoid exposure to the wet or to cold draughts.

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

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

=Symptoms.=--The rash may be the first sign of the disease and more frequently is so in children. In others, for a day or two preceding the eruption, there may be headache, soreness, and redness of the throat, the appearance of red spots on the upper surface of the back of the mouth, chilliness, soreness in the muscles, loss of appet.i.te, watering of the eyes. Catarrhal symptoms are most generally absent, an important point in diagnosis. When present, they are always mild.

These preliminary symptoms, if present, are much milder and of shorter duration than in measles, where they last for four days before the rash appears; and the hard, persistent cough of measles is absent in German measles. Also, while there is sore throat in the latter, there is not the severe form with swollen tonsils covered with white spots so often seen in scarlet fever. Fever is sometimes absent in German measles; usually it ranges about 100 F., rarely over 102 F. Thus, German measles differs markedly from both scarlet fever and measles proper. The rash usually appears first on the face, then on the chest, and finally covers the whole body, in the s.p.a.ce of a few hours--twenty-four hours at most. The eruption takes the form of rose-red, round or oval, slightly raised spots--from the size of a pin head to that of a pea--sometimes running together into uniform redness, as in scarlet fever. The rash remains fully developed for about two days, and often changes into a coppery hue as it gradually fades away. There are often lumps--enlarged glands--to be felt under the jaw, on the sides and back of the neck, which occur more commonly in German than in true measles. The glands at the back of the neck are the most characteristic. They are enlarged in about two-thirds of the cases.

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

German measles differs from true measles in the following points: the preliminary period--before the rash--is mild, short, or absent; fever is mild or absent; the cold in the nose and eyes and cough are slight or may be absent, as contrasted with these symptoms in measles, while the enlarged glands in the neck are more p.r.o.nounced than in measles.

The onset of German measles is not so sudden as in scarlet fever and not accompanied with vomiting as in the latter, while the sore throat and fever are much milder in German measles. The peeling, which is so prominent in scarlet fever with the disappearance of the rash, is not infrequently present. It may be absent. Its presence or absence seems to depend upon the severity of the eruption. The desquamation when present is finer than in either measles or scarlet fever.

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

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

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

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

=Symptoms.=--There is a preliminary period of from twenty-four to forty-eight hours after the beginning of the disease before an eruption occurs. The onset is ushered in by a set of symptoms simulating those seen in severe _grippe_, for which smallpox is often mistaken at this time. The patient is suddenly seized with a chill, severe pains in the head, back, and limbs, loss of appet.i.te and vomiting, dizziness on sitting up, and fever--103 to 105 F. In young children convulsions often take the place of the chill seen in adults. On the second day a rash often appears on the lower part of the belly, thighs, and armpits, which may resemble that characteristic of measles or scarlet fever, but does not last for over a day or two.

It is very evanescent and, consequently, rarely seen. Diarrhea often occurs, as well as vomiting, particularly in children. On the evening of the fourth day the true eruption usually appears; first on the forehead or face, and then on the arms, hands, and legs, palms, and soles. The eruption takes successively four forms: first, red, feeling like hard pimples or like shot; then, on the second or third day of the eruption, these pimples become tipped with little blisters with depressed centers, and surrounded by a red blush. Two or three days later the blisters are filled with "matter" or pus and present a yellowish appearance and are rounded on top. Finally, on about the tenth day of the eruption, the pustules dry up and the matter exudes, forming large, yellowish or brownish crusts, which, after a while, drop off and leave red marks and, in severe cases, pitting. The fever preceding the eruption often disappears upon the appearance of the latter and in mild cases does not reappear, but in severe forms the temperature remains about 100 F., and when the eruption is at its height again mounts to 103 to 105 F., and gradually falls with convalescence. The eruption is most marked on the face, hands, and forearms, and occurs less thickly on the body. It appears also in the mouth and throat and when fully developed on the face gives rise to pain and considerable swelling and distortion of the features, so that the eyes are closed and the patient becomes frightfully disfigured and well-nigh unrecognizable. Delirium is common at this time, and patients need constant watching to prevent their escape from bed. In the severe forms the separate eruptive points run together so that the face and hands present one distorted ma.s.s of soreness, swelling, and crusting. In these, pitting invariably follows, while in those cases where the eruption remains distinct, pitting is not certain to occur.

A still worse form is that styled "black smallpox," in which the skin becomes of a dark-purplish hue, from the fact that each pustule is a small blood blister, and bleeding occurs from the nose, mouth, etc.

These cases are almost, without exception, fatal in five to six days.

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

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

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

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

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

Whether cowpox is a modified form of smallpox or a distinct disease is unknown.

The period of protection afforded by a successful vaccination is uncertain, because it varies with different individuals. In a general way immunity for about four or five years is thus secured; ten or twelve years after vaccination the protection is certainly lost and smallpox may be then acquired. Every individual should be vaccinated between the second and third month after birth, and between the ages of ten and twelve, and at other times whenever an epidemic threatens.

An unvaccinated person should be vaccinated and revaccinated, until the result is successful, as immunity to vaccination in an unvaccinated person is practically unknown. When unsuccessful, the vaccine matter or the technique is faulty. A person continuously exposed to smallpox should be vaccinated every few weeks--if unsuccessful, no harm or suffering follow; if successful, it proves liability to smallpox. A person previously vaccinated successfully may "take" again at any time after four or five years, and, in event of possible exposure to smallpox, should be revaccinated several times within a few weeks--if the vaccination does not "take"--before the attempt is given up. An unvaccinated person, who has been exposed to smallpox, can often escape the disease if successfully vaccinated within three days from the date of the exposure, but is not sure to do so.

Diseases are not introduced with vaccination now that the vaccine matter is taken from calves and not from the human being, as formerly.

Most of the trouble and inflammation of the vaccinated part following vaccination may be avoided by cleanliness and proper care in vaccinating.

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

If the scab is knocked off and an open sore results it should be treated like any wound.

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

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

The special treatment of an attack of smallpox is largely a matter of careful nursing. A physician or nurse can scarcely lay claim to any great degree of heroism in caring for smallpox patients, as there is no danger of contracting the disease providing a successful vaccination has been recently performed upon them. The patient should be quarantined in an isolated building, and all unnecessary articles should be removed from the sick room, in the way of carpets and other furnishings. It is well that the room be darkened to save irritation of the eyes. The diet should be liquid: milk, broths, and gruels.

Laudanum, fifteen drops, or paregoric, one tablespoonful in water, may be given to adults, once in three hours, to relieve pain during the first few days. Sponging throughout the course of the disease is essential; first, with cool water, as directed for scarlet fever, with the use of cold on the head to relieve the itching, fever, and delirium. The cold pack is still more efficient. To give this, the patient is wrapped in a sheet wrung out in water at a temperature between 68 and 75 F. The sheet surrounds the naked body from feet to neck, and is tucked between the legs and between the body and arms; the whole is then covered with a dry blanket, and a cold, wet cloth or ice cap is placed upon the head. The patient may be permitted to remain in the pack for an hour, when it may be renewed, if necessary, to allay fever and restlessness; otherwise it may be discontinued. The cold sponging or cold pack are indicated when the temperature is over 102.5 F., and when with fever there are restlessness and delirium.

Great cleanliness is important throughout the disease; the bedclothes should be changed daily and the patient sponged two or three times daily with warm water, unless fever is high. Cloths wet with cold carbolic-acid solution (one-half teaspoonful to the pint of hot water) should be kept continuously on the face and hands. Holes are cut in the face mask for the eyes, nose, and mouth, and the whole covered with a similar piece of oil silk to keep in the moisture. Such applications give much relief, and to some extent prevent pitting.

The hair must be cut short, and crusts on the scalp treated with frequent sponging and applications of carbolized vaseline, to soften them and hasten their falling. The boric-acid solution should be dropped into the eyes as recommended for measles, and the throat sprayed every few hours with Dobell's solution. Diarrhea in adults may be checked with teaspoonful doses of paregoric given hourly in water.

Vaseline and cloths used on a patient must not be employed on another, as boils are thus readily propagated. All clothing, dishes, etc., coming in contact with a patient must be boiled, or soaked in a two-per cent carbolic-acid solution for twenty-four hours, or burned.