Chapter III: Part 3

No. I. contains twice the amount of extractives as No. II. If the stronger juice is desired, No. II. may be made by adding only ℥iv of water instead of ℥viij.

VEGETABLE SOUP FOR BABIES.

1 handful of spinach;
1 beet;
2 carrots.

Chop fine and boil two hours in 1 quart of water. Strain through gauze and add sterile water to make up deficiency to 1 quart.

TOOTHACHE: Its Forms, Diagnosis, and Treatment for Relief.

The =sharp, paroxysmal, shooting= pain which is caused by the application of cold, heat, sweets or sours, or by biting some substances into a cavity, is due to a live pulp, and the treatment is quite simple. Clean out the cavity as well as possible, then saturate a small pellet of cotton with oil of cloves, or one drop of carbolic acid, or a solution of cocaine hydrochlorate and clove oil. Place this in the cavity and add another pellet of cotton to prevent the solution from being washed out by saliva. Relief should be immediate, but if not, reapply within a few minutes.

The =dull, throbbing= pain, with swelling of the face and a sensation of elongation of the tooth, is caused by either a putrescent pulp or an imperfect root canal filling. There is infection; therefore, the first thing to do is to remove the pus.

_Dental Treatment._—If there is a large cavity in the tooth, try to enter the root canals and remove the putrescent matter. If the face is badly swollen, make a digital examination, and over the root of the affected tooth you will find a spot about the center of the swelling where it seems to be spongy, appearing to hold the impress of the finger. Take a clean, sharp, cycle-shaped lancet, place on the spot, holding the patient’s head firm with your other arm for fear of his moving. Press the lancet firmly and directly through to the bone, then draw it out with a pulling motion so as to make a cut about an eighth of an inch or more. If this has been done properly, a creamy flow of pus should follow the lancet. Place the fingers on either side of the incision and massage toward incision. To relieve the pain, give _hot_ foot-baths, _cold_ applications to face (never _hot_), and some other sedative internally, such as remedies given for a headache. When a tooth is sore to percussion, so that the food cannot be masticated, but is without pain when left at rest, if there is no pain over the root of the tooth, it is best to give the tooth a rest, and apply counterirritants over the roots of the adjacent teeth.

This condition is called =apical pericementitis=, an inflammation of the layer of bone about the fangs of teeth. For relief, give hot foot-baths and pain remedies, as in abscessed tooth. A dead pulp in a tooth will form gas and cause the sensation of elongation and soreness. If the putrefaction is not removed, an abscess will result. At first there will be no soreness to pressure over the root, but on application of heat, such as drinking hot coffee, there will be pain, while cold water will temporarily remove it.

_Dental Treatment._—Open the chamber and remove the putrescent pulp, being careful not to go beyond the apical foramen. Use a barbed broach, then wash out with peroxide of hydrogen on a thread of absorbent cotton wrapped smoothly about the broach. Do not push the instrument up into the canal very far for fear of sending some putrescent matter beyond the tooth. Then withdraw the broach and apply oil of cloves or carbolic acid, leaving the canal open and clean for the gas to escape. Hot foot-baths and headache remedies will relieve the pain.

=Gum-boils= are abscessed teeth, and may be deep-rooted or very superficial. The treatment is the same as given above. Hot applications are very often prescribed, but as an infection will always follow the line of least resistance, it can be readily understood why such a treatment should not be given. The abscess may gather in the cheek, necessitating lancing, which will leave a scar. Cold cloths will allay the infection and simplify the treatment to the gums alone. Teeth are withdrawn, leaving unsightly cavities, which could be avoided by a more deliberate treatment. Treat the abscess of the tooth the same as an abscess in any other part of the body, thereby saving the root of the tooth, if not the entire portion, which can be crowned and give a permanent good tooth.

Mastication is the most important part of the digestive system, and mastication cannot be done without good teeth. Therefore, it behooves everyone to preserve his own teeth and to give this benefit to others who may not have had dental treatment. There are dentists who will extract a tooth upon the patient’s request, and it is best to seek the most progressive and modern dental doctors for the preservation of the teeth to prevent the untimely loss of a tooth, which means also many times a preventive against other ailments affecting the digestive tract. A good dentist should be consulted at least once a year, although the teeth may appear sound and in good condition.

ERUPTION OF THE DECIDUOUS OR MILK-TEETH.

Lower central incisors, 6 to 9 months.
Upper “ 8 “ 10 “
Lower lateral “ 15 “ 21 “ { also first
{ molars.
Canines, 16 “ 20 “
Second molars, 20 “ 24 “

Twenty teeth in all: eight incisors, four on each jaw; four canines, two on each jaw; eight molars, four on each jaw.

Permanent teeth:

First molars coming back of baby molars, 6 years.
Centrals, 7 “
Laterals, 8 “
First bicuspid, 9 “
Second “ 10 “
Canines, 11-12 “
Second molars, 12-13 “
Third “ or wisdom teeth, 17-21 “

NURSING IN ACUTE FEVERS.

TYPHOID OR ENTERIC FEVER.

Typhoid fever is an acute infectious disease, excited by the _typhoid bacillus_. It is most prevalent in the autumn, although it occurs at all seasons. The disease is not directly contagious, and can only be acquired by taking the special bacillus into the alimentary canal. This is usually accomplished through the medium of polluted water, milk contaminated with infected water, raw vegetables (celery, lettuce, water-cress) which have grown in infected soil, or raw shell-fish (oysters) taken from the beds of polluted streams. Occasionally physicians and nurses are infected directly in handling the patient or his clothing which has become soiled with his discharges.

The bacilli are contained in nearly all the secretions of the patients, especially in the stools and urine.

While the bacilli are widely distributed through tissues, the only characteristic lesions of the disease are in the glands of the intestines (Peyer’s patches), which in the first few days become red and swollen, about the beginning of the second week soft and pale, and in the third week ulcerated. If the patient survive, cicatrization usually begins in the fourth week.

Death may result from exhaustion, the result of the systemic poisoning, from perforation of the bowel by an ulcer, from intestinal hemorrhage, the result of erosion of a blood-vessel, or from some complication, like pneumonia.

=Symptoms.=—The _initial symptoms_, which may last a week or two before there is any fever, are headache, weakness, loss of appetite, nose-bleed, and perhaps slight diarrhea.

The _fever_ rises gradually, reaching its maximum (104°-105° F.) in about a week; it remains stationary for one, two, or three weeks, and then falls, reaching the normal in another week, thus making the febrile period of the disease of four or five weeks’ duration. Throughout its course the evening temperature is apt to be two or three degrees higher than the morning temperature.

The abdominal symptoms consist of distention of the abdomen (tympanitis), pain and tenderness in the right iliac region, and often diarrhea.

Between the seventh and ninth days a rash usually appears on the abdomen, consisting of small rose-red spots. These come out in crops and disappear on pressure.

The _pulse_ becomes rapid and feeble, and the heart sounds become weak and dull.

The _respiratory symptoms_ include cough, hurried breathing, and slight expectoration.

_Nervous symptoms_ are not always marked. In severe cases there may be delirium, stupor, twitching of the muscles, picking at the bed-clothes, and coma.

The _face_ is dull and listless. The _tongue_ is coated and tremulous. In severe cases it becomes dry, brown, and fissured, and sordes tend to collect upon the teeth.

Relapses are common. In some cases they are due to the too early use of solid food, to excitement, or to overexertion.

When typhoid fever is prevalent, the most reliable _preventive measures_ consist in thorough boiling of all water and milk used for drinking purposes and the avoidance of uncooked vegetables, oysters, and shell-fish.

=Management.=—Unless otherwise directed take _temperature_, _respiration_, and _pulse_ every three hours, in mouth or axilla, as desired. If for any reason a change is made in taking temperature, it should be noted on the chart. Note the effect of _sponging_ or of _bathing_ upon temperature and pulse. Note the character of pulse, and effect, if any, which stimulants have had upon it. Note the amount of _cough_, and the character and quantity of the _expectoration_; also any pain that may occur in the chest.

Note the amount of _flatulence_ and the number and character of the _stools_; especially be on the lookout for blood or undigested food in the discharges.

Note carefully any _abdominal pain_, any _increase in the distention_, as these symptoms, with or without a rather abrupt _fall in temperature_, _chills_, and _pinched features_, are suggestive of perforation.

=Treatment for Hemorrhage.=—Stop all orders immediately, including diet. Elevate the foot of the bed. Give morphin sulphate, gr. ¼ (gm. 0.015), hypodermically, and apply an ice coil or iced compresses to the abdomen until the physician arrives.

Note the occurrence of _vomiting_ and the character of vomit.

Be on the lookout for retention of _urine_, which is quite common. Note the amount of urine passed in a day and any abnormalities connected with its appearance.

Note the condition of the _skin_ and _tongue_.

Note the amount of _sleep_, its character, whether quiet or restless and whether or not there have been delirium, stupor, or twitching of the muscles.

Note the exact amount and character of _nourishment_ taken, and the time it was given; also the amount, time of administration, and effect of _medicines_ and _stimulants_.

Cleanse the mouth and teeth frequently with some antiseptic wash, such as listerine, 1 part; water, 3 parts.

Bed-sores can nearly always be prevented by keeping the patient and bedding perfectly clean, the skin absolutely dry, and the bed-linen smooth. Changes of position are also important. Parts subjected to pressure and soiling should be washed at least twice daily with soap and water, thoroughly dried, gently rubbed with alcohol, and then dusted with a powder like the following:

Boric acid, 1 part;
Starch, 1 “
Zinc oxid, 1 “

If the skin be reddened and tender it may be painted with collodion and then dusted. When the part cannot be kept dry, it should be smeared with zinc ointment and powdered. In very prolonged cases it usually becomes necessary to use water- or air-pillows or water- or air-beds.

To _disinfect the feces and urine_, use a solution of chlorinated soda (Labarraque’s solution). Cover the urine and feces with the solution and leave the contents stand for an hour. Cleanse pan thoroughly and pour into it the Labarraque solution.

PNEUMONIA.

Pneumonia is a general infection, excited by a special organism—the pneumococcus—and manifested by a local inflammatory process in the lung and severe systemic disturbances.

Exposure to cold and lowered vitality from overwork, alcoholism, or some previous disease render persons liable to infection.

=Symptoms.=—These consist in a decided chill, pain in the side, fever rising rapidly to 104°-105° F., and lasting for five, seven, nine, or eleven days, and then rapidly falling; cough; tenacious bloody expectoration, shortness of breath, delirium and stupor, and physical signs indicating a solid condition of the affected lung.

In fatal cases death usually results from exhaustion, the result of the systemic poisoning, but occasionally it is due to a failure of the heart to propel the blood through the solid lung, to suffocation, or a complication, such as inflammation of the covering of the heart (pericarditis) or lining of the heart (endocarditis).

=Management.=—The room should be well ventilated, but free from drafts. The temperature should be maintained between 65° and 70° F. Cool water should be given freely. The points mentioned in connection with temperature, respiration, and pulse in dealing with typhoid fever are applicable here. Note the frequency of cough, the amount and character of expectoration, and whether the latter is raised readily or with difficulty. Note the occurrence of pain and its location; also amount of sleep, amount of nourishment, amount of urine, number of stools, etc., and the effect of sponging, of medicines, and of local applications. Clean the mouth and teeth at intervals, being extremely careful, however, in all manipulations not to tire or exhaust the patient.

SCARLET FEVER.

Scarlet fever is an acute, highly contagious disease characterized by a sudden onset with chill, vomiting, or convulsions; a high fever of from a week to ten days’ duration; a very rapid pulse; severe sore throat; a bright red rash, appearing on the second day, lasting about a week, and followed by desquamation and a marked tendency to nephritis.

The most serious complications are nephritis, suppurative inflammation of the middle ear (otitis media), inflammation of the endocardium or pericardium, and pneumonia.

Scarlet fever, while contagious at all periods, is probably most so during the period of desquamation. The organism may cling to furniture, clothing, etc., and reproduce the disease after very long periods. The contagion may be carried by persons coming in contact with the sick, or the disease may be transmitted through the air of the sick-room or through clothing, utensils, etc., which have been used by the sick.

=Prevention of contagion= consists in isolating the patient; in disinfecting everything that has been in contact with him; in anointing the patient’s body with an antiseptic oil until desquamation is complete; and in thoroughly disinfecting the room after the patient’s removal.

=Management.=—Have the patient, if possible, in a large, airy room, preferably at the top of the house. Keep the temperature uniform and the room well ventilated. Wear a loose wrapper and cap, and leave these inside the room when obliged to leave it.

With cloths moistened with a 3 per cent. solution of carbolic acid wipe the floor, furniture, sills, door-knobs, mantelpiece, etc., once a day, but never dust or sweep. Thoroughly disinfect the secretions of the patient and all articles used by him before they leave the room.

Allow the patient no food except what has been ordered, which will usually be milk, koumiss, junket, fruit-juices, and gruels. Encourage the patient to drink water freely. Apply to the body, at least once a day, a bland ointment. Note temperature, respiration, pulse, stools, quantity of nourishment, sleep, and effect of baths and medicine as in typhoid fever. Note especially the quantity and appearance of the urine, and have a sample in a clean bottle ready each day for the physician’s examination.

Keep the nose and throat clean with mild antiseptic sprays or washes. Relieve pain in the throat, unless otherwise directed, with ice-poultices or hot-water compresses.

MEASLES.

Measles is an acute contagious disease characterized by moderate fever of about a week’s duration; by an eruption on the skin, appearing on the third or fourth day as small red spots that soon coalesce into crescentic blotches, remain three or four days, and then disappear with a branny desquamation; and by catarrhal symptoms involving the eyes, nose, and bronchial tubes (conjunctivitis, coryza, and bronchitis). The most common complications of the disease are catarrhal pneumonia, inflammation of the gastro-intestinal tract, and inflammation of the middle ear.

=Management.=—The preventive measures described in connection with scarlet fever are applicable in measles. The room should be maintained at a temperature of 70° F., and should be moderately darkened. The bed should be so arranged that the face will be directed away from the light. Milk, broths, and gruels are suitable forms of nourishment. The temperature, pulse, respiration, hours of sleep, quantity of nourishment, amount of urine, and the effects of therapeutic measures should be carefully noted as in other fevers. Daily inunctions of the body with cold cream or olive oil are useful. Spraying the nose and throat with a mild antiseptic solution, and washing the eyes with boric acid solution (15 grains to the ounce of water) are usually ordered. Hot baths and hot drinks are indicated when the rash is delayed. Fever is generally controlled by sponging. Great care is necessary during convalescence to avert complications.

DIPHTHERIA.

Diphtheria is an acute contagious disease characterized by moderate fever of an irregular type, and of from one to two weeks’ duration; by considerable weakness and prostration; and by the formation of a grayish or whitish false membrane upon the throat, nose, larynx, and adjacent parts. The exciting cause of disease is the _bacillus of diphtheria_, which is found chiefly in secretions of the affected mucous membrane. The constitutional symptoms are due to the absorption of a toxin produced by this bacillus.

Diphtheria involving the larynx is sometimes termed _true croup_ or pseudomembranous croup. This form is characterized by irregular fever, hoarseness of the voice, croupy cough, and progressive difficulty in breathing. Death frequently results from suffocation, unless tracheotomy or intubation of the larynx be performed.

The chief =complications= of diphtheria are pneumonia, degeneration of the heart-muscle, inflammation of the middle ear, and paralysis the result of an inflammation of the nerves.

=Preventive measures= consist in isolation of the sick, the thorough disinfection of the bedroom, bedding, clothing, and all articles used by the sick, and the administration of an immunizing dose (500 units) of antitoxin (see page 25) to those who have already come in contact with the patient or who have otherwise been exposed to the contagion. The sick-room should be well ventilated and maintained at a temperature of 70° F. The atmosphere should be made moist by slaking lime in the room or by generating steam in a kettle. In membranous laryngitis treatment in a steam-moistened tent is desirable. On account of the tendency to sudden heart failure absolute quiet and rest are to be enjoined. The diet should consist of milk, unseasoned broths, koumiss, junket, and eggs.

The patient’s temperature, pulse, respiration, nourishment, urine, sleep, and bowel movements should be noted as in other fevers. Local applications of boric acid solution, hydrogen peroxid (1: 3), or normal salt solution are usually ordered; they should be made with utmost gentleness. Externally, ice-poultices or hot fomentations are useful in relieving soreness.

The utmost care should be exercised during convalescence to guard the patient against undue effort, as at this time sudden heart failure is especially liable to occur.

POLIOMYELITIS.

=Poliomyelitis—Infantile Paralysis.=—This disease occurs in all countries and was recognized more than a hundred years ago. The first of the great epidemics appeared in 1905, and it was then proved that the malady is a contagious disease. Peculiar facts connected with previous epidemics of poliomyelitis have made it appear possible that the disease when not spread directly from one person to another, like the most acute infectious diseases, may be dependent upon some intermediate agent, or perhaps upon some other host, or a living reservoir, or upon the combination of the two. If the disease is communicated by human contact, mild cases, abortive cases, and convalescents may carry the germs for years. A normal carrier is an individual who is not suffering from the disease and may carry the germs and transmit them to another without being the least suspected. Laboratory experiments would seem to show that the disease is passed directly from one affected human individual to another through immediate contact involving the transfer of the virus from the first person to the nasal passages of the second, and spread through the agency of dust or by various other means, a population other than human, one acting as an undercurrent and influencing the progress of the epidemic. There seems to be no relation between the sanitary conditions and the incidence of cases. Poliomyelitis is most prevalent during the warm months, even when it is not epidemic. Under the same conditions of temperature, rainfall, humidity, cloudiness, sunshine, wind, dust, etc., the outbreak will progress in one part of the city and subside in another. The course of the epidemic is not materially modified by weather conditions. No age, no sex, or race is exempt; the incidence is greater under five years of age, and the blonde children appear to be especially susceptible, while the colored race are rarely attacked, and the strongest children seem to be the greatest sufferers. That this disease can and often does end fatally has been clearly shown by the history of the past epidemics, and it has been frequently demonstrated by clinicians in various parts of the world that complete recovery from paralysis is not only possible but it is by no means uncommon.

=Summary Results from Public School Reports.=—1. A large number of children with poliomyelitis show pathologic conditions of the nose and throat, either diseased and hypertrophied tonsils and adenoids, or both.

2. A large number show marked hyperemia of the nasopharynx and throat, often resembling a scarlet or streptococcus throat.

3. Only a small percentage of cases previously operated for tonsils and adenoids were found to be affected with the disease, and in this group of cases the percentage of recovery was very much higher than in unoperated cases. The number of cases in this group is, of course, rather small to draw from it any definite conclusion, but it is at least suggestive. In another investigation of 1404 children in the public schools, made to determine whether any of them whose tonsils had been removed had been ill with poliomyelitis during the recent epidemic, a similar result was obtained. Of the 1404 children whose tonsils had been operated upon not one developed poliomyelitis during this epidemic, although in 18 instances cases developed in the family, and in 93 instances cases developed in the same house.

Poliomyelitis defined: _Polio_ (gray), _myel_ (marrow), _itis_ (inflammation), meaning inflammation of the gray matter of the spinal cord.

=Pathology= of the disease: Infantile paralysis is a general infection, with lesions most marked in the central nervous system. Clinical manifestations exhibit a wide-spread and scattered motor paralysis or weakening. The large majority of all cases are of the central nervous system, but there are variations in which the symptoms are not of the usual kind.

=Classification.=—1. _Non-paralytic or Abortive Type._—These are cases in which the nerve-cells are not sufficiently injured to produce paralysis; and those classed as meningitis cases, tuberculous meningitis without motor disturbances, often called encephalitic; in these cases the motor cortical areas are not involved, but there is evidence of disturbance of the sensorium.

2. _Ataxic Type._—Here the motor cells are evidently not involved, but there is a lack of co-ordination—ataxia, nystagmus.

3. _Cortical Type._—The upper motor neuron is here affected, with resulting spastic paralysis.

4. _Ordinary Spinal or Subcortical Type._—Here the lower motor neuron is affected, with resulting flaccid paralysis; a manifestation of poliomyelitis difficult to classify is blindness. The most important symptoms of the disease may be described under the _non-paralytic_ or _abortive_ cases and those of _ordinary spinal form_.

=Symptoms of Onset.=—There is no typical onset for this disease. It is believed that there is an interval of from a few days to two weeks between the time of exposure and the appearance of symptoms. No one symptom or group of symptoms will always be found to identify it before the paralysis is apparent. Fever is the most constant of all symptoms; it varies a great deal; there may be much or there may be little. Vomiting occurs quite frequently, and in a child old enough to talk headache may be complained of. Sometimes there is considerable pain in the back. The child is often very drowsy and desires to be alone. Movements of any kind seem to cause pain, and muscle tenderness is plainly evident. Marked irritability and sweating are also often prominent features. Such symptoms may all appear suddenly following a day of great activity and good health. These symptoms may continue for from two to four days, when it is noticed that the child is unable to move a hand, an arm, a foot, or a leg. There may merely be a paralysis of one side of the face or only weakness in an arm or leg. In some mild cases it is occasionally hard to convince parents of the true nature of the disease. In some instances the first knowledge of a child’s indisposition is the discovery that it cannot walk or has difficulty in using an arm. Cases of this character are often attributed to “catching cold,” to going in bathing for too long, or perhaps a fall.

In the majority of cases temperature is down to normal within a week and there is seldom an extension of the paralysis after that time. In most instances all the paralysis which is going to occur is present at the time it is first noticed.

Within two weeks all the tenderness has usually left the muscles, which are now found to be soft and flabby from lack of use. No matter what extremity may be affected by the paralysis, there is one condition which is nearly always present in these cases. If the child’s shoulders are raised up from the bed, the head drops back almost as if on a string. The child is unable to keep its head in a line with the body, and if the head is raised and forcibly bent forward so as to cause the chin to touch the chest, marked pain results.

=Treatment.=—By the end of three weeks in favorable cases there may be some motion obtained by the patient in the limb which was paralyzed, or there may be evidence of threatened deformity. It is at this time and in the weeks and months to follow that so much depends upon treatment. The muscles of a leg or arm may waste away so as to make them useless if not promptly cared for. If contractions of muscles are not prevented, a club-foot, toe-drop, or some similar deformity may develop. _Such deformities may be hastened by the pressure of the bed-clothes._ At times it is well to put a wire cradle over the affected limbs. Well-padded splints seem to take the strain from unaffected muscles.

By some wonderful adaptation of nature there is a great effort to make other nerve channels take up the work of the destroyed cells, and hence the value of keeping the muscles artificially active by the use of massage and mild electric treatment. This treatment should be used early in the case, and then only with the advice and supervision of a competent physician.

The destruction of nerve-cells in the segment of the spinal cord is sometimes so extreme that a total paralysis of one or more extremities follows. This is a grave shock to the growing child, and it may be that all growth of that member will stop. The long bones will not lengthen. If one group of muscles remain active and unopposed in their action, deformity will follow. These deformities can be corrected by the orthopedic surgeon, and can usually be checked if the physician’s advice is sought.

_Serum Treatment._—The serum injections were given even as long as thirty years ago. Intraspinal injection of an immune serum is effective when introduced in the preparalytic stage.

_Prophylaxis._—The _virus_ or germ of _poliomyelitis_ is found _in the nose, the mouth, and intestinal tract_ (it is also found in various other parts of the body). As house-flies may carry the virus after crawling over the person suffering from the disease, all insects are a dangerous asset to any household. Disinfection of secreta and excreta should be carried out. The mouth and nose should be disinfected.

=Quarantine= should be rigidly enforced, and all the necessary precautions taken to prevent the spread of a contagious, infectious disease.

DISINFECTION OF FECES AND URINE.

Disinfect the feces and urine by mixing with each evacuation double its volume of 1 per cent. chlorid of lime solution or double its volume of 5 per cent. carbolic acid solution. Cover the vessel and allow it to stand for from one to two hours before emptying its contents into the closet.

Put all typhoid linens in cans used for that purpose only. Sprinkle with formalin and keep covered until sent to laundry.

N. B.—While performing work in which the hands come in contact with soiled linen and bed-pans, fill finger-nails with soap to keep them clean and to prevent them from acting as carriers of disease.

A WASHING FLUID FOR SOILED CLOTHES.

One can of lye, 10 cents;
Lump of ammonia, 5 “
Salts of tartar, 5 “

Put in a stone jar and set it in the open air. Pour over it 1 gallon of boiling water. Use ½ cupful to a boiler of clothes and add ½ bar of soap. Soak clothes over night in cold water; then place clothes into the boiler and boil for twenty minutes. Plain pieces need very little rubbing. Rinse two or three times in clear water before hanging clothes out to dry.

INCUBATION PERIOD AND QUARANTINE.

A constant period of incubation is not to be expected. In most instances, as will be seen from the following table, the difference between the maximum and the minimum period is not very great. It seems remarkable, however, that a disease should show such extremes as typhoid fever:

Normal. Maximum. Minimum.
Variola 12 days. 14 days. 9 days.
Varicella 14 “ 19 “ 13 “
Measles 10 “ 14 “ 4 “
Rubella 18 “ 21 “ 8 “
Scarlatina 2 “ 7 “ 1 day.
Influenza 3 “ 5 “ 1 “
Diphtheria 2 “ 7 “ 2 days.
Typhoid fever 12 “ 23 “ 5 “
Mumps 19 “ 25 “ 12 “

It is a peculiar fact that the diseases in which the period of incubation is shortest are those in which the infection persists the longest.

The period of quarantine must be guided largely by the period of incubation, hence the subject is an important one for a variety of reasons. The “Medical Magazine” (London) states that the period of quarantine should be at least a day longer than the maximum period of incubation for each disease. This is a very uncertain rule, however, for the patient should be free from all signs of illness, and especially from fever. The period of infection is very doubtful. It may be greatly prolonged by complications. This is especially true of small-pox, diphtheria, typhoid and scarlet fevers. The period during which a disease may be infectious cannot be stated definitely. It varies with different diseases, and must be determined according to the symptoms and character of the case. Measles, chicken-pox, and mumps lose the direct power of infection very early, and the infective principle does not remain active for a long period in the room in which the patient has been ill. Measles, mumps, and chicken-pox may be infectious in the earlier stages before becoming definite in character. Smallpox is not actually dangerous until the eruption appears.

THE CARE OF THE SKIN AND MOUTH IN FEVERS.

BY HARRIET HIGBEE, Graduate Illinois Training School for Nurses.

_From the American Journal of Nursing._

The prevention and treatment of bed-sores have been and are frequently discussed in medical books and journals. But as it is a subject that often taxes the nurse’s ingenuity to the extreme, it can not be dwelt upon too frequently. Many preventive measures are familiar to us, as the soap and water bath for cleanliness, followed by rubbing with alcohol and dusting with boric-acid powder, or boric-acid powder and bismuth subnitrate in equal parts for dryness. _The relief of pressure is most important._ Make use of air-cushions, cotton-pads, pillows, water-bed and _frequent change of position_ where that is possible. In addition to these, there are a few measures not generally used which after a thorough test have proved satisfactory. One is a simple inexpensive contrivance used to relieve pressure of heel, elbow, and ear. It is a pig’s bladder filled two-thirds full of either warm or cold water, as the case requires, tied securely, and placed under a cotton ring. The weight of the head or elbow rests on the ring and the tender point rests on the soft fluctuating mass. If the skin is inactive, as in paralysis, or there is frequent or constant moisture from perspiration or involuntary evacuations of urine or feces, the alcohol and boric acid, etc., are of very little value. They do not prevent the absorption of the moisture by the skin and its subsequent softness or excoriation, which is commonly followed by infection. In such cases the back should be washed with soap and water every six or eight hours, or after every involuntary evacuation, and thoroughly rubbed with a small amount of oil-substance, as camphorated oil or a mixture like the following:

Mutton tallow, ℥j;
Olive oil, f℥j;
Carbolic acid, 95 per cent., ♏︎j.

Render out mutton tallow on the back part of the stove; do not brown it. Strain through a piece of muslin; add the olive oil and carbolic acid; set dish into cold water and beat its contents until set. This will make an ointment the consistence of vaseline, and it will keep indefinitely. If the skin needs a great deal of stimulation, camphorated oil or, better still, castor oil may be substituted for the olive oil in the above recipe.

When the skin becomes excoriated the part should be cleansed as mentioned before, not with soap and water, but with boric-acid solution, normal salt solution, or sterile water; then gently painted with oxide of zinc ointment made into liquid form by the addition of olive oil, castor oil, and balsam of Peru in equal parts, or castor oil alone, and covered with a clean cloth fastened on with a binder. Gentle massage may be used around the excoriated surface with excellent results.

_The_ =treatment of bed-sores= _is usually directed by the physician_; but if it is left to the nurse, she will find the following method helpful. If there is necrotic tissue or suppuration present, she may irrigate the cavity once daily with peroxid of hydrogen, one glass syringeful, followed by normal salt solution, boric-acid solution, or sterile water. Then apply a hot boric-acid dressing, one inch thick, every four hours until wound is clean. If the stimulation of the tissues is needed, fill the cavity with a sterile dressing saturated with balsam of Peru and castor oil, equal parts bovinine, castor oil, or camphorated oil alone. When the depression is filled with granulation tissue, it can be treated as an excoriation.

THE MOUTH.

The subject of the care of the mouth in fever nursing is equally as important as that of prevention of bed-sores. An unclean mouth is not only very unpleasant and often painful to the patient, but is a source of infection. The accumulation of food and mucus is a fertile field for the lodgement of bacteria. If this infected material is allowed to remain, it can easily spread to the middle ear and the mastoid cells, and cause abscesses or be carried by the food to the already overburdened alimentary tract to add to its infection. When the accumulation of sordes is profuse and persistent the patient’s mouth ought to be cleansed after every feeding. This may be done by wrapping a two-inch square piece of linen or gauze, saturated with the mouth-wash, around the little finger and wiping every portion of the cavity—not far enough on back of the tongue to provoke nausea. If it is necessary to clean the throat, a small swab may be employed. For thorough cleaning of the mouth several sponges are necessary. These may be received in a piece of paper and at once burned. While cleaning the mouth of a delirious patient the nurse for her own protection must place some hard substance between the patient’s teeth. A rubber cork is the best, but if that is not available, a fork-handle may be used. Its prongs must be carefully wrapped to avoid an accident. If the cork is used, the nurse must hold it in place to prevent its falling down the patient’s throat. There are numerous preparations used for cleaning the mouth, as:

1. Listerin, f℥j;
Water, f℥ij.

_Dobell’s Solution._
2. Borax, ʒss;
Sodium bicarbonate, ʒiv;
Listerin, fʒj;
Carbolic acid, 95 per cent., ♏︎viij;
Warm water, f℥x.

3. Boric-acid solution, f℥j;
Alcohol, fʒss;
Glycerin, fʒj;
Tincture of myrrh, f♏︎j.

4. Glycerin,
Water, of each, f℥ss.

The following three formulæ have been found excellent for special cases:

_For Mucus-coated Mouth._

1. Sodium bicarbonate, gr. x;
Glycerin, fʒij;
Water, enough to make, f℥ij.

If the coating be of long standing, thick and dry, this solution may be applied with an applicator every five or ten minutes for one hour, and then the cleansing may be done with sponges. In these cases it is necessary to use a toothpick to gently loosen the sordes between the teeth.

For dry or fissured lips and tongue, and for anointing the baby’s nose, the following will be found useful:

2. Lanolin,
Vaselin, of each, ℥j;
Oil of gaultheria, ♏︎xxx.
Apply small quantity several times daily.

In rare cases there is a persistent bleeding from the gums. The application, several times daily, of the following solution is effectual:

3. Tincture of myrrh, ♏︎xxx;
Water, f℥j.

_Mouth-Wash._

A solution of potassium chlorate and cinnamon water.

DISINFECTION OF ROOMS.

Seal all crevices about doors and windows. Keep the room closed for twenty-four hours to allow dust to settle. At the end of this time vaporize in a lamp from fifty to sixty paraform tablets to each 1000 cubic feet of space or vaporize 1 pound of formaldehyd solution in a _special apparatus_ designed for the purpose. If no special apparatus is obtainable, sprinkle sheets with the following solution, using a gallon of the mixture for a medium-sized room, and fill the room with steam:

Formaldehyd sol., 4 parts;
Glycerin, 1 part;
Water, 2 parts.

The steam and glycerin prevent to some extent the conversion of the formaldehyd gas into paraform, which in itself is useless.

Another and more modern method is to pour 12 ounces of formaldehyd into a vessel and then add 4 ounces of crystals of potassium permanganate. Place the vessel in the room and leave the room closed for from four to six hours. To get rid of the fumes quickly after the disinfection is completed, sprinkle 4 ounces of ammonia on a sheet and leave the sheet in the room until the ammonia is evaporated.

_Sulphate of copper_ solution is a very cheap disinfectant, and may be used to advantage in typhoid fever.

After this treatment again keep the room closed for four or five hours. Then wipe floor, walls, and woodwork with corrosive sublimate solution (1: 2000) or carbolic acid solution (3 per cent.).

DISINFECTION IN PRIVATE NURSING.

In a private home (M. D. P., _American Journal of Nursing_) if contagion has taken the family by surprise and a room has not been especially prepared, leave in the room all the furniture and fittings in order that everything may be disinfected finally.

During the progress of the disease no blankets, coverings, etc., must ever be shaken from the windows. They can only be aired within the room, or rooms, occupied by the patient. Moist sheets hung outside the door leading to the rest of the house prevent the passage of dust from the sick-room. It is sufficient to keep them sprinkled with plain water, as the important thing is the moisture. However, a solution of carbolic acid may be used. They should be kept wet by some one on the clean side of the house. Soiled linen from the sick-room should be placed in a wash-boiler or metal can full of water, never taken to the laundry in a dry condition. Here also a weak solution of carbolic acid maybe used, or a very weak solution of soda. However, plain water will be sufficient. They should be boiled for at least half an hour. Patients’ dishes and silver should be kept in the room, and before returning to the house should be boiled.

All cleaning within the patient’s room during illness should be done with moist cloths, which should be put into paper bags and burnt.

Upon leaving the room the patient should receive an unusually thorough bath, hair and all, with tincture of green soap, a dilute alcohol rub, and finally a sponge-bath of bichlorid of mercury, 1: 2000 to 1: 4000, according to age.

The mode of disinfecting rooms is, generally, to use formaldehyd.

Before setting free formaldehyd in any form the nurse should put on rubber gloves, glasses, and a thick mouth and nose protector, as the fumes are very irritating. After leaving the room she should seal up the door and leave all over night, and then thoroughly air and house-clean on the morrow. Mattresses and pillows had better be steam-sterilized if there is any sterilizing plant in the town, or, in the country, made over and sunned thoroughly.

SURGICAL SUPPLIES.

TO STERILIZE INSTRUMENTS.

1. All instruments should be boiled for at least fifteen minutes in a 1 per cent soda solution. _Wrap the blades of knives and scissors in cotton_, put them in a separate towel, and in one corner stick the needles before folding it. Some surgeons prefer to have the latter simply washed and placed in absolute carbolic acid and then in alcohol for a few minutes. Water _must boil_ before instruments are put in and the boiler must be kept closely covered.

2. In a German medical journal, published at Leipsic, Gerson corroborates his former assertions as to the efficacy of disinfection of instruments with tincture of soap, citing extensive bacteriologic tests in evidence. He wraps the blades in Brun’s cotton, impregnated with tincture of soap. The cotton protects them from the air and the tincture is an efficient disinfectant. The instruments are then ready for use at any moment. After using them he rubs them clean with cotton moistened with the same tincture, then wraps them in a fresh piece and lays them aside. No boiling or steaming is required, and the instruments are not harmed by the process. He recommends this method especially for military and other practice where steam disinfecting appliances are not available. He has found that instruments infected with pus, etc., and not even wiped off after having been used, proved perfectly sterile after a few days in the wet cotton wrapper. No colonies developed when they were rubbed on agar plates or soaked in bouillon.

_To Arrange Instruments for the Convenience of the Operator._—Instruments for immediate use are laid in trays on a small movable table on the operator’s right hand. Instruments that may not be needed are kept in another tray. A separate tray is used for suturing material, needles, a pair of sharp-pointed scissors, and long forceps. Before placing instruments in the tray, dry with sterile towels.

TO CLEAN INSTRUMENTS.

_First of all_, the knives, scissors, and needles should be laid carefully aside and cleaned at once. Scrub all instruments in cold water to remove blood and pus, then in hot water with plenty of soap. Rinse thoroughly in hot water, then place in boiling water, take them out singly and dry; _do not drain_. Following pus cases all instruments must be boiled for at least fifteen minutes in 1 per cent. soda solution.

TO STERILIZE GLOVES.

Examine carefully to see that they are in perfect condition. Select a pair, then wrap each one in a separate piece of gauze, fasten together, and boil at least 15 minutes in salt solution.

TO DRY STERILE GLOVES.

Cover a table with a sterile sheet. Prepare hands and person as for an operation, and draw on a pair of sterile gloves. Then dry gloves with sterile towel, and powder them inside with sterile powdered talcum.

TO CLEAN GLOVES.

Soak in cold water, then wash with green soap and hot water. Rinse and dry. If used in pus cases, boil 15 minutes before laying away.

TO STERILIZE SILK-WORM GUT OR SILK THREAD.

Boil in sterile water 20 minutes and preserve in alcohol, 95 per cent., or first sterilize in steam sterilizer for 20 minutes, then boil in sterile water for 20 minutes and preserve in alcohol, 95 per cent.

TO STERILIZE HORSE-HAIR.

1. Wash thoroughly in green soap and water. Rinse several times. Soak in ether 24 hours. Boil in sterile water 20 minutes. Preserve in alcohol, 95 per cent.

2. Soak in bichlorid solution 1: 1000 for 6 hours. Then boil 3 minutes in sterile water. Place in alcohol, 50 per cent.

TO STERILIZE CATGUT (FORMALDEHYD METHOD).

Immerse in formaldehyd sol., 5 per cent., for 24 hours. Wash by soaking in sterile water for 24 hours, which must be changed every hour. Then boil in sterile water and basins about 10 minutes, according to size of the catgut. Lift out carefully, and place on a sterile towel until all moisture is absorbed. Prepare table, hands, and person as for an operation. Cut in required lengths, from 14 to 25 inches. Coil smoothly, and preserve in glass jars (which have been previously boiled for 20 minutes) containing the following solution:

Corrosive sublimate, 1 part;
Boiled glycerin, 200 parts;
Alcohol, 95 per cent., 1000 “ .

CHROMIC CATGUT.

1. Soak in ether 1 to 2 weeks, according to size.

2. Wind on glass spools.

3. Soak in chromic acid solution, 5 gr. to 1 pint water, 3 to 6
hours, according to size.

4. Dry in sun 3 days.

5. Boil in 95 per cent. alcohol 1 hour, under 15 pounds pressure,
in autoclave.

Use Mason fruit jars.
Do not screw the top down when in sterilizer.

TO STERILIZE LINEN THREAD.

Wind several yards of thread into coils. Boil for 30 minutes in a 1 per cent. solution of bicarbonate of soda. Wash in fresh cold water, and allow to stand in cold distilled water for 6 hours. Then boil in fresh water for 30 minutes. Place in absolute alcohol for 48 hours, then in a solution of Schering’s celloidin with equal parts of alcohol and ether. The mixture must stand for 12 hours, or until dissolved; keep tightly corked. When ready for use add 1 per cent. of sterile oleum ricini, and immerse thread for 48 hours. Then wind upon a frame to dry. This will require from 1 to 3 days. When dry, cut into lengths and coil or wind on glass slides. Boil for 1 hour in normal salt solution. Preserve in Chinesol solution, 1: 500.

=To Sterilize Glycerin or Any Kind of Oil.=—Place bottle uncorked in a vessel of boiling water for 2 hours.

TO PREPARE RUBBER TUBING.

Place different sizes in a deep dish of water. Add bicarbonate of soda to make a 10 per cent. solution. Let come to a boil over a slow fire, then with a stiff brush or cloth rub each piece well. This removes all sulphur, leaving a black surface. Rinse several times, then boil in clean water 15 minutes. Boil 15 minutes before immediate use.

TO PREPARE SIX YARDS OF IODOFORM GAUZE.

Prepare the following solution:

Sterile iodoform, ℥iij;
Sterile glycerin, ℥iij.

Mix thoroughly, gradually add alcohol (95 per cent.), f℥iij, then very quickly, ether, f℥vij. Have gauze ready in desired lengths, and drop into solution. Press gauze uniformly to preserve evenness of color. Work rapidly. Prepare table, hands, and person as for an operation. Roll strips, and place in sterile glass jars.

TO PREPARE IODOFORM GAUZE (GREEN-SOAP METHOD).

To saturated boric-acid solution Oj, add green soap to make a good suds. Boil half an hour. To this add iodoform ℥j, then boil 15 minutes. When cool add carbolic acid (95 per cent.) ʒj, stir solution, dip gauze, and roll in strips. Keep in sterile glass jars.

Castile soap is a good substitute for green soap.

IODOFORM EMULSION.

I. Nine parts sterile glycerin in 1 part of iodoform. Dissolve powder for eight hours in bichlorid solution (1: 500). Pour off solution and break up the iodoform after having rinsed it thoroughly in sterile water. Then mix with glycerin.

II. Iodoform, ℥j; sterile glycerin, ℥ix. Put the iodoform in a sterile basin. With a sterile spoon stir in glycerin, a few drops at a time, until a smooth paste has been made. Then add remainder of glycerin.

TO PREPARE PROTECTIVE STRIPS.

Scrub with green soap and rinse well in sterile water. Cut into strips. Disinfect in bichlorid (1: 500) for twenty-four hours. Keep in sterile water three hours. Then place in boric-acid solution. Put in normal salt solution when preparing for immediate use.

TO PREPARE TINCTURE OF GREEN SOAP.

Green soap, 3 parts;
Alcohol, 95 per cent., 2 “ ;
Ether, 1 part.

To prepare by cold process: Mix ingredients in a pitcher and stir briskly for a few minutes every hour until a solution is formed.

To prepare by warm process: Melt the soap over a slow fire; then remove it to a cool place and stir occasionally. Before it hardens add solutions and mix thoroughly.

Caution: Prepare where there is no danger of the ether igniting.

STERILIZING HAND-BRUSHES.

1. Clean with green soap and water; rinse thoroughly.

2. Place in saturated oxalic solution for 30 minutes.

3. Place in sterile water 30 minutes.

4. Change water twice.

5. Keep dry.

TO PREPARE A PATIENT FOR A SURGICAL OPERATION.

The preliminary preparations are of the _greatest importance_. The usual standing orders should be followed only when no directions have been given by the surgeon. When express directions for preparation are given by the surgeon, the usual standing orders must be disregarded. Caution in the use of cathartics can not be too strongly emphasized, for even a simple laxative at such a time may cost the patient’s life.

The usual standing orders are: For the previous day, liquid diet only. Give a cathartic, a bath, and a hair-wash during the afternoon, and flush the bowels thoroughly a few hours later. Surgical preparations should be completed before retiring time for the night.

Have room and all preparations ready before disturbing patient. Keep patient covered as much as possible. Protect table with a Kelly pad or a good substitute for same. Have at hand a drainage-pan and a bucket.

Shave field of operation.

Scrub with tincture of green soap and rinse with sterile water; then cleanse with ether, followed by alcohol, 70 per cent.

Put on dry sterile dressing (a towel), apply a suitable bandage and fasten securely.

Douches are given only by direction of the surgeon—sterile water preferred.

The final preparation is given in the operating-room a few minutes before the operation is begun, consisting of a heavy coating of tincture of iodin, applied by the surgeon in attendance.

=Morning of Operation.=—Have a specimen of urine ready for analysis. No food six hours before operation. If patient cannot urinate a few minutes before going to the operating-room, catheterize, with doctor’s permission. Remove false teeth, jewelry, and protect patient from the cold.

TO PREPARE A ROOM FOR A MAJOR OPERATION.

BY EVELEEN HARRISON, Graduate of the Post-Graduate Hospital, New York.

_From the American Journal of Nursing._

Of necessity this is far more extensive than the requirement of a minor operation, and should be commenced the day before if possible.

The selection of the room comes first, and as an abundance of clear light is more essential than anything else in an operating-room, let the choice of the room depend on that. When possible avoid using a room into which the sun will shine directly during the time of the operation; but in any case, take the room that gives the most light.

When the house is large enough to allow it, and your choice is not limited, use a room adjoining, or at least on the same floor as the one to be occupied afterward by the patient, and as near the bath-room as possible.

Sometimes it is necessary to use your patient’s bedroom, in which case the bed, after being prepared, should be pushed up in a corner out of the way.

All the furniture that it is possible to remove is taken out of the room; any large piece that has to remain should be covered completely with sheets fresh from the laundry. Carpets and curtains must be removed, _unless the surgeon prefers to have them covered with moist sheets_, and the room thoroughly cleaned, floor scrubbed, windows washed, etc.

As the surgeon will need all the light you can give him, cover only the lower panes of the window with thin muslin curtains, cheese-cloth, or—what will answer the purpose equally as well and is ready at hand—a thick lather of soap rubbed all over the panes and allowed to dry, thus shutting off the gaze of outsiders without excluding valuable light.

The temperature should be about 75° F. and the room well aired beforehand, as no window will be opened during the operation.

A list of articles usually required for a major operation is as follows: