The Home Medical Library Volume I Part 17

When the patient is entirely free from scabs, after bathing and putting on disinfected or new clothes outside of the sick room, he is fit to reenter the world.

=CHICKENPOX.=--Chickenpox is a contagious disease, chiefly attacking children. While it resembles smallpox in some respects, at times simulating the latter so closely as to puzzle physicians, it is a distinct disease and is in no way related to smallpox. This is shown by the fact that chickenpox sometimes attacks a patient suffering with, or recovering from, smallpox. Neither do vaccination nor a previous attack of smallpox protect an individual from chickenpox.

Chickenpox is not common in adults, and its apparent presence in a grown person should awaken the liveliest suspicion lest the case be one of smallpox, since this mistake has been frequently made, and with disastrous results, during an epidemic of mild smallpox. One attack of chickenpox usually protects against another, but two or three attacks in the same individual are not unknown. The disease may be transmitted from the patient to another person from the time of the first symptom until the disappearance of the eruption. The disease ordinarily occurs in epidemics, but occasionally in isolated cases.

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

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

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

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

=Treatment.=--Children should be kept in bed during the eruptive stage until the blisters have dried. To prevent scratching, the calamine lotion may be used (Vol. II, p. 145), or carbolized vaseline, or bathing with a solution of baking soda, one teaspoonful to the pint of tepid water. The diet should be that recommended for German measles.

Patients should be kept in the house and isolated until all signs of the eruption are pa.s.sed, and then receive a good bath and fresh clothing before mingling with others. The sick room should be thoroughly cleaned and aired; thorough chemical disinfection is not essential.

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

CHAPTER II

=Infectious Diseases=

_Typhoid Fever--How it is Contracted--Complications and Sequels--Rest, Diet, and Bathing the Requisites--Mumps--Whooping Cough--Erysipelas._

=TYPHOID FEVER (ENTERIC FEVER).=--Through ignorance which prevailed before the discovery of the germ of typhoid fever and exact methods for determining the presence of the same, the term was loosely applied and is to this day. Thus mild forms of typhoid are called gastric fever, slow fever, malarial fever, nervous fever, etc., all true typhoid in most cases; while typhoid fever, common to certain localities and differing in some respects from the typical form, is often named after the locality in which it occurs, as the "mountain fever" common to the elevated regions of the western United States.

This want of information is apt to prevail in regions remote from medical centers, and leads to neglect of the necessary strict measures for the protection of neighboring communities, for the excretion of one typhoid patient has led to thousands of cases and hundreds of deaths.

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

=Cause and Modes of Communication.=--While the typhoid germ is always the immediate cause, yet it is brought in contact with the body in various ways. Contamination of water supply through bad drainage is the princ.i.p.al source of epidemics of typhoid. Before carefully protected public water supplies were in vogue in Ma.s.sachusetts, there were ninety-two deaths from typhoid fever in 100,000 inhabitants, while thirty-five years after town water supplies became the rule, there were only nineteen deaths for the same population. Whenever typhoid is prevalent, the water used for drinking and all other household purposes should be boiled, and uncooked food should be avoided. Flies are carriers of typhoid germs by lighting on the nose, the mouth, and the discharges of typhoid patients, and then conveying the germs to food, green vegetables, and milk. Cooking the food, preventing contact of flies with the patients, and keeping flies out of human habitations becomes imperative. Milk is a source of contagion through contaminated water used to wash cans, or to adulterate it, or through handling of it by patients or those who have come in contact with patients. Oysters growing in the mouths of rivers and near the outlets of drains and sewers are carriers of typhoid germs, and, if eaten raw, sometimes communicate typhoid fever. Dust is an occasional medium of communication of the germ. It is probable, however, that the germ always enters the body by being swallowed with food or drink, and does not enter through the lungs. There is little doubt on this point.

Ice may harbor the germ for many months, for freezing does not kill it, and epidemics have been traced to this source. Clothing, wood, utensils, door handles, etc., which have been contaminated by contact with discharges from patients, may also prove mediums of communication of the typhoid germ to healthy individuals. Typhoid germs escape from patients sick with the disease chiefly in the bowel discharges and urine, sometimes in the sweat, saliva, and vomited matter.

Sewer gas and emanations from sewage and filth will not communicate typhoid fever directly, but the latter afford nutriment for the growth of the germ, and after becoming infected, may eventually come in contact with drinking water or food, and so prove dangerous. Improper care of discharges of excrement and urine--with the a.s.sistance of flies--are responsible for the enormous typhoid epidemics in military camps, so that in the late Spanish-American War one-fifth of all our soldiers in camp contracted the disease. In the upper layers of the soil typhoid germs may live for six months through frosts and thaws.

The disease is preventable, and will probably be stamped out in time.

In some of the most thickly populated cities in the world, as in Vienna, its occurrence is most infrequent, owing to intelligent sanitary control and pure water supply, while in the most salubrious country districts its inroads are the most serious and fatal through ignorance and carelessness.

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

=Symptoms.=--Typhoid fever is subject to infinite variations, and it will here be possible only to outline what may be called a typical case. In a work of this kind the preliminary symptoms are of most importance in warning one of the probability of an attack, so that the prospective patient can govern himself accordingly, as in no other disease is rest in bed of more value. Patients who persist in walking about with typhoid fever for the first week or so are most likely to die of the disease.

The average duration of the disease is about one month. During the first week the onset is gradual, the temperature mounting a little higher each day--as 99.5 F. the first evening, 101 the second, 102 the fourth, 104 the fifth, 105 the sixth, and 105.5 the seventh. In the morning of each day the temperature is usually about a degree or more lower than that of the previous night. From the end of the first week to the beginning of the third the temperature remains at its highest point, being about the same each evening and falling one or two degrees in the morning. During the third week the temperature gradually falls, the highest point each evening being a degree or so lower than the previous day, while in the fourth week the temperature may be below normal in the morning and a degree or so above normal at night. So much for this symptom. After the entrance of typhoid germs into the bowels and before the recognized onset of the disease, there may be la.s.situde and disinclination for exertion. The disease begins with headache, backache, loss of appet.i.te, sometimes a chill in adults or a convulsion in children, soreness in the muscles, pains in the belly, nosebleed, occasional vomiting, diarrhea, coated tongue, often some cough, flushed face, pulse 100, gradually increasing as described.

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

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

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

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

Among the many and frequent variations from the type described, there may be a fever prolonged for five or six weeks, with a good recovery.

Chills are not uncommon during the disease, sometimes owing to complications. Relapse, or a return of the fever and other symptoms all over again, occurs in about ten per cent of the cases. This may happen more than once, and as many as five relapses have been recorded in one patient. A slight return of the fever for a day or two is often seen, owing to error in diet, excitement, or other imprudence after apparent recovery. Death may occur at any time from the first week, owing to complications or the action of the poison of the disease.

Pneumonia, perforation of and bleeding from the bowels are the most frequent dangerous complications. Unfavorable symptoms are continued high fever (105 to 106 F.), marked delirium, and trembling of the muscles in early stages, and bleeding from the bowels; also intense and sudden pain with vomiting, indicating perforation of the intestines. The result is more apt to prove unfavorable in very fat patients, and especially so in persons who have walked about until the fever has become p.r.o.nounced. Bleeding from the bowels occurs in four to six per cent of all cases and is responsible for fifteen per cent of the deaths; perforation of the bowels happens in one to two per cent of all cases and occasions ten per cent of the deaths.

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

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

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

=Treatment.=--There is perhaps no disease in which the services of a physician are more desirable or useful than in typhoid fever, on account of its prolonged course and the number of complications and incidents which may occur during its existence. It is the duty of the physician to report cases of typhoid to the health authorities, and thus act as a guardian of the public health. If, however, in any circ.u.mstances one should have the misfortune to have the care of a typhoid patient remote from medical aid, it is a consolation to know that the outlook is not greatly altered by medicine or special treatment of any sort. There have been epidemics in remote parts of this country where numbers of persons have suffered with typhoid without any professional care, and yet with surprisingly good results.

Thus, in an epidemic occurring in a small community in Canada, twenty-four persons sickened with typhoid and received no medical care or treatment whatever, and yet there was but one death. The essentials of treatment are comprised in _Rest, Diet, and Bathing_. Rest to the extent of absolute quiet in the horizontal position, at the first suspicion of typhoid, is requisite in order to avoid the dangers of bleeding and perforation of the bowels resulting from ulceration of structures weakened by the disease. The patient should be a.s.sisted to turn in bed, must make no effort to rise during the sickness, and should pa.s.s urine and bowel discharges into a bedpan or urinal under cover. In case of bleeding from the bowels, the bedpan should not be used, but the discharges may be received for a time in cloths, without stirring the patient.

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

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

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

The immersion of patients in tubs of cold water, as practiced with benefit in hospitals, is out of the question for use by inexperienced laymen. The patient should have a woven-wire spring bed and soft hair mattress, over which is laid a folded blanket covered by a rubber sheet. Sponging the naked body with ice water will suffice in some cases; in others, when the temperature is over 102-1/2 F., enveloping the whole body in a sheet wet in water at 65, and either rubbing the surface with ice or cloths wet in ice-cold water, for ten or fifteen minutes, is advisable. Rubbing of the skin of the chest and sides is necessary during the application of cold to prevent shock. The use of a cold cloth on the head and hot-water bottle at the feet, during the sponging, will also prove beneficial. In children and others objecting to these cold applications, the vapor bath is effective. For this a piece of cheese cloth (single thickness) is wet with warm water--100 to 105--and is wrapped about the naked body from shoulders to feet, and is continually wet by sprinkling with water at the temperature of 98. The evaporation of the water will usually, in fifteen to twenty minutes, cool the body sufficiently if the patient is fanned continuously by two attendants. In warm weather the patient should only be covered with a sheet for a while after the bath, which should reduce the temperature to 3. Hot water at the feet, and a little brandy or whisky given before the sponging if the pulse be feeble, will generally prevent a chill. Patients should be gently dried after the bath and covered with dry bedclothing. The utmost care should be taken not to agitate a feeble patient during sponging.

The long period of lying in bed favors the occurrence of bedsores.

These are apt to appear about the lower part of the spine, and begin with redness of the skin, underneath which a lump may be felt.

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

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

The greatest care must be exercised by attendants to escape contracting the disease and to prevent its communication to others.

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

=MUMPS.=--Mumps is a contagious disease characterized by inflammation of the parotid glands, situated below and in front of the ears, and sometimes of the other salivary glands below the jaw, and rarely of the t.e.s.t.i.c.l.es in males and the b.r.e.a.s.t.s in females.

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

=Development.=--A period of from one to three weeks elapses, after exposure to the disease, before the first signs develop. The germ has not yet been discovered, and the means of communication are unknown.

The breath has been thought to spread the germs of the disease, and mumps can be conveyed from the sick to the well, by nurses and others who themselves escape.

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

=Complications and Sequels.=--Recovery without mishap is the usual result in mumps, with the exception of involvement of the t.e.s.t.i.c.l.es.

Rarely there are high fever, delirium, and great prostration.

Sometimes after inflammation of both t.e.s.t.i.c.l.es in the young the organs cease to develop, and remain so, but s.e.xual vigor is usually retained.

Sometimes abscess and gangrene of the inflamed parotid gland occur.

Recurring swelling and inflammation of the gland may occur, and permanent swelling and hardness remain. Meningitis, nervous and joint complications are among the rarer sequels.